NEET-PG 2015 - Surgery Practice Questions

Q: A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -

Proceed to laparotomy and appendicectomy. ***Proceed to laparotomy and appendicectomy*** - A **rising pulse rate, tachycardia, and fever** indicate **worsening sepsis** or **perforation** of the appendicular mass, necessitating urgent surgical intervention. - Continuing conservative management in the face of these signs carries a high risk of **morbidity and mortality** from peritonitis or widespread sepsis. *Continue Ochsner Sherren regimen with close monitoring* - The Ochsner Sherren regimen is a **conservative approach** for a stable appendicular mass, which is no longer the case with signs of deterioration. - **Clinical worsening** (tachycardia, rising fever, increased pulse) signifies failure of conservative management and requires a shift to surgical intervention. *Continue conservative management* - Continuing conservative management despite **signs of deterioration** (rising pulse, tachycardia, fever) would lead to further progression of the disease and potential life-threatening complications. - These symptoms suggest that the infection is **not contained** and is likely spreading, indicating the need for immediate surgical treatment. *Intravenous antibiotics* - While intravenous antibiotics are part of the initial conservative management, they are **insufficient** alone for an appendicular mass showing signs of deterioration. - The worsening clinical picture suggests a **failed antibiotic response** or a more severe underlying issue (e.g., abscess rupture) that requires surgical drainage or removal.

Q: Under what guidelines is treatment started for a patient presenting with appendicular mass on a CT scan?

Ochsner Sherren Regimen. ***Ochsner Sherren Regimen*** - The **Ochsner Sherren regimen** is a conservative management approach specifically used for patients presenting with an **appendicular mass** (a palpable mass formed by the inflamed appendix, omentum, and small bowel loops). - This regimen involves **nil by mouth**, **intravenous fluids**, **antibiotics**, and **analgesia**, with close observation to allow the inflammation to subside before potential interval appendectomy. *Conservative management and discharge* - While the Ochsner Sherren regimen is a form of conservative management, simply stating "conservative management and discharge" is incomplete and potentially dangerous for a patient with an **appendicular mass**. - **Discharge** is not appropriate without a period of observation and specific medical interventions like antibiotics, as there's a risk of abscess formation or perforation. *Kocher's Regimen* - **Kocher's regimen** is not a recognized treatment protocol for an appendicular mass. - The term "Kocher" is more commonly associated with a **surgical incision** (Kocher incision for cholecystectomy) or a **maneuver** (Kocher maneuver for duodenal mobilization). *Immediate Laparotomy* - **Immediate laparotomy** is generally contraindicated in the presence of a well-formed **appendicular mass**. - Operating on a friable, inflamed mass can disrupt the natural containment, leading to widespread peritonitis and increased morbidity. The Ochsner Sherren regimen aims to cool down the inflammation first.

Q: Treatment of choice for mucinous carcinoma of the gall bladder in the early stage is -

Simple cholecystectomy. ***Simple cholecystectomy*** - For **early-stage (T1a) mucinous carcinoma of the gallbladder**, **simple cholecystectomy** is the treatment of choice - T1a disease (tumor confined to mucosa) has an excellent prognosis with **5-year survival >90%** after simple cholecystectomy alone - Extended resection offers **no survival benefit** for T1a disease and increases surgical morbidity - If incidentally discovered post-cholecystectomy with negative margins, no further surgery is needed *Extended cholecystectomy* - **Extended cholecystectomy** (cholecystectomy + liver segments IVb/V resection + portal lymphadenectomy) is indicated for **T2 or higher stage** disease (tumor invading muscularis propria or beyond) - This is **not** the treatment for early-stage disease as it increases morbidity without survival benefit - Reserved for more advanced tumors with deeper invasion *Cholecystectomy with wedge resection of liver* - This describes a component of extended cholecystectomy and is similarly indicated for **T2+ disease**, not early-stage - Wedge resection aims to achieve negative margins when tumor extends beyond the gallbladder wall - Not appropriate for early-stage mucinous carcinoma confined to mucosa *Chemotherapy only* - **Chemotherapy alone** is not curative for early-stage gallbladder carcinoma - Surgery remains the primary curative treatment for resectable disease - Chemotherapy is reserved for advanced, metastatic, or unresectable disease as palliative treatment

Q: Prostate cancer that is limited to the capsule and not the urethra would be staged as -

T2. ***T2*** - A T2 stage indicates that the prostate cancer is **confined within the prostate capsule**, meaning it has not spread beyond the outer layer of the prostate gland. - While it is not limited to the urethra, the key defining characteristic of T2 is **capsular confinement**, which is described in the question. *T1* - T1 stage prostate cancer is typically **non-palpable** on digital rectal exam (DRE) and not visible on imaging. - It is often found incidentally, for example, during a **transurethral resection of the prostate (TURP)** for benign prostatic hyperplasia. *T3* - A T3 stage indicates that the prostate cancer has **extended beyond the prostate capsule**, but has not metastasized to distant sites. - This typically involves invasion into the **seminal vesicles** or other periprostatic tissues. *T0* - T0 means there is **no evidence of primary tumor**, which is not consistent with a diagnosed prostate cancer. - This staging is used when there is no measurable tumor.

Q: A high-riding prostate is indicative of which injury?

Membranous Urethral Injury. ***Membranous Urethral Injury*** - A **high-riding prostate** is a classic sign of **membranous urethral injury**, often resulting from **pelvic fractures**. - The disruption of the **urethra** above the perineal membrane causes the prostate to be displaced superiorly and appear "high." *Extraperitoneal Bladder rupture* - This typically occurs with **pelvic fractures** and involves urine leaking into the **retropubic space**. - While associated with pelvic trauma, it does not directly cause a high-riding prostate; the bladder itself may be ruptured, but the relative position of the prostate is not significantly altered. *Intraperitoneal Bladder Rupture* - This type of rupture usually results from a direct blow to a **full bladder** and involves urine extravasating into the **peritoneal cavity**. - It does not cause a high-riding prostate, as the injury is to the dome of the bladder, not the structures supporting the prostate. *Bulbar Urethral Injury* - A **bulbar urethral injury** usually results from a **straddle injury** and is located in the anterior urethra. - This type of injury does not affect the anatomical position of the prostate, which is posterior and superior to the bulbar urethra.

Q: All of the following may lead to gall bladder carcinoma except which of the following?

Echinococcus Granulosus Infection. ***Echinococcus Granulosus Infection*** - Echinococcus granulosus is primarily associated with **hydatid cyst formation**, not directly linked to gallbladder carcinoma. - This infection typically affects the **liver** rather than inducing malignant transformation in the gallbladder. *Typhoid carriers* - Chronic infection with **Salmonella typhi** in carriers can cause **gallbladder inflammation** and is a risk factor for gallbladder cancer. - Typhoid carriers retain the bacteria in the gallbladder, leading to chronic irritation and potentially malignant changes. *Gall Bladder Polyps* - Certain types of gallbladder polyps, especially those larger than **1 cm**, have a significant risk of undergoing malignant transformation. - They are associated with **chronic inflammation** and may progress to cancer if not monitored. *Exposure to carcinogens like nitrosamine* - Nitrosamines are known **carcinogens** that can induce protein modifications leading to DNA damage, contributing to gallbladder cancer. - Long-term exposure to such chemicals can result in **cellular mutations** in the gallbladder epithelial lining.

Q: Which of the following is NOT a feature of membranous urethral injury?

Perineal butterfly hematoma. ***Perineal butterfly hematoma*** - A **perineal butterfly hematoma** is more characteristic of an injury to the **anterior urethra**, specifically the bulbar urethra, often caused by a straddle injury. - It occurs due to the extravasation of blood into the subcutaneous tissue of the perineum, outlining the shape of a butterfly. *blood at the meatus* - **Blood at the meatus** is a classic sign of urethral injury, regardless of the segment (anterior or posterior). - It indicates disruption of the urethral mucosa and bleeding from the damaged blood vessels. *Retention of urine* - **Retention of urine** can occur due to either a complete or partial urethral transection, preventing normal urine flow. - The inability to void can lead to bladder distension and is a significant symptom in assessing urethral trauma severity. *Pelvic fracture* - **Pelvic fractures** are frequently associated with **membranous urethral injuries** because the membranous urethra is fixed within the pelvic ring. - Shear forces from pelvic trauma can cause the prostatomembranous junction to avulse.

Q: Which of the following stoma is formed in Hartmann's procedure?

End Colostomy. ***End Colostomy*** - Hartmann's procedure involves resection of a diseased segment of the **colon**, typically the sigmoid colon, with the creation of a **proximal colostomy** and closure of the distal rectal stump. - The proximal end of the colon is brought out through the abdominal wall to form a **stoma**, which is a type of end colostomy. *End Ileostomy* - An end ileostomy involves bringing the **ileum** (small intestine) to the abdominal wall, which is not part of the standard Hartmann's procedure. - This is typically performed after a **total colectomy** or in cases of severe Crohn's disease affecting the colon. *Loop Ileostomy* - A loop ileostomy involves bringing a **loop of the ileum** to the surface of the abdomen, creating two openings that are then joined together. - This is often a **temporary diversion** and does not involve resection of the colon in the same manner as Hartmann's procedure. *Caecostomy* - A caecostomy is a stoma created from the **cecum**, the beginning of the large intestine. - This is typically performed for various reasons such as **bowel decompression** or management of fecal incontinence, and is not a component of Hartmann's procedure.

Q: Most common site of colorectal carcinoma?

Sigmoid Colon. ***Sigmoid Colon*** - The **sigmoid colon** is the most common site for colorectal carcinoma, accounting for approximately **25%** of all cases. - This higher incidence is potentially due to its role in stool storage, leading to longer contact time with potential carcinogens. *Rectum* - While the rectum is a common site, it accounts for about **15-20%** of colorectal cancers, making it less frequent than the sigmoid colon. - Rectal cancers often present with **hematochezia** and changes in bowel habits. *Ascending Colon* - The **ascending colon** is less frequently affected, around **10-15%** of cases. - Tumors here are often associated with **iron deficiency anemia** due to chronic blood loss. *Descending Colon* - The **descending colon** is also less commonly affected, making up approximately **5-10%** of colorectal cancers. - Tumors in this segment may present with **obstruction** due to the narrower lumen.

Question 1

A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -

Accepted Answer

Proceed to laparotomy and appendicectomy

Answer

Intravenous antibiotics

Answer

Continue Ochsner Sherren regimen with close monitoring

Answer

Continue conservative management

Question 2

Under what guidelines is treatment started for a patient presenting with appendicular mass on a CT scan?

Accepted Answer

Ochsner Sherren Regimen

Answer

Conservative management and discharge

Answer

Kocher's Regimen

Answer

Immediate Laparotomy

Question 3

Treatment of choice for mucinous carcinoma of the gall bladder in the early stage is -

Accepted Answer

Simple cholecystectomy

Answer

Extended cholecystectomy

Answer

Cholecystectomy with wedge resection of liver

Answer

Chemotherapy only

Question 4

Prostate cancer that is limited to the capsule and not the urethra would be staged as -

Accepted Answer

T2

Answer

T1

Answer

T3

Answer

T0

Question 5

A 35 year old male came with jaundice, palpable mass in the right hypochondrium not associated with pain. The probable diagnosis is -

Accepted Answer

Pancreatic head carcinoma

Answer

Hepatocellular carcinoma

Answer

Choledochal cyst

Answer

Acute cholecystitis

Question 6

A high-riding prostate is indicative of which injury?

Accepted Answer

Membranous Urethral Injury

Answer

Extraperitoneal Bladder rupture

Answer

Intraperitoneal Bladder Rupture

Answer

Bulbar Urethral Injury

Question 7

All of the following may lead to gall bladder carcinoma except which of the following?

Accepted Answer

Echinococcus Granulosus Infection

Answer

Gall Bladder Polyps

Answer

Typhoid carriers

Answer

Exposure to carcinogens like nitrosamine

Question 8

Which of the following is NOT a feature of membranous urethral injury?

Accepted Answer

Perineal butterfly hematoma

Answer

blood at the meatus

Answer

Retention of urine

Answer

Pelvic fracture

Question 9

Which of the following stoma is formed in Hartmann's procedure?

Accepted Answer

End Colostomy

Answer

End Ileostomy

Answer

Loop Ileostomy

Answer

Caecostomy

Question 10

Most common site of colorectal carcinoma?

Accepted Answer

Sigmoid Colon

Answer

Ascending Colon

Answer

Descending Colon

Answer

Rectum

NEET-PG 2015 — Surgery