Hepatobiliary Surgery (Liver Tumors, Gall Bladder, Bile Duct, Pancreas) MCQs

Surgery · 188 free questions with answers & explanations.

A 55-year-old man with chronic HBV-related cirrhosis is found to have a 3 cm arterially enhancing hepatic lesion on contrast CT that shows washout in the portal venous phase. AFP is 450 ng/mL. The most likely diagnosis is:
A 60-year-old woman presents with painless progressive jaundice, weight loss, and a palpable non-tender gallbladder. CT confirms a mass in the head of the pancreas. The most appropriate surgical procedure with curative intent is:
A 45-year-old obese woman presents with right upper quadrant colic radiating to the right shoulder after fatty meals. Ultrasound reveals multiple gallstones but a normal common bile duct. The next best step in management is:
Klatskin tumour refers to cholangiocarcinoma arising at the:
A 55-year-old jaundiced man has a Bismuth-Corlette type IIIa hilar cholangiocarcinoma on MRCP. This classification indicates that the tumor involves:
Intraoperatively, a patient undergoing laparoscopic cholecystectomy is found to have the cystic artery arising directly from the right hepatic artery running in front of the common hepatic duct (caterpillar/Moynihan's hump variant). The single most important safety maneuver is:
A 62-year-old man undergoes Whipple's pancreaticoduodenectomy for carcinoma of the head of pancreas. On POD 3, drain amylase is 4800 U/L (>3× upper limit of serum amylase). He is clinically well with no fever or abdominal tenderness. This is classified as:
A 38-year-old woman has a 5 cm hepatic lesion found incidentally. MRI shows T1 hypointensity, T2 hyperintensity, and strong arterial enhancement with rapid washout. Serum AFP is 1200 ng/mL. She is on oral contraceptives and has no cirrhosis. The most likely diagnosis is:
Regarding the management of acalculous gallbladder disease in a critically ill ICU patient, which intervention is most appropriate if the patient is too unstable for general anaesthesia?
A 65-year-old woman with known gallstones develops progressive obstructive jaundice, a palpable non-tender gallbladder, and weight loss over 3 months. The most likely diagnosis and eponym for this clinical sign is:
Mirizzi syndrome occurs when a large gallstone impacts in the Hartmann's pouch or cystic duct, causing extrinsic compression of the common hepatic duct. Which classification system is used and what does Type II/III involve?
A 50-year-old patient develops post-ERCP pancreatitis. The most significant independent risk factor for this complication is:
In assessing resectability of pancreatic ductal adenocarcinoma of the head, which of the following findings on CT would define 'borderline resectable' status according to the AHPBA/SSAT/SSO consensus criteria?
Caroli's disease is a congenital non-obstructive dilatation of the intrahepatic bile ducts. The association of Caroli's disease with hepatic fibrosis and portal hypertension is called Caroli syndrome. The underlying genetic mutation most often implicated is in the gene encoding:
A 58-year-old man with hepatitis B-related cirrhosis (Child-Pugh A, MELD 10) has a 3.2 cm hepatocellular carcinoma on a background of cirrhosis. AFP is 280 ng/mL. CT shows arterial enhancement with washout (LI-RADS 5). He is being evaluated for treatment. According to the Barcelona Clinic Liver Cancer (BCLC) classification and current guidelines, which treatment offers the BEST chance of cure?
A 50-year-old woman undergoes laparoscopic cholecystectomy for gallstone disease. The frozen section of the gallbladder specimen shows incidental gallbladder carcinoma (GBC) with the following: adenocarcinoma invading into perimuscular connective tissue (pT2) without serosal involvement. Cystic duct margin is clear. The most appropriate further management is:
A 68-year-old man presents with progressive jaundice and CT showing a hilar biliary stricture. MRCP confirms a hilar cholangiocarcinoma with involvement of the left hepatic duct confluence extending to secondary radicals on the right. Left portal vein is occluded. Using Bismuth-Corlette classification, this is most accurately classified as:
A 65-year-old woman undergoes a Whipple procedure (pancreaticoduodenectomy) for a 2.8 cm pancreatic head adenocarcinoma. On postoperative day 4, the drain amylase level is 4,200 U/L (>3x upper limit of serum amylase). The patient is clinically stable with no fever and tolerating oral fluids. According to the International Study Group on Pancreatic Fistula (ISGPF) classification, this is:
A 55-year-old cirrhotic patient with hepatocellular carcinoma (HCC) has two lesions: one 4 cm in segment VI and one 2 cm in segment III. No vascular invasion is detected on MRI. He is Child-Pugh A with a MELD score of 10. According to Milan criteria, what is the most appropriate management?
The Bismuth-Corlette classification of hilar cholangiocarcinoma (Klatskin tumor) is used to guide surgical planning. Which type indicates involvement of the right and left hepatic ductal confluence with extension into both right and left secondary radicles?
Following a Whipple (pancreaticoduodenectomy) procedure, a patient on postoperative day 3 develops drain amylase >3× upper limit of normal with significant drain output. Which is the most important immediate management step according to ISGPF criteria for Grade B postoperative pancreatic fistula (POPF)?
In a patient with gallbladder carcinoma found incidentally after laparoscopic cholecystectomy (T2 lesion — tumor invades the perimuscular connective tissue), what is the recommended management?
A 55-year-old man with hepatitis B cirrhosis (Child-Pugh A) is found to have a 2.5 cm arterially enhancing liver lesion with portal venous washout on triphasic CT. No biopsy is performed. According to Barcelona Clinic Liver Cancer (BCLC) staging guidelines, this lesion is classified as BCLC stage A (early HCC). What is the preferred curative treatment option?
During laparoscopic cholecystectomy, the critical view of safety (CVS) is achieved when which two structures, and only those two structures, are seen entering the gallbladder?
A Whipple procedure (pancreaticoduodenectomy) specimen from a 60-year-old man shows pancreatic ductal adenocarcinoma with perineural invasion and R0 resection margins. Post-operatively, what is the current standard adjuvant chemotherapy regimen according to ESPAC-4 and APACT trials?
A patient with chronic calcific pancreatitis and a dilated main pancreatic duct (>7 mm) has intractable pain despite medical treatment. Which surgical procedure, by creating a side-to-side pancreaticojejunostomy, provides the best long-term pain relief?
A 60-year-old man with biliary stricture and progressive jaundice is found to have a perihilar cholangiocarcinoma (Klatskin tumor). MRI shows involvement of the right hepatic duct up to the secondary radicles and left hepatic duct, with compression of the right portal vein. This corresponds to which Bismuth-Corlette classification?
A 55-year-old patient is found to have a 3-cm pancreatic head mass with bile duct and pancreatic duct dilation (double duct sign) on MRCP. CA 19-9 is 1200 U/mL. CT staging shows no vascular involvement and no distant metastases. What is the next best step?
The Child-Pugh score assesses liver functional reserve. Which variable is NOT included in the Child-Pugh scoring system?
A patient develops post-ERCP pancreatitis. Serum amylase measured 24 hours post-ERCP is 1400 U/L, and the patient has severe epigastric pain requiring hospital admission. Which scoring system best predicts the severity of acute pancreatitis at 48 hours of admission?
In the Bismuth-Corlette classification of hilar cholangiocarcinoma (Klatskin tumor), a type IIIb lesion extends into which specific ductal system?
In the management of colorectal liver metastases (CRLM), the 'two-stage hepatectomy' with portal vein embolization (PVE) is used when future liver remnant (FLR) is insufficient. What is the MINIMUM acceptable FLR volume as a percentage of total functional liver volume to safely proceed with major hepatectomy in a previously healthy liver?
Pancreatic ductal adenocarcinoma (PDAC) is classified as 'borderline resectable' (BR-A) by NCCN criteria. Which of the following features qualifies a tumor as BR-A?
A 58-year-old presents with obstructive jaundice and a dilated common bile duct. CT shows a low-density mass in the head of the pancreas. During Whipple's procedure (pancreaticoduodenectomy), what is the most critical anastomosis for post-operative morbidity, and what technique reduces the risk of post-operative pancreatic fistula (POPF)?
A patient with Child-Pugh A cirrhosis has a 4.5 cm single hepatocellular carcinoma (HCC) within the Milan criteria. ECOG performance status is 0. Locoregional therapies are available. According to BCLC (Barcelona Clinic Liver Cancer) 2022 staging update, what is the first-line curative-intent treatment if liver transplantation waiting time exceeds 6 months?
A 60-year-old woman with incidental gallbladder carcinoma found on cholecystectomy specimen has T2a disease (involvement of peritoneal side without hepatic involvement). The cystic duct margin is negative. According to NCCN guidelines, what additional surgery is required?
During Whipple's pancreaticoduodenectomy for a periampullary carcinoma, the surgeon encounters a replaced right hepatic artery arising from the superior mesenteric artery (SMA) running posterior to the portal vein. What is the most significant intraoperative implication of this anatomical variant?
A 55-year-old man presents with painless progressive jaundice, weight loss, and a positive Courvoisier's sign. ERCP shows a short stricture at the lower end of the common bile duct. CA 19-9 is 840 U/mL. CT shows a 3.2 cm head-of-pancreas mass with portal vein abutment (< 180° contact, no distortion). According to borderline resectability criteria (AHPBA/NCCN), what is the standard management?
A 65-year-old patient with hilar cholangiocarcinoma (Klatskin tumor) is staged as Bismuth-Corlette type IIIa. This implies the tumor involves:
A 60-year-old man undergoes Whipple's procedure (pancreaticoduodenectomy) for pancreatic head adenocarcinoma. On postoperative day 4, drain amylase is measured at 3,200 U/L with a drain output of 400 mL/day. According to ISGPS 2016 definition, this represents:
A patient with primary sclerosing cholangitis (PSC) and ulcerative colitis develops a dominant stricture in the bile duct. Which feature on cholangiography MOST strongly suggests transition from PSC to cholangiocarcinoma rather than benign inflammatory stricture?
A 55-year-old patient with pancreatic head cancer is being evaluated for resectability. CT shows the tumor abuts the superior mesenteric artery (SMA) over 170 degrees of circumference with no fat plane. According to NCCN/AHPBA 2017 consensus, this is classified as:
A 55-year-old man with Child-Pugh A cirrhosis (HBV-related) presents with a single 4.5 cm hepatocellular carcinoma on background cirrhosis. BCLC staging places him at Stage B. He has ECOG performance status 0. According to current BCLC 2022 guidelines, the preferred treatment is:
A 70-year-old woman presents with progressive painless jaundice and a CT scan showing a dilated CBD, bile ducts, and a pancreatic mass at the head of pancreas. CA 19-9 is 850 U/mL. CT shows the SMA and SMV appear clear of tumour involvement with no involvement of the portal vein. The superior mesenteric artery contact is <180°. According to NCCN resectability criteria, this tumour is classified as:
A 50-year-old woman presents with right hypochondrial pain and fever. MRCP shows a dilated CBD with a filling defect at the mid-CBD and two intrahepatic ductal stones. She has Mirizzi syndrome Type II on imaging. The defining feature of Mirizzi syndrome Type II compared to Type I is:
Following pancreaticoduodenectomy (Whipple's procedure), the patient develops post-pancreatectomy haemorrhage on day 7, preceded by a 'sentinel bleed' and elevated drain amylase. CT shows a pseudoaneurysm of the right hepatic artery. This complication is classified as Grade C post-pancreatectomy haemorrhage by the ISGPS definition. The best initial management is:
An incidental cystic pancreatic lesion is found on CT in a 58-year-old asymptomatic man — a unilocular 22 mm cyst in the body of the pancreas with no solid component or main duct dilation. MRI/MRCP confirms a branch duct intraductal papillary mucinous neoplasm (BD-IPMN). According to Fukuoka 2017 guidelines, the most appropriate management is:
A 58-year-old man with chronic HCV cirrhosis (Child-Pugh A, MELD 9) is found to have a 2.5 cm arterially enhancing hepatic lesion with washout on portal-venous phase and capsule appearance on MRI. Per LI-RADS v2018, this lesion is classified as LR-5 (hepatocellular carcinoma). The Barcelona Clinic Liver Cancer (BCLC) stage is 0 (very early) for lesions <2 cm and A for solitary 2–5 cm. First-line curative treatment for this BCLC Stage A patient with preserved liver function is:
During laparoscopic cholecystectomy, the critical view of safety (CVS) — as described by Strasberg — requires dissection of the hepatocystic triangle to clearly identify two structures entering the gallbladder. These two structures are:
A Whipple's procedure (pancreaticoduodenectomy) is performed for a 2 cm ductal adenocarcinoma of the pancreatic head. The International Study Group on Pancreatic Fistula (ISGPF/ISGPS) defines a clinically relevant postoperative pancreatic fistula (CR-POPF) as Grade B or C. Grade C POPF is specifically defined as fistula requiring:
In the Bismuth-Corlette classification of hilar cholangiocarcinoma (Klatskin tumor), a Type IV lesion involves:
A 58-year-old man with HCV cirrhosis (Child-Pugh A, MELD 8) is found to have a 2.8 cm arterially enhancing, washout-positive hepatic lesion on dynamic MRI. AFP is 120 ng/mL. The Barcelona Clinic Liver Cancer (BCLC) stage is 0/A. He has adequate liver remnant. What is the first-line recommended treatment?
A 65-year-old woman is found on CT to have a 4 cm pancreatic head mass with duct-of-Wirsung dilatation. EUS-FNA confirms pancreatic ductal adenocarcinoma. CT criteria show tumor abutting the superior mesenteric artery (SMA) over 150° circumferentially and 2 cm involvement of the hepatic artery. Per NCCN criteria, this tumor is classified as:
Post-Whipple procedure on day 5, a patient develops an amylase-rich drain output of 4,500 U/L (>3× upper limit of serum amylase) from the abdominal drain. He is afebrile and tolerating oral diet. Per ISGPF (International Study Group on Pancreatic Fistula) classification, this is:
Which feature of a gallbladder polyp on ultrasound most reliably predicts malignancy and mandates cholecystectomy regardless of size?
A 55-year-old patient with primary sclerosing cholangitis (PSC) develops a dominant stricture of the proximal bile duct. MRI/MRCP shows a 3 cm hilar mass. Staging reveals no distant metastasis. The lesion is classified as Bismuth-Corlette type IIIa. What defines this classification?
During laparoscopic cholecystectomy, the 'critical view of safety' (CVS) is not achieved due to excessive inflammation. Which technique is recommended to minimize bile duct injury in this scenario?
A 62-year-old patient has a 3 cm pancreatic head adenocarcinoma with portal vein involvement over a 1.5 cm segment without occlusion. CA 19-9 is 420 U/mL. CT shows no distant metastasis. How is this tumor classified per NCCN 2024 borderline resectability criteria?
Post-pancreaticoduodenectomy, a patient develops a post-operative pancreatic fistula (POPF). Drain amylase on day 3 is 4500 U/L (>3x upper limit). The patient is well with no fever or peritonitis. According to the International Study Group of Pancreatic Surgery (ISGPS) classification, what grade is this POPF?
A 65-year-old man with resectable pancreatic head adenocarcinoma undergoes pancreaticoduodenectomy (Whipple's procedure). On day 4 post-operatively, his drain amylase is 8,500 IU/L with clinically significant drainage and he requires radiological drainage. According to the ISGPS 2016 classification, this is categorised as:
A 55-year-old woman with Klatskin tumour (Bismuth-Corlette type IIIa) has a right portal vein occluded on CT angiography. The future liver remnant (FLR) is estimated at 22%. Which of the following sequential manoeuvres best maximises resectability?
A 50-year-old male incidentally found to have a 35 mm main-duct intraductal papillary mucinous neoplasm (MD-IPMN) of the pancreatic body on CT. He is asymptomatic with no obstructive jaundice. On MRI, main pancreatic duct diameter is 12 mm. According to the 2017 International Fukuoka Guidelines, which of the following represents a 'high-risk stigmata' mandating surgical resection?
A 40-year-old woman presents with recurrent right upper quadrant pain, jaundice, and cholangitis. MRCP reveals multiple intrahepatic biliary strictures with saccular dilatations and a normal extrahepatic duct. Which classification system best describes the pattern of her disease and guides surgical planning?
A 55-year-old woman without cirrhosis is found to have a 5 cm hepatic lesion showing arterial hyperenhancement with venous washout on CT. Serum AFP is 1200 ng/mL. She is Child-Pugh A and ECOG 0. What is the preferred curative treatment?
Bismuth-Corlette classification of Klatskin tumors: which type is NOT resectable with curative intent using standard hepatic resection alone?
A 68-year-old man undergoes Whipple's procedure (pancreaticoduodenectomy) for pancreatic head carcinoma. On postoperative day 3, drain amylase is 4500 U/L (>3× upper limit of normal serum amylase). He is clinically stable with no fever. According to ISGPS criteria, this is classified as:
A 72-year-old woman has an incidentally found 3.5 cm main duct intraductal papillary mucinous neoplasm (MD-IPMN) of the pancreatic head with main duct diameter 12 mm. What is the recommended management?
In the Bismuth-Corlette classification of hilar cholangiocarcinoma (Klatskin tumour), which type is considered unresectable on the basis of biliary involvement alone?
A 65-year-old patient with jaundice undergoes ERCP showing a distal CBD stricture. CA 19-9 is 520 U/mL and CT shows a hypoechoic pancreatic head mass with superior mesenteric vein (SMV) contact >180°. According to NCCN/ISGPS borderline resectable criteria, the next best step is:
After pancreaticoduodenectomy, the most significant determinant of anastomotic leak leading to post-pancreatectomy haemorrhage is failure of which anastomosis?
In gallbladder carcinoma, T2 disease (tumour invading perimuscular connective tissue, not beyond serosa) found incidentally after laparoscopic cholecystectomy — what is the recommended surgical management?
In Klatskin tumor (hilar cholangiocarcinoma), the Bismuth-Corlette classification type IIIb indicates involvement up to which level?
The ESPAC-4 trial changed the standard of care for resected pancreatic ductal adenocarcinoma. What adjuvant regimen did it establish?
A 60-year-old patient presents with painless jaundice. ERCP shows a stricture at the lower end of the common bile duct with pancreatic duct dilation (double duct sign). CA 19-9 is 3200 U/mL. CT shows a 3 cm pancreatic head mass without vascular involvement. What is the most appropriate initial management?
In a patient who underwent laparoscopic cholecystectomy, bile leakage is noted postoperatively. ERCP shows a Strasberg E2 bile duct injury. Which structure has been transected?
A 60-year-old woman presents with painless progressive jaundice, weight loss, and a palpable, non-tender gallbladder (Courvoisier's sign). CA 19-9 is 450 U/mL. CT shows a mass at the head of the pancreas with no vascular involvement and no distant metastases. What is the standard surgical procedure?
A 38-year-old woman with known gallstones presents with severe epigastric pain radiating to the back, vomiting, and a serum lipase of 1800 U/L (normal <60). On day 3 of admission, CT scan shows a Balthazar grade E finding with 50% pancreatic necrosis. Which intervention is indicated at this point?
A 55-year-old man with a 5 cm hepatocellular carcinoma in segments VI/VII on a background of Child-Pugh A cirrhosis is referred for treatment. AFP is 320 ng/mL. He has a single lesion with no vascular invasion and no extrahepatic disease. The future liver remnant after resection is estimated at 38%. The preferred treatment is:
A 50-year-old man presents with obstructive jaundice. MRCP shows a stricture at the confluence of the left and right hepatic ducts extending into both. This is classified as Bismuth-Corlette type:
An intraoperative cholangiogram during laparoscopic cholecystectomy reveals a filling defect in the common bile duct (CBD). The CBD diameter is 10 mm. What is the most appropriate next step?
A 65-year-old man with known chronic hepatitis C cirrhosis (Child-Pugh A) presents with a 4.2 cm arterially enhancing hepatic lesion with washout on portal venous phase CT. AFP is 850 ng/mL. Staging is within Milan criteria. What is the MOST appropriate treatment with curative intent?
A 55-year-old woman undergoes laparoscopic cholecystectomy for gallstones. Intraoperative cholangiogram reveals a clip inadvertently placed across the common bile duct with complete transection. She is haemodynamically stable. The surgeon is proficient but has no hepatobiliary specialist immediately available. What is the BEST immediate action?
Bismuth-Corlette classification is used to characterise hilar cholangiocarcinoma (Klatskin tumour). A tumour involving the right main hepatic duct and extending into the right anterior and right posterior sectoral ducts, with the left hepatic duct uninvolved, is classified as:
A 70-year-old man presents with painless progressive jaundice, pale stools, and dark urine. CT shows a 2.8 cm hypodense mass in the head of the pancreas with bile duct and pancreatic duct dilatation ('double duct sign'). CA 19-9 is markedly elevated. There is no vascular involvement and no distant metastases. What is the standard surgical procedure?
A 40-year-old woman is found to have a 3 cm branch-duct intraductal papillary mucinous neoplasm (BD-IPMN) of the pancreatic body incidentally on CT. It has no 'worrisome features' or 'high-risk stigmata' on imaging. According to the 2023 European guidelines (European Study Group on Cystic Tumours of the Pancreas), what is the recommended management?
A 55-year-old woman with a history of primary sclerosing cholangitis (PSC) presents with progressive jaundice and weight loss. MRI shows a 3 cm hilar mass with biliary obstruction. Which serum marker is most useful (though not perfectly specific) for diagnosis of cholangiocarcinoma in this context?
The Bismuth-Corlette classification of hilar cholangiocarcinoma (Klatskin tumour) is used to plan resection. A type IIIb tumour extends into:
A 68-year-old man undergoes staging CT for pancreatic head adenocarcinoma. The report notes tumour contact with the superior mesenteric artery (SMA) spanning 200°, contact with the superior mesenteric vein (SMV) with deformity but preserved contour, and no distant metastases. Per NCCN 2024 guidelines, this is classified as:
The Child-Pugh score is used to assess hepatic functional reserve before hepatic resection. A patient with hepatic cirrhosis has bilirubin 2.8 mg/dL, albumin 2.7 g/dL, PT prolongation of 6 seconds, grade II encephalopathy, and moderate ascites. Computing the score: bilirubin 2.8 = 2 pts, albumin 2.7 = 3 pts, PT +6 sec = 3 pts, encephalopathy grade 2 = 2 pts, moderate ascites = 2 pts — total = 12 points. What is the Child-Pugh class and operability?
Mirizzi syndrome involves extrinsic compression of the common hepatic duct (CHD) by a stone impacted in the cystic duct or Hartmann's pouch. The McSherry (Csendes) classification defines Type II as:
A 35-year-old woman presents with a 7 cm liver lesion. MRI shows a large central stellate scar with radiating fibrous septa, lobulated borders, and arterial enhancement with washout on venous phase. Serum AFP is normal. Oral contraceptive use for 10 years. Which lesion best fits this description and what is the appropriate management?
A 58-year-old man with hepatocellular carcinoma (HCC) has a single tumor of 4 cm within the right hepatic lobe with no vascular invasion, no extrahepatic spread, and Child-Pugh A cirrhosis. ECOG performance status is 0. According to the Barcelona Clinic Liver Cancer (BCLC) staging system, what is the stage and optimal treatment?
A 62-year-old man is diagnosed with cholangiocarcinoma involving the bifurcation of the hepatic ducts extending into both the right and left hepatic ducts. According to the Bismuth-Corlette classification, what is the type?
A 70-year-old woman undergoes Whipple's procedure (pancreaticoduodenectomy) for pancreatic head adenocarcinoma. On postoperative day 4, she develops nausea, vomiting, and a nasogastric tube output of >1.5L/day with an otherwise non-tender abdomen and no fever. Amylase-rich fluid is not noted. What is the most likely complication?
A 48-year-old woman undergoes laparoscopic cholecystectomy. Intraoperatively, the surgeon inadvertently transects the common hepatic duct. After recognizing the injury, what is the most appropriate management?
A 65-year-old woman with primary sclerosing cholangitis (PSC) develops progressive jaundice and weight loss. MRCP shows multifocal biliary strictures. Brush cytology from ERCP confirms cholangiocarcinoma. She has no distant metastasis. Which staging approach is used and what novel treatment option (Mayo Clinic protocol) may be considered?
A 50-year-old man has a 2.5 cm pancreatic cystic lesion incidentally found on CT. MRCP shows it communicates with the main pancreatic duct. EUS-FNA cytology shows mucinous content. This is consistent with a main duct IPMN (intraductal papillary mucinous neoplasm). What is the recommended management?
The Bismuth-Corlette classification of hilar cholangiocarcinoma (Klatskin tumor) — Type IV is defined as:
Portal vein embolization (PVE) is performed preoperatively in patients with hepatocellular carcinoma scheduled for major hepatectomy when the estimated future liver remnant (FLR) is below which threshold in a patient with underlying cirrhosis?
The CONKO-001 trial established the benefit of which adjuvant treatment in resected pancreatic ductal adenocarcinoma?
A patient undergoes laparoscopic cholecystectomy. The bile duct is injured and a segment of 1.5 cm of the common bile duct is excised. According to the Strasberg classification, this injury is classified as:
Regarding post-Whipple pancreaticoduodenectomy, the most common and significant cause of postoperative morbidity and mortality is:
A 55-year-old woman with primary sclerosing cholangitis (PSC) develops obstructive jaundice. CA 19-9 is 450 U/mL. MRI/MRCP shows a dominant stricture at the hilum with satellite lesions. Brushing cytology is reported as atypical. What is the most reliable diagnostic investigation to establish cholangiocarcinoma?
A 62-year-old male patient undergoes pancreaticoduodenectomy (Whipple procedure) for pancreatic head carcinoma. On postoperative day 3, drain amylase is 8400 U/L (>3× upper limit of serum amylase). He is hemodynamically stable with no clinical peritonism. According to the ISGPF classification, what grade of postoperative pancreatic fistula (POPF) does this represent?
A 70-year-old man is found to have a 3 cm main pancreatic duct (MPD)-type intraductal papillary mucinous neoplasm (IPMN) with MPD dilation of 12 mm. According to the revised Fukuoka guidelines (Gut 2017), this finding warrants:
The Bismuth-Corlette classification of hilar cholangiocarcinoma (Klatskin tumor) defines Type IIIa as:
According to the Barcelona Clinic Liver Cancer (BCLC) classification, a patient with a single hepatocellular carcinoma nodule of 4 cm in diameter, preserved liver function (Child-Pugh A), no portal hypertension, and good performance status (ECOG 0) is classified as:
The Milan criteria for liver transplantation in hepatocellular carcinoma specify tumour characteristics as:
A 60-year-old man presents with painless obstructive jaundice. CECT shows a periampullary tumour. Serum CA 19-9 is 850 U/mL. He is found to have blood group O. The CA 19-9 result must be interpreted with caution because:
The Bismuth-Corlette classification is used to describe the extent of hilar cholangiocarcinoma (Klatskin tumour). Type IV involvement means:
During laparoscopic cholecystectomy, the critical view of safety (CVS) requires dissection of Calot's triangle to expose two specific structures. These two structures are:
A 55-year-old man with alcoholic cirrhosis (Child-Pugh A) has a 3 cm solitary hepatocellular carcinoma on MRI showing arterial enhancement with portal-phase washout. No vascular invasion or extrahepatic spread. He is BCLC stage A. According to BCLC guidelines, the first-line treatment options include:
A 62-year-old woman presents with progressive jaundice, weight loss, and a Courvoisier's sign. CT scan shows a 3 cm mass at the head of pancreas with dilated CBD and pancreatic duct. CA 19-9 is 850 U/mL. CT shows no vascular encasement or distant metastasis. She is deemed borderline resectable. The MOST appropriate neoadjuvant approach is:
The Bismuth-Corlette classification of hilar cholangiocarcinoma (Klatskin tumour) is used for surgical planning. A type III b lesion involves:
Gallbladder carcinoma incidentally found on histology after laparoscopic cholecystectomy is staged T1b (muscle layer invasion, not beyond). The correct management is:
Mirizzi syndrome type II (McSherry classification) is characterized by which finding?
A 55-year-old male presents with painless jaundice, weight loss, and a palpable gallbladder. CT shows a mass at the pancreatic head with dilation of the main pancreatic duct and common bile duct (double-duct sign). CA 19-9 is markedly elevated. According to current criteria, which of the following would make this tumor UNRESECTABLE?
The International Study Group on Pancreatic Fistula (ISGPF/ISGPS) grades postoperative pancreatic fistula (POPF) into three grades. A patient has a drain amylase >3× upper limit of normal on postoperative day 3, requires prolonged drainage only, and has no clinical consequences. This corresponds to which grade?
A 45-year-old woman presents with recurrent episodes of right upper quadrant pain and episodic jaundice. MRCP reveals multiple stones within the intrahepatic biliary radicles of the left lobe with left hepatic atrophy. This presentation is most consistent with:
A 65-year-old jaundiced patient has a hilar cholangiocarcinoma on MRCP. The Bismuth-Corlette classification is used for surgical planning. Which type is associated with the worst resectability and requires the most extensive surgery?
Todani classification of choledochal cysts guides surgical management. A Type I choledochal cyst in a child is best managed by:
The Balthazar CT severity index (CTSI) is used in acute pancreatitis. A patient has CT showing pancreatic necrosis involving 50% of the gland and a peripancreatic fluid collection. What is the CTSI score?
The Whipple procedure (pancreaticoduodenectomy) carries significant morbidity. Which of the following is the MOST common serious complication after pancreaticoduodenectomy?
A 55-year-old jaundiced patient has a hilar cholangiocarcinoma. MRI/MRCP shows bilateral hepatic duct involvement extending to the second-order ducts on the right and first-order duct on the left, with right portal vein involvement. What is the Bismuth–Corlette classification?
A 50-year-old woman with known primary sclerosing cholangitis (PSC) develops progressive jaundice and a dominant stricture on MRCP. Which tumour marker elevation is most specific for cholangiocarcinoma superimposed on PSC?
A 62-year-old man with a 3 cm pancreatic head mass undergoes staging CT and is found to have superior mesenteric vein (SMV) involvement over a 2 cm segment with complete occlusion. The superior mesenteric artery (SMA) is uninvolved. Per National Comprehensive Cancer Network (NCCN) criteria, this tumor is classified as:
A 68-year-old man who had a Whipple procedure for pancreatic head adenocarcinoma 4 years ago now presents with a bilious draining wound over the upper abdomen. CT shows a fistula tract from the hepaticojejunostomy to the skin. Output is 200 mL/day. Which factor determines whether this will close with conservative management?
A 72-year-old woman with incidental 2.5 cm main duct IPMN (intraductal papillary mucinous neoplasm) of the pancreas has a main pancreatic duct of 8 mm on MRI. She has no jaundice or weight loss. Per Fukuoka guidelines, the most appropriate management is:
A 60-year-old man with chronic hepatitis B-related cirrhosis (Child-Pugh A, MELD 9) has a single 2.5 cm hepatocellular carcinoma on surveillance CT. Contrast-enhanced MRI shows arterial enhancement with washout on portal venous phase. AFP is 450 ng/mL. He is within Milan criteria. The PREFERRED treatment per AASLD/EASL guidelines for this patient as a bridge/definitive therapy is:
During laparoscopic cholecystectomy, an intraoperative cholangiogram reveals a filling defect in the distal common bile duct. The cystic duct is short and the patient has been jaundiced for 3 days. According to Strasberg's classification, an injury where the common bile duct is completely transected and a segment is excised is classified as:
A 70-year-old man presents with painless progressive jaundice, 10 kg weight loss over 3 months, and a palpable gallbladder. CT shows a 3 cm mass in the head of the pancreas causing ductal dilatation. CA 19-9 is 680 U/mL. On CT, the superior mesenteric vein (SMV) shows < 180° tumour contact without deformity. This tumour is classified as:
Pancreatic fistula after distal pancreatectomy is graded by the International Study Group on Pancreatic Fistula (ISGPF). A Grade B pancreatic fistula is defined as one requiring:
A 70-year-old woman presents with progressive jaundice, right upper quadrant pain, and an abdominal mass. MRCP shows a hilar biliary stricture involving the right and left hepatic ducts up to their secondary branches with no common duct involvement. This is classified as Bismuth-Corlette Type:
The CHILD score (Child-Turcotte-Pugh) assigns points for which five parameters to assess hepatic reserve?
A 50-year-old woman has incidentally found a 4 cm gallbladder mass on ultrasound. CT shows extension into the liver parenchyma for 2 cm but no involvement of major hepatic vessels or bile ducts. According to AJCC 8th edition T-staging of gallbladder carcinoma, what T stage is this?
A 60-year-old jaundiced man is found to have a Klatskin tumour (hilar cholangiocarcinoma) on MRCP. The tumour involves the right and left hepatic ducts up to their secondary radicles with right portal vein involvement. What is the Bismuth-Corlette classification?
A 65-year-old man undergoes Whipple's procedure (pancreaticoduodenectomy) for a 2.5 cm pancreatic head adenocarcinoma. Pathology shows R0 resection, N1 (3 of 18 nodes positive). Which adjuvant chemotherapy regimen is now the standard of care based on PRODIGE-24/APACT trials?
A 55-year-old woman is found to have a 3 cm cystic lesion in the head of the pancreas with a dilated main pancreatic duct of 8 mm on MRI. MRCP shows communication between the cyst and the main pancreatic duct. Endoscopic ultrasound shows mural nodules. What is the most appropriate management?
In the Charcot's triad of ascending cholangitis, the three classic features are fever with rigors, jaundice, and right upper quadrant pain. Reynolds' pentad adds two more features. Which two features distinguish Reynolds' pentad from Charcot's triad?
The Bismuth-Corlette classification of hilar cholangiocarcinoma (Klatskin tumour) is used to guide resectability. A Type IIIa tumour involves:
A 50-year-old woman is found to have a 2.8 cm incidental gallbladder polyp on ultrasound. She has no symptoms and no cholelithiasis. The most appropriate management is:
The Strasberg classification of bile duct injuries after laparoscopic cholecystectomy designates a Type E injury. Which description best matches a Type E4 injury?
A 65-year-old man has resectable pancreatic head adenocarcinoma. Post-Whipple resection, the specimen shows R0 margins. He receives adjuvant chemotherapy. According to the ESPAC-4 trial, which regimen improved overall survival compared to gemcitabine alone?
In the revised Atlanta Classification (2012) of acute pancreatitis, a collection with a well-defined wall arising after 4 weeks from necrotising pancreatitis involving both pancreatic parenchyma and peripancreatic tissue is termed:
In primary sclerosing cholangitis (PSC), the association with inflammatory bowel disease is well established. Which statement regarding PSC management is most accurate?
In cholangiocarcinoma, serum CA 19-9 and CEA have limited sensitivity. Which additional biomarker, measured in bile or serum, has been studied as a diagnostic adjunct for intrahepatic cholangiocarcinoma?
The Bismuth-Corlette classification of hilar cholangiocarcinoma is critical for surgical planning. Which type requires contralateral hepatectomy along with biliary reconstruction due to involvement of the secondary biliary radicles bilaterally?
The MELD score used in liver transplant allocation in end-stage liver disease incorporates which three laboratory values?
Portal vein embolization (PVE) before major hepatectomy for colorectal liver metastases is indicated when the future liver remnant (FLR) volume falls below which threshold in a non-cirrhotic liver?
The International Study Group of Pancreatic Surgery (ISGPS) grades postoperative pancreatic fistula (POPF) after pancreaticoduodenectomy. Which grade is defined by pancreatic fistula requiring percutaneous or endoscopic intervention but without re-operation?
Mirizzi syndrome is a complication of gallstone disease. The McSherry-Csendes classification of Mirizzi syndrome distinguishes Type I from Type II based on:
In the assessment of resectability of pancreatic ductal adenocarcinoma, borderline resectable disease (NCCN criteria) is defined by which arterial criterion?
Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is classified as main-duct, branch-duct, or mixed type. Which radiological finding is an absolute indication for surgical resection according to Fukuoka guidelines?
The Bismuth-Corlette classification of hilar cholangiocarcinoma (Klatskin tumour) divides tumours by ductal involvement. A Type IIIb tumour involves:
Mirizzi syndrome Type II (Csendes classification) is characterised by:
In the PRODIGE 24/CCTG PA.6 trial, which adjuvant regimen demonstrated superior disease-free and overall survival compared to gemcitabine alone after R0/R1 resection of pancreatic ductal adenocarcinoma?
A patient with chronic pancreatitis has a dilated main pancreatic duct (>7 mm) with a dominant inflammatory head mass. Which surgical procedure offers both decompression and mass resection with preservation of the duodenum?
Couinaud's liver segmentation is based on which anatomical structures to define segment boundaries?
Bismuth-Corlette classification is used for hilar cholangiocarcinoma (Klatskin tumour). Which type is considered potentially resectable with hepatic lobectomy?
The ESPAC-4 trial in pancreatic cancer demonstrated which of the following regarding adjuvant therapy after pancreaticoduodenectomy (Whipple's procedure)?
A 55-year-old male has a 4 cm branch-duct IPMN (intraductal papillary mucinous neoplasm) of the pancreatic head with a mural nodule of 7 mm on MRI and a dilated main pancreatic duct of 6 mm. According to the revised Fukuoka guidelines (2017), what is the appropriate management?
Courvoisier's law states that in a patient with obstructive jaundice, a palpable non-tender gallbladder suggests malignant obstruction rather than gallstone disease. What is the anatomical/pathological basis for the exception (when stones cause a palpable gallbladder)?
A 55-year-old woman is incidentally found to have a 4 cm hepatic adenoma on MRI. She is on oral contraceptive pills. What is the MOST important reason for recommending resection?
A 48-year-old man undergoes ERCP for obstructive jaundice. Cholangiogram shows a stricture at the confluence of the right and left hepatic ducts extending into both ducts. According to the Bismuth-Corlette classification, this is which type?
A 60-year-old man is diagnosed with pancreatic head carcinoma. CT shows the superior mesenteric vein (SMV) abutment without encasement. Which of the following BEST describes the resectability status per NCCN criteria?
Which of the following is the MOST common post-ERCP complication, and what is the primary predictor of its severity?
A 58-year-old man presents with painless progressive jaundice, dark urine, pale stools, and a 6 kg weight loss over 2 months. On examination a non-tender, palpable gallbladder is felt in the right upper quadrant. CA 19-9 is markedly elevated. CT abdomen shows a mass in the head of the pancreas with bile duct dilatation but no distant metastases or vascular involvement. Which clinical sign is best described by the palpable gallbladder in this context?
A 62-year-old woman undergoes laparoscopic cholecystectomy for symptomatic gallstone disease. On postoperative day 2 she develops worsening right upper quadrant pain, fever, and rising bilirubin. A bile leak is suspected. Which investigation is most appropriate to confirm the diagnosis and localise the site of leak?
A 50-year-old woman is found to have a solitary 4 cm hepatic lesion on CT done for an unrelated reason. She has no history of chronic liver disease or viral hepatitis. The lesion is hypervascular on arterial phase with washout on the portal venous phase. AFP is 2.1 ng/mL (normal). She takes the combined oral contraceptive pill. What is the most likely diagnosis?
A 70-year-old man with resectable pancreatic head carcinoma (no distant metastases, no encasement of the superior mesenteric artery or coeliac trunk) proceeds to surgery. Which surgical procedure is performed for resection of carcinoma of the head of the pancreas?
A 45-year-old man presents with recurrent episodes of right upper quadrant pain, fever, and jaundice (Charcot's triad) for the past 6 months. USS shows multiple intrahepatic and extrahepatic bile duct stones. He has no history of gallstone disease. Which investigation is most specific for the underlying aetiology in a patient from a Southeast Asian background?
A 50-year-old woman with primary sclerosing cholangitis (PSC) develops a dominant stricture. CA 19-9 is markedly elevated at 1200 U/mL. What additional investigation is MOST useful to differentiate malignant stricture from dominant benign stricture in PSC?
A 60-year-old man is found to have a 28 mm pancreatic body cystic lesion on CT. EUS shows it communicates with the main pancreatic duct and the duct is dilated to 7 mm. Cytology shows mucinous cells with high-grade dysplasia. What is this lesion and the appropriate management?
In ERCP for suspected choledocholithiasis, which clinical and biochemical combination has the highest predictive value for common bile duct stones, allowing direct ERCP without prior EUS or MRCP?
Intraductal papillary mucinous neoplasm (IPMN) of the pancreas — 'worrisome features' per the Fukuoka 2017 consensus guidelines include which of the following?
The Child-Pugh score is used to assess liver functional reserve before hepatic resection. Which parameter is NOT included in Child-Pugh scoring?
A 60-year-old woman with gallstones presents with acute cholecystitis. She is stabilised medically. What is the OPTIMAL timing of laparoscopic cholecystectomy according to current evidence?
A 55-year-old woman is found to have an incidental 1.5 cm gallbladder polyp on ultrasound. She has no symptoms. Which management is MOST appropriate?
A 50-year-old man is diagnosed with chronic pancreatitis and intractable pain not responding to medical management. Imaging shows a dilated main pancreatic duct of 8 mm with multiple calculi. Which procedure is MOST appropriate?
The Couinaud segmental anatomy of the liver divides the liver into 8 functional segments based on portal pedicles and hepatic vein territories. The caudate lobe corresponds to which segment?
The Child-Pugh-Turcotte (CTP) score assesses liver function and surgical risk in patients with cirrhosis. Which set of parameters is included in the CTP score?
Portal hypertension is defined as a hepatic venous pressure gradient (HVPG) above which threshold, and clinical complications (variceal bleeding) typically begin at which HVPG level?
The ISGLS (International Study Group of Liver Surgery) defines post-hepatectomy liver failure (PHLF) using the '50-50 criteria' on postoperative day 5. These criteria are:
IPMN (intraductal papillary mucinous neoplasm) of the pancreas is classified by duct involvement. Which subtype carries the highest risk of harboring invasive carcinoma and warrants resection in fit patients?
A 60-year-old woman undergoes elective laparoscopic cholecystectomy for symptomatic gallstones. On post-operative review of the pathology report, the gallbladder specimen shows incidental T1b gallbladder carcinoma (tumour invading perimuscular connective tissue, not beyond). What is the appropriate management?
A 48-year-old man with alcoholic chronic pancreatitis has intractable pain and a dilated pancreatic duct of 8 mm on MRCP. CT shows no calcification in the head and no inflammatory mass. Which surgical procedure offers best pain relief with the lowest recurrence rate?
A 65-year-old patient is scheduled for right hepatectomy. Preoperative CT volumetry shows future liver remnant (FLR) of 22% of total liver volume. To prevent post-hepatectomy liver failure, the most appropriate preoperative intervention is:
A 55-year-old man has chronic pancreatitis with a dilated main pancreatic duct (8 mm) and intractable pain not responding to endoscopic therapy. CT shows no dominant mass. The surgical procedure of choice offering pain relief while preserving pancreatic tissue is:

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