1. Department of Surgery UST Faculty of Medicine & Surgery

2. General Review Guidelines Adequate content coverage Adequate content coverage Time management Time management Testmanship Testmanship

3. Testmanship Too encompassing/absolute statements Too encompassing/absolute statements One or more completion types One or more completion types (A - 1,2,3, correct; C - 2,4 correct etc…) All of the above/none of the above All of the above/none of the above Try to anticipate what is in the mind of the examiner Try to anticipate what is in the mind of the examiner

11. Hepatocallular Carcinoma 5 th most common 1 M new cases annually Asia: 30-65/100T USA - 2/100T Risk Factors: Cirrhosis Viral Hepatitis

12. Cholangiocarcinoma 2 nd most common liver malignancy 2 nd most common liver malignancy Hilar – Klatskin tumor Hilar – Klatskin tumor

13. Treatment Options for Liver Cancer Treatment Options for Liver Cancer Hepatic resection mortality rates < 5%; 5 yr recurrence 50% Hepatic resection mortality rates < 5%; 5 yr recurrence 50% Liver transplantation Liver transplantation Ablation techniques Ablation techniques Radiofrequency ablation Radiofrequency ablation Ethanol ablation Ethanol ablation Cryoablation Cryoablation Microwave ablation Microwave ablation Regional liver therapies Regional liver therapies Chemoembolization/embolization Chemoembolization/embolization Hepatic artery pump chemoperfusion Hepatic artery pump chemoperfusion Internal radiation therapy (yttrium 90 internal radiation) Internal radiation therapy (yttrium 90 internal radiation) External beam radiation therapy External beam radiation therapy Stereotactic radiosurgery (CyberKnife, Trilogy, Synergy) Stereotactic radiosurgery (CyberKnife, Trilogy, Synergy) Intensity-modulated radiation therapySystemic Intensity-modulated radiation therapySystemic chemotherapyMultimodality approach chemotherapyMultimodality approach

15. Right hepatic lobestomy

16. Left hepatic lobectomy

17. Gall Bladder 30-50cc 300 cc distended Triangle of Calot Gall stones pigment Cholecystolithiasis Cholecystitis Choledocholithisis Cholangitis Courvosieur’s

18. Pancreas Psuedocysts Periampullary lesions Pancreatic carcinoma Duodenal carcinoma Insulinomas Whipple’s triad symptomatic hypoglycemia glucose levels below50 relieved by glucose Whipple’s procedure pancrearicoduodenectomy Serous cystadenomas

19. Splenectomy Trauma Hematologic EXC: G6PD hereditary elliptocytosis staging OSPI - strep pneumoniae - hemophilus influenza - meningococcus

20. A 55 y/o man who is extremely obese reports weakness, sweating, tachycardia, confusion and headache whenever he fast for more than a few hours. He has prompt relief of symptoms when he eats. These symptoms are most suggestive of which of the following disorders? A. Diabetes mellitus B. Insulinoma C. Zollinger-Ellison syndrome D. Carcinoid syndrome

21. Most likely cause of UGI bleeding in patient with cirrhosis is: A. Acute erosive gastritis B. Bleeding esophageal varices C. Bleeding peptic ulcer D. Zollinger-Ellison syndrome

22. The following are causes of extrahepatic portal venous system obstruction, EXCEPT: A. Infection B. Trauma C. Tumor D. Schistosomiasis

23. The most important tributary of the portal vein after it is formed by the confluence of the superior mesenteric and splenic veins is the: A. Right gastric vein B. Coronary vein C. Duodenal vein D. Cystic vein

24. Two months after laparoscopic cholecystectomy, a patient is determined to have obstructive jaundice, secondary to a 1.5 cm stone in the distal common bile duct. The best approach to the removal of this stone is: A. Endoscopic papillotomy and extraction of the stone B. Laparotomy and CBD exploration C. Administration of oral bile acids D. Endoscopic introduction of litholytic agents

25. The origin of the cystic artery is: A. Variable B. Almost always from the right hepatic artery C. Frequently from the left hepatic artery D. Usually from the common hepatic artery

26. As a therapeutic modality, splenectomy might be indicated for a patient who had the following, EXCEPT: A. Hereditary spherocytosis B. Sickle cell anemia C. Idiopathic autoimmune hemolytic anemia D. Glucose-6-phosphate deficiency

27. A liver function study in a jaundiced patient reveals conjugated hyperbilirubinemia. All of the following conditions should be considered in the differential diagnosis, Except: A. CBD obstruction secondary to choledocholithiasis B. Periampullary carcinoma C. Hemolysis secondary to spherocytosis D. Intrahepatic cholestasis without hepatocyte damage

28. A patient undergoing an ERCP (endoscopic retrograde pancreatogram) is noted to have a pancreas divisum. What consequence will arise because of this abnormality: A. Pancreatic carcinoma B. Acute pancreatitis C. Biliary obstruction D. No pathology will necessarily develop

29. Following a splenectomy in pediatric patients, what is the most common etiologic agent in severe post- splenectomy sepsis: A. Streptococcus penumoniae B. Staphylococcus aureus C. Group B hemolytic streptococcus D. Hemophilus ducreyi

30. A 50-year old known alcoholic and cirrhotic man develops moderate ascites. How should he be treated : A. Spironolactone and salt restriction B. Intermittent paracentesis abdominis C. Use a peritoneo-venous shunt D. Porto-systemic shunting while his risk status is good

31. A post-operative t-tube chonagiogram done 12 days after cholectystectomy with common bile duct exploration reveals a 0.5 cm residual stone in the common bile duct. In this patient: A. Endoscopic papillotomy with stone retrieval is the best treatment B. Litholytic agents should be instilled into the CBD C. Immediate reexploration should be done D. The stone can be removed through the t- tube tract when the tract is mature

32. A 30-year old woman who has undergone appendectomy for ruptured appendicitis develops upper abdominal pain and fever. A CT scan reveals a 6-cm complex mass in the infero-posterior aspect of segment 6 of the liver. How should she be treated: A. Percutaneous aspiration alone B. Appropriate antibiotics C. Exploratory laparotomy and drainage D. Antibiotics plus percutaneous aspiration

33. Several months after a laparoscopic cholecystectomy for cholelithiasis, a 50-year old obese woman develops obstructive jaundice. In this patient: A. If a common bile stone is diagnosed, a CBD exploration should be done B. An ERCP should be performed C. Bile duct ultrasonography is the best diagnostic procedure D. Bile duct imaging should be performed

34. The anatomical anomaly known as pancreas divisum is associated with: A. Wirsung’s duct does not drain into the ampulla of Vater B. An almost 100% incidence of pancreatitis C. Santorini’s duct serves as the main drainage channel for pancreatic juice D. The presence of an annular pancreas

35. A poor-risk 65-year old patient with obstructive jaundice secondary to pancreatic head carcinoma associated with hepatic insufficiency is best managed by: A. Choledocho-enterostomy B. Cholecysto-enterostomy C. Endoscopic bile-duct stenting D. Percutaneous trans-hepatic bile duct drainage

36. Everything else being equal, of the periampullary carcinomas, the poorest prognosis is associated with carcinoma of the: A. Body and tail of the pancreas B. Distal common bile duct C. Head of the pancreas D. Duodenum

37. Two months after an apparently straight forward/laparoscopic cholecystectomy, the patient develops jaundice and highly colored urine. In this patient: A. Both a liver function study and ERCP should be done B. A liver function study is indicated C. A biliary imaging procedure should be done D. An ERCP is indicated

38. Six months after blunt trauma to the abdomen which was managed non- operatively, a young man complaining of vague upper abdominal discomfort is discovered to have a 10-cm cystic mass in the spleen on ultrasonography. In this patient: A. Marsupialization is a reasonable alternative to spelenctomy B. Splenectomy should be done C. Malignancy should be suspected D. Percutaneous aspiration of the cyst is the best treatment

39. Two years after an uncomplicated, apparently straight forward laparoscopic cholecystectomy, a 50-year old woman develops jaundice associated with upper abdominal discomfort and pruritus. The stools are described as pasty grayish. Which of the following procedures should be done: A. ERCP B. Ultrasound of the liver and biliary tree C. Percutaneous transhepatic cholangiography D. Bile duct imaging using a radioactive tracer

40. Two weeks after penetrating abdominal trauma, in which repair of a deep laceration of the right lobe of the liver was done, a patient develops fever, jaundice and GI bleeding. In this patient, the most useful diagnostic procedure is: A. Selective arteriography B. PTC C. Upper GI endoscopy D. ERCP

41. A 72 year old female previously diagnosed to have sigmoid diverticulitis now presents with tender hepatomegaly and fever. US of the liver showed multiple complex masses in the ® lobe. The initial treatment of choice is: A. Parenteral antibiotics alone B. Open surgical evacuation C. Percutaneous aspiration D. Laparoscopic drainage

42. A 22 year old male sought consult because of RUQ pain, fever, and bloody diarrhea. At US of the liver there was a solitary 10 cm complex mass at the (L) lobe. The initial treatment of choice is: A. Open surgical drainage B. Percutaneous aspiration C. Antibiotic alone D. Laparoscopic drainage

43. The most important diagnostic tool for this 38 year old male from Samar with Schistosomiasis presenting with massive splenomegaly w/o any other clinical signs of portal hypertension is: A. UGIE B. UGIS C. Splenoportography D. Aortography

44. A 50 year old female who on routine abdominal US for annual check up was found to have a 9 cm solitary hepatic cystic lesion at the ® lobe. Treatment of choice is : A. Laparoscopic cystectomy B. Open surgical drainage C. Percutaneous US guided aspiration with sclerotherapy D. None of the above

45. At CBDE, a tightly impacted distal common duct stone could not be removed through a supraduodenal choledochotomy. Assuming that the OR is not equipped with a choledochoscope, the next procedure of choice is: A. Transduodenal sphinctorotomy with sphincteroplasty B. T-Tube drainage then postoperative ERCP C. Intraoperative ERCP D. Choledochoduodenostomy and leave the stone

46. A 33 year old female presents with fever and jaundice, and ® upper quadrant pain. At US, the GB was distended, with thickened wall but without evidence of calculus. Both SGPT and SGOT are markedly elevated. She is HbsAg reactive. Treatment of choice: A. Open cholecystectomy B. Laparoscopic cholecystectomy C. Supportive medical therapy alone D. Cholecystostomy

47. After an elective cholecystectomy, the final histopathologic report of the GB came in as a T2 adenocarcinoma at the fundus. The definitive therapy is: A. Hepatic resection B. Already completed C. Cholecystectomy and postop chemotherapy D. Cholecystectomy and postop radiotherapy

48. A 37 year old male has postnecrotic cirrhosis and liver function of Child’s- Pugh Class C. He has relative in Hong kong who is offering the possibility of liver transplant. But he bleed profusely but was resuscitated. The best management option is: A. Non-shunt devascularization B. TIPS C. Medical supportive therapy alone D. Porto-systemic shunting procedure

49. A 44 year old female with no previous abdominal surgery presents with signs and symptoms of intestinal obstruction. Flat plate showed aerobilia with multiple air- fluid levels. This is most likely: A. PPUD B. Gallstone ileus C. Perforated GI malignancy D. Biliary ascariasis

50. Asymptomatic cholecystolithiasis is best managed by: A. Observation alone B. Open cholecystectomy C. Laparoscopic cholecystectomy D. ESWL

51. Biliary ascariasis in cholangitis without evidence of biliary calculi is best managed by: A. Open cholecystectomy with CBDE B. Antiparasitic drugs alone C. ERCP D. ERCP followed by laparoscopic cholecystectomy

52. A 42 year old female sought consult for your opinion. A month ago she underwent ERCP for a successful retrieval of what appears to be a secondary common duct stone. She is now scheduled though asymptomatic for cholecystectomy. You will recommend: A. Observation alone B. Open cholecystectomy C. Laparoscopic cholecystectomy D. Additional work up

53. What is the most likely etiologic diagnosis in this 67 year old male presenting with significant weight loss accompanied by progressive jaundice, anorexia, tea- colored urine and who at PE has a palpable slightly tender GB and a smooth liver: A. Acute cholecystitis B. Hepatoma C. Pancreatic head tumor D. Cirrhosis of the liver

54. In order to confirm your clinical impression in the above case your initial work up is: A. Upper abdominal US B. Upper abdominal CT-Scan C. Upper GI endoscopy D. Upper GI series

55. In order to plan the appropriate therapy, assess the extent of disease, and prognosticate probable outcome, the following can be done: A. Laparoscopy B. Abdominal CT-Scan C. Exploratory laparotomy D. All

56. Eight months after an acute episode of pancreatitis, this 54 year old female presented with a virtually asymptomatic, gradually expanding, firm, nodular mass at the LUQ. The interval history was unremarkable save for intermittently recurring epigastric discomfort. Your clinical impression for the case is: A. Ampullary cholangiocarcinoma B. Pancreatic CA C. True pancreatic cyst D. Pseudocyst of the pancreas

57. From the above-given data, where do you think is the location of the lesion?: A. Head B. Body C. Neck D. Tail E. None of the above

58. Assuming that the patient with the above lesion does not present with signs of infection and the size of the lesion is about 10 cm, the recommended treatment is: A. Internal drainage B. Percutaneous drainage C. External drainage D. Observation alone

59. The severe, progressive and continuous, abdominal pain that radiates at the back accompanied by vomiting of this healthy 38 year old who, does not drink alcohol nor a diabetic may be due to: A. PUD B. Acute cholecystitis C. Acute pancreatitis D. Any of the above

60. Indication/s for surgical intervention in cases of pancreatitis: A. Necrotizing complications B. Acute hemorrhagic complications C. Infected pancreatic necrosis D. All

61. The most common cause/s of death among patients with complications of pancreatitis is/are: A. Acute Renal Failure (ARF) B. Acute Respiratory Distress Syndrome (ARDS) C. Acute Compartment Syndrome (ACS) D. A and B

62. Non surgical therapy of simple pancreatitis consist of: A. Adequate pain control B. Resuscitation and maintenance of fluid and electrolyte balance C. Rest of the exocrine function of the pancreas D. All

63. Sudden hematemesis of a 38 year old male presenting with jaundice, RUQ pain and fever, your primary consideration is: A. Bleeding from an upper GI tumor B. Peptic ulcer disease C. Hemobilia D. Deulafouy

64. One week after a blunt abdominal trauma, this 26 y/o male vomited fresh blood. But at UGI endoscopy the esophagus, stomach, and duodenum appeared normal. The most likely source of blood is: A. Jejunum B. Biliary tree C. Liver D. Pancreas

65. A 55 year old asymptomatic male presents with a solitary, solid 5 cm mass at the ® lobe of the liver. He most likely has: A. Amoebic abscess B. Metastatic malignancy C. Hepatocellular carcinoma D. Liver adenoma

66. The single most important diagnostic test for a solid, 4 cm, single liver mass at the ® lobe is: A. CT-Scan B. FNAB C. Serum CEA D. Serum AFP

67. Given a 7 cm solitary, hypoechoic mass at the (L) lobe of the liver, assuming availabilityof full diagnostic complement, your next step towards the management of this 54 year old male is: A. FNAB B. Abdominal CT-Scan C. Surgical resection D. Angiography

68. A 45 year old female who on routine company check up was found to have cholecystolithiasis by US. You will recommend: A. Laporatomy cholecystectomy B. Observation alone C. Open cholecystectomy D. ESWL

69. Obstructive biliary tract disease in an otherwise healthy 30 year old male is most likely due to: A. Cholangiocarcinoma B. Choledocholithiasis C. Early ampulalary malignancy D. Hepatobiliary TB

70. Curative treatment for a 6cm solid, solitary liver mass with serum AFP level of 600 IU/ml is: A. Hepatic resection B. Alcohol injection C. Radiofrequency therapy D. Chemoembolization

71. Extrahepatic biliary duct obstruction by US with curvousier’s GB in a 62 y/o jaundiced (but not in cholangitis) female clinically means: A. Periampullary malignancy B. Distal CBD stones C. Biliary ascariasis D. Hepatobiliary TB

72. Progressive jaundice in a hyposthenic patient with untreated pulmonary tuberculosis presenting with RUQ colicky pain, intermittent low grade fever with chills and by US showed multiple hepatic calcifications is: A. Pyogenic liver abscess B. Hepatobiliary TB C. Metastatic liver malignancy D. Biliary ascariasis

73. The procedure of choice for extrahepatic biliary obstruction suspected of hepatobiliary TB is: A. PTC B. ERCP C. TIPS D. FNAB of hepatic calcifications

74. At cholangiogram the typical image HB Tuberculosis will make is: A. Fusiform CBD dilatation B. Rosary-bead ductal deformity C. An elongated-luminal-tubular structure w/in the CBD D. Multiple radioluscent filling defects along the ducts

75. Upper GI bleeding on the background of stigmata of liver cirrhosis, HbsAg reactive, and splenomegaly, clinically means: A. Hepatoma with hemobilia B. Variceal bleeding due to portal hypertension C. Complicated primary hypersplenism D. Acute erosive gastritis

76. For this 48 y/o male who possesses the above-mentioned clinical picture and who is not in hypovolemic shock, the first line of treatment: A. Emergency shunting procedure B. Endoscopic sclerotherapy or banding C. Supportive therapy alone D. Emergency devascularization procedure

77. If the variceal bleeding is controlled or spontaneously stopped your recommended definitive treatment is: A. Elective shunting procedure B. Propanolol therapy with serial endoscopic sclerotherapy C. Elective devascularization surgery D. Liver transplantation

78. High grade fever preceded by alternating constipation & diarrhea 1- 2 weeks ago now presenting with tender hepatomegaly in a 23 y/o male is most likely due to: A. Amoebic abscess B. Pyogenic abscess C. Biliary TB D. Biliary ascariasis

79. Acutely excruciating, colicky RUQ pain with cholangitis in a 15 y/o male who did not show any stone in the biliary tree by US require an immediate: A. ERCP B. PTC C. CT-Scan D. MRI

80. In the absence of a history of abdominal trauma, repeated hemobilia in a 70 y/o female with a negative abdominal US merits a/an: A. Contrast CT-Scan B. ERCP C. MRI-ANGIO D. Selective angiography