acalculus cholecystitis
Surgery Examination
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Q1. Der meiste allgemeine Aufstellungsort für Gallengangkarzinom ist
a) Intrahepatisch
b) Gabelung des hepatischen Luftschachtes
c) Untereres Ende von CBD (allgemeiner Gallenweg)
d) niedrigerem 1/3. von CBD

Q2. Welches ist in den anatomischen Veränderungen des extrahepatic Gallensystems das wenig allgemeine?
a) Trifurcation der rechten vorhergehenden, rechten hinteren und linken hepatischen Luftschachte.
b) Rechter vorhergehender Luftschacht, der den allgemeinen hepatischen Luftschacht verbindet
c) Rechtes Hinterteil, das den allgemeinen hepatischen Luftschacht verbindet
d) Abweichungen der thegall Blase

Q3. Which of the following is not true for Acalculus cholecystitis?
a) It accounts for 5-10% cases of Acute Cholecystitis.
b) This entity has a more fulminant course of disease progression
c) More commonly seen after burns trauma or major cardiac surgeries.
d) Cholescintigraphy is the investigation of choice for detecting Acute Acalculus Cholecystitis.

Q4. How much bile is produced by the liver each day?
a)  100-300 ml
b)   300-500 ml
c)   500-1000ml
d)   500-1200 ml

Q 5. Which of the following is not a criteria for diagnosing Sphincter of Oddi Dysfunction
a) CBD diameter more than 12 mm on USG
b) Decrease in CBD pressure after infusion of Cholecystokinin
c) Ampullary pressure more than 40 mm Hg
d) Delayed emptying of contrast from CBD after ERCP
Answers

1.b
In Cholangiocarcinoma tumor can be anywhere from intrahepatic
duct to ampulla of vater.
60-80% of tumors are located at the Hepatic Duct bifurcation.
(Sabiston 18th edition page 1584) In earlier reviews (Maingot'
10th edition page 1841) , the most common site mentioned is
Common bile Duct (33-40%)  followed by  Common Hepatic
duct (30-32%) and Hepatic duct bifurcation (20%).
From other reviews 55% are in the upper 1/3rd, 15% in the
middle 1/3rd and 20% in the lower 1/3rd 10 % are diifuse.
Sabiston 18 th page 1584.


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2. d
Variations are very common in the anatomy
of extraheaptic system.The typical anatomy
of the left hepatic duct formation by the ducts
draining segments II, III, and IV of the liver and
right hepatic formation by the right posterior
(segments VI and VII) and right anterior
(segments V and VIII) hepatic ducts is seen in 55-60% cases.






Trifurcation of Left hepatic duct, 
right posterior duct  and right anterior
duct is seen in 12%



Right anterior joins CHD distal to
the junction of Right Posterior and
LHDin 16%






Right posterior joins CHD distal to
the junction of RA and LHD in 4%






Gallbladder anomalies are the least common.

3. d
1-2% of all patients undergoing cholecystectomy have a diagnosis of Acute acalculus cholecystitis. In 5-10 % cases of acute cholecystitis no gall \stones are found.
Most frequently Acalculus cholecystitis occur in the elderly patients in ICU setting eg after major trauma, burns, Long term parenteral nutrition or after major Vascular or cardiac surgery.
Main Pathophysiology is gallbladder stasis, gallbladder ischemia and visceral ischemia so the gall bladder is more prone for gangrene and perforation.
Ultrasound is the investigation of choice and not Cholescintigraphy because with the latter false positive rate maybe as high as 40%.  More questions on Gallbladder

4. c
Bile flow is approximately 500ml to 1000 ml in most patients. It is dependent on neurogenic, chemical and humoral system.
Increase in  bile secretion                                 Decrease in bile secretion
Vagal stimulation                                                Splanchnic nerve secretion
Secretin
Cholecystokinin
 
5. b
In sphincter of Oddi Dysfunction, after CCK infusion, the pressure in the CBD increases and not decrease.
All other choices are true
Acute cholecystitis

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Right posterior and left posterior join to make Right hepatic duct that joins Left hepatic duct
Trifurcation of Right hepatic duct, left hepatic duct and left hepatic duct
Right posterior and left hepatic duct form common hepatic duct, Right anterior joins
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