Mcq Salad 005

Front 1

Thromboxane causes:

A. Fibroblast chemotaxis

B. Vasoconstriction

C. Collagen cross linking

D. Endothelial proliferation

E. Bacterial lysis

Back 1

B

Front 2

Iron deficiency has an impact on wound healing by decreasing:

A. Early tensile strength

B. DNA synthesis

C. Conversion of hydroxyproline to proline

D. Tissue oxygenation

E. Fibroblast proliferation

Back 2

A

Front 3

Hypertrophic scar is:

A. Another term for keloids

B. More likely to occur on the face

C. Genetic in origin

D. Preventable

E. Worsened with glucocorticoids

Back 3

D

Front 4

The effects of diabetes on wound healing include:

A. Slowed epithelialization

B. Reduced phagocytosis

C. Glycosylated collagen

D. Thickened basement membrane

E. All of the above

Back 4

E

Front 5

Ionizing radiation causes hypoxia by:

A. Direct cellular injury to endothelium

B. Basal membrane injury

C. Release of histamine and serotonin

D. Preventing the hypoxic stimulus of angiogenesis

E. Increased dermal fibrosis and thickening

Back 5

D

Front 6

Nicotine ingestion affects wound healing by:

A. Increasing fibroblast proliferation

B. Increasing platelet adhesion

C. Competitively competing with oxygen

D. Inhibiting oxidative metabolism

E. Inhibiting oxygen transport

Back 6

B

Front 7

Which of the following events occurs in the proliferative phase of wound healing?

A. Histamine release

B. Collagen cross linking

C. Thromboxane release

D. Phagocytosis

E. Collagen synthesis

Back 7

B

Front 8

Chronic wounds characteristically have:

A. Tissue inflammation

B. Decreased tissue inhibitor of metalloproteinases levels

C. Increased gelatinase levels

D. Increased collagenase levels

E. All of the above

Back 8

E

Front 9

The wound healing impairment caused by corticosteroid administration can be reversed by:

A. Vitamin A

B. Vitamin C

C. Zinc

D. Vitamin K

E. Vitamin B12

Back 9

A

Front 10

Which of the following glycosaminoglycans is not a component of skin?

A. Hyaluronic acid

B. Chondroitin sulfate

C. Dermatan sulfate

D. Heparin sulfate

E. Heparin

Back 10

D

Front 11

Most human collagen is:

A. Type I

B. Type III

C. Type IV

D. Type V

E. Type VII

Back 11

A

Front 12

Endothelial cells are induced to form tubules by:

A. Vascular endothelial growth factor (VEGF)

B. Hypoxia

C. Tumor necrosis factor-α (TNF-α)

D. Transforming growth factor-β (TGF-β)

Back 12

C

Front 13

A35-year-old CEO underwent an antrectomy and vagotomy for a bleeding ulcer. Although usually careful with his diet, he ate a large meal during a business lunch. Within 1 hour, he felt lightheaded and developed abdominal cramping and diarrhea. His symptoms may be attributed to:

(A) Anemia

(B) Jejunogastric intussusception

(C) Dumping syndrome

(D) Afferent loop syndrome

(E) Alkaline reflux gastritis

Back 13

(C)

Postgastrectomy syndromescollectively refer to complications that can occur after gastric surgery. This constellation of syndromes includes delayed gastric emptying, recurrent ulcers, diarrhea, anemia, jejunogastric intussusception, afferent loop syndrome, alkaline reflux gastritis, and dumping syndrome. There are two types of dumping syndrome, early and late. Early dumping occurs within 30 minutes and is caused by rapid gastric emptying of a hyperosmolar load into the small bowel. Late (hypoglycemic) dumping occurs 1–3 hours after eating. Symptoms are mostly vasomotor. They are related to the excessive release of insulin in response to the rapid rise in postprandial glucose

Front 14

A 63-year-old man has an upper gastrointestinal (UGI) study as part of his workup for abdominal pain. The only abnormal finding was in the antrum, where the mucosa prolapsed into the duodenum. There were no abnormal findings on endoscopy. What should he do?

(A) Sleep with his head elevated.

(B) Be placed on an H2 antagonist.

(C) Undergo surgical resection of the antrum. (D) Be observed and treated for pain accordingly.

(E) Have laser treatment of the antral mucosa.

Back 14

(D)

Prolapse of gastric mucosa into the duodenum may be difficult to distinguish from a polyp in the antrum. It may be detected in a patient who is asymptomatic. Surgical correction should be reserved for patients with obstructive symptoms (e.g., vomiting). Sleeping with they head elevated, H2 antagonist, and laser treatment have no role.

Front 15

A 63-year-old man underwent gastric resection for severe peptic ulcer disease. He had complete relief of his symptoms but developed “dumping syndrome.” This patient is most likely to complain of which of the following?

(A) Gastric intussusception

(B) Repeated vomiting

(C) Severe diarrhea

(D) Severe vasomotor symptoms after eating (E) Intestinal obstruction

Back 15

(D)

Dumping syndrome is a symptom complex ocurring after gastric surgery. It is characterized by fatigue, abdominal distension, pain, and vasomotor symptoms caused by the rapid entry of food into the small intestine. Tachycardia, sweating, and feeling lightheaded after eating are symptoms patients may feel. There are two types of dumping syndrome, early and late.

Front 16

A 65-year-old man was admitted to the hospital for severe bilious vomiting following gastric surgery. This occurs in which circumstance?

(A) Following ingestion of gaseous fluids

(B) Spontaneously

(C) Following ingestion of fatty foods

(D) Following ingestion of bulky meals

(E) In the evening

Back 16

(B)

Bilious vomiting is usually spontaneous and should be differentiated from vomiting that occurs after eating. The most likely cause of this complication is reflex of bile into the stomach. Bile gastritis with intestinalization of the gastric mucosa is a likely cause.

Front 17

A 64-year-old man has had intermittent abdominal pain as a result of duodenal ulcer disease for the past 6 years. Symptoms recurred 6 weeks before admission. He is most likely to belong to which group?

(A) Aand secretor (blood group antigen in body fluid)

(B) B and Lewis antigen

(C) AB

(D) O and nonsecretor

(E) O and secretor

Back 17

(D)

Group O is the most common blood type in patients with duodenal ulcer disease. In patients who have bled from a duodenal ulcer, this observation is even more striking. Secretors have an excess of blood group antigen that is absent in nonsecretors. The secretor antigen on the red blood cell appears in body fluids also. Nonsecretors are more prone to develop dueodenal ulcers than secretors.

Front 18

A 64-year-old man was evaluated for moderate protein deficiency. He underwent a gastrectomy 20 years earlier. He is more likely to show which of the following?

(A) Porphyria

(B) Hemosiderosis

(C) Aplastic anemia

(D) Hemolytic anemia

(E) Iron deficiency anemia

Back 18

(E)

There is a varying degree of impairment in carbohydrate, fat, protein, and mineral absorption after gastrectomy. These changes are most severe after a subtotal gastrectomy and gastrojejunostomy (Billroth II) (Fig. 5–7), in most patients these changes are mild. An acid environment is necessary to release ferric ion from food and make it available for absorption in the small intestine.

Front 19

A 68-year-old woman has been diagnosed with a benign ulcer on the greater curvature of her stomach, 5 cm proximal to the antrum. After 3 months of standard medical therapy, she continues to have guaiac positive stool, anemia, and abdominal pain with failure of the ulcer to heal. Biopsies of the gastric ulcer have not identified a malignancy. The next step in management is which of the following?

(A) Treatment of the anemia and repeat all studies in 6 weeks

(B) Endoscopy and bipolar electrocautery or laser photocoagulation of the gastric ulcer

(C) Admission of the patient for total parenteral nutrition (TPN), treatment of anemia, and endoscopic therapy

(D) Surgical intervention, including partial gastric resection

(E) Surgical intervention, including total gastrectomy

Back 19

(D)

In general, vagotomy with a gastric drainage procedure is less satisfactory in the treatment of primary gastric ulcer. Treatment of a gastric ulcer may include partial gastrectomy with a gastroduodenal anastomosis (Billroth I). Vagotomy is not necessary because gastric ulcers are usually not associated with acid hypersecretion. Agastric ulcer that fails to heal despite medical therapy should be excised.

Front 20

Investigations of a 43-year-old woman with pluriglandular syndrome were scheduled to determine if a gastrinoma (ZES) was present. The serum gastrin level was slightly elevated. Further assessment to establish the diagnosis can be made by repeating the serum gastrin level after stimulation with which of the following?

(A) Phosphate

(B) Potassium

(C) Calcium

(D) Chloride

(E) Magnesium

Back 20

(C)

In ZES gastrin levels may be only mildly elevated but can be increased with provocation with intravenous calcium or secretin. Most patients with gastrinoma have serum gastrin levels that exceed 500 pg/mL. When the range is lower than 200–500 pg/mL, a stimulation test is performed to confirm the diagnosis. A rise of 200 pg/mL after 15 minutes, or a doubling of the fasting level is diagnostic. ZES can occur sporadically or as part of multiple endocrine neoplasia (MEN) I.

Front 21

Over the past 6 months, a 60-year-old woman with long standing duodenal ulcer disease has been complaining of anorexia, nausea, weight loss and repeated vomiting. She recognizes undigested food in the vomitus. Examination and workup reveal dehydration, hypokalemia, and hypochloremic alkalosis. What is the most likely diagnosis?

(A) Carcinoma of the fundus

(B) Penetrating ulcer

(C) Pyloric obstruction due to cicatricial stenosis of the lumen of the duodenum

(D) ZES (Zollinger Ellison Syndrome)

(E) Anorexia nervosa

Back 21

(C)

Chronic duodenal ulcer, with recurrent episode of healing and repair, may lead to pyloric obstruction due to scarring and stenosis of the duodenum. Painless vomiting of undigested food may occur once or twice a day. Surgical intervention should be carried out after correction of fluid and electrolyte imbalances. Preoperative antibiotics should be used due to bacterial overgrowth secondary to gastric statis.

Front 22

A 50-year-old woman presents with duodenal ulcer disease and high basal acid secretory outputs. Secretin stimulated serum gastrin levels are in excess of 1000 pg/mL. She has a long history of ulcer disease that has not responded to intense medical therapy. What is the most likely diagnosis?

(A) Hyperparathyroidism

(B) Pernicious anemia

(C) Renal failure

(D) ZES

(E) Multiple endocrine neoplasia

Back 22

(D)

ZES is characterized by duodenal ulcer disease, high basal acid secretory output, and a pancreatic tumor. Stimulated serum gastrin levels may be in excess of 1000 pg/mL or as high as 10,000 pg/mL. ZES is due to a true pancreatic tumor in adults, but may be secondary to hyperplasia in children. Growth of the tumor is usually slow and survival is often prolonged. If an isolated tumor is found on CAT scan, surgical resection is indicated. About two-thirds of these tumors are malignant. About one-forth of patients have MEN I syndrome tumors of parathyroid pituitary and pancreas

Front 23

The following constitute the Saints triad except ?A) Gall stones

B) Jaundice

C) Hiatus hernia

D) Colonic diverticulosis

Back 23

B

Front 24

The following statements regarding small bowel tuberculosis are correct except ?

A) There are two types: ulcerative and hyperplastic

B) The strictures are common in the ulcerative type

C) In the ulcerative type, the bowel serosa is studded with tubercles

D) The ulcerative type occurs when the virulence of the organism is greater than the host defence

Back 24

C

Front 25

Tidy wounds inflicted by sharp instruments and containing no devitalised tissues are expected to heal by ?

A) Secondary healing

B) Primary healing

C) Formation of contracture

D) Skin graftingAnswer

Back 25

B

Front 26

A 30-year-old woman complains of suprasternal dysphagia only for solids. She also has a long-standing untreated menorrhagia leading to iron deficiency anaemia. What is the most probable cause for her dysphagia ?

A) Pharyngeal pouch

B) Carcinoma oesophagus

C) Dysphagia lusoria

D) Patterson-Kelly syndrome

Back 26

D

Hint 26

Plummer–Vinson syndrome (PVS), also called Paterson–Brown–Kelly syndrome or sideropenic dysphagia, is a rare disease characterized by difficulty in swallowing, iron deficiency anemia, glossitis, cheilosis and esophageal webs.

Front 27

Zollinger-Ellison syndrome is characterised by the following except ?

A) Profound gastric hypersecretion

B) Large diarrhoea with occasional steatorrhoea

C) Hypocalcaemia

D) Hypergastrinaemia

Back 27

C

Front 28

A meningomyelocoele is most commonly situated in the ?

A) Cervical spine

B) Thoracic spine

C) Dorsolumbar spine

D) Lumbosacral

Back 28

D

Front 29

A fracture of the middle cranial fossa may result in an injury of the ?

A) Sixth cranial nerve

B) Eighth cranial nerve

C) Tenth cranial nerve

D) Eleventh cranial nerveAnswer

Back 29

A

Front 30

Which one of the following statements regarding seminoma testis is correct ?

A) It is the most common type of testicular cancer

B) It frequently metastasizes to the liver and bones

C) It does not respond to radiation

D) Its five-year survival rates approach 50 percent

Back 30

A

Front 31

29: A patient is diagnosed to have a Stage T3a carcinoma of the prostate. Clinically, this implies ?

A) Involvement of both the lobes but the disease is limited to within the prostatic capsule

B) Involvement of both the lobes but the disease has extended through the prostatic capsule

C) Involvement of the seminal vesicles

D) Involvement of the pelvic wall

Back 31

B

Front 32

A 40-year old alcoholic male complains of acute pain in the epigastrium associated with vomiting for the last 10 days. On clinical examination, he is found to have a mass in the epigastrium. The most likely diagnosis is ?

A) Perforated peptic ulcer with subhepatic abscess

B) Pseudopancreatic cyst

C) Carcinoma of head of the pancreas

D) Hepatoma in left lobe of liver

Back 32

B

Front 33

Contra-indications to day care surgery in children include:

A. Long distance from the home

B. Preterm delivery of a child

C. Lack of education of parent

D. Absence of community health nurses E. Low socio-economic status of parent

Back 33

A,B

Front 34

Co-morbid conditions that may make day care surgery unsafe include:

Back 34

A. Sickle cell disease

B. Cardiac failure

E. Renal anomaly

wrong:

C. Extra-digit

D. Pre-auricular skin tag

Front 35

13. Indications for day care surgery in children include:

Back 35

A. Inguinal hernias

B. Hydrocoles

C. Umbilical hernias

D. Rectal Biopsies

E. Circumcisions

Front 36

14. Those who must be involved in preparing a child for day care surgery include:

Back 36

A. The parents mainly

B. The surgeon mainly

C. The Anaesthetist mainly

D. The nurse mainly

E. All of the above

Front 37

15. It is not possible to do day care surgery without the following:

A. A community health nurse

B. Internet facilities

C. Good Communication system

D. Good transportation system

E. A ward dedicated solely to day care surgery

Back 37

C

Front 38

Congenital anomaliesthat may present as ACUTE Emergencies in the new born include:

Back 38

A. Diaphragmatic hernia

C. Micrognathia

D. Aganglionic megacolon

Wrong:

B. Hypertrophic pyloric stenosis

E. Meningocele Wrong:

Front 39

Acute respiratory obstruction immediately after birth may be due to:

Back 39

B. Bilateral posterior choanal atresia

D. Goitre

E. Mediastinal tumour

Wrong:

A. Patent ductus arteiosus

C. Oesophageal atresia

Front 40

A 2-day old neonate with respiratory distress and cyanosis has a scaphold abdomen. The apex beat is in the 5th interspace on the right of the sternum and no murmurs are heard. You will suspect:

Back 40

B. Congenital lobar emphysema

C. Diaphragmatic hernia

Wrong:

A. Dextrocardia

D. Atresia of the jejunum

E. Co-arctation of the oarta

Front 41

A 2-day old neonate with respiratory distress and cyanosis has a scaphold abdomen. The apex beat is in the 5th interspace on the right of the sternum and no murmurs are heard. Urgent measures will include:

Back 41

B. Intubation and administration of oxygen

C. Plain X-ray of the chest and abdomen

Wrong:

A. Administration of oxygen with a face mask D. Barium swallow

E. Barium swallow administration of antibiotics

Front 42

In micrognatha:

Back 42

C. Feeding is done with the baby lying prone over the mother who is in the supine position D. Tube feeding is occasionally necessary

E. The crisis is usually over by 3 months after birth

Wrong:

A. Respiratory obstruction is usually most severe when the baby is sleeping

B. The baby should be nursed on the lateral side

Front 43

Which of the following effects are advantages of combined vasopressin and nitroglycerin intravenous infusion, as compared with vasopressin infusion alone, in controlling acute variceal bleeding?

A. Lower frequency of encephalopathy.

B. Lower incidence of vasopressin side effects.

C. More effective control of bleeding.

D. Less “rebound effect” when discontinuing the infusion.

Back 43

Answer: BC

DISCUSSION: Vasopressin acts through vasoconstriction of splanchnic arterioles. Both portal venous inflow and portal venous pressure are reduced, resulting in control of acute variceal bleeding in approximately 50% of patients. However, the adverse side effects of systemic hypertension, bradycardia, decreased cardiac output, and coronary vasoconstriction are quite common during vasopressin infusion. Simultaneous administration of nitroglycerin or nitroprusside eliminates these side effects—and in one controlled trial enhanced therapeutic effectiveness. Although the mechanism of action of this combined infusion is not clear, vasodilation of portal-systemic collaterals, resulting in a further reduction in portal pressure, may be responsible.

Front 44

Which of the following statements about the peritoneovenous shunt (PVS) is/are correct?

A. For cirrhotic patients with intractable ascites, the LeVeen shunt is an effective “bridge” to liver transplantation.

B. Replacement of ascites with saline or lactated Ringer's solution reduces the coagulopathy following PVS.

C. For patients with cirrhotic ascites, the survival using repeated paracentesis with 5% albumin infusion is equivalent to that with the PVS.

D. Oliguria (less than 25 ml. per hour) in the immediate postoperative period following PVS should be treated with a 5% albumin infusion.

E. The transjugular intrahepatic portacaval shunt with stent (TIPSS) works on the same principle as the PVS.

Back 44

Answer: BC

DISCUSSION: The PVS is a palliative procedure that does not prolong life. In comparing the early risks of the procedure with those of repeated paracentesis, the shunt cannot be justified as a temporizing procedure to facilitate ascites control in the patient awaiting liver transplantation. Oliguria is common in the first 24 hours after shunt insertion. A correctly placed PVS (patency confirmed using an intraoperative “shuntogram”) expands the intravascular volume with a continuous reinfusion of ascites. Inspection should identify elevation of the jugular venous pressure, and a diuretic (usually furosemide) is needed. The mechanisms of action of the two shunts are very different. TIPSS reduces portal pressure and controls ascites by reducing the rate of ascites formation. PVS reinfuses the ascites fluid, thereby reducing the prerenal stimulus to sodium retention and making the patient more responsive to diuretic therapy.

Front 45

Which of the following clinical situations are considered good indications for PVS?

A. A 50-year-old cirrhotic man had an emergency portacaval shunt for bleeding varices and postoperatively had an ascites leak and mild superficial wound infection.

B. A 57-year-old woman with primary biliary cirrhosis (PBC) has difficult to control ascites and diuretic-induced encephalopathy.

C. A 46-year-old resistant alcoholic has chronic ascites uncontrolled by diuretics combined with repeat paracentesis.

D. A 34-year-old woman taking BCPs had rapid onset of ascites and is found to have hepatic vein thrombosis causing the Budd-Chiari syndrome.

Back 45

Answer: C

DISCUSSION: Because of the high complication rate and the long-term failure rate, the PVS is used only when other, more lasting options for therapy either are not available or are contraindicated. The chronic alcoholic patient may benefit from a peritoneovenous shunt because his ascites is the dominant problem related to his chronic liver disease, and persistent alcoholism is a contraindication to liver replacement in most centers. PVS may be quite effective for the temporary management of acute intractable postoperative ascites, such as in patient A; however, it is absolutely contraindicated in the presence of infection. Patient B has ascites as her dominant problem as well; however, with PBC as the underlying liver disease, she is an excellent candidate for transplantation. Patient D also has ascites as the major problem; however, the side-to-side portosystemic shunt is a far better long-term treatment option than PVS.

Front 46

24. Which of the following explanations account(s) for the fact that hepatitis C is the most common cause of posttransfusion hepatitis?A. There are more carriers of hepatitis C virus (HCV) in the normal population who serve as blood donors.

B. Blood infected with hepatitis B virus (HBV) is eliminated through routine testing, leaving only HCV as the other blood-borne pathogen.

C. Current serologic tests for HCV antigen do not exclude carriers.

D. Questions designed to eliminate risk groups for HCV from the normal donor population may not be as specific as would be desirable.

E. Hepatitis C is a more virulent form of viral hepatitis, so it is expected that more cases of posttransfusion hepatitis would occur.

Back 46

Answer: BD

DISCUSSION: The ability to specifically identify persons infected with HCV has only recently become available. Therefore, data about epidemiology are less than complete. It is very likely not true that more blood donors carry HCV because of the large preponderance of HBV in the United States. It is true, however, that successful elimination of most of the HBV carriers occurs through routine testing. Although serologic tests are available for HCV, they are tests, not of antigen, but of antibody. Therefore, this test alone may not screen out persons who are infected but have not yet developed or may never develop antibody. Risk groups for the relatively newly defined HCV may well not be comprehensively established, and therefore this explanation may be a contributor. There are no differences in virulence between these classes of hepatitis virus.

Front 47

True or false: HBV infections:

A. Are usually asymptomatic.

B. May not be clinically recognized but may lead to chronic hepatitis.

C. Reliably protect against subsequent HBV infection regardless of the measured antibody titer to hepatitis B surface antigen (HBsAg).

D. Are completely prevented by postexposure administration of HBIg hepatitis B immunoglobulin (HBIg).

E. Preclude subsequent infection with HDV.

Back 47

Answer: TRUE: BC, FALSE ADE

DISCUSSION: Although some types of hepatitis are more often asymptomatic than symptomatic, that is not the case for hepatitis B. Further, even if the HBV infection is asymptomatic, serious long-term side effects may occur. A prior infection with hepatitis B confers lifelong immunity even if the antibody titer wanes below the protective level of 10 mIU. HBIg is useful in reducing the incidence of postexposure HBV infection from around 30% with no intervention, to 15% with standard immune globulin, to about 5% to 7% with HBIg. HBV infection is required for infection with HDV and is therefore an essential step toward, rather than preventive of, HBV infection.

Front 48

Which of the following statements about choledocholithiasis are correct?

A. Common duct stones can originate in the gallbladder and migrate to the common duct, and stones can form de novo in the duct system.

B. Calcium bilirubinate stones are associated with the presence of bacteria in the duct system.

C. Common duct stones discovered at laparoscopic cholecystectomy should be treated by postoperative endoscopic extraction.

D. The serum bilirubin value is usually greater than 15 mg. per dl. in the patient with a symptomatic common duct stone.

Back 48

Answer: ABC

DISCUSSION: Most common duct stones originate in the gallbladder and migrate to the common duct, where they may become larger. These stones tend to consist predominantly of cholesterol (about 80% of gallbladder stones are predominantly cholesterol). Stones found in the bile ducts after cholecystectomy may have been overlooked, but de novo stone formation does occur. Arbitrarily, stones found 2 years after cholecystectomy are assumed to have formed within the duct system. Calcium bilirubinate stones are thought to result from precipitation of insoluble bilirubin monoglucuronide formed by deconjugation of bilirubin diglucuronide, a reaction promoted by the enzyme beta-glucuronidase, which is produced by bacteria in the biliary tract. Calcium bilirubinate stones are found almost exclusively in patients who have some form of biliary tract lesion that causes partial obstruction, and these patients tend to have bactibilia. Stones smaller than approximately 5 mm. often can be extracted through a dilated cystic duct or pushed into the duodenum. Larger stones are best left for postoperative endoscopic sphincterotomy and extraction. Patients with more than five stones or stones larger than 1.5 cm. should be treated by open choledocholithotomy or, when indicated, a biliary-enteric anastomosis. Not all patients with symptomatic common duct stones have elevated serum bilirubin, but when jaundice is present the bilirubin is only rarely greater than 15 mg. per dl.

Front 49

27. A benign biliary duct stricture:A. Need not be treated unless it causes clinical jaundice.B. Should always be treated by percutaneous balloon drainage.C. Is prone to recur after treatment with biliary-enteric anastomosis.D. When due to chronic pancreatitis should be treated by side-to-side choledochoduodenostomy.

Back 49

Answer: CDDISCUSSION: Even a minor obstructing lesion in the extrahepatic duct system can produce cirrhosis over time, and the development of portal hypertension, ascites, and esophageal varices. Therefore, all biliary strictures should be treated unless this is not possible or there is no chance for success. The presence or absence of jaundice is of no significance. Often, the only biochemical abnormality is mild elevation of alkaline phosphatase. The long-term results of percutaneous balloon dilatation are not yet known, but short-term results are good. Although some argue that balloon dilatation should be the initial treatment, its role is ill-defined, and it should not be viewed as standard therapy at this time. Biliary-enteric anastomoses are predisposed to stricture, for reasons that are ill-understood. A mucosa-to-mucosa anastomosis, large size of the anastomosis, a normal duct at the point of anastomosis, and stenting appear to be elements that work against stricture. About 70% of anastomoses are not complicated by strictures. Common duct strictures caused by chronic pancreatitis are located in the distal portion of the duct and are easily treated by side-to-side choledochoduodenostomy. A wide anastomosis is usually possible, and because of this stenting often is not necessary. Although a Roux-en-Y biliary-enteric reconstruction is acceptable treatment, no advantage over choledochoduodenostomy has been demonstrated.

Front 50

28. Which statements about extrahepatic bile duct cancer are correct?A. Cholangiography is essential in evaluating patients for resectability.B. The prognosis is excellent when appropriate surgical and adjuvant therapy are given.C. The location of the tumor determines the type of surgical procedure.D. The disease usually becomes manifest by moderate to severe right-side upper quadrant pain.

Back 50

Answer: ACDISCUSSION: Cholangiography is essential for both diagnosis and evaluation of resectability. Brushings of the lesion for diagnosis and temporary stenting, done percutaneously or endoscopically, are often done at the time of cholangiography. Angiography and CT are helpful, but in the absence of hepatic artery or portal vein occlusion these tests are not accurate predictors of resectability. The primary obstacles to complete resection are invasion of the portal vein or the hepatic artery and proximal extension of the tumor into the liver. The long-range prognosis for patients who undergo treatment for extrahepatic bile duct cancer is poor, even when the lesion is surgically resectable and adjuvant therapy is given. Only about 10% of patients are alive without disease at 10 years. Nevertheless, bile duct cancer tends not to metastasize to distant sites, so resection and radiation therapy are useful in prolonging symptom-free life. Tumors in the proximal third of the extrahepatic bile duct system are treated by a Roux-en-Y biliary-enteric anastomosis. To ensure excision of the entire tumor this anastomosis usually must be made to the individual hepatic ducts, which must be stented individually. Tumors of the middle third usually require anastomosis to the proximal hepatic duct. In contrast, lesions of the distal third require Whipple's procedure with appropriate reconstruction. Thus, the treatment of extrahepatic bile duct cancer depends on the location of the tumor. Pain is not a prominent feature of bile duct cancer. Most cases become manifest by the insidious development of jaundice.