As the surgical registrar, you review a man with a resectable 2.5 cm pancreatic head carcinoma on CT. Bilirubin is 12 mg/dL, there is no cholangitis, and surgery can be done within one week. The physician asks for an ERCP stent first. What do you advise?

Surgery without preoperative stenting

Endoscopic metal stent and repeat CT in 3 months

ERCP plastic stent, then surgery after 6 weeks

Percutaneous transhepatic drainage, then surgery

In obstructive jaundice, a palpable, non-tender gallbladder makes which cause most likely?

Malignant obstruction of the distal CBD

Mirizzi syndrome with a stone in Hartmann's pouch

Stones impacted in the distal CBD

In the paediatric surgery casualty, a 3-year-old boy with a known choledochal cyst awaiting surgery has had sudden severe abdominal pain, fever and abdominal distension for 12 hours. He has generalised tenderness, pulse 150/min and BP 80/50 mmHg after a fluid bolus. Abdominal paracentesis drains bile-stained fluid, and ultrasound shows free fluid with a collapsed cyst. After resuscitation and antibiotics, what is the safest operative plan?

Peritoneal lavage with external drainage of the cyst, definitive excision later

Primary suture of the perforation and cystoduodenostomy

Immediate cyst excision with Roux-en-Y hepaticojejunostomy

Endoscopic stenting and observation alone

Hepatobiliary and pancreatic surgery with classifications

52 NEET-PG practice questions on Hepatobiliary and pancreatic surgery with classifications, 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 · Medium
As the surgical registrar, you review a man with a resectable 2.5 cm pancreatic head carcinoma on CT. Bilirubin is 12 mg/dL, there is no cholangitis, and surgery can be done within one week. The physician asks for an ERCP stent first. What do you advise?
1. ASurgery without preoperative stenting
2. BEndoscopic metal stent and repeat CT in 3 months
3. CERCP plastic stent, then surgery after 6 weeks
4. DPercutaneous transhepatic drainage, then surgery
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Answer: A · Surgery without preoperative stenting
Routine preoperative biliary drainage increases overall complications (stent infection, cholangitis, pancreatitis) without improving surgical outcome, as shown in randomised trials. Drainage is kept for cholangitis, very high bilirubin with symptoms, delay before surgery, or neoadjuvant therapy. Early surgery is best here. Key point: For resectable periampullary cancer, early surgery without routine preoperative biliary stenting is preferred.
- B: Waiting 3 months for a resectable cancer allows progression.
- C: Routine stenting raises complications and the delay gives no benefit.
- D: PTBD has the same drawbacks and adds bleeding and leak risks.
Question 2 · Easy
In obstructive jaundice, a palpable, non-tender gallbladder makes which cause most likely?
1. AMirizzi syndrome with a stone in Hartmann's pouch
2. BAcute calculous cholecystitis
3. CStones impacted in the distal CBD
4. DMalignant obstruction of the distal CBD
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Answer: D · Malignant obstruction of the distal CBD
Courvoisier's law: in a jaundiced patient a palpable gallbladder is unlikely to be due to stones, because gallstone disease scars and contracts the gallbladder. A distended gallbladder points to a slowly growing distal obstruction such as periampullary or pancreatic head cancer. Key point: Courvoisier's law: jaundice with a palpable non-tender gallbladder suggests distal malignant obstruction, not stones.
- A: Mirizzi syndrome involves stone impaction and a chronically inflamed gallbladder.
- B: Acute cholecystitis gives a tender gallbladder and rarely deep jaundice.
- C: Stones usually leave a fibrosed, shrunken gallbladder.
Question 3 · Hard
In the paediatric surgery casualty, a 3-year-old boy with a known choledochal cyst awaiting surgery has had sudden severe abdominal pain, fever and abdominal distension for 12 hours. He has generalised tenderness, pulse 150/min and BP 80/50 mmHg after a fluid bolus. Abdominal paracentesis drains bile-stained fluid, and ultrasound shows free fluid with a collapsed cyst. After resuscitation and antibiotics, what is the safest operative plan?
1. APrimary suture of the perforation and cystoduodenostomy
2. BImmediate cyst excision with Roux-en-Y hepaticojejunostomy
3. CEndoscopic stenting and observation alone
4. DPeritoneal lavage with external drainage of the cyst, definitive excision later
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Answer: D · Peritoneal lavage with external drainage of the cyst, definitive excision later
Spontaneous rupture of a choledochal cyst causes biliary peritonitis, usually in young children. In a septic, unstable child with inflamed tissues, a damage-control approach is safest: lavage and external (T-tube or tube) drainage of the cyst, then elective excision with hepaticojejunostomy once he has recovered. Key point: A ruptured choledochal cyst in a sick child: lavage and external drainage first, definitive excision later.
- A: Cystoduodenostomy is obsolete because of cholangitis and cancer.
- B: One-stage excision in an unstable child with peritonitis carries high morbidity and leak risk.
- C: Endoscopy in a 3-year-old with peritonitis does not drain the abdomen.
Question 4 · Medium
Statements about choledochal cyst: 1. Females are affected more often than males. 2. It is more common in Asian populations. 3. The classic triad of pain, jaundice and mass is seen in most adults. 4. Cancer risk falls after excision but does not become zero. Which are correct?
1. A1, 2 and 4 only
2. B2, 3 and 4 only
3. C1, 2 and 3 only
4. D1 and 4 only
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Answer: A · 1, 2 and 4 only
Choledochal cysts are about three to four times more common in females and much more frequent in East Asia. The full triad is uncommon, seen mostly in children; adults usually present with pain, cholangitis or pancreatitis, so statement 3 is false. Malignancy can still develop after excision, mainly in residual ducts, so long-term follow-up is advised. Key point: Choledochal cyst: female and Asian predominance; the full triad is uncommon in adults; follow up even after excision.
- B: Statement 3 is false and statement 1 is true.
- C: Statement 3 is false: most adults do not have the full triad.
- D: Statement 2 is also true: it is commoner in Asians.
Question 5 · Easy
About a classic Whipple pancreaticoduodenectomy: 1. The distal stomach is removed. 2. The gallbladder and distal CBD are removed. 3. The spleen is removed. 4. A pancreaticojejunostomy is one of the anastomoses. Which are correct?
1. A1, 2, 3 and 4
2. B1, 2 and 4 only
3. C1, 2 and 3 only
4. D2 and 4 only
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Answer: B · 1, 2 and 4 only
The classic Whipple removes the distal stomach (antrum), duodenum, first part of the jejunum, head of the pancreas, distal CBD and gallbladder. Reconstruction joins the pancreas, hepatic duct and stomach to the jejunum. The spleen is kept; it is removed in a distal pancreatectomy, not a Whipple. The pylorus-preserving version keeps the stomach and pylorus. Key point: Whipple removes distal stomach, duodenum, pancreatic head, distal CBD and gallbladder; the spleen stays.
- A: Statement 3 is false, so all four cannot be correct.
- C: Statement 3 is false: the spleen is not removed.
- D: Statement 1 is also true in the classic operation.
Question 6 · Medium
MRCP report: abrupt stricture of the distal CBD and of the main pancreatic duct in the head of the pancreas, with both ducts dilated upstream. The patient is a 64-year-old smoker with painless jaundice and 6 kg weight loss; there are no stones and the gland is not calcified. Which diagnosis does this suggest most?
1. APrimary sclerosing cholangitis
2. BCholedocholithiasis
3. CCarcinoma of the head of the pancreas
4. DChronic calcific pancreatitis
Answer and explanation in LearnFree account
Question 7 · Medium
Statements about periampullary cancers: 1. Ampullary carcinoma has a better prognosis than pancreatic head carcinoma. 2. Ampullary tumours present early because they obstruct the bile duct when small. 3. Duodenal adenocarcinoma is linked with FAP. 4. Pancreatic head carcinoma has the best resectability rate of the four. Which are correct?
1. A1 and 2 only
2. B2, 3 and 4 only
3. C1, 2, 3 and 4
4. D1, 2 and 3 only
Answer and explanation in LearnFree account
Question 8 · Hard
In the HPB clinic, a nurse aged 36 with recurrent cholangitis brings her MRCP: fusiform dilatation of the CBD and common hepatic duct to 3.5 cm, with saccular dilatation of the intrahepatic ducts limited to segments II and III, which contain several stones. The right-sided intrahepatic ducts are normal. A long common pancreaticobiliary channel is seen. LFTs are normal between attacks and there is no portal hypertension. A previous surgeon advised removing only the extrahepatic cyst. Which operation best treats her disease and its cancer risk?
1. AExtrahepatic cyst excision, left lateral sectionectomy and hepaticojejunostomy
2. BExtrahepatic cyst excision with hepaticojejunostomy alone
3. CLiver transplantation
4. DLeft lateral sectionectomy alone
Answer and explanation in LearnFree account
Question 9 · Medium
During evaluation of intermittent jaundice, MRCP shows a saccular outpouching arising from the lateral wall of a normal-calibre supraduodenal CBD, joined by a narrow neck. The common hepatic duct, intrahepatic ducts and pancreaticobiliary junction are normal, and there is no mass. What is the treatment of choice?
1. AExcision of the diverticulum
2. BEndoscopic sphincterotomy
3. CObservation with yearly MRCP
4. DCyst excision with Roux-en-Y hepaticojejunostomy
Answer and explanation in LearnFree account
Question 10 · Medium
CT shows an apparently resectable 4 cm pancreatic body-head junction tumour, and CA 19-9 after biliary drainage is 1,800 U/mL. What is the next useful step before laparotomy?
1. ARepeat CT after 6 months
2. BBone scan
3. CPET-CT of the brain
4. DStaging laparoscopy
Answer and explanation in LearnFree account
Question 11 · Hard
An IT professional, aged 30, has an incidental 3.5 cm Todani type I choledochal cyst on ultrasound done for dyspepsia. She is symptom-free, LFTs are normal and the gallbladder looks normal. MRCP shows an anomalous pancreaticobiliary junction. She asks whether surgery can be avoided, or whether only the cyst need be removed and her normal gallbladder kept. What is the best advice?
1. AEndoscopic sphincterotomy to stop the reflux
2. BYearly ultrasound and MRCP, with surgery only if symptoms appear
3. CExcision of the cyst alone, keeping the normal gallbladder
4. DCyst excision with cholecystectomy and hepaticojejunostomy
Answer and explanation in LearnFree account
Question 12 · Easy
At a district hospital, a 9-year-old girl has had recurrent right upper abdominal pain, two bouts of jaundice and a smooth mass below the right costal margin. Ultrasound shows a large cystic lesion in the porta hepatis separate from the gallbladder. Which investigation best defines the anatomy before surgery?
1. AMRCP
2. BERCP
3. CContrast-enhanced CT
4. DHIDA scan
Answer and explanation in LearnFree account
Question 13 · Hard
In the tumour board, the case of a 58-year-old schoolteacher is presented: deeply jaundiced (bilirubin 17 mg/dL), itchy, with a 3 cm pancreatic head carcinoma that touches the superior mesenteric vein for more than 180 degrees with short-segment narrowing, reconstructable, and less than 180 degrees of contact with the SMA. CA 19-9 after excluding cholangitis is 600 U/mL. No metastases on CT chest and abdomen. The board decides on neoadjuvant FOLFIRINOX. A biopsy has not been taken yet, and he has had no biliary procedure. His performance status is ECOG 1. What should be done before chemotherapy starts?
1. AEUS-guided biopsy and biliary drainage with a metal stent
2. BStart chemotherapy at once and stent only if cholangitis develops
3. CPercutaneous biopsy through the liver and a plastic stent
4. DImmediate pancreaticoduodenectomy with vein resection
Answer and explanation in LearnFree account
Question 14 · Medium
A choledochal cyst left untreated into adult life is most strongly linked with which malignancy?
1. ACholangiocarcinoma
2. BDuodenal adenocarcinoma
3. CHepatocellular carcinoma
4. DPancreatic acinar cell carcinoma
Answer and explanation in LearnFree account
Question 15 · Hard
At laparotomy for a pancreaticoduodenectomy in a jaundiced 61-year-old with a 3 cm pancreatic head carcinoma that looked resectable on CT, the surgeon finds a 1 cm firm nodule on the surface of segment III; frozen section confirms metastatic adenocarcinoma. The tumour itself is mobile and free of the SMV. Preoperatively, he had a plastic biliary stent that is now blocked, and the duodenum is not narrowed but the tumour is close to it. The peritoneum is otherwise clear. He is fit, with good nutrition, and the family was told before surgery that the aim was cure. What is the most appropriate course?
1. AProceed with Whipple and wedge excision of the nodule
2. BProceed with Whipple alone and give chemotherapy later
3. CAbandon resection; consider hepaticojejunostomy with gastrojejunostomy
4. DClose the abdomen without any procedure
Answer and explanation in LearnFree account
Question 16 · Easy
Which gene is mutated in more than 90% of pancreatic ductal adenocarcinomas?
1. AKRAS
2. BAPC
3. CTP53
4. DBRCA2
Answer and explanation in LearnFree account
Question 17 · Medium
MRCP in an adult woman with abdominal pain: fusiform dilatation of the CBD and common hepatic duct to 3 cm, together with several dilated segments of the right and left intrahepatic ducts; a long common pancreaticobiliary channel. The gallbladder is distended but has no stones, and the pancreatic duct is normal. Which Todani type is this?
1. AType I
2. BType IVb
3. CType V
4. DType IVa
Answer and explanation in LearnFree account
Question 18 · Easy
A retired bank clerk has fluctuating jaundice, anaemia and occult blood in the stool. His stool has a pale silvery colour. Haemoglobin is 8.9 g/dL, bilirubin rose and fell twice over 2 months, and ultrasound shows a dilated CBD and gallbladder. Which tumour is most likely?
1. ACarcinoma of the ampulla of Vater
2. BCarcinoma of the gallbladder
3. CCarcinoma of the head of the pancreas
4. DHilar cholangiocarcinoma
Answer and explanation in LearnFree account
Question 19 · Medium
Pancreatic-protocol CT in a fit man with painless jaundice shows a 2 cm hypodense mass in the pancreatic head with a double duct sign, no vascular contact and no metastases. He wants surgery as soon as possible. Is a preoperative biopsy needed?
1. ANo; proceed to resection without a biopsy
2. BYes; CT-guided percutaneous biopsy first
3. CNo; but repeat CT after 3 months first
4. DYes; EUS-FNA must be positive before resection
Answer and explanation in LearnFree account
Question 20 · Medium
Consider these statements about Caroli disease: 1. It is Todani type V. 2. Caroli syndrome adds congenital hepatic fibrosis. 3. It is associated with autosomal recessive polycystic kidney disease. 4. It carries no increased risk of cholangiocarcinoma. Which are correct?
1. A1, 2 and 3 only
2. B1 and 2 only
3. C1, 2, 3 and 4
4. D2, 3 and 4 only
Answer and explanation in LearnFree account
Question 21 · Medium
Histology after an R0 pancreaticoduodenectomy for pancreatic ductal adenocarcinoma shows pT2 N1 disease. The patient is 56, ECOG 0, and recovers well by week 6, eating normally with no fistula or diabetes. Margins are clear and 3 of 18 nodes are involved. Which adjuvant treatment is preferred?
1. ARadiotherapy alone to the tumour bed
2. BObservation with CA 19-9 every 3 months
3. CModified FOLFIRINOX for 6 months
4. DGemcitabine alone for 3 months
Answer and explanation in LearnFree account
Question 22 · Medium
New-onset diabetes in a thin 66-year-old man, with 8 kg of weight loss over 4 months and vague epigastric pain going through to the back, should prompt which investigation first?
1. ASerum amylase and lipase
2. BContrast CT of the pancreas
3. COral glucose tolerance test
4. DUpper GI endoscopy
Answer and explanation in LearnFree account
Question 23 · Hard
From the gastroenterology ward, a referral: a mechanic, aged 34, has had more than ten attacks of cholangitis in two years despite antibiotics and stone clearance. MRCP shows saccular dilatation of the intrahepatic ducts in both lobes with intraductal stones and a normal extrahepatic duct. Liver biopsy shows bands of fibrous tissue with ductal plate malformation. He has splenomegaly, platelets 72,000/mm3 and grade II oesophageal varices. Kidney ultrasound shows enlarged echogenic kidneys; creatinine is 1.1 mg/dL. His sister, also on dialysis follow-up for kidney cysts, asks whether a second partial liver resection, like the one offered elsewhere, would solve his problem. What is the best long-term treatment?
1. AExcision of the extrahepatic duct with hepaticojejunostomy
2. BRight hepatectomy
3. CPercutaneous transhepatic drainage of both lobes
4. DLiver transplantation
Answer and explanation in LearnFree account
Question 24 · Medium
Regarding CA 19-9 in pancreatic cancer: 1. It is not produced by people who are Lewis antigen negative. 2. Obstructive jaundice can raise it without cancer. 3. It is a good screening test for the general population. 4. Its fall after surgery predicts better survival. Which are correct?
1. A1, 2 and 4 only
2. B1, 2 and 3 only
3. C1 and 4 only
4. D2 and 3 only
Answer and explanation in LearnFree account
Question 25 · Medium
ERCP in a woman with recurrent epigastric pain and mild pancreatitis shows a smooth bulge of the distal CBD into the duodenal lumen at the papilla; the rest of the biliary tree is normal. Serum lipase was 3 times normal during the last attack, and ultrasound shows no gallstones. What is the preferred treatment?
1. ATransduodenal excision with sphincteroplasty only after age 60
2. BEndoscopic sphincterotomy with unroofing
3. CCyst excision and hepaticojejunostomy
4. DWhipple pancreaticoduodenectomy
Answer and explanation in LearnFree account

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Hepatobiliary and pancreatic surgery with classifications

As the surgical registrar, you review a man with a resectable 2.5 cm pancreatic head carcinoma on CT. Bilirubin is 12 mg/dL, there is no cholangitis, and surgery can be done within one week. The physician asks for an ERCP stent first. What do you advise?

In obstructive jaundice, a palpable, non-tender gallbladder makes which cause most likely?

Statements about choledochal cyst: 1. Females are affected more often than males. 2. It is more common in Asian populations. 3. The classic triad of pain, jaundice and mass is seen in most adults. 4. Cancer risk falls after excision but does not become zero. Which are correct?

About a classic Whipple pancreaticoduodenectomy: 1. The distal stomach is removed. 2. The gallbladder and distal CBD are removed. 3. The spleen is removed. 4. A pancreaticojejunostomy is one of the anastomoses. Which are correct?

CT shows an apparently resectable 4 cm pancreatic body-head junction tumour, and CA 19-9 after biliary drainage is 1,800 U/mL. What is the next useful step before laparotomy?

A choledochal cyst left untreated into adult life is most strongly linked with which malignancy?

Which gene is mutated in more than 90% of pancreatic ductal adenocarcinomas?

A retired bank clerk has fluctuating jaundice, anaemia and occult blood in the stool. His stool has a pale silvery colour. Haemoglobin is 8.9 g/dL, bilirubin rose and fell twice over 2 months, and ultrasound shows a dilated CBD and gallbladder. Which tumour is most likely?

Pancreatic-protocol CT in a fit man with painless jaundice shows a 2 cm hypodense mass in the pancreatic head with a double duct sign, no vascular contact and no metastases. He wants surgery as soon as possible. Is a preoperative biopsy needed?

Consider these statements about Caroli disease: 1. It is Todani type V. 2. Caroli syndrome adds congenital hepatic fibrosis. 3. It is associated with autosomal recessive polycystic kidney disease. 4. It carries no increased risk of cholangiocarcinoma. Which are correct?

Histology after an R0 pancreaticoduodenectomy for pancreatic ductal adenocarcinoma shows pT2 N1 disease. The patient is 56, ECOG 0, and recovers well by week 6, eating normally with no fistula or diabetes. Margins are clear and 3 of 18 nodes are involved. Which adjuvant treatment is preferred?

New-onset diabetes in a thin 66-year-old man, with 8 kg of weight loss over 4 months and vague epigastric pain going through to the back, should prompt which investigation first?

Regarding CA 19-9 in pancreatic cancer: 1. It is not produced by people who are Lewis antigen negative. 2. Obstructive jaundice can raise it without cancer. 3. It is a good screening test for the general population. 4. Its fall after surgery predicts better survival. Which are correct?