Part 2: 5 Advanced-Level MCQs

MCQ 1 (Critical Analysis)

Question

A 67-year-old patient with known hilar cholangiocarcinoma presents with acute cholangitis. ERCP is attempted, but the scope cannot navigate past the hilar stricture to achieve adequate drainage. The patient’s coagulopathy is partially corrected, and he remains clinically unstable. According to current guidelines and the excerpt, which second-line drainage approach is generally preferred, considering the need for internal drainage and the availability of expertise?

Answer Choices

A. Repeat ERCP with balloon enteroscopy

B. Endoscopic ultrasound–guided bile duct drainage (EUS-BD)

C. Immediate surgical exploration for T-tube placement

D. Percutaneous transhepatic cholangial drainage (PTCD)

Correct Answer

B. Endoscopic ultrasound–guided bile duct drainage (EUS-BD)

Explanation

Why B is correct: EUS-BD has emerged as a viable second-line technique after a failed ERCP, offering high technical success (around 90%–100% in experienced centers) and internal drainage advantages (no external tube, reduced fluid/electrolyte imbalances).
Why others are incorrect:
- (A) Balloon enteroscopy may be considered in altered anatomy but is less successful for hilar blockages and can be time-consuming.
- (C) Immediate surgical drainage carries the highest morbidity and mortality and is typically a last resort, particularly in an unstable patient.
- (D) PTCD is a well-established second-line but often provides external drainage, carries a risk of tube dislodgment, and could be more prone to superficial site complications. EUS-BD is often favored if the center has the expertise because it avoids external catheters.

Key Takeaways (4–5 sentences)

When ERCP fails or is not feasible in cholangitis cases, EUS-guided drainage has become a strong alternative, especially for malignant obstructions. It can achieve internal decompression, preserving patient comfort and potentially reducing complications associated with external drainage. However, it demands specialized training and equipment. PTCD remains a valid backup option where EUS expertise or equipment is lacking. Surgical exploration is considered last-line due to higher associated morbidity and mortality.

Reference:

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

Chapter 43: “Cholangitis,” Subtopic: “Endoscopic Ultrasound–Guided Bile Duct Drainage” (pp. 628–630).

MCQ 2 (Interpretation / Problem-Solving)

Question

A 62-year-old patient with decompensated cirrhosis presents with severe acute cholangitis. He undergoes ultrasound and CT that reveal large volume ascites and a dilated intrahepatic biliary system with suspected malignant obstruction at the proximal CBD. Based on the excerpt, which drainage method is contraindicated or least preferable in this situation?

Answer Choices

A. Endoscopic transpapillary biliary drainage

B. Endoscopic ultrasound–guided biliary drainage

C. Percutaneous transhepatic cholangial drainage (PTCD)

D. Surgical T-tube placement via laparotomy

Correct Answer

C. Percutaneous transhepatic cholangial drainage (PTCD)

Explanation

Why C is correct: PTCD is contraindicated or relatively contraindicated in patients with significant ascites because the needle track can lead to bile leakage into the peritoneal cavity, significantly elevating the risk of bile peritonitis.
Why others are incorrect:
- (A) Endoscopic drainage is typically first-line if feasible.
- (B) EUS-BD can be considered if ERCP is not possible or fails, as it can still achieve internal drainage.
- (D) Surgical drainage is a last resort but still more feasible than PTCD in massive ascites if a minimal approach fails.

Key Takeaways (4–5 sentences)

Significant ascites makes PTCD risky due to the potential for bile leakage and subsequent peritonitis. In severe cholangitis, ensuring timely decompression is paramount, so endoscopic approaches (transpapillary or EUS-guided) are usually favored. Surgical intervention is typically reserved for irreparable endoscopic failures or emergent complications. Evaluating ascites volume and correcting coagulopathy are essential steps before any invasive procedure.

Reference:

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

Chapter 43: “Cholangitis,” Subtopic: “Percutaneous Transhepatic Cholangial Drainage” (pp. 628–630).

MCQ 3 (All are true EXCEPT)

Question

Regarding surgical common bile duct (CBD) exploration in the setting of severe cholangitis, which of the following statements is NOT true?

Answer Choices

A. It has the highest overall mortality rate among biliary drainage options

B. It should be considered only after noninvasive procedures have failed

C. A horizontal choledochotomy incision is preferred over a vertical incision

D. A T-tube can be placed to maintain ductal patency and allow for external drainage

Correct Answer

C. A horizontal choledochotomy incision is preferred over a vertical incision

Explanation

Why C is correct (NOT true): The excerpt clearly states that a vertical incision along the CBD is recommended. A horizontal incision limits extension, risks damaging the axial arterial supply of the duct, and can create stenosis upon closure.
Why the other statements are true:
- (A) Surgical CBD exploration indeed carries the highest morbidity and mortality among the drainage options.
- (B) With advancements in endoscopic and interventional radiology techniques, surgical intervention is a last resort.
- (D) T-tube placement is a recognized option for decompression and postoperative access to the duct.

Key Takeaways (4–5 sentences)

Although historically common, open surgical CBD exploration is now reserved for complicated cases where less invasive methods fail. It carries greater risk, so operators attempt endoscopic or percutaneous techniques first. When performed, a vertical incision is crucial for surgical access and to preserve the duct’s blood supply. A T-tube can be used to ensure ongoing drainage and potential access for postoperative cholangiography. This approach limits the duration of the procedure and potential complications in a critically ill patient.

Reference:

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

Chapter 43: “Cholangitis,” Subtopic: “Surgical Common Bile Duct Exploration” (pp. 628–630).

MCQ 4 (Scenario-Based / Advanced Guideline Interpretation)

Question

A 70-year-old patient with moderate cholangitis and a large stone burden undergoes initial ERCP with partial clearance of stones and stent placement. Two days later, despite adequate antibiotic therapy, the patient remains febrile, with imaging showing residual choledocholithiasis and partial stent occlusion. What is the most appropriate next step to definitively manage this patient's persistent cholangitis and stone burden?

Answer Choices

A. Repeat endoscopic intervention with possible sphincterotomy extension or balloon clearance

B. Discharge with conservative management and wait for the stent to self-clear

C. Immediate laparotomy and open CBD exploration

D. Percutaneous transhepatic drainage without further attempts at stone extraction

Correct Answer

A. Repeat endoscopic intervention with possible sphincterotomy extension or balloon clearance

Explanation

Why A is correct: Persistent fever and stent occlusion indicate ongoing obstruction. A repeat ERCP to remove the remaining stones and possibly adjust or replace the stent is the most appropriate next step. Endoscopic re-intervention is typically favored over more invasive options if technically feasible.
Why others are incorrect:
- (B) Conservative management is inappropriate when there is evidence of ongoing cholangitis and obstruction.
- (C) While surgical exploration could be an option for definitive stone removal, it is more invasive and not first-line unless endoscopic options fail.
- (D) Percutaneous drainage may provide decompression but may not address the stone burden effectively unless endoscopic approaches are not possible.

Key Takeaways (4–5 sentences)

Residual stones and partial stent occlusion can perpetuate cholangitis. Repeating endoscopic therapy is often the most efficient way to achieve definitive clearance. Sometimes a larger sphincterotomy or balloon/basket retrieval can eradicate the remaining burden. Should endoscopic methods fail or become unfeasible, percutaneous or surgical options are considered. Timely and comprehensive clearance of obstruction is vital to resolve cholangitis.

Reference:

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

Chapter 43: “Cholangitis,” Subtopic: “Endoscopic Transpapillary Biliary Drainage and Stone Management” (pp. 628–630).

MCQ 5 (Critical Analysis of Advanced Technique)

Question

After a failed ERCP in a patient with distal biliary obstruction, an endoscopist successfully punctures the common bile duct transduodenally under EUS guidance and places a stent for internal drainage. Which major potential complications specific to EUS-guided biliary drainage should clinicians vigilantly monitor for, based on the excerpt?

Answer Choices

A. Bile leakage and peritonitis

B. Retroperitoneal abscess formation from the stent tract

C. Superior mesenteric artery thrombosis

D. Recurrent pyogenic cholangitis

Correct Answer

A. Bile leakage and peritonitis

Explanation

Why A is correct: EUS-BD involves creating an artificial communication between the GI tract and the bile duct. If the stent migrates or the tract isn’t sealed, bile can leak into the peritoneal or retroperitoneal space, leading to peritonitis. This risk of bile extravasation is one of the major concerns unique to EUS-BD.
Why others are incorrect:
- (B) Although a retroperitoneal abscess is possible in various procedures, it is less commonly cited than free bile leakage and resultant peritonitis in EUS-BD.
- (C) SMA thrombosis is not a typical direct complication of EUS-BD.
- (D) Recurrent pyogenic cholangitis is typically associated with chronic infection and biliary strictures, not specifically with newly created EUS-BD tracts.

Key Takeaways (4–5 sentences)

EUS-guided biliary drainage has high technical success but carries a risk profile related to tract creation between the GI lumen and bile duct. Bile leakage can occur if stent positioning is suboptimal or if the tract dilates further. This can lead to severe peritonitis and requires close clinical monitoring. Experienced endoscopists and careful follow-up are crucial to minimize these risks. Nonetheless, EUS-BD still represents an excellent rescue option compared to more invasive alternatives.

Reference:

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

Chapter 43: “Cholangitis,” Subtopic: “Endoscopic Ultrasound–Guided Bile Duct Drainage” (pp. 628–630).

Key Takeaways for the Entire Topic

Prompt Biliary Drainage is Essential: Regardless of etiology or method, swift decompression of the biliary system in acute cholangitis is crucial to control infection and prevent deterioration.
Endoscopic Transpapillary Drainage First-Line: ETBD (via ERCP) is the gold standard for managing cholangitis when anatomy allows. ENBD and EBS both have advantages and can be chosen based on patient preference, stone location, and clinical stability.
Alternative Techniques: EUS-BD, PTCD, and surgical exploration each have unique indications. EUS-BD is a strong second-line if ERCP fails, PTCD is used if endoscopic options are not possible, and surgery is reserved for rare scenarios or complicated failures.
Decision-Making Depends on Anatomy and Stability: Complex or altered anatomy (e.g., Roux-en-Y) or severe instability may necessitate PTCD or EUS-BD. Severe coagulopathy and large ascites are relative contraindications to PTCD.
Timing and Technique: In stable patients, definitive stone clearance can be attempted during initial endoscopic drainage. In septic or unstable patients, the goal is quick and safe decompression with minimal manipulation, deferring definitive treatment until stabilization.