Part 1: 5 Basic-Level MCQs

MCQ 1

Question

Which procedure is considered the gold standard for biliary drainage in patients with cholangitis (benign or malignant etiologies)?

Answer Choices

A. Percutaneous transhepatic cholangial drainage (PTCD)

B. Endoscopic transpapillary biliary drainage (ETBD)

C. Endoscopic ultrasound–guided biliary drainage (EUS-BD)

D. Surgical common bile duct (CBD) exploration

Correct Answer

B. Endoscopic transpapillary biliary drainage (ETBD)

Explanation

Why B is correct: According to the excerpt, endoscopic transpapillary biliary drainage (ETBD) is less invasive and carries a lower risk of complications compared to percutaneous or surgical approaches. It is therefore recognized as the first-line (“gold standard”) technique for relieving biliary obstruction in cholangitis.
Why others are incorrect:
- (A) PTCD is an effective second-line technique but carries higher complication rates (bleeding, tube dislodgment, etc.) compared to ETBD.
- (C) EUS-BD is a viable second-line option if ETBD fails or is not feasible, but it requires advanced expertise and specialized equipment.
- (D) Surgical exploration of the CBD has the highest morbidity and mortality and is a last resort.

Key Takeaways (4–5 sentences)

Endoscopic transpapillary biliary drainage has become the mainstay of managing acute cholangitis due to its minimal invasiveness and relatively low complication rate. Early decompression is crucial in cholangitis to reduce sepsis and stabilize patients. Selecting the optimal drainage method also depends on local expertise, anatomy, and comorbid conditions. In most centers, ETBD is the first attempt unless contraindications or challenging anatomy exist. Alternatives like PTCD, EUS-BD, or surgery are considered when standard endoscopic approaches fail or are not feasible.

Reference:

Blumgart’s Surgery of the Liver, Biliary Tract and Pancreas, 7th edition,

Chapter 43: “Cholangitis,” Subtopic: “Procedures for Biliary Decompression” (pp. 628–630).

MCQ 2 (All are true EXCEPT)

Question

All of the following are recognized advantages of endoscopic nasobiliary drainage (ENBD) EXCEPT:

Answer Choices

A. Ability to monitor bile output continuously

B. Capability for repeated biliary lavage

C. Minimal patient discomfort

D. Ease of obtaining additional bile culture specimens

Correct Answer

C. Minimal patient discomfort

Explanation

Why C is correct (EXCEPT): ENBD often causes patient discomfort due to the external catheter. This discomfort can lead to accidental dislodgment of the tube and can also be associated with fluid and electrolyte imbalances if drainage is excessive.
Why others are correct (advantages of ENBD):
- (A) Continuous observation of bile output is feasible, aiding in monitoring.
- (B) The tube allows for repeated saline or antibiotic lavage.
- (D) Cultures can be sampled repeatedly to guide antibiotic therapy.

Key Takeaways (4–5 sentences)

Nasobiliary drainage provides an external route for decompression and offers the benefit of real-time bile monitoring and repeated cultures. This can be particularly useful in severe or persistent cholangitis when close monitoring is needed. However, the external tube often leads to patient discomfort and potential dislodgment. Internal stenting (EBS) bypasses some of these concerns but may have a higher risk of stent occlusion in certain settings. The choice between ENBD and EBS can be tailored to patient preference, clinical scenario, and local expertise.

Reference:

Blumgart’s Surgery of the Liver, Biliary Tract and Pancreas, 7th edition,

Chapter 43: “Cholangitis,” Subtopic: “Procedures for Biliary Decompression” (pp. 628–630).

MCQ 3 (Scenario-Based)

Question

A 58-year-old patient presents with mild cholangitis and a common bile duct stone confirmed on imaging. He is hemodynamically stable, afebrile, and not coagulopathic. According to standard recommendations, which of the following is the best management approach?

Answer Choices

A. Postpone all interventions until after complete resolution of infection

B. Place a nasobiliary drain only and avoid stone manipulation

C. Perform endoscopic sphincterotomy and attempt stone removal in the same session

D. Proceed directly to surgical common bile duct exploration

Correct Answer

C. Perform endoscopic sphincterotomy and attempt stone removal in the same session

Explanation

Why C is correct: In mild or moderate cholangitis where the patient is stable and not coagulopathic, endoscopic intervention with possible sphincterotomy and stone extraction is feasible and recommended. Prompt definitive clearance of the CBD stones can resolve the cause of obstruction and reduce infectious complications.
Why others are incorrect:
- (A) Delaying all procedures in a stable patient can lead to complications or prolonged cholangitis.
- (B) Merely placing a nasobiliary drain without addressing the stone might result in recurrent or persistent obstruction.
- (D) Surgical intervention is more invasive and typically reserved for cases where endoscopic methods fail or are contraindicated.

Key Takeaways (4–5 sentences)

In mild to moderate cholangitis, if the patient is stable, an endoscopic approach to both decompress the biliary tree and remove stones is usually the first-line. Endoscopic sphincterotomy (EST) can be done at the same session for efficient stone extraction. Deferring stone removal is more common in severely septic or unstable patients. By quickly alleviating the obstruction, the risk of ongoing infection and potential sepsis is significantly reduced. Surgical approaches are reserved for endoscopic or percutaneous failure or when anatomy precludes less invasive access.

Reference:

Blumgart’s Surgery of the Liver, Biliary Tract and Pancreas, 7th edition,

Chapter 43: “Cholangitis,” Subtopic: “Procedures for Biliary Decompression” (pp. 628–630).

MCQ 4

Question

Which statement best describes endoscopic papillary balloon dilation (EPBD) compared with endoscopic sphincterotomy (EST) in the management of choledocholithiasis?

Answer Choices

A. EPBD has a significantly lower risk of bleeding but a higher risk of pancreatitis

B. EST is associated with a lower success rate of stone extraction

C. EPBD preserves the sphincter of Oddi and is always the first-line therapy

D. EST is contraindicated in patients with mild cholangitis

Correct Answer

A. EPBD has a significantly lower risk of bleeding but a higher risk of pancreatitis

Explanation

Why A is correct: Comparative studies show EPBD leads to less bleeding compared with EST but has a higher risk of pancreatitis. These differences in risk profiles guide clinicians in selecting the best method for individual patients.
Why others are incorrect:
- (B) EST generally has a high success rate in stone extraction and is considered the gold standard for choledocholithiasis.
- (C) EPBD is not always first-line; it is used selectively, especially when there is a high bleeding risk.
- (D) EST is typically indicated in patients with stone-induced cholangitis (if no coagulopathy or instability).

Key Takeaways (4–5 sentences)

Endoscopic papillary balloon dilation is a technique that preserves the sphincter of Oddi architecture and has lower hemorrhage rates compared to EST. However, it poses an increased risk of post-procedure pancreatitis. Endoscopic sphincterotomy remains the more widely used approach, especially when stone extraction is needed immediately. Balloon dilation is reserved for certain clinical scenarios, such as patients at high risk of bleeding. Clinicians weigh these trade-offs to choose the most appropriate intervention for each patient.

Reference:

Blumgart’s Surgery of the Liver, Biliary Tract and Pancreas, 7th edition,

Chapter 43: “Cholangitis,” Subtopic: “Procedures for Biliary Decompression” (pp. 628–630).

MCQ 5

Question

Which of the following best describes a situation in which percutaneous transhepatic cholangial drainage (PTCD) might be preferable to endoscopic transpapillary drainage?

Answer Choices

A. A patient with uncomplicated, mild cholangitis who can undergo ERCP easily

B. A patient with severe coagulopathy and hemodynamic instability

C. A patient with a Roux-en-Y gastric bypass in whom the duodenal papilla cannot be accessed endoscopically

D. A patient who refuses any external drainage method

Correct Answer

C. A patient with a Roux-en-Y gastric bypass in whom the duodenal papilla cannot be accessed endoscopically

Explanation

Why C is correct: PTCD is often a second-line approach but is indicated when an endoscopic approach is not feasible due to surgically altered anatomy, such as a Roux-en-Y reconstruction that prevents accessing the ampulla.
Why others are incorrect:
- (A) In typical cases of mild cholangitis with accessible papilla, endoscopic drainage is preferred.
- (B) Severe coagulopathy makes PTCD relatively contraindicated due to bleeding risk (and also endoscopic procedures need caution until coagulopathy is corrected).
- (D) PTCD involves an external catheter, which is precisely what this patient refuses.

Key Takeaways (4–5 sentences)

Percutaneous transhepatic cholangial drainage is an established second-line or rescue procedure when endoscopic access fails or is impossible. Examples include complex surgical anatomies like Roux-en-Y anastomoses. It can be highly effective if performed in experienced centers, though it carries risks such as bleeding, catheter dislodgement, and potential bile leak. Clinicians must carefully evaluate anatomy and patient conditions before choosing PTCD. Whenever possible, endoscopic approaches remain first-line given their less invasive nature and lower complication profile.

Reference:

Blumgart’s Surgery of the Liver, Biliary Tract and Pancreas, 7th edition,

Chapter 43: “Cholangitis,” Subtopic: “Procedures for Biliary Decompression” (pp. 628–630).

(Please review Part 1 and provide any feedback. Once confirmed, we will proceed with Part 2: 5 Advanced-Level MCQs.)