A 64-year-old woman with known gallstones is admitted with 2 days of right upper quadrant pain, fever with rigors and jaundice. Over 6 hours she becomes drowsy and confused; BP is 82/50 mmHg despite 2 L of IV fluid and IV antibiotics. Bilirubin is 6.8 mg/dL and ALP 640 U/L. Ultrasound shows a CBD of 13 mm with a distal stone. What is the next best step?

Urgent ERCP with biliary drainage

MRCP to confirm the CBD stone first

Early laparoscopic cholecystectomy

A 61-year-old man with symptomatic gallstones is booked for cholecystectomy. Bilirubin is 2.4 mg/dL, ALP is raised, and ultrasound shows a CBD of 8 mm but no stone in the duct. He has no fever. What is the most appropriate next step?

Cholecystectomy without further tests

ERCP with sphincterotomy straightaway

A 32-year-old farmer from Uttar Pradesh has had two episodes of variceal bleeding. He has massive splenomegaly, normal LFTs and no ascites. Doppler shows a patent portal vein and hepatic veins. Hepatic venous pressure gradient is 6 mmHg (normal up to 5), and liver biopsy shows no cirrhosis. What is the most likely diagnosis?

Extrahepatic portal vein obstruction

A 44-year-old woman is admitted with right upper quadrant pain, fever and a positive Murphy sign for 36 hours. Ultrasound shows gallstones, a thick gallbladder wall and pericholecystic fluid; the CBD is 5 mm and LFTs are normal. She is otherwise healthy. What is the best management?

Laparoscopic cholecystectomy during this admission

Antibiotics now and cholecystectomy after 6 weeks

Gallstones, CBD stones, liver abscess and portal hypertension

37 NEET-PG practice questions on Gallstones, CBD stones, liver abscess and portal hypertension, part of General Surgery. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Hard
A 64-year-old woman with known gallstones is admitted with 2 days of right upper quadrant pain, fever with rigors and jaundice. Over 6 hours she becomes drowsy and confused; BP is 82/50 mmHg despite 2 L of IV fluid and IV antibiotics. Bilirubin is 6.8 mg/dL and ALP 640 U/L. Ultrasound shows a CBD of 13 mm with a distal stone. What is the next best step?
1. AEmergency open CBD exploration
2. BMRCP to confirm the CBD stone first
3. CUrgent ERCP with biliary drainage
4. DEarly laparoscopic cholecystectomy
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Answer: C · Urgent ERCP with biliary drainage
Pain, fever and jaundice (Charcot triad) with hypotension and confusion (Reynolds pentad) is severe (Tokyo grade III) acute cholangitis from an obstructing CBD stone. Pus under pressure in the bile ducts drives bacteraemia, so after resuscitation and antibiotics the duct must be drained urgently. Endoscopic drainage (ERCP with sphincterotomy, stone extraction or a stent or nasobiliary drain) is the first choice; percutaneous transhepatic drainage is the fallback if ERCP fails. Cholecystectomy is done later, once she has recovered.
- A: Open surgery in a septic, shocked patient has much higher mortality than endoscopic drainage.
- B: Ultrasound already shows the dilated duct and stone; MRCP only delays drainage.
- D: Removing the gallbladder does not drain the obstructed, infected CBD.
Question 2 · Medium
A 61-year-old man with symptomatic gallstones is booked for cholecystectomy. Bilirubin is 2.4 mg/dL, ALP is raised, and ultrasound shows a CBD of 8 mm but no stone in the duct. He has no fever. What is the most appropriate next step?
1. ACholecystectomy without further tests
2. BContrast CT of the abdomen
3. CMRCP or endoscopic ultrasound
4. DERCP with sphincterotomy straightaway
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Answer: C · MRCP or endoscopic ultrasound
Suspected choledocholithiasis is graded by risk. A stone seen in the CBD, cholangitis, or bilirubin over 4 mg/dL with a dilated duct is high risk and goes straight to ERCP. Abnormal LFTs, a dilated duct or age over 55, without these, is intermediate risk; here MRCP or EUS confirms or excludes a stone first, sparing many patients an unnecessary ERCP and its risk of pancreatitis. If a stone is found, ERCP or duct exploration follows, with cholecystectomy.
- A: Operating without clarifying the duct risks a retained stone.
- B: CT is less sensitive than MRCP or EUS for duct stones.
- D: Diagnostic ERCP exposes patients without stones to pancreatitis and bleeding.
Question 3 · Medium
A 47-year-old woman had a cholecystectomy 6 months ago and now has recurrent biliary-type pain with mildly raised ALP. MRCP is normal, but clinical suspicion of a small CBD stone remains. Which investigation is the most sensitive for small CBD stones?
1. ATransabdominal ultrasound
2. BContrast-enhanced CT
3. CRepeat MRCP after 1 week
4. DEndoscopic ultrasound
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Answer: D · Endoscopic ultrasound
Endoscopic ultrasound places a high-frequency probe in the duodenum, close to the distal CBD, and is the most sensitive non-invasive test for small (under about 5 mm) duct stones and sludge, which MRCP can miss. It has a much lower risk than diagnostic ERCP. If EUS shows a stone, ERCP with clearance can follow in the same session. Transabdominal ultrasound often misses distal duct stones because of bowel gas.
- A: Transabdominal ultrasound often misses distal CBD stones.
- B: CT misses many non-calcified duct stones.
- C: Repeating MRCP does not overcome its limit with small stones.
Question 4 · Medium
A 32-year-old farmer from Uttar Pradesh has had two episodes of variceal bleeding. He has massive splenomegaly, normal LFTs and no ascites. Doppler shows a patent portal vein and hepatic veins. Hepatic venous pressure gradient is 6 mmHg (normal up to 5), and liver biopsy shows no cirrhosis. What is the most likely diagnosis?
1. AExtrahepatic portal vein obstruction
2. BNon-cirrhotic portal fibrosis
3. CCompensated cirrhosis
4. DBudd-Chiari syndrome
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Answer: B · Non-cirrhotic portal fibrosis
Non-cirrhotic portal fibrosis (idiopathic non-cirrhotic portal hypertension) is a presinusoidal cause of portal hypertension seen in young Indian adults, with variceal bleeding, massive splenomegaly and preserved liver function. Because the obstruction is in the small portal radicles before the sinusoids, the wedged hepatic venous pressure, and so the HVPG, stays normal or only slightly raised despite marked portal hypertension. In cirrhosis, the resistance is sinusoidal and the HVPG is high (10 mmHg or more is clinically significant).
- A: EHPVO needs a thrombosed portal vein, which is patent here.
- C: Cirrhosis raises the HVPG and is excluded by biopsy.
- D: Budd-Chiari needs blocked hepatic veins, which are patent here.
Question 5 · Medium
A 44-year-old woman is admitted with right upper quadrant pain, fever and a positive Murphy sign for 36 hours. Ultrasound shows gallstones, a thick gallbladder wall and pericholecystic fluid; the CBD is 5 mm and LFTs are normal. She is otherwise healthy. What is the best management?
1. ALaparoscopic cholecystectomy during this admission
2. BPercutaneous cholecystostomy
3. CAntibiotics now and cholecystectomy after 6 weeks
4. DERCP with sphincterotomy
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Answer: A · Laparoscopic cholecystectomy during this admission
This is acute calculous cholecystitis in a fit patient. Early laparoscopic cholecystectomy, ideally within 72 hours of admission and within about a week of symptom onset, is preferred: it has similar complication rates to delayed surgery, a shorter total hospital stay and avoids recurrent attacks while waiting. Antibiotics and analgesia are given meanwhile. Delayed (interval) surgery is kept for late presenters or those unfit at the time.
- B: Cholecystostomy is for patients too ill for surgery.
- C: Waiting 6 weeks risks recurrent attacks and readmission.
- D: ERCP is for duct stones; her duct and LFTs are normal.
Question 6 · Easy
A 58-year-old woman in a district hospital has right upper quadrant pain, fever with rigors and yellow eyes for 2 days. She is alert, with BP 124/80 mmHg. Ultrasound shows a dilated common bile duct. What condition does this triad of findings indicate?
1. AAcute cholangitis
2. BAcute calculous cholecystitis
3. CAcute viral hepatitis
4. DAcute pancreatitis
Answer and explanation in LearnFree account
Question 7 · Medium
A 55-year-old man with cirrhosis continues to bleed from oesophageal varices despite terlipressin, antibiotics and two sessions of endoscopic band ligation within 24 hours. A balloon tamponade tube has been placed and he is stabilising. What is the definitive rescue treatment?
1. AEmergency oesophageal transection
2. BTransjugular intrahepatic portosystemic shunt
3. COral propranolol
4. DThird attempt at band ligation
Answer and explanation in LearnFree account
Question 8 · Easy
A 34-year-old man in Kerala who drinks toddy daily has fever and right upper quadrant pain for 2 weeks. Ultrasound shows a single 6 cm hypoechoic lesion in the right lobe of the liver, and Entamoeba histolytica serology is positive. What is the drug of choice?
1. AMetronidazole
2. BDiloxanide furoate
3. CChloroquine alone
4. DAlbendazole
Answer and explanation in LearnFree account
Question 9 · Medium
A 38-year-old man has been in the burns ICU for 3 weeks with 45% burns, on parenteral nutrition and noradrenaline. He develops fever and right upper quadrant tenderness. Ultrasound shows a distended gallbladder with a 5 mm thick wall and pericholecystic fluid, and no stones. What is the most likely diagnosis?
1. AAcute acalculous cholecystitis
2. BEmphysematous cholecystitis
3. CAcute cholangitis
4. DGallbladder carcinoma
Answer and explanation in LearnFree account
Question 10 · Hard
A 56-year-old woman with alcohol-related cirrhosis is assessed before an elective umbilical hernia repair. Results: bilirubin 2.4 mg/dL, albumin 3.1 g/dL, INR 1.5, mild ascites controlled with diuretics, and no encephalopathy. What is her Child-Pugh class and score?
1. AClass C, 10 points
2. BClass B, 8 points
3. CClass B, 9 points
4. DClass A, 6 points
Answer and explanation in LearnFree account
Question 11 · Medium
A 6-year-old boy on day 8 of high-dose IV ceftriaxone for bacterial meningitis develops right upper quadrant pain. Ultrasound shows echogenic sludge with acoustic shadowing in the gallbladder; LFTs are normal and he has no fever from a new source. What is the most likely explanation?
1. ACholesterol stones from rapid weight loss
2. BAcalculous cholecystitis from sepsis
3. CPrecipitation of ceftriaxone-calcium in bile
4. DPigment stones from haemolysis
Answer and explanation in LearnFree account
Question 12 · Hard
A 49-year-old man has a variceal bleed controlled with terlipressin and band ligation 12 hours ago. Results: bilirubin 3.6 mg/dL, albumin 2.6 g/dL, INR 1.9, mild ascites on ultrasound, and no encephalopathy. He has no contraindication to TIPS. What is the best next step?
1. APre-emptive TIPS within 72 hours
2. BBalloon tamponade for 24 hours
3. COral propranolol alone from today
4. DTerlipressin for 5 days, then beta-blocker with ligation
Answer and explanation in LearnFree account
Question 13 · Medium
An 84-year-old man with severe heart failure (ejection fraction 20%) has acute calculous cholecystitis. After 48 hours of IV antibiotics he remains febrile and hypotensive, and the anaesthetist judges him unfit for general anaesthesia. What is the best next step?
1. APercutaneous cholecystostomy
2. BSwitch to a broader antibiotic and wait
3. CERCP with sphincterotomy
4. DEmergency open cholecystectomy
Answer and explanation in LearnFree account
Question 14 · Medium
A 42-year-old woman is about to undergo ERCP for CBD stone extraction. She has had post-ERCP pancreatitis before. She has no kidney disease or allergy to NSAIDs. Which drug given rectally just before or after the procedure reduces her risk of pancreatitis?
1. AIndomethacin
2. BOctreotide
3. CPantoprazole
4. DHyoscine butylbromide
Answer and explanation in LearnFree account
Question 15 · Medium
A surgical resident is doing her first laparoscopic cholecystectomy under supervision. Which step best protects against injury to the common bile duct?
1. AAchieving the critical view of safety before clipping
2. BRoutine on-table cholangiography in every case
3. CDissecting from the cystic duct towards the CBD
4. DUsing a fourth port for retraction
Answer and explanation in LearnFree account
Question 16 · Medium
A 30-year-old man from a coastal village in Karnataka has had fever and a dull ache in the right upper abdomen for 12 days. He has tender hepatomegaly and tenderness in the right lower intercostal spaces. Ultrasound shows a single 7 cm hypoechoic lesion in the posterosuperior part of the right lobe. He has no biliary disease. What is the most likely diagnosis?
1. AAmoebic liver abscess
2. BHydatid cyst of the liver
3. CPyogenic liver abscess
4. DHepatocellular carcinoma
Answer and explanation in LearnFree account
Question 17 · Hard
A 9-year-old girl with extrahepatic portal vein obstruction has had three variceal bleeds despite regular band ligation, with massive splenomegaly, platelets 48,000/µL and poor growth. Imaging shows a patent left portal vein in the Rex recess and a usable superior mesenteric vein. Which operation is most appropriate?
1. AMeso-Rex bypass
2. BSplenectomy alone
3. CDistal splenorenal shunt
4. DTIPS
Answer and explanation in LearnFree account
Question 18 · Medium
A 50-year-old man with alcohol-related cirrhosis has recovered from his first variceal bleed. Before discharge, the team discusses his secondary prophylaxis: 1. A non-selective beta-blocker combined with repeated band ligation. 2. Sclerotherapy is preferred over band ligation. 3. Band ligation is repeated every 2-4 weeks until the varices are eradicated. 4. If he rebleeds despite this, TIPS should be considered. Which statements are correct?
1. A3 and 4 only
2. B1, 3 and 4 only
3. C1, 2 and 3 only
4. D2 and 4 only
Answer and explanation in LearnFree account
Question 19 · Medium
A 13-year-old girl has recurrent jaundice, splenomegaly and biliary colic. Her mother had a splenectomy. Blood film shows many spherocytes, and osmotic fragility is increased. Ultrasound shows multiple small gallstones. What type of gallstone does she most likely have?
1. ABlack pigment stones
2. BPure cholesterol stones
3. CCalcium carbonate stones
4. DBrown pigment stones
Answer and explanation in LearnFree account
Question 20 · Hard
A 63-year-old man with a CBD stone and bilirubin 14 mg/dL is being prepared for surgery at a medical college hospital after a failed ERCP. Consider: 1. A prolonged prothrombin time should correct with parenteral vitamin K. 2. He is at higher risk of postoperative acute kidney injury. 3. His pruritus is due to retained bile salts. 4. Wound healing and resistance to infection are impaired. Which statements are correct?
1. A2 and 3 only
2. B1, 2, 3 and 4
3. C1, 3 and 4 only
4. D1, 2 and 3 only
Answer and explanation in LearnFree account
Question 21 · Hard
A 54-year-old man with poorly controlled diabetes has fever for 10 days. CT shows a single 6 cm gas-free liver abscess, and he now complains of a painful red left eye with blurred vision. Blood culture grows a Gram-negative bacillus whose colonies form a viscous string over 5 mm when touched with a loop. Which organism is most likely?
1. AEscherichia coli
2. BHypervirulent Klebsiella pneumoniae
3. CStaphylococcus aureus
4. DBurkholderia pseudomallei
Answer and explanation in LearnFree account
Question 22 · Medium
A 52-year-old woman has jaundice and right upper quadrant pain. Ultrasound and MRCP show a large stone impacted in the neck of the gallbladder, with dilated common hepatic and intrahepatic ducts but a normal-calibre lower CBD and no stone within the duct. What is the most likely diagnosis?
1. AMirizzi syndrome
2. BPrimary sclerosing cholangitis
3. CCholedochal cyst
4. DKlatskin tumour
Answer and explanation in LearnFree account
Question 23 · Medium
Two weeks after a TIPS for refractory ascites, a 58-year-old man with cirrhosis becomes confused and drowsy, with a flapping tremor. He has no bleeding, fever or new drug. What is the most likely cause?
1. AIntracranial bleed from coagulopathy
2. BHepatic encephalopathy from shunted portal blood
3. CHyponatraemia from diuretic overuse
4. DStent thrombosis with rebleeding
Answer and explanation in LearnFree account
Question 24 · Easy
A 42-year-old woman has had recurrent episodes of right upper quadrant pain lasting 2-3 hours after heavy meals, radiating to the right shoulder blade. Between attacks she is well and her LFTs are normal. What is the investigation of choice?
1. AUltrasound of the abdomen
2. BPlain X-ray of the abdomen
3. COral cholecystography
4. DMRCP
Answer and explanation in LearnFree account
Question 25 · Medium
A 66-year-old woman with diabetes, who had ERCP for CBD stones a year ago, has fever with rigors and right upper quadrant pain. CT shows a 7 cm multiloculated liver abscess with a liquefied centre. Blood cultures grow E. coli. She is stable. What is the best management?
1. AIV antibiotics alone for 6 weeks
2. BIV antibiotics with percutaneous catheter drainage
3. COpen surgical drainage of the abscess
4. DRight hepatectomy
Answer and explanation in LearnFree account

12 more Gallstones, CBD stones, liver abscess and portal hypertension questions

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Gallstones, CBD stones, liver abscess and portal hypertension

A 61-year-old man with symptomatic gallstones is booked for cholecystectomy. Bilirubin is 2.4 mg/dL, ALP is raised, and ultrasound shows a CBD of 8 mm but no stone in the duct. He has no fever. What is the most appropriate next step?

A 47-year-old woman had a cholecystectomy 6 months ago and now has recurrent biliary-type pain with mildly raised ALP. MRCP is normal, but clinical suspicion of a small CBD stone remains. Which investigation is the most sensitive for small CBD stones?

A 44-year-old woman is admitted with right upper quadrant pain, fever and a positive Murphy sign for 36 hours. Ultrasound shows gallstones, a thick gallbladder wall and pericholecystic fluid; the CBD is 5 mm and LFTs are normal. She is otherwise healthy. What is the best management?

A 58-year-old woman in a district hospital has right upper quadrant pain, fever with rigors and yellow eyes for 2 days. She is alert, with BP 124/80 mmHg. Ultrasound shows a dilated common bile duct. What condition does this triad of findings indicate?

A 55-year-old man with cirrhosis continues to bleed from oesophageal varices despite terlipressin, antibiotics and two sessions of endoscopic band ligation within 24 hours. A balloon tamponade tube has been placed and he is stabilising. What is the definitive rescue treatment?

A 34-year-old man in Kerala who drinks toddy daily has fever and right upper quadrant pain for 2 weeks. Ultrasound shows a single 6 cm hypoechoic lesion in the right lobe of the liver, and Entamoeba histolytica serology is positive. What is the drug of choice?

A 56-year-old woman with alcohol-related cirrhosis is assessed before an elective umbilical hernia repair. Results: bilirubin 2.4 mg/dL, albumin 3.1 g/dL, INR 1.5, mild ascites controlled with diuretics, and no encephalopathy. What is her Child-Pugh class and score?

A 6-year-old boy on day 8 of high-dose IV ceftriaxone for bacterial meningitis develops right upper quadrant pain. Ultrasound shows echogenic sludge with acoustic shadowing in the gallbladder; LFTs are normal and he has no fever from a new source. What is the most likely explanation?

A 49-year-old man has a variceal bleed controlled with terlipressin and band ligation 12 hours ago. Results: bilirubin 3.6 mg/dL, albumin 2.6 g/dL, INR 1.9, mild ascites on ultrasound, and no encephalopathy. He has no contraindication to TIPS. What is the best next step?

An 84-year-old man with severe heart failure (ejection fraction 20%) has acute calculous cholecystitis. After 48 hours of IV antibiotics he remains febrile and hypotensive, and the anaesthetist judges him unfit for general anaesthesia. What is the best next step?

A 42-year-old woman is about to undergo ERCP for CBD stone extraction. She has had post-ERCP pancreatitis before. She has no kidney disease or allergy to NSAIDs. Which drug given rectally just before or after the procedure reduces her risk of pancreatitis?

A surgical resident is doing her first laparoscopic cholecystectomy under supervision. Which step best protects against injury to the common bile duct?

A 13-year-old girl has recurrent jaundice, splenomegaly and biliary colic. Her mother had a splenectomy. Blood film shows many spherocytes, and osmotic fragility is increased. Ultrasound shows multiple small gallstones. What type of gallstone does she most likely have?

A 52-year-old woman has jaundice and right upper quadrant pain. Ultrasound and MRCP show a large stone impacted in the neck of the gallbladder, with dilated common hepatic and intrahepatic ducts but a normal-calibre lower CBD and no stone within the duct. What is the most likely diagnosis?

Two weeks after a TIPS for refractory ascites, a 58-year-old man with cirrhosis becomes confused and drowsy, with a flapping tremor. He has no bleeding, fever or new drug. What is the most likely cause?

A 42-year-old woman has had recurrent episodes of right upper quadrant pain lasting 2-3 hours after heavy meals, radiating to the right shoulder blade. Between attacks she is well and her LFTs are normal. What is the investigation of choice?

A 66-year-old woman with diabetes, who had ERCP for CBD stones a year ago, has fever with rigors and right upper quadrant pain. CT shows a 7 cm multiloculated liver abscess with a liquefied centre. Blood cultures grow E. coli. She is stable. What is the best management?