QUESTION-1:
Follow up increasing LFTs:
Correct Answer: Choledochocyst
- Surgical resection and hepaticojejunal anastomosis with pre-op decompression with bilateral biliary drains
- Percutaneous stone retrieval:
- Segura baskets
- Angioplasty of ampulla and push stones through with a balloon
- Dilatation of tract for fiberoptic choledochoscopy
TYPE 4 CHOLEDOCHOCYST WITH STONES:
Treatment options:
Differential Diagnosis:
- Type 1 – dilation of cbd
- Type 2 – diverticular cyst off cbd
- Type 3 – choledochocele
- Type 4a – multiple intra and extrahepatic cysts
- Type 4b – multiple extrahepatic cysts
- Type 5 – intrahepatic cystic dilatation (Caroli’s)
Pearls:
- Caroli disease is congenital disorders comprising of multifocal cystic dilatation of segmental intrahepatic bile ducts. Limited to the dilatation of larger intrahepatic bile ducts.
References:
- https://bit.ly/3wZ6UsT
QUESTION-2:
Abnormal finding found on CT:
Correct Answer: Aberrant right subclavian
- 4th branch from prox. descending aorta
- Most common congenital arch anomaly
- Assoc. with Down’s syndrome
- CHD in 10 – 15%
- Location:
- 80% behind esophagus (Dysphasia lusoria)
- 15% between esoph and trach
- 5% ant to trach
QUESTION-3:
No pertinent history given:
Correct Answer: Diverticulum of Kommerell
- Remnant of embryonic right arch
- Esophageal compression (dysphagia lusoria; more common in patients with a right sided aortic arch)
- May present with chest pain, or blood pressure difference in the upper limbs.
- KD may also predispose toward aortic dissection or rupture.
QUESTION-4:
Presenting to the ED with chest pain:
Correct Answer: Aortic injury
- Aortic transection
- Laceration/rupture from sudden decel injury
- 88 – 95% at aortic isthmus
- 4.5% at aortic arch with avulsion of brachiocephalic trunk
- 1% ascending aorta just above aortic valve
- 1.8% descending aorta
Radiographic Features:
- Normal on admission in 28%
- Mediastinal width > 8 cm at aortic knob
- Poorly defined, irregular aortic contour
- Partial obliteration of descending aorta
- Opacification of AP window
- Deviation of NGT to Rt at T4 (67%)
- Tracheal compression and deviation to Rt (61%)
- Lt hemothorax
- Apical cap
- 1st and 2nd rib fractures
Differential Diagnosis:
- Mediastinal hematoma
- 87% specificity
- 99 – 100% sensitivity
- Direct signs of aortic injury
- Contour abnormality/pseudoaneurysm
- Intimal flap
- Pseudo-coarctation
- 99 % specificity
- 90 – 97% sensitivity
QUESTION-5:
MVA 2 months ago:
Correct Answer: Traumatic pseudoaneurysm
Differential Diagnosis:
- Coarctation of aorta: “figure 3” sign – indentation of lateral margin arch with post-stenotic dilatation, rib notching (3rd – 8th)
- Pseudo-coarctation of aorta
- No pressure gradient
- No rib notching
QUESTION-6:
What is the origin of the left bronchial artery? What is the origin of the left bronchial artery?:
Correct Answer: thoracic aorta
The bronchial arteries supply blood to the connective tissue of the bronchial tree. The two left bronchial arteries arise from the superior part of the thoracic aorta, superior and inferior to the left main bronchus. The single right bronchial artery often arises as a common trunk with the third or fifth posterior intercostals artery or from the superior left bronchial artery. Moore 76, 115, 118
QUESTION-7:
Chronic leg pain:
Correct Answer: Buerger’s disease
- Thromboangiitis obliterans
- Obliterative vasculitis of small to medium sized arteries
- Assoc. with cigarette smoking
- Legs > arms
- Absence of generalized arteriosclerosis/Ca
- Direct collateral following in path of orginial artery (Martorell sign) in 80%
QUESTION-8:
Diffuse abdominal pain:
Correct Answer: Jejunal bleeding
- Pitressin infusion
- Embolization
- Microcoils superselectively in branch supplying bleed
- Less effective in SB due to rich collaterals from vasa recta
- Surgery
- Assisted by selective injection of methylene blue dye to aid with visualization
QUESTION-9:
Chronic leg pain and swelling:
Correct Answer: May-Thurner Syndrome
- Left iliac vein occlusion due to compression/synechiae by the overlying right common iliac artery
- Present with leg swelling, iliofemoral DVT
- Treatment
- Thrombolysis if needed
- Stent placement
- Primary patency for stenting iliofemoral stenoses is 50 – 85%
- Secondary patency of 90 – 100%
QUESTION-10:
What is the origin of the uterine artery?:
Correct Answer: anterior division of internal iliac artery.
This vessel usually arises separately from the internal iliac artery, but it may arise from the umbilical artery. It descends on the lateral wall of the pelvis, anterior to the internal iliac artery, and enters the root of the broad ligament where it passes superior to the lateral portion of the fornix of the vagina to reach the lateral margin of the uterus. The uterine artery passes anterior and superior to the ureter near the lateral portion of the fornix. Clemente 4th Plate 265.The fact that the uterine artery crosses anterior and superior to the ureter near the lateral portion of the fornix of the vagina is clinically important. The ureter is in danger of being inadvertently clamped or severed during a hysterectomy when the uterine artery is tied off. The point of crossing of the uterine artery and ureter lies about 2 cm superior to the ischial spine. The left ureter is particularly vulnerable because it is very close to the lateral aspect of the cervix.
QUESTION-11:
Chronic abdomen pain:
Correct Answer: Choledochal cyst
- Most common type (85 – 90%):
- Type 1a – cystic dilatation of cbd
- Type 1b – focal, segmental cbd dilatation
- Type 1c – fusiform choledochal dilatation - Type 1 – dilation of cbd
- Type 2 – diverticular cyst off cbd
- Type 3 – choledochocele
- Type 4a – multiple intra and extrahepatic cysts
- Type 4b – multiple extrahepatic cysts
- Type 5 – intrahepatic cystic dilatation (Caroli’s)
Pearls:
- Primary sclerosing cholangitis (PSC) is a long-term progressive disease of the liver and gallbladder characterized by inflammation and scarring of the bile ducts.
- PSC affects the biliary tree resulting in multiple strictures, liver damage, and eventually cirrhosis.
References:
- https://bit.ly/3ePNFLY
QUESTION-12:
Abnormal LFTs:
Correct Answer: Primary sclerosis cholangitis
- Multifocal strictures of intra and extrahepatic bile ducts
- Lack of intrahepatic dilatation characteristic
- Treatment options limited
- Endoscopic drainage and balloon dilatation
- Percutaneous biliary drainage
- Transplantation for hepatic failure, variceal bleeding, acsites
EXTRAHEPATIC BILIARY OBSTRUCTION
- Benign lesions: Smooth tapering
- Malignant lesions
- Abruptly tapered
- Irregular margins
MALIGNANT BILIARY OBSTRUCTION - LOCATION
- Distal CBD – ampullary CA
- Mid (to distal)CBD – pancreatic CA, lymphoma
- CHD or biliary confluence – gallbladder CA, metastsatic dz: lung, colon, breast, cholangiocarcinoma
HILAR OBSTRUCTION
- Cholangiocarcinoma
- Gallbladder carcinoma
- Mets to porta-hepatis
- Post-op stricture
- Inflammatory stx – Mirizzi syn.
QUESTION-13:
Hypertension workup:
Correct Answer: Fibromuscular dysplasia
- Intimal fibroplasia (1-2%)
- Focal stenosis - Medial fibroplasia (60 – 70%)
- “string of beads” - Medial hyperplasia (5 – 15%)
- Long, smooth narrowing - Perimedial fibroplasia (15 – 25%)
- Irreg. Stenosis, beading (without aneurysm) - Medial dissection (5%)
- False channel, aneurysm - Adventitial fibroplasia (<1%)
- Long, segmental stenosis
QUESTION-14:
The inferior pancreaticoduodenal artery is a branch off of what other artery?:
Correct Answer: SMA
References:
- Netter plates 282, 283; Dahnert 5th 781
