UPSC-CMS 2014 - Surgery Practice Questions

Q: On second day following femoral embolectomy, the leg is found to be tender, tense and dusky with feeble dorsalis pedis pulse. The most appropriate management would be:

Fasciotomy. ***Fasciotomy*** - The symptoms (tender, tense, dusky leg with feeble dorsalis pedis pulse) occurring after revascularization strongly suggest developing **compartment syndrome**. - **Fasciotomy** is the most appropriate management to relieve pressure, restore blood flow, and prevent irreversible muscle and nerve damage. *Dye studies* - While imaging like angiography (dye studies) can assess vascular patency, they are not the immediate solution for suspected **compartment syndrome**. - Delaying definitive treatment for compartment syndrome for imaging can lead to **irreversible tissue damage**. *Doing re-embolectomy* - The problem is unlikely to be a persistent or recurrent embolus given the prior embolectomy and the presentation suggesting **compartment syndrome**, not ongoing arterial occlusion. - Repeating the procedure without addressing the underlying compartment pressure would be ineffective and potentially harmful. *Anticoagulant therapy* - Anticoagulation is crucial for preventing new clots or re-thrombosis but does not resolve the acute mechanical compression and ischemia of **compartment syndrome**. - It's part of the overall management but not the primary intervention for the immediate life-threatening limb condition described.

Q: An air fluid level with dilated oesophagus and “bird beak” appearance in a barium swallow is diagnostic of:

Achalasia cardia. ***Achalasia cardia*** - The classic radiographic features of achalasia on a barium swallow include a **dilated esophagus** with proximal food retention (leading to an **air-fluid level**) and a characteristic narrowing at the gastroesophageal junction, creating a **"bird-beak" appearance**. - This appearance is due to the failure of the lower esophageal sphincter to relax during swallowing, combined with absent esophageal peristalsis. *Carcinoma oesophagus* - Oesophageal carcinoma typically presents as an **irregular, constricting lesion** or a **filling defect** on barium swallow, often with mucosal irregularity or shelf-like margins, rather than a smooth "bird beak." - While it can cause dysphagia and possibly proximal dilation, the specific "bird beak" morphology is not characteristic of cancer. *Barrett's oesophagus* - Barrett's esophagus is a histological diagnosis involving **metaplastic changes** in the esophageal lining, usually due to chronic GERD. - It does not have a distinct radiographic appearance on barium swallow, though it might be associated with reflux changes or **ulcerations**, but not a "bird beak" sign. *Hiatus hernia* - Hiatus hernias are characterized by the **protrusion of a portion of the stomach into the chest cavity** through the esophageal hiatus of the diaphragm. - On a barium swallow, this appears as an **accumulation of barium above the diaphragm**, often with a wide opening at the esophagogastric junction, which is distinct from the narrowed "bird beak" of achalasia.

Q: A colonic carcinoma involving muscularis propria, with one or two nodes involved with a solitary metastasis in the liver, the TNM stage would be:

T2 N1 M1. ***T2 N1 M1*** **(Correct Answer)** - **T2** indicates the tumor invades the **muscularis propria** in the TNM classification for colorectal cancer. - **N1** signifies involvement of **one to three regional lymph nodes**, which corresponds to "one or two nodes involved" in the question. - **M1** denotes the presence of **distant metastasis**, specifically a "solitary metastasis in the liver" as described. *T1 N2 M1* - **T1** describes a tumor that invades the **submucosa** but not the muscularis propria, which is less advanced than the scenario described. - **N2** would imply involvement of **four or more regional lymph nodes**, contradicting the "one or two nodes involved" stated in the question. *T1 N1 M1* - **T1** indicates invasion into the **submucosa**, not reaching the muscularis propria as specified in the case description. - The **N1** and **M1** components are consistent with the nodal involvement and distant metastasis, but the **T stage** is incorrect. *T2 N2 M1* - While **T2** is correct for invasion into the muscularis propria, **N2** incorrectly implies involvement of **four or more regional lymph nodes**. - The question states "one or two nodes involved," making **N1** the appropriate nodal classification.

Q: After undergoing surgery, for carcinoma of colon, a patient developed single liver metastasis of 2 cm. What would be the next treatment?

Resection. ***Resection*** - For a **single, resectable liver metastasis** from colorectal carcinoma, surgical **resection offers the best chance of cure** and is the gold standard of treatment. - The size of the metastasis (2 cm) is well within the criteria for surgical removal, and the absence of multiple lesions or widespread disease makes it a prime candidate for curative surgery. *Radio frequency ablation* - **RFA** is typically considered for patients with **unresectable liver metastases** or those who are not surgical candidates. - While it can be effective for small lesions, it is generally preferred when resection is not possible due to factors like lesion location (e.g. adjacent to major vessels), patient comorbidities, or multiple lesions. *Chemo-radiation* - **Chemoradiation** is more commonly used in the treatment of the **primary colorectal cancer** itself, especially in locally advanced rectal cancer, or for palliative purposes in metastatic disease. - It is **not the primary curative treatment** for an isolated, resectable liver metastasis. *Acetic acid injection* - **Acetic acid injection** is a form of **chemical ablation** and is sometimes used for small liver tumors, particularly hepatocellular carcinoma. - It is generally considered **less effective and less predictable** than RFA or surgical resection for colorectal liver metastases and is not the preferred treatment for a resectable lesion.

Q: Which one of the following is given a score of two in Alvarado score?

Leukocytosis. ***Leukocytosis*** - A **leukocyte count greater than 10,000/mm³** (leukocytosis) is assigned a score of **two points** in the Alvarado score. [2] - This parameter reflects the systemic inflammatory response often associated with acute appendicitis. [1] *Anorexia* - **Anorexia**, or loss of appetite, is a common symptom in acute appendicitis but is only assigned **one point** in the Alvarado score. - It is a non-specific symptom that can be present in numerous conditions. *Pyrexia* - **Pyrexia** (fever) is another indicator of inflammation, but in the Alvarado score, a **fever of 37.3°C or higher** is given only **one point**. - This symptom, while important, does not carry the same weight as a significant elevation in white blood cell count. *Rebound tenderness* - **Rebound tenderness** is a sign of peritoneal irritation and is given **one point** in the Alvarado score. [1] - While strongly correlated with appendicitis, it is a clinical finding rather than a laboratory marker.

Q: Which one of the following parts of intussusception is most susceptible to ischaemia and perforation?

Apex. ***Apex*** - The **apex** is the **leading edge** (distal tip) of the intussusceptum that protrudes furthest into the intussuscipiens. - It is the **most distal point** from its blood supply and experiences the **greatest degree of vascular compromise**. - The apex suffers from **pressure necrosis** due to compression against the intussuscipiens and maximal venous congestion. - This makes it the **most susceptible site for ischemia, necrosis, and perforation** in intussusception. - Clinically, when perforation occurs, it is **most commonly at the apex**. *Neck* - The **neck** is the constricted point where the intussusceptum enters the intussuscipiens. - While the neck does compress the **mesentery and blood vessels**, causing venous outflow obstruction that affects the entire intussusceptum, it is not itself the most susceptible site for perforation. - The neck causes the ischemia, but the apex suffers the most from it. *Intussuscipiens* - The **intussuscipiens** is the **outer receiving segment** that engulfs the intussusceptum. - Its blood supply remains relatively intact as it is not invaginated. - It is **not susceptible** to ischemia in the same way as the invaginated segment. *Intussusceptum* - The **intussusceptum** refers to the **entire invaginated inner segment**. - While the whole intussusceptum can become ischemic, the question asks for the **specific part** most susceptible. - Within the intussusceptum, the **apex is the most vulnerable point** for ischemia and perforation.

Q: A 30 year old lady comes with history of bloody discharge from her right nipple while taking bath. On examination, there is a cystic swelling in the subareolar region. The clinical diagnosis would be:

Intraductal papilloma. ***Intraductal papilloma*** - **Bloody nipple discharge**, especially unilateral and spontaneous, is the hallmark symptom of an **intraductal papilloma**. - The presence of a **subareolar cystic swelling** further supports this diagnosis, as papillomas are benign growths arising within the breast ducts. *Duct ectasia* - This condition typically presents with a **thick, sticky, multi-colored nipple discharge**, not usually bloody. - It is more common in **perimenopausal** or postmenopausal women and is often associated with inflammation and nipple retraction. *Fibrocystic disease* - Characterized by **cyclic breast pain**, tenderness, and multiple palpable masses, often bilateral. - Nipple discharge, if present, is usually **clear, green, or brown**, but rarely bloody. *Intraductal carcinoma* - While it can cause bloody nipple discharge, it is less common in this age group (30-year-old). - More likely to present with a **firm or hard palpable mass** rather than a cystic swelling, and often accompanied by skin changes or nipple retraction. - The benign cystic nature of the swelling makes intraductal papilloma more likely in this clinical scenario.

Q: Which one of the following is the safest gas for creating pneumoperitoneum in operative laparoscopy?

Carbon dioxide. ***Carbon dioxide*** - **Carbon dioxide (CO2)** is the gold standard for creating **pneumoperitoneum** because it is rapidly absorbed from the **peritoneal cavity** and excreted by the lungs, minimizing the risk of gas embolism. - Its **high solubility in blood** (20x more soluble than nitrogen) reduces the risk of serious complications if inadvertently injected intravascularly. - **Non-combustible** and does not support combustion, making it safe to use with electrocautery and other heat sources during surgery. *Oxygen* - **Oxygen** is highly **combustible** and would create a significant fire hazard in the presence of electrocautery or other heat sources during surgery. - It could also cause **gas emboli** if it enters the bloodstream, as it is less soluble than CO2. - Risk of **oxidative tissue damage** with prolonged exposure. *Carbon monoxide* - **Carbon monoxide** is extremely **toxic** and binds irreversibly to hemoglobin with 200-250 times greater affinity than oxygen, forming **carboxyhemoglobin**, which impairs oxygen transport. - Even minimal exposure can be life-threatening due to systemic hypoxia. - Absolutely contraindicated for clinical use. *Nitrous oxide* - **Nitrous oxide** can diffuse into gas-filled spaces (bowel loops) 30x faster than nitrogen, potentially causing **bowel distension** and increased intra-abdominal pressure during prolonged procedures. - Although less of a fire risk than oxygen, it can **support combustion** at high concentrations. - Less rapidly absorbed than CO2, posing higher embolism risk if intravascular injection occurs.

Question 1

On second day following femoral embolectomy, the leg is found to be tender, tense and dusky with feeble dorsalis pedis pulse. The most appropriate management would be:

Accepted Answer

Fasciotomy

Answer

Dye studies

Answer

Doing re-embolectomy

Answer

Anticoagulant therapy

Question 2

An air fluid level with dilated oesophagus and “bird beak” appearance in a barium swallow is diagnostic of:

Accepted Answer

Achalasia cardia

Answer

Carcinoma oesophagus

Answer

Barrett's oesophagus

Answer

Hiatus hernia

Question 3

A colonic carcinoma involving muscularis propria, with one or two nodes involved with a solitary metastasis in the liver, the TNM stage would be:

Accepted Answer

T2 N1 M1

Answer

T1 N2 M1

Answer

T1 N1 M1

Answer

T2 N2 M1

Question 4

After undergoing surgery, for carcinoma of colon, a patient developed single liver metastasis of 2 cm. What would be the next treatment?

Accepted Answer

Resection

Answer

Radio frequency ablation

Answer

Chemo-radiation

Answer

Acetic acid injection

Question 5

Which one of the following is given a score of two in Alvarado score?

Accepted Answer

Leukocytosis

Answer

Anorexia

Answer

Pyrexia

Answer

Rebound tenderness

Question 6

Which one of the following parts of intussusception is most susceptible to ischaemia and perforation?

Accepted Answer

Apex

Answer

Neck

Answer

Intussuscipiens

Answer

Intussusceptum

Question 7

A 30 year old lady comes with history of bloody discharge from her right nipple while taking bath. On examination, there is a cystic swelling in the subareolar region. The clinical diagnosis would be:

Accepted Answer

Intraductal papilloma

Answer

Duct ectasia

Answer

Fibrocystic disease

Answer

Intraductal carcinoma

Question 8

Which one of the following is the safest gas for creating pneumoperitoneum in operative laparoscopy?

Accepted Answer

Carbon dioxide

Answer

Oxygen

Answer

Carbon monoxide

Answer

Nitrous oxide

UPSC-CMS 2014 — Surgery