Hepatobiliary and Pancreatic Surgery

A 52-year-old woman with a history of symptomatic gallstones undergoes an elective laparoscopic cholecystectomy. The surgery is uneventful, and she is discharged the next day. However, three days later, she presents to the emergency department with worsening right upper quadrant pain, nausea, and low-grade fever. On examination, she has mild tenderness in the right upper quadrant, but no signs of peritonitis. Laboratory investigations reveal leukocytosis and mildly elevated liver enzymes. A right upper quadrant ultrasound shows a small perihepatic fluid collection, and an MRCP confirms a bile leak from the cystic duct stump. An ERCP is performed, and the leak is visualized.
What is the most appropriate next step in management?

A 45-year-old man with a history of alcohol abuse was admitted 6 weeks ago for an episode of acute alcoholic pancreatitis. He was managed conservatively and has since made gradual clinical improvement. At a 6-week follow-up, he complains of persistent, vague upper abdominal fullness. On examination, there is diffuse mild epigastric tenderness, and a soft mass is palpable in the upper abdomen. Laboratory studies show a mildly elevated serum amylase. A contrast-enhanced CT scan of the abdomen reveals a well-circumscribed, homogeneous fluid collection located in the lesser sac, posterior to the stomach.
What is the most likely explanation for this patient’s findings?

A 63-year-old man with a history of gallstones is admitted to the intensive therapy unit (ITU) with a severe episode of gallstone pancreatitis. His condition rapidly deteriorates, and he develops acute respiratory distress syndrome (ARDS), necessitating ventilatory support. Over the past several days, his clinical status has worsened, with persistent high fevers, escalating inflammatory markers (CRP 400, WCC 25.1), and hemodynamic instability. A repeat CT scan of the abdomen reveals a significant area of pancreatic necrosis. Fluid aspirated from the necrotic area grows a gram-negative bacillus, confirming infection. Although percutaneous drainage was attempted, the patient’s clinical condition has not improved.
What is the best course of action for this patient?

During an elective cholecystectomy for cholecystitis secondary to gallstones, the surgeon encounters significant inflammation and scarring, which obscure Calot’s triangle. In the midst of this difficult dissection, the distal aspect of the bile duct is inadvertently transected. Recognizing the gravity of the situation, the surgeon must decide on the safest and most effective management strategy. The available options are:

A 43-year-old woman with a history of gallstones and type 2 diabetes mellitus presents to the emergency department with a 24-hour history of progressively worsening right upper quadrant pain, fever, and chills. She reports nausea and two episodes of vomiting. Her family states that she appeared confused earlier in the day. On examination, she is febrile (38.9°C), hypotensive (BP 90/60 mmHg), and tachycardic (HR 118 bpm). She has scleral icterus and is visibly jaundiced. Abdominal examination reveals significant tenderness in the right upper quadrant with guarding, and Murphy’s sign is negative. Laboratory tests show leukocytosis (WBC 17,000/mm³), elevated total bilirubin (5.2 mg/dL), alkaline phosphatase (480 U/L), and markedly raised gamma-glutamyl transferase (GGT). Abdominal ultrasound reveals a dilated common bile duct with echogenic debris but no gallbladder wall thickening or pericholecystic fluid. What is the most likely diagnosis?

A 73-year-old woman undergoes a laparotomy for small bowel obstruction, where a gallstone ileus is identified. Intraoperatively, the gallbladder is found to be densely adherent to the duodenum. What is the correct course of action?

A 41-year-old woman presents to the emergency department with a 12-hour history of intermittent, colicky right upper quadrant pain radiating to her back. She reports nausea but denies vomiting or fever. Her past medical history is significant for mild gastroesophageal reflux disease, but she has no history of liver disease or previous abdominal surgeries. On examination, her vital signs are stable, and she is afebrile. Abdominal examination reveals mild tenderness in the right upper quadrant, but there is no guarding or rebound tenderness. Murphy’s sign is negative.
An abdominal ultrasound shows multiple gallstones within the gallbladder but no pericholecystic fluid or gallbladder wall thickening. The common bile duct measures 6 mm in diameter, and no stones are seen in the common bile duct.
What is the most appropriate initial course of action?

A 40-year-old woman presents with a 24-hour history of worsening right upper quadrant pain. She has a history of repeated episodes of similar colicky pain in the past. On examination, she is febrile and has localized peritonism in the right upper quadrant. Laboratory tests reveal leukocytosis with a white cell count of 23 × 10⁹/L, but her liver function tests are within normal limits. An abdominal ultrasound shows multiple gallstones within a thick-walled gallbladder, but the common bile duct measures 4 mm with no evidence of dilation or obstruction.
What is the best course of action?

A 45-year-old man presents with a history of intermittent right upper quadrant pain, which has worsened over the past 24 hours. On examination, he has mild tenderness in the right upper quadrant but no fever or signs of jaundice. An abdominal ultrasound confirms the presence of multiple gallstones in the gallbladder, but the common bile duct appears normal with no evidence of dilation.
What proportion of patients presenting for cholecystectomy for treatment of biliary colic due to gallstones will have stones in the common bile duct?

A 42-year-old woman presents with recurrent episodes of biliary colic. She undergoes an ultrasound, which confirms the presence of multiple gallstones in her gallbladder. During her medical history, she reports having undergone an ileal resection for Crohn’s disease several years ago.
Which of the following procedures is most likely to increase the risk of gallstone formation?

A 48-year-old woman undergoes a laparoscopic cholecystectomy for biliary colic due to gallstones. The surgery is complicated by a large stone impacted in Hartmann’s pouch, making the procedure technically challenging. Postoperatively, the patient develops jaundice, and bile is observed draining from a surgical drain
What is the best course of action?

A 58-year-old woman with a history of alcohol use disorder is admitted to the hospital after presenting with severe epigastric pain, vomiting, and fever. Her laboratory results reveal elevated amylase and lipase levels, and a CT scan confirms the diagnosis of acute pancreatitis. She is managed in the intensive care unit (ICU), where she remains intubated and receives aggressive fluid resuscitation. Initially, she makes progress, but after 10 days, her clinical condition worsens with increasing abdominal distension, fever, and worsening leukocytosis. A follow-up CT scan reveals that over 40% of her pancreas is necrotic, with areas of fluid collection. Given the high concern for infection of the necrotic pancreatic tissue, what is the most appropriate course of action?

A 34-year-old woman undergoes an elective cholecystectomy after repeated attacks of cholecystitis, which are attributed to gallstones. The surgery is uneventful, and the gallbladder is sent for microscopic examination. What is the most likely finding on histopathological analysis of the gallbladder?

A 22-year-old man returns to the UK after a three-week trip to India. He presents with painless jaundice, fatigue, and mild nausea. On examination, he is mildly icteric but does not have hepatosplenomegaly or right upper quadrant tenderness. His liver function tests show elevated bilirubin and transaminases, with normal alkaline phosphatase levels. What is the most likely cause of his condition?

A 45-year-old man presents to the emergency department with severe epigastric pain radiating to the back, nausea, and vomiting. His symptoms started suddenly a few hours ago. On examination, he has epigastric tenderness and mild tachycardia. The physician suspects acute pancreatitis and orders laboratory tests to confirm the diagnosis. Which of the following is the most sensitive blood test for diagnosing acute pancreatitis?

A 34-year-old woman is admitted with acute pancreatitis of moderate severity based on the Glasgow criteria. The etiology remains unclear, and imaging reveals no gallstones but shows fluid collection around the pancreas. She is hemodynamically stable with no signs of organ failure or infection. What is the most appropriate initial management option?

A 53-year-old man is referred for further evaluation after an ultrasound performed for suspected gallstone disease incidentally identifies a lesion in the left lobe of the liver. The ultrasound shows a large gallstone within a thin-walled gallbladder. Further imaging with MRI characterizes the liver lesion as a 6 cm hepatocellular adenoma. The patient is asymptomatic, with no history of liver disease, alcohol misuse, or significant medication use, including anabolic steroids or oral contraceptives. What is the most appropriate course of action?

A 43-year-old man with a history of chronic hepatitis B presents for routine follow-up. He has no significant symptoms, but recent blood tests show an increase in alpha-fetoprotein (AFP) levels. An abdominal ultrasound reveals a 2 cm lesion in segment V of the liver with no signs of vascular invasion. He has compensated liver function, with normal bilirubin and albumin levels and an INR of 1.1. The patient does not have any history of prior liver masses or extrahepatic malignancies. What is the most appropriate course of action?

A 23-year-old woman is admitted with right upper quadrant pain. On examination, she is tender in the right upper quadrant. Imaging confirms acute cholecystitis due to gallstones, but the common bile duct appears normal, and liver function tests are within normal limits. What is the most appropriate course of action?

A 34-year-old woman is admitted with cholangitis, presenting with jaundice and elevated bilirubin (180 µmol/L) and alkaline phosphatase (348 U/L). She becomes progressively unwell, developing abdominal pain, and laboratory investigations reveal an amylase level of 1080 U/L, indicating concurrent pancreatitis. Standard treatment is initiated, and her Glasgow score for acute pancreatitis is 3, suggesting moderate severity. What is the most appropriate course of action?

A 34-year-old woman is undergoing a laparoscopic cholecystectomy for acute cholecystitis. She has been unwell for the past 10 days, suggesting a prolonged inflammatory process. Upon attempting to dissect the gallbladder, the surgeon finds it distended and covered with dense adhesions, making visualization of Calot’s triangle difficult. Despite efforts, only the gallbladder fundus can be identified, and safe dissection is not possible. What is the best course of action?

A 53-year-old man with a history of chronic alcohol use is admitted with acute pancreatitis. His condition initially improves but remains complicated by persistent ileus, preventing oral intake. A contrast-enhanced CT scan is performed, revealing a large pancreatic pseudocyst. Over the next several weeks, serial imaging demonstrates no resolution of the pseudocyst, and the patient begins to experience worsening early satiety and mild epigastric discomfort. His vital signs remain stable, and there is no evidence of infection or systemic deterioration. Given his persistent symptoms and imaging findings, what is the best course of action?

A 56-year-old man with a long-standing history of alcohol misuse and a known diagnosis of cirrhosis presents to the emergency department with progressive jaundice, fatigue, and unintentional weight loss over the past two months. He reports a recent episode of upper right quadrant pain after a heavy drinking session. He has also been experiencing nausea and vomiting intermittently. His medical history includes chronic hepatitis C, and he has had multiple hospitalizations for alcohol-related liver disease in the past. On examination, the patient is visibly jaundiced, with scleral icterus and hepatomegaly. The abdomen is soft but tender in the right upper quadrant with no signs of peritonitis. Ultrasound imaging reveals multiple hyperechoic lesions in both lobes of the liver, with some lesions appearing larger than 2 cm in diameter. A contrast-enhanced CT scan confirms the presence of heterogeneous liver lesions. His laboratory results show an elevated serum alpha-fetoprotein (AFP) level of 800 ng/mL (normal range < 10 ng/mL). His liver function tests reveal elevated bilirubin (total: 5.2 mg/dL), aspartate aminotransferase (AST: 112 U/L), and alanine aminotransferase (ALT: 88 U/L). The patient’s international normalized ratio (INR) is 1.4. Given this patient’s history and findings, what is the most likely diagnosis?

A 42-year-old woman with a long history of hepatitis C and cirrhosis presents for routine follow-up. An ultrasound reveals a 2.5 cm lesion in the right lobe of the liver. Given her medical history and imaging findings, what is the most likely diagnosis?

A 32-year-old man with a long history of Crohn’s disease presents with episodes of intermittent jaundice. The jaundice is of an obstructive nature and typically resolves spontaneously. Given his history and clinical presentation, what is the most likely cause of his jaundice?

A 65-year-old man is admitted with cholangitis. Investigations reveal a carcinoma of the pancreatic head, and an ERCP is attempted to manage the obstructive jaundice. However, the surgeon is unable to cannulate the ampulla. Given this complication and the diagnosis of pancreatic cancer, what is the most appropriate next step in management?

An 82-year-old woman is taken to the operating room for common bile duct exploration due to a stone impacted at the distal aspect of the common bile duct. Despite the best efforts, the stone cannot be removed. The surgeon is now faced with the challenge of managing this difficult scenario. Given the patient’s age and the complexity of the procedure, what is the most appropriate next step in management?

A 43-year-old woman with a history of acute cholecystitis presents with symptoms that have failed to resolve despite conservative management. During a laparoscopic cholecystectomy, the surgeon identifies an empyema of the gallbladder, and Calot’s triangle is found to be severely inflamed. There is a suspicion that the patient may have developed Mirizzi syndrome, a condition in which a stone impacted in the cystic duct or gallbladder neck compresses the common bile duct, potentially causing obstruction and cholangitis. Given the difficult anatomy and the risk of bile duct injury, what is the most appropriate course of action?

A 43-year-old woman with a history of repeated episodes of abdominal pain presents with acute symptoms of small bowel obstruction. Imaging studies reveal dilated small bowel loops and an air-fluid level suggestive of bowel obstruction. During surgery, a gallstone ileus is identified. The gallstone has caused a mechanical obstruction in the small intestine, likely due to a fistula between the gallbladder and the duodenum, which allows the stone to pass into the bowel. The surgeon faces
the challenge of managing the obstruction and deciding the most appropriate surgical course. What is the best management approach for this patient?

A 43-year-old woman presents with a two-week history of progressively worsening jaundice, dark urine, and pale stools. She also reports vague epigastric discomfort but no significant weight loss or appetite changes. Imaging, including CT scan, reveals a mass in the head of the pancreas with associated biliary dilation. The staging investigations show no evidence of metastatic disease. Given the diagnosis of carcinoma of the head of the pancreas, the patient is deeply jaundiced and requires biliary decompression to relieve symptoms and optimize her for potential surgery. What is the most appropriate method of biliary decompression in this patient with resectable disease?

A 41-year-old woman presents to the hospital with a 3-day history of colicky right upper quadrant pain. She reports intermittent episodes of nausea and vomiting associated with the pain. On examination, she is mildly febrile and clinically jaundiced with a tender right upper quadrant. An abdominal ultrasound confirms the presence of gallstones in the gallbladder but does not show any dilation of the bile ducts. Due to the severity of her symptoms and the failed response to conservative management, she is taken to the operating room for an open cholecystectomy. However, during surgery, the surgeon notes that Calot’s triangle is nearly impossible to delineate due to extensive scarring and inflammation. What is the most likely underlying cause for this challenging surgical finding?

A 55-year-old man presents with a 2-day history of jaundice, fever (39°C), and chills. He has a past medical history of gallstones but has never required intervention. On examination, he is febrile, with a palpable right upper quadrant mass, and signs of systemic sepsis. Blood cultures reveal a gram-negative bacillus. Liver function tests show elevated bilirubin (total 4.8 mg/dL), alkaline phosphatase (AP 320 U/L), and transaminases. An abdominal ultrasound reveals a dilated bile duct measuring 1.2 cm in diameter. A subsequent CT scan confirms no evidence of gallbladder perforation or abscess formation. Given his clinical condition and the confirmed presence of a bacterial infection, what is the most appropriate treatment option?

A 43-year-old woman is admitted with a 48-hour history of severe upper abdominal pain, nausea, and vomiting. She has a history of intermittent right upper quadrant colicky pain and has been diagnosed with gallstones in the past, but she has not sought treatment. On examination, she is febrile (38.5°C), tachycardic, and exhibits tenderness in the right upper quadrant with guarding. Her laboratory results show an elevated white blood cell count (16,000/µL) and mild hyperbilirubinemia (total bilirubin 2.5 mg/dL). Serum amylase is elevated (500 IU/L). A CT scan of the abdomen confirms the diagnosis of acute pancreatitis with a peripancreatic fluid collection and identifies multiple gallstones in the gallbladder. The bile duct appears normal in calibre (6mm), and there is no evidence of choledocholithiasis. After 48 hours of supportive management with IV fluids, her pain subsides, and her vitals stabilize. However, she remains mildly jaundiced with ongoing mild epigastric discomfort. What is the most appropriate next step in her management?

A 34-year-old woman with no significant past medical history is admitted with jaundice and suspected biliary obstruction. She has a history of intermittent right upper quadrant pain, which has recently worsened. The decision is made to perform an ERCP to evaluate for any biliary ductal abnormalities. However, the procedure proves difficult due to a previously undiagnosed duodenal diverticulum, leading to multiple attempts at cannulating the bile duct. After the procedure, the patient is returned to the ward still jaundiced but otherwise stable. Several hours later, she develops sudden-onset, generalized severe abdominal pain, and her vital signs become unstable, with a temperature of 38.5°C. Laboratory tests show a rising white cell count and elevated serum amylase.
Given the patient’s presentation and the recent ERCP, what is the best course of action?

A 63-year-old man is admitted with obstructive jaundice that has developed progressively over the past 3 weeks. He was previously well, but on examination, a smooth mass is palpated in his right upper quadrant. What is the most likely underlying diagnosis?

A 72-year-old man with a history of distal gastrectomy for carcinoma of the stomach presents with jaundice 8 months postoperatively. His liver function tests indicate cholestasis. An abdominal ultrasound shows no focal liver lesions, a normal-caliber common bile duct, but dilatation of the intrahepatic bile ducts. Given these findings, what is the most likely cause of his jaundice?

A 22-year-old teacher presents with severe epigastric pain that has been progressively worsening over the past few hours. She denies any recent trauma or history of gallstones. On examination, she has localized tenderness in the epigastric region. Her serum amylase levels are within the normal range, and you are concerned about the possibility of a perforated viscus as well as pancreatitis. What is the most appropriate next step in managing this patient to rule out these conditions?