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Arab Board Surgery Clinical study materials
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Arab Board Surgery Clinical practice questions

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Question 1General Surgery and Gastrointestinal Surgery

A 24-year-old man presents with 12 hours of periumbilical pain that has migrated to the right lower quadrant, with anorexia and low-grade fever. Which single finding on examination most strongly supports acute appendicitis?

  1. Rebound tenderness at McBurney's point Correct answer.
  2. Painless palpable mass in the right iliac fossa
  3. Pain on passive extension of the right hip
  4. Hyperesthesia over the left iliac fossa

Explanation

Localized peritoneal irritation over the appendix produces rebound tenderness at McBurney's point, which is the classic sign of appendicitis. Hip extension pain suggests retrocecal irritation of the psoas rather than being the primary diagnostic sign.

Question 2General Surgery and Gastrointestinal Surgery

A 55-year-old woman has a 3 cm firm, painless breast lump fixed to skin. Core biopsy shows invasive ductal carcinoma. Which feature of the triple assessment most reliably establishes the diagnosis?

  1. Mammographic microcalcification pattern
  2. Histopathological core biopsy Correct answer.
  3. Fine needle aspiration cytology
  4. Clinical examination alone

Explanation

Core biopsy provides tissue architecture and grade, making it the definitive component of triple assessment. Cytology cannot distinguish invasive from in-situ disease and clinical or radiological features alone are insufficient.

Question 3General Surgery and Gastrointestinal Surgery

A 40-year-old man has a reducible indirect inguinal hernia. During open repair, which anatomical structure lies immediately lateral to the inferior epigastric vessels at the deep inguinal ring?

  1. Femoral vein
  2. Inferior epigastric artery
  3. Spermatic cord Correct answer.
  4. Rectus abdominis muscle

Explanation

The deep inguinal ring lies lateral to the inferior epigastric vessels, and the spermatic cord passes through it. Indirect hernias enter the canal at this point.

Question 4General Surgery and Gastrointestinal Surgery

A 62-year-old man has painless obstructive jaundice and a palpable gallbladder. Which diagnosis must be considered because of this combination?

  1. Gallstone impaction in the cystic duct
  2. Acute cholecystitis with empyema
  3. Chronic pancreatitis with pseudocyst
  4. Carcinoma of the head of the pancreas Correct answer.

Explanation

A palpable, non-tender gallbladder with obstructive jaundice suggests malignant distal biliary obstruction, classically pancreatic head carcinoma. Gallstone disease usually produces a fibrotic, non-distensible gallbladder.

Question 5General Surgery and Gastrointestinal Surgery

A 30-year-old woman has a 2 cm thyroid nodule. Fine needle aspiration is reported as Bethesda category III (atypia of undetermined significance). What is the most appropriate next step?

  1. Observation with annual ultrasound
  2. Repeat FNA or molecular testing Correct answer.
  3. Total thyroidectomy without further testing
  4. Radioiodine ablation

Explanation

Bethesda III carries a low but real malignancy risk and is managed by repeat sampling or molecular testing to guide surgery. Immediate total thyroidectomy over-treats an undetermined result.

Question 6General Surgery and Gastrointestinal Surgery

A 70-year-old man has a 5 cm abdominal aortic aneurysm. Which diameter threshold generally justifies elective repair in an average-risk man?

  1. 3.0 cm
  2. 7.0 cm
  3. 4.0 cm
  4. 5.5 cm Correct answer.

Explanation

Elective repair is offered at about 5.5 cm in men because rupture risk rises sharply above this size. Smaller aneurysms are surveilled because repair does not improve survival.

Question 7General Surgery and Gastrointestinal Surgery

A 45-year-old man has hematemesis and melena. Endoscopy shows a spurting ulcer in the duodenal bulb. After initial endoscopic therapy, which management most reduces rebleeding and mortality?

  1. Oral antacid every four hours
  2. Immediate total gastrectomy
  3. High-dose intravenous proton pump inhibitor Correct answer.
  4. Routine nasogastric lavage

Explanation

High-dose intravenous PPI after endoscopic hemostasis stabilizes the clot and reduces rebleeding. Endoscopic therapy is the primary hemostatic intervention, with PPI as adjunct.

Question 8General Surgery and Gastrointestinal Surgery

A 58-year-old woman has a 4 cm non-functioning pancreatic neuroendocrine tumor in the body of the pancreas without metastases. Which operation is most appropriate?

  1. Enucleation alone
  2. Whipple procedure
  3. Distal pancreatectomy with splenectomy Correct answer.
  4. Total pancreatectomy

Explanation

Tumors in the body and tail are best treated by distal pancreatectomy, often with splenectomy for oncologic clearance. Enucleation risks inadequate margins and duct injury.

Question 9General Surgery and Gastrointestinal Surgery

A 35-year-old man has a 2 cm nodule in the tail of the pancreas and a fasting glucose of 55 mg/dL with neuroglycopenic symptoms. Which finding confirms an insulinoma?

  1. High insulin with low glucose and high C-peptide Correct answer.
  2. Elevated serum gastrin
  3. High insulin with low C-peptide
  4. Elevated urinary metanephrines

Explanation

Insulinoma shows endogenous hyperinsulinism: high insulin and C-peptide with hypoglycemia. Suppressed C-peptide would instead suggest exogenous insulin.

Question 10General Surgery and Gastrointestinal Surgery

A 28-year-old woman has a 4 cm simple hepatic cyst found incidentally. She is asymptomatic and serology for hydatid disease is negative. What is the best management?

  1. Observation Correct answer.
  2. Percutaneous aspiration and sclerosis
  3. Laparoscopic deroofing
  4. Formal hepatic resection

Explanation

Asymptomatic simple hepatic cysts require no intervention; they are benign and rarely cause complications. Treatment is reserved for symptoms or complications.

Question 11General Surgery and Gastrointestinal Surgery

A 60-year-old man has a 5 cm hepatocellular carcinoma in a cirrhotic liver with preserved synthetic function and no extrahepatic disease. Which treatment offers the best chance of cure?

  1. Surgical resection Correct answer.
  2. Transarterial chemoembolization
  3. Systemic sorafenib
  4. Percutaneous ethanol injection

Explanation

Resection offers curative potential for a solitary tumor in a patient with adequate functional reserve. TACE and sorafenib are palliative or bridging therapies.

Question 12General Surgery and Gastrointestinal Surgery

A 50-year-old woman has right upper quadrant pain and fever. Ultrasound shows gallstones and a thickened gallbladder wall. Which finding best supports acute cholecystitis over biliary colic?

  1. Normal white cell count
  2. Presence of gallstones
  3. Postprandial pain relief
  4. Sonographic Murphy sign with wall thickening Correct answer.

Explanation

Acute cholecystitis is characterized by persistent pain, fever, and inflammatory changes including wall thickening and a positive sonographic Murphy sign. Gallstones alone occur in asymptomatic patients.

Question 13General Surgery and Gastrointestinal Surgery

A 65-year-old woman with a 3 cm distal rectal adenocarcinoma staged T3N1M0 is fit for surgery. Which approach is most appropriate?

  1. Wide local excision with adjuvant chemotherapy
  2. Local excision alone
  3. Emergency Hartmann procedure
  4. Neoadjuvant chemoradiotherapy then total mesorectal excision Correct answer.

Explanation

Locally advanced rectal cancer benefits from neoadjuvant chemoradiotherapy to downstage before total mesorectal excision, reducing local recurrence. Local excision is inadequate for T3 disease.

Question 14General Surgery and Gastrointestinal Surgery

A 30-year-old man has a 2 cm nodule in the right thyroid lobe. FNA shows papillary thyroid carcinoma. Which operation is standard for a tumor of this size with no nodal disease?

  1. Total thyroidectomy with modified radical neck dissection
  2. Radioiodine ablation without surgery
  3. Ipsilateral lobectomy only without lymph node assessment
  4. Hemithyroidectomy or total thyroidectomy Correct answer.

Explanation

For a small, low-risk papillary carcinoma, either hemithyroidectomy or total thyroidectomy may be appropriate depending on risk factors. Prophylactic radical neck dissection is not indicated without nodal disease.

Question 15General Surgery and Gastrointestinal Surgery

A 40-year-old man has a 3 cm firm, painless testicular mass. Tumor markers show elevated alpha-fetoprotein. What is the most likely diagnosis?

  1. Epididymal cyst
  2. Yolk sac tumor Correct answer.
  3. Seminoma
  4. Leydig cell tumor

Explanation

Elevated AFP points to a non-seminomatous germ cell tumor, classically yolk sac or mixed tumor. Pure seminoma does not raise AFP.

Question 16General Surgery and Gastrointestinal Surgery

A 25-year-old man has a stab wound to the left chest with hypotension and distended neck veins. Breath sounds are reduced on the left. What is the immediate priority?

  1. Pericardiocentesis
  2. Urgent CT scan
  3. Chest radiograph before any intervention
  4. Needle decompression of the left chest Correct answer.

Explanation

Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression before imaging. Delay for radiography risks cardiac arrest.

Question 17General Surgery and Gastrointestinal Surgery

A 70-year-old man has a 3 cm ulcerated lesion in the anal canal extending into the dentate line. Biopsy shows squamous cell carcinoma. Which treatment is first-line for localized disease?

  1. Local excision alone
  2. Abdominoperineal resection
  3. Chemoradiotherapy Correct answer.
  4. Inguinal lymph node dissection

Explanation

Squamous cell carcinoma of the anal canal is treated primarily with chemoradiotherapy, reserving surgery for salvage. This preserves sphincter function.

Question 18General Surgery and Gastrointestinal Surgery

A 50-year-old woman has a 2 cm solitary pulmonary nodule with a history of breast cancer. Which feature most increases the likelihood of malignancy?

  1. Smooth well-defined margins
  2. Stable size over 3 years
  3. Spiculated margins Correct answer.
  4. Diffuse calcification

Explanation

Spiculated margins suggest invasive growth and raise suspicion of malignancy. Stability over years and benign calcification favor a benign process.

Question 19General Surgery and Gastrointestinal Surgery

A 60-year-old man has a 4 cm tumor in the sigmoid colon obstructing the lumen. He is stable with no peritonitis. What is the most appropriate initial management?

  1. Self-expanding metallic stent as bridge to surgery Correct answer.
  2. Immediate Hartmann procedure
  3. Primary anastomosis without resection
  4. Chemotherapy alone

Explanation

A colonic stent relieves obstruction and allows optimization before elective resection, reducing stoma rates. Emergency surgery is reserved for perforation or peritonitis.

Question 20General Surgery and Gastrointestinal Surgery

A 35-year-old woman has a 3 cm cystic lesion in the liver. Serology for Echinococcus is positive. What is the most appropriate management?

  1. Albendazole with puncture-aspiration-injection-reaspiration Correct answer.
  2. Immediate resection without antiparasitic therapy
  3. Percutaneous aspiration alone
  4. Observation

Explanation

Hydatid cysts are managed with albendazole plus PAIR to reduce spillage risk and recurrence. Aspiration alone risks anaphylaxis and dissemination.

Question 21General Surgery and Gastrointestinal Surgery

A 55-year-old man has a 6 cm pancreatic head mass with jaundice and weight loss. CT shows no vascular involvement or metastases. Which operation is indicated?

  1. Total pancreatectomy
  2. Bypass gastrojejunostomy only
  3. Distal pancreatectomy
  4. Pancreaticoduodenectomy Correct answer.

Explanation

Resectable tumors of the pancreatic head are treated by pancreaticoduodenectomy (Whipple). Bypass is reserved for unresectable disease.

Question 22General Surgery and Gastrointestinal Surgery

A 45-year-old woman has a 2 cm papillary thyroid carcinoma and undergoes total thyroidectomy. Which finding on final pathology most increases recurrence risk?

  1. Lymphovascular invasion Correct answer.
  2. Unifocal disease
  3. Encapsulated tumor
  4. Tumor size 2 cm

Explanation

Lymphovascular invasion is an adverse prognostic feature associated with higher recurrence. Tumor size and encapsulation alone are less predictive.

Question 23General Surgery and Gastrointestinal Surgery

A 60-year-old man has a 5 cm abdominal aortic aneurysm and presents with sudden severe abdominal and back pain and hypotension. What is the most likely diagnosis?

  1. Ruptured abdominal aortic aneurysm Correct answer.
  2. Acute pancreatitis
  3. Mesenteric ischemia
  4. Renal colic

Explanation

Sudden pain with hypotension in a patient with a known large aneurysm strongly suggests rupture. Immediate operative management is required.

Question 24General Surgery and Gastrointestinal Surgery

A 50-year-old man has a 1 cm nodule in the tail of the pancreas and symptoms of hypoglycemia relieved by glucose. Which imaging modality best localizes the lesion?

  1. Plain radiograph
  2. Endoscopic ultrasound Correct answer.
  3. Contrast-enhanced CT
  4. MRI with gadolinium

Explanation

Endoscopic ultrasound is highly sensitive for small pancreatic neuroendocrine tumors and allows biopsy. CT and MRI are useful but less sensitive for lesions under 1 cm.

Question 25General Surgery and Gastrointestinal Surgery

A 65-year-old woman has a 2 cm distal rectal tumor staged T1N0. She declines major surgery. Which option is most appropriate?

  1. Abdominoperineal resection
  2. Chemoradiotherapy alone
  3. Observation
  4. Local excision if favorable features Correct answer.

Explanation

Selected T1N0 tumors with favorable histology may be treated by local excision when major surgery is declined. Abdominoperineal resection is excessive for early disease.

Question 26General Surgery and Gastrointestinal Surgery

A 45-year-old man has a 2.5 cm gallstone impacted in the infundibulum of the gallbladder, causing constant right upper quadrant pain. Murphy sign is positive and ultrasound shows a thickened gallbladder wall with pericholecystic fluid. What is the most appropriate management?

  1. Percutaneous cholecystostomy followed by interval cholecystectomy
  2. Discharge with oral ursodeoxycholic acid and review in 6 weeks
  3. Endoscopic retrograde cholangiopancreatography with sphincterotomy
  4. Laparoscopic cholecystectomy during the same admission Correct answer.

Explanation

Acute calculous cholecystitis in a fit patient is treated by early laparoscopic cholecystectomy, ideally within 72 hours of presentation, because delayed surgery carries higher rates of readmission and conversion.

Question 27General Surgery and Gastrointestinal Surgery

A 62-year-old woman has a 1.5 cm gastric submucosal lesion found on endoscopy. Endoscopic ultrasound shows a homogeneous hypoechoic mass arising from the muscularis propria, and biopsy confirms a gastrointestinal stromal tumor (GIST). What is the most important prognostic factor for this tumor?

  1. Serum carcinoembryonic antigen level
  2. Helicobacter pylori status
  3. Tumor size and mitotic rate Correct answer.
  4. Presence of mucosal ulceration

Explanation

Risk stratification of GIST relies on tumor size and mitotic index, which together predict recurrence and guide adjuvant imatinib therapy.

Question 28General Surgery and Gastrointestinal Surgery

A 38-year-old man presents 6 hours after a blunt abdominal injury with generalized peritonitis. CT shows free fluid and a grade III splenic laceration. He is tachycardic at 120/min and hypotensive despite 2 L of crystalloid. What is the most appropriate next step?

  1. Non-operative management with repeat CT in 6 hours
  2. Splenic artery embolization
  3. Diagnostic peritoneal lavage before any decision
  4. Emergency laparotomy Correct answer.

Explanation

Hemodynamic instability with peritonitis after blunt splenic trauma mandates immediate laparotomy; non-operative pathways apply only to stable patients.

Question 29General Surgery and Gastrointestinal Surgery

A 55-year-old man has a 2 cm villous adenoma in the mid-rectum with a small focus of invasive adenocarcinoma extending into the submucosa. The polyp was removed piecemeal. What is the most appropriate management?

  1. Topical 5-fluorouracil therapy
  2. Formal oncologic rectal resection Correct answer.
  3. Repeat snare polypectomy in 3 months
  4. Surveillance sigmoidoscopy in 1 year

Explanation

A malignant polyp removed piecemeal cannot be assessed for margin clearance, so oncologic resection is required; piecemeal excision alone is inadequate for invasive cancer.

Question 30General Surgery and Gastrointestinal Surgery

A 30-year-old man has a 3 cm firm mass in the left lobe of the liver. Serum alpha-fetoprotein is normal and hepatitis serology is negative. Biopsy shows a well-differentiated hepatocellular adenoma. What is the most appropriate management?

  1. Surgical resection Correct answer.
  2. Systemic chemotherapy
  3. Observation with annual ultrasound
  4. Radiofrequency ablation

Explanation

Hepatocellular adenomas larger than 5 cm are resected for rupture and malignant transformation risk, but even smaller adenomas in men are generally resected because male sex is an independent risk factor for malignancy.

Question 31General Surgery and Gastrointestinal Surgery

A 70-year-old man has a 2 cm ulcerated squamous cell carcinoma of the anal margin that does not involve the sphincter complex. There is no inguinal lymphadenopathy. What is the most appropriate initial treatment?

  1. Abdominoperineal resection
  2. Chemoradiotherapy with mitomycin and 5-fluorouracil
  3. Wide local excision Correct answer.
  4. Inguinal lymph node dissection

Explanation

Small, well-differentiated anal margin tumors that do not involve the sphincter are treated by wide local excision with clear margins, preserving continence.

Question 32General Surgery and Gastrointestinal Surgery

A 48-year-old woman has a 3 cm mass in the body of the pancreas. She has episodic confusion relieved by eating, and a fasting glucose of 40 mg/dL with a raised insulin level. What is the most appropriate management?

  1. Dietary modification with frequent small meals
  2. Diazoxide therapy as definitive treatment
  3. Surgical resection of the pancreatic lesion Correct answer.
  4. Observation with annual fasting glucose

Explanation

An insulinoma is the most common functioning pancreatic neuroendocrine tumor and is cured by surgical enucleation or resection; medical therapy is only for patients unfit for surgery.

Question 33General Surgery and Gastrointestinal Surgery

A 60-year-old man has a 4 cm mass in the head of the pancreas with painless jaundice. CT shows a dilated pancreatic duct and common bile duct, and a double-duct sign. What does this finding most suggest?

  1. Pancreatic head adenocarcinoma Correct answer.
  2. Pancreatic pseudocyst
  3. Chronic pancreatitis
  4. Serous cystadenoma

Explanation

Simultaneous dilation of both the pancreatic and bile ducts, the double-duct sign, is highly suggestive of a pancreatic head malignancy obstructing both ducts.

Question 34General Surgery and Gastrointestinal Surgery

A 52-year-old woman has a 2 cm nodule in the left thyroid lobe. FNA is reported as follicular neoplasm. She is euthyroid and has no lymphadenopathy. What is the most appropriate next step?

  1. Diagnostic hemithyroidectomy Correct answer.
  2. Total thyroidectomy with central neck dissection
  3. Repeat FNA in 6 months
  4. Radioactive iodine ablation

Explanation

FNA cannot distinguish follicular adenoma from follicular carcinoma because the diagnosis depends on capsular or vascular invasion, so diagnostic hemithyroidectomy is required.

Question 35General Surgery and Gastrointestinal Surgery

A 65-year-old man has a 3 cm distal rectal adenocarcinoma staged T2N0M0. He is fit for surgery. What is the most appropriate operation?

  1. Low anterior resection with total mesorectal excision Correct answer.
  2. Local excision with transanal endoscopic microsurgery
  3. Hartmann procedure
  4. Abdominoperineal resection

Explanation

A T2 distal rectal cancer in a fit patient is treated by anterior resection with total mesorectal excision, which provides adequate oncologic clearance while preserving the sphincter when feasible.

Question 36General Surgery and Gastrointestinal Surgery

A 40-year-old man has a 2 cm firm, painless mass in the right testis. Ultrasound shows a solid intratesticular lesion and serum alpha-fetoprotein is elevated. What is the most appropriate initial management?

  1. Inguinal lymph node dissection
  2. Systemic chemotherapy before any surgery
  3. Radical inguinal orchiectomy Correct answer.
  4. Transscrotal biopsy

Explanation

A solid intratesticular mass is presumed malignant and treated by radical inguinal orchiectomy, which provides diagnosis and local control; scrotal violation risks altering lymphatic drainage.

Question 37General Surgery and Gastrointestinal Surgery

A 58-year-old man has a 1 cm nodule in the tail of the pancreas and symptoms of hypoglycemia relieved by glucose. What is the most likely diagnosis?

  1. Gastrinoma
  2. Glucagonoma
  3. Insulinoma Correct answer.
  4. VIPoma

Explanation

Insulinoma causes fasting hypoglycemia with neuroglycopenic symptoms that improve with glucose; it is the most common functioning pancreatic neuroendocrine tumor.

Question 38General Surgery and Gastrointestinal Surgery

A 50-year-old man has a 1 cm nodule in the tail of the pancreas. He has symptoms of hypoglycemia relieved by glucose and elevated insulin and C-peptide levels. What is the most appropriate management?

  1. Diazoxide therapy as definitive treatment
  2. Observation with annual fasting glucose
  3. Surgical resection of the pancreatic lesion Correct answer.
  4. Dietary modification with frequent small meals

Explanation

An insulinoma is the most common functioning pancreatic neuroendocrine tumor and is cured by surgical enucleation or resection; medical therapy is reserved for patients unfit for surgery.

Question 39General Surgery and Gastrointestinal Surgery

A 70-year-old man has a 2 cm ulcerated lesion in the anal canal extending into the dentate line. Biopsy shows squamous cell carcinoma. What is the most appropriate initial treatment?

  1. Wide local excision
  2. Abdominoperineal resection
  3. Inguinal lymph node dissection
  4. Chemoradiotherapy with mitomycin and 5-fluorouracil Correct answer.

Explanation

Squamous cell carcinoma of the anal canal is treated primarily with chemoradiotherapy, which achieves sphincter preservation and good local control; surgery is reserved for salvage.

Question 40General Surgery and Gastrointestinal Surgery

A 55-year-old man has a 2 cm gastric ulcer with a raised, irregular edge. Biopsy shows adenocarcinoma limited to the mucosa with no lymphovascular invasion. What is the most appropriate management?

  1. Partial gastrectomy with D2 lymphadenectomy
  2. Endoscopic submucosal dissection Correct answer.
  3. Chemotherapy followed by surgery
  4. Observation with repeat endoscopy in 6 months

Explanation

Early gastric cancer confined to the mucosa without lymphovascular invasion has a very low risk of nodal metastasis and can be treated by endoscopic submucosal dissection, preserving the stomach.

Question 41Hepatobiliary, Pancreatic and Splenic Surgery

A 45-year-old woman has symptomatic gallstones and undergoes laparoscopic cholecystectomy. During dissection of the triangle of Calot, which structure must be positively identified and clipped before dividing the cystic duct?

  1. Common bile duct
  2. Cystic duct Correct answer.
  3. Right hepatic duct
  4. Cystic artery

Explanation

The critical view of safety requires clear identification of the cystic duct and cystic artery entering the gallbladder before any structure is clipped or divided. The cystic duct is the structure that drains the gallbladder and is ligated at cholecystectomy. Mistaking the common bile duct for the cystic duct risks major bile duct injury.

Question 42Hepatobiliary, Pancreatic and Splenic Surgery

Which finding on abdominal ultrasound is the most reliable indicator of acute cholecystitis?

  1. A single large gallstone of 3 cm
  2. Postprandial gallbladder contraction
  3. Gallbladder wall thickening with pericholecystic fluid Correct answer.
  4. Presence of multiple gallstones

Explanation

Acute cholecystitis produces mural edema and inflammation, seen as wall thickening and pericholecystic fluid on ultrasound. The mere presence of stones indicates cholelithiasis, which is often asymptomatic. Wall thickening plus a sonographic Murphy sign supports the diagnosis of acute inflammation.

Question 43Hepatobiliary, Pancreatic and Splenic Surgery

A 60-year-old man presents with painless jaundice and a palpable gallbladder (Courvoisier sign). Which diagnosis should be suspected?

  1. Gallstone impaction in the cystic duct
  2. Chronic cholecystitis with a shrunken gallbladder
  3. Periampullary or pancreatic head malignancy Correct answer.
  4. Acute calculous cholecystitis

Explanation

A palpable, non-tender gallbladder with painless jaundice suggests malignant obstruction of the distal bile duct, typically periampullary or pancreatic head cancer. Chronic stone disease usually produces a fibrotic, non-distensible gallbladder that cannot dilate. This is the basis of Courvoisier law.

Question 44Hepatobiliary, Pancreatic and Splenic Surgery

Which of the following is the most common cause of acute pancreatitis worldwide?

  1. Hypertriglyceridemia
  2. Endoscopic retrograde cholangiopancreatography
  3. Alcohol
  4. Gallstones Correct answer.

Explanation

Gallstones and alcohol are the two leading causes of acute pancreatitis, with gallstones being the most frequent overall. Stone passage transiently obstructs the ampulla, triggering pancreatic autodigestion. Identifying the cause guides management, including cholecystectomy for gallstone pancreatitis.

Question 45Hepatobiliary, Pancreatic and Splenic Surgery

A hemodynamically stable patient has a Grade III splenic laceration on CT after blunt trauma with no active contrast extravasation. What is the most appropriate initial management?

  1. Splenic artery embolization in all cases
  2. Diagnostic peritoneal lavage
  3. Nonoperative management with observation Correct answer.
  4. Immediate splenectomy

Explanation

Hemodynamically stable patients with blunt splenic injury and no active bleeding are managed nonoperatively with monitoring. Preservation of the spleen maintains immunologic function and avoids operative risk. Embolization is reserved for specific findings such as contrast blush or pseudoaneurysm.

Question 46Hepatobiliary, Pancreatic and Splenic Surgery

Which tumor marker is most useful in the follow-up of patients treated for pancreatic ductal adenocarcinoma?

  1. Carcinoembryonic antigen
  2. Alpha-fetoprotein
  3. CA 19-9 Correct answer.
  4. CA 125

Explanation

CA 19-9 is the most widely used serum marker in pancreatic adenocarcinoma and correlates with disease burden and recurrence. It lacks sufficient sensitivity and specificity for screening but is valuable for monitoring. Alpha-fetoprotein and CA 125 are used for other malignancies.

Question 47Hepatobiliary, Pancreatic and Splenic Surgery

A 55-year-old woman has a 2.5 cm gallbladder polyp on ultrasound. Which feature most strongly suggests malignancy and warrants cholecystectomy?

  1. Multiple small polyps of 4 mm
  2. A polyp that decreases in size on repeat scan
  3. A sessile polyp with irregular margins and internal vascularity Correct answer.
  4. A polyp in a patient with a family history of gallstones

Explanation

Polyp size over 1 cm, sessile morphology, irregular borders, and internal vascularity raise concern for malignancy. These features warrant cholecystectomy with oncologic intent. Small, stable, or regressing polyps are typically benign and can be observed.

Question 48Hepatobiliary, Pancreatic and Splenic Surgery

A patient develops fever, jaundice, and right upper quadrant pain with hypotension and confusion. What is the most urgent initial priority in management?

  1. Elective cholecystectomy in six weeks
  2. Oral ursodeoxycholic acid therapy
  3. Immediate open common bile duct exploration
  4. Resuscitation and antibiotics with biliary drainage Correct answer.

Explanation

This presentation is ascending cholangitis with sepsis (Charcot triad plus hypotension and altered mental status, i.e., Reynolds pentad). Initial management is hemodynamic resuscitation, broad-spectrum antibiotics, and urgent biliary decompression by ERCP. Definitive stone clearance follows once the patient stabilizes.

Question 49Hepatobiliary, Pancreatic and Splenic Surgery

During laparoscopic cholecystectomy, a patient develops a major bile duct injury recognized intraoperatively. Which factor most strongly determines long-term outcome?

  1. Immediate repair over a T-tube by the operating surgeon
  2. Placement of a percutaneous drain alone
  3. Prompt recognition and repair by an experienced hepatobiliary surgeon Correct answer.
  4. Delayed repair after six months regardless of presentation

Explanation

Outcomes after bile duct injury depend heavily on early recognition and repair by an experienced hepatobiliary surgeon, preferably with a Roux-en-Y hepaticojejunostomy. Inexperienced or delayed repair increases the risk of stricture and reintervention. Adequate drainage of sepsis is also important but does not replace definitive expert repair.

Question 50Hepatobiliary, Pancreatic and Splenic Surgery

A patient has a 1.5 cm stone in the common bile duct with a normal gallbladder on imaging and no prior cholecystectomy. What is the most appropriate management?

  1. Percutaneous transhepatic cholangiography with stone removal
  2. Long-term ursodeoxycholic acid
  3. ERCP with sphincterotomy and stone extraction followed by cholecystectomy Correct answer.
  4. Observation with repeat imaging in one year

Explanation

Common bile duct stones are managed by endoscopic extraction, usually with sphincterotomy, followed by cholecystectomy to prevent recurrence. Leaving the gallbladder in place after duct clearance risks further stone migration. Surgery is performed once the duct is cleared.