ABSITE - Biliary - Questions
A 44-12 months-antique lady with a frame mass index of 38 gives to the emergency department
with fever, nausea, vomiting, and right top quadrant ache. A proper top quadrant ultrasound
suggests an obstructing cystic duct stone and a ordinary-performing commonplace bile duct.
You undertake a laparoscopic cholecystectomy but the case is difficult, requiring conversion to
an open technique because of excessive chronic inflammation and fibrosis within the
hepatocystic triangle and porta hepatis. You accidentally input the duodenum at some stage in
your dissection and near it in layers. It regarded to be in continuity with the gallbladder, that's
then eliminated. Four days later the nasogastric tube output is consistently elevated. An
aqueous assessment upper gastrointestinal series with small bowel observe-via shows no
proximal stricture or leak, however evaluation does not reach the cecum after 12 hours. A CT
experiment suggests a excessive-grade obstruction in the di - ANS-Meticulous intraoperative
exam of the small bowel
Correct.
When a cholecystoenteric fistula is known or encountered at operation, it's far crucial to
cautiously look at the entire small bowel at the time of surgery to make sure that any and all
stones are eliminated.
A 55-12 months-old lady with a records of biliary colic affords with a 24-hour records of nausea,
bilious emesis, and stomach distention. She has not passed flatus for 18 hours and has no
longer had a bowel movement in three days. She notes that she had forty eight hours of proper
top quadrant ache 1 week ago that resolved spontaneously. She has had no earlier stomach
surgeries and has no hernias on examination. An obstructive collection suggests moderate
diffuse dilation of the small bowel with out a clear transition factor. Which is the pleasant test or
maneuver to pursue to make clear the prognosis?
A. Computed tomography (CT) experiment of the abdomen and pelvis with PO and IV
assessment
B. Right higher quadrant ultrasound
C. Upper gastrointestinal series with small bowel comply with-through
D. Magnetic resonance enterography - ANS-Computed tomography (CT) experiment of the
abdomen and pelvis with PO and IV comparison
Correct.
Although it's miles viable to diagnose gallstone ileus with simple films, a CT test is required to
outline the character of the cholecystoenteric fistula and is useful for operative planning. IV
comparison is useful in comparing for ischemic bowel, and oral evaluation can also enhance
visualization of the cholecystoenteric fistula. An upper gastrointestinal collection with small
bowel follow-via will probable now not reach the distal ileum in a affected person with a
high-grade obstruction. Magnetic resonance enterography can define enteric fistulas but would
now not be the take a look at of desire on this acutely ill affected person.
, A sixty four-year-vintage male is TPN-established 2-weeks popularity publish bowel resection
for perforated duodenal ulcer. He develops right top quadrant pain, and stomach ultrasound
shows acute acalculous cholecystitis. Which are accurate hazard elements for the improvement
of acalculous cholecystitis?
A. Critical illness, parenteral vitamins, sustained narcotic remedy, and trauma
B. Parenteral nutrients, history of cholelithiasis, burns, and trauma
C. Critical contamination, history of biliary colic, sepsis, and sustained narcotic remedy
D. Previous cholecystectomy, recent surgical treatment, sepsis, and parenteral vitamins
E. Critical infection, known cholelithiasis, parenteral nutrition, and trauma - ANS-Critical illness,
parenteral nutrition, sustained narcotic therapy, and trauma
Correct.
Acute acalculous cholecystitis is an extraordinary situation, typically visible in patients who are
hospitalized and seriously sick. It has been pronounced in zero.7-zero.9% of patients following
open abdominal aortic reconstruction, in 0.5% of sufferers following cardiac surgical procedure,
and in as many as 4% popularity publish bone marrow transplantation. Risk elements include:
essential infection, trauma, surgical treatment, sepsis/hypotension, and overall parenteral
nutrition (TPN). Predisposing factors include gallbladder ischemia (in sufferers with shock or
trauma) and biliary stasis (in prolonged fasting, hyperalimentation, and sustained narcotic
therapy).
History or regarded cholelithiasis, history of biliary colic, and former cholecystectomy aren't
known threat factors for improvement of acalculous cholecystitis.
A 65-yr-antique man with a history of cholecystitis previously managed by percutaneous
cholecystostomy (three years ago), coronary artery sickness status put up drug-eluting stent
placement (maximum these days 2 years in the past), persistent obstructive pulmonary ailment,
and dyslipidemia gives with a excessive-grade small bowel obstruction. Nonoperative
management by using nasogastric decompression is unsuccessful, and the affected person is
taken to the running room for exploration. A firm, stonelike, cell intraluminal mass is palpated in
the distal ileum, 10 cm proximal to the ileocecal valve. The bowel seems mildly dilated and well
perfused. What is the precise subsequent maneuver?
A. Small bowel resection and stapled facet-to-side useful cease-to-end anastomosis with 5-cm
margin
B. Enterotomy with elimination of the stone and transverse -layered closure
C. Small bowel resection with handsewn anastomosis and cholecystectomy
D. Diverting loop ileostomy - ANS-Enterotomy with removal of the stone and transverse -layered
closure
Correct.
Simultaneous cholecystectomy and cholecystoduodenal fistula closure are reserved for
low-threat patients, because they bring about a doubling of the mortality risk and expanded
morbidity in patients with gallstone ileus.
A 68-year-vintage man with a history of chronic pancreatitis affords with painless jaundice,
weight loss, fatigue, and back pain. A right upper quadrant ultrasound demonstrates intrahepatic
