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SU28.10-12 | Hepatobiliary and Splenic Surgery — Graded Quiz
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A 70-year-old man presents with progressive painless jaundice, weight loss and a palpable, non-tender gallbladder. By Courvoisier's law, what does the palpable non-tender gallbladder in a jaundiced patient most strongly suggest?
Courvoisier's law: in a jaundiced patient a palpable, non-tender gallbladder is unlikely to be due to stones (which scar and shrink the gallbladder) and suggests a malignant cause such as a periampullary or pancreatic-head tumour.
Courvoisier's law: painless jaundice + palpable non-tender gallbladder ⇒ think malignancy, not stones. Investigate with imaging (US, CT) and MRCP/ERCP.
Courvoisier's law points away from stones and towards malignant distal obstruction when the gallbladder is palpable and non-tender.
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A 40-year-old obese woman has recurrent right upper quadrant pain after fatty meals. During examination you ask her to breathe in while you palpate under the right costal margin; she catches her breath in pain. What sign is this and what does it indicate?
Arrest of inspiration on palpation of the inflamed gallbladder fossa is Murphy's sign, classically positive in acute cholecystitis.
Murphy's sign = inspiratory arrest on RUQ palpation = acute cholecystitis; gold-standard treatment is laparoscopic cholecystectomy.
Inspiratory arrest on RUQ palpation is Murphy's sign — the bedside marker of acute cholecystitis.
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During a difficult laparoscopic cholecystectomy, the surgeon dissects Calot's triangle to obtain the 'critical view of safety' before clipping any structure. What is the primary purpose of achieving this view?
The critical view of safety ensures only the cystic duct and cystic artery enter the gallbladder, preventing inadvertent division of the common bile duct — the most feared complication of cholecystectomy.
Calot's triangle (cystic duct, common hepatic duct, liver edge) contains the cystic artery; the critical view of safety prevents CBD injury.
The critical view of safety is about avoiding bile-duct injury by correctly identifying the cystic duct and artery in Calot's triangle.
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A patient with obstructive jaundice and a suspected common bile duct stone needs imaging of the biliary tree before any intervention. Which investigation provides detailed, non-invasive imaging of the ducts without the procedural risks of ERCP?
MRCP is the non-invasive gold standard for imaging the biliary tree; ERCP is reserved for therapeutic intervention (stone extraction, stenting) because it carries risks such as pancreatitis.
MRCP = non-invasive diagnostic biliary imaging; ERCP = therapeutic (stone extraction, stenting) with risks (pancreatitis, bleeding).
MRCP is the non-invasive imaging test; ERCP is kept for therapy because of its procedural risks.
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A surgeon planning a major hepatic resection refers to Couinaud's classification. What is the surgical significance of this segmental anatomy of the liver?
Couinaud divides the liver into eight functionally independent segments, each with its own portal pedicle and venous drainage, which is what makes anatomical, segment-sparing resection possible.
Couinaud's eight segments + the dual (portal ~75% + arterial ~25%) blood supply explain why the liver can be resected segment by segment.
Couinaud's classification defines eight independent liver segments — the basis for anatomical resection.
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A previously well young man with a pyogenic liver abscess is found to have the abscess seeded via the portal vein. Which is the most plausible primary source for portal-venous seeding of a pyogenic liver abscess?
The portal vein drains the gut, so intra-abdominal sepsis (e.g. appendicitis, diverticulitis) is the classic portal source seeding a pyogenic liver abscess; treatment is antibiotics plus drainage and control of the source.
Pyogenic liver abscess often follows portal seeding from gut sepsis (appendicitis/diverticulitis), or via the biliary tree; treat with antibiotics + drainage + source control.
Portal-vein seeding implies a gut source — appendicitis or diverticulitis — not a systemic or skin source.
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A haemodynamically stable adult with a CT-confirmed low-grade splenic laceration and no other indication for laparotomy is admitted. What is the most appropriate initial management strategy?
A haemodynamically stable patient — even with a higher-grade injury — can be managed non-operatively with close observation and selective angioembolisation, preserving the spleen and avoiding OPSI risk.
Spleen-preserving, non-operative management (± angioembolisation) is the goal in the stable patient; it avoids the lifelong OPSI risk of splenectomy.
Stable patients are managed non-operatively to preserve the spleen; splenectomy is reserved for haemodynamic instability or failed non-operative management.
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A patient with a left-lobe amoebic liver abscess fails to defervesce after several days of metronidazole, and imaging shows a large abscess threatening to rupture into the pericardium. What is the most appropriate next step?
Although amoebic abscess is primarily medical, aspiration/drainage is indicated for large lesions, left-lobe abscesses threatening rupture, or failure to respond to metronidazole. Albendazole/PAIR is for hydatid disease, not amoebic abscess.
Drain an amoebic abscess if it is large, left-lobe with impending rupture, or fails to respond to metronidazole; albendazole + PAIR is for hydatid, not amoebic, disease.
Indications to drain an amoebic abscess include large size, left-lobe/impending rupture, and non-response — drainage is added to amoebicidal drugs, not albendazole.
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