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Exam- Biliary ABSITE Questions and Answers
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Exam- Biliary ABSITE Questions and AnswersA 44-year-old woman with a body mass index of 38 presents to the emergency department
with fever, nausea, vomiting, and right upper quadrant pain. A right upper quadrant
ultrasound shows an obstructing cystic duct stone and a normal-appearing common bile duct.
You undertake a laparoscopic cholecystectomy but the case is difficult, requiring conversion to
an open approach due to severe chronic inflammation and fibrosis in the hepatocystic triangle
and porta hepatis. You unintentionally enter the duodenum during your dissection and close
it in two layers. It appeared to be in continuity with the gallbladder, which is then removed.
Four days later the nasogastric tube output is persistently elevated. An aqueous contrast
upper gastrointestinal series with small bowel follow-through shows no proximal stricture or
leak, but contrast does not reach the cecum after 12 hours. A CT scan shows a high-grade
obstruction in the di Correct Answer-Meticulous intraoperative examination of the small
bowel
Correct.
When a cholecystoenteric fistula is known or encountered at operation, it is important to
carefully examine the entire small bowel at the time of surgery to ensure that any and all
stones are removed.
Reproduction of biliary colic with which of the following tests best identifies patients likely to
benefit from transduodenal sphincteroplasty?
, Exam- Biliary ABSITE Questions and Answers
A. Secretin stimulation test
B. Morphine-neostigmine (Nardi) test
C. Glucagon stimulation test
D. Cholecystokinin (CCK) test
E. Corticotropin stimulation test Correct Answer-Morphine-neostigmine (Nardi) test
Correct.
Reproduction of pain with morphine (resulting in sphincter contraction) and neostigmine
(resulting in biliary contraction) has been historically used to identify patients with sphincter
of Oddi dysfunction that would benefit from transduodenal sphincterectomy.
A 68-year-old man with a history of chronic pancreatitis presents with painless jaundice,
weight loss, fatigue, and back pain. A right upper quadrant ultrasound demonstrates
intrahepatic ductal dilation without any hepatic masses. A pancreas protocol CT scan shows
mild scattered calcifications in the pancreas and dilated biliary ducts but no definite mass. The
next best step is:
A. Diagnostic laparoscopy followed by Whipple procedure
B. ERCP with endoscopic ultrasound
, Exam- Biliary ABSITE Questions and Answers
C. Whole body PET scan
D. Repeat pancreas protocol CT scan in 3 months
E. HIDA scan Correct Answer-ERCP with endoscopic ultrasound
Correct.
While the patient's history is suggestive of an obstructing periampullary neoplasm or possibly
a pancreatic duct stricture, no definitive diagnosis has been made. ERCP permits identification
and biopsy of periampullary tumors and will further define ductal anatomy. In this setting,
EUS with FNA has a sensitivity of about 90% for pancreatic cancer. Choice A is not indicated
because no definite mass is seen. Choice C is not indicated because it is not sensitive or
specific for periampullary neoplasm, and no definitive diagnosis has been made yet. Choice D
is incorrect because this scenario requires further diagnostic workup. Choice E is not indicated
because it does not establish a diagnosis in this scenario, and at best would demonstrate
biliary obstruction, which is already evident from the patient's jaundice and intrahepatic
ductal dilation.
The incidence of recurrent pancreatitis or other gallstone-related complications during the 6-
week period following an episode of gallstone pancreatitis in patients who do not undergo
cholecystectomy is:
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