Internal Medicine
1 questionsAll of the following may lead to gall bladder carcinoma except which of the following?
NEET-PG 2015 - Internal Medicine NEET-PG Practice Questions and MCQs
Question 1091: All of the following may lead to gall bladder carcinoma except which of the following?
- A. Gall Bladder Polyps
- B. Typhoid carriers
- C. Echinococcus Granulosus Infection (Correct Answer)
- D. Exposure to carcinogens like nitrosamine
Explanation: ***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.
Surgery
9 questionsWhat is the appropriate management for a patient with a carcinoid tumor of the appendix larger than 2 cm?
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 -
Under what guidelines is treatment started for a patient presenting with appendicular mass on a CT scan?
Treatment of choice for mucinous carcinoma of the gall bladder in the early stage is -
What is the primary indication for the Nigro Regimen?
A 35 year old male came with jaundice, palpable mass in the right hypochondrium not associated with pain. The probable diagnosis is -
A 60-year-old male presented with jaundice, pale stools, dark urine, and a mass in the epigastric region. Which of the following diagnoses is least likely to be the cause of these symptoms?
Which of the following statements about Gallbladder carcinoma is true?
Which of the following stoma is formed in Hartmann's procedure?
NEET-PG 2015 - Surgery NEET-PG Practice Questions and MCQs
Question 1091: What is the appropriate management for a patient with a carcinoid tumor of the appendix larger than 2 cm?
- A. Right hemicolectomy (Correct Answer)
- B. Appendicectomy
- C. Appendicectomy + abdominal CT scan
- D. Appendicectomy + 24 hrs urinary HIAA
Explanation: ***Right hemicolectomy*** - Carcinoid tumors of the appendix larger than **2 cm** are considered at high risk for **lymph node metastasis** and recurrence. - A **right hemicolectomy** provides adequate margins and allows for lymph node dissection, which is essential for staging and definitive treatment in such cases. *Appendicectomy* - An **appendicectomy** alone is typically sufficient for carcinoid tumors of the appendix that are **less than 1 cm** and localized to the tip. - For larger tumors, appendicectomy carries an unacceptably high risk of **incomplete resection** and metastatic disease. *Appendicectomy + abdominal CT scan* - While an **abdominal CT scan** is useful for assessing local spread and distant metastases, it does not address the need for a more extensive surgical resection for a **large primary tumor**. - A simple **appendicectomy** in this scenario would be inadequate as definitive treatment. *Appendicectomy + 24 hrs urinary HIAA* - **24-hour urinary 5-hydroxyindoleacetic acid (5-HIAA)** is a biomarker used to detect and monitor **carcinoid syndrome**, which occurs in a minority of patients with carcinoid tumors. - Measuring 5-HIAA is primarily for assessing systemic symptoms rather than determining the primary surgical management of the **tumor size**.
Question 1092: 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 -
- A. Proceed to laparotomy and appendicectomy (Correct Answer)
- B. Intravenous antibiotics
- C. Continue Ochsner Sherren regimen with close monitoring
- D. Continue conservative management
Explanation: ***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.
Question 1093: Under what guidelines is treatment started for a patient presenting with appendicular mass on a CT scan?
- A. Ochsner Sherren Regimen (Correct Answer)
- B. Conservative management and discharge
- C. Kocher's Regimen
- D. Immediate Laparotomy
Explanation: ***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.
Question 1094: Treatment of choice for mucinous carcinoma of the gall bladder in the early stage is -
- A. Simple cholecystectomy (Correct Answer)
- B. Extended cholecystectomy
- C. Cholecystectomy with wedge resection of liver
- D. Chemotherapy only
Explanation: ***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
Question 1095: What is the primary indication for the Nigro Regimen?
- A. Anal Carcinoma (Correct Answer)
- B. Rectal Carcinoma
- C. Sigmoid Colon Carcinoma
- D. Duodenal Carcinoma
Explanation: ***Anal Carcinoma*** - The **Nigro Regimen** is a standard treatment protocol involving concurrent **chemotherapy** (5-fluorouracil and mitomycin C) and **radiation therapy** for anal carcinoma. - Its primary goal is to achieve **organ preservation** and avoid the need for abdominoperineal resection, which would result in a permanent colostomy. *Rectal Carcinoma* - Treatment for **rectal carcinoma** often involves surgery (e.g., low anterior resection), radiation, and chemotherapy, but the specific **Nigro Regimen** is not the primary protocol. - While some chemotherapy drugs might overlap, the combined regimen and indications are distinct. *Sigmoid Colon Carcinoma* - **Sigmoid colon carcinoma** is typically treated primarily with **surgical resection**, often followed by adjuvant chemotherapy based on staging. - The Nigro Regimen is specifically designed for tumors in the **anal canal**, not the more proximal colon. *Duodenal Carcinoma* - **Duodenal carcinoma** is a rare gastrointestinal cancer usually managed with surgical resection, such as a **Whipple procedure**, and sometimes adjuvant chemotherapy. - This type of cancer is anatomically and etiologically distinct from anal carcinoma, making the Nigro Regimen irrelevant.
Question 1096: A 35 year old male came with jaundice, palpable mass in the right hypochondrium not associated with pain. The probable diagnosis is -
- A. Hepatocellular carcinoma
- B. Choledochal cyst
- C. Acute cholecystitis
- D. Pancreatic head carcinoma (Correct Answer)
Explanation: ***Pancreatic head carcinoma*** - **Pancreatic head carcinoma** classically presents with **painless progressive jaundice**, which is the hallmark feature of malignant biliary obstruction. - The **palpable mass in the right hypochondrium** represents a **palpable, non-tender gallbladder** known as **Courvoisier's sign** - indicating distal common bile duct obstruction with gallbladder distension. - **Courvoisier's law** states: "A palpable gallbladder in the presence of jaundice is unlikely to be due to stones and suggests malignant obstruction of the biliary tree." - The **absence of pain** is characteristic, as the obstruction develops gradually, unlike acute inflammatory conditions. *Hepatocellular carcinoma* - **Hepatocellular carcinoma (HCC)** can present with a palpable hepatic mass and hepatomegaly in the right hypochondrium. - However, jaundice in HCC is typically a **late feature** occurring with massive liver involvement, extensive hepatic replacement by tumor, or portal vein thrombosis - not early painless jaundice. - HCC more commonly presents with abdominal pain, weight loss, and symptoms of chronic liver disease rather than painless obstructive jaundice. *Acute cholecystitis* - **Acute cholecystitis** presents with severe **right upper quadrant pain** (Murphy's sign positive), fever, and leukocytosis. - The **absence of pain** in this patient makes acute cholecystitis very unlikely. - While a tender palpable gallbladder may be present, painless presentation is not characteristic. *Choledochal cyst* - **Choledochal cysts** can present with the classic triad of **jaundice, abdominal pain, and palpable mass**. - However, they are **more common in children and young females** (80% present before age 10). - The presentation usually includes **episodic abdominal pain** due to recurrent cholangitis or pancreatitis, making the painless presentation less typical. - In a 35-year-old male with painless jaundice, pancreatic malignancy is more likely.
Question 1097: A 60-year-old male presented with jaundice, pale stools, dark urine, and a mass in the epigastric region. Which of the following diagnoses is least likely to be the cause of these symptoms?
- A. Biliary Cancer
- B. Periampullary Cancer
- C. Pancreatic Cancer
- D. Chronic Cholecystitis (Correct Answer)
Explanation: ***Chronic Cholecystitis*** - While chronic cholecystitis can cause epigastric pain, it rarely presents with **jaundice**, **pale stools**, and **dark urine** because it typically does not obstruct the common bile duct. - The presence of a palpable **epigastric mass** is also not a common feature of chronic cholecystitis. *Biliary Cancer* - **Biliary cancer**, particularly choledochal cancer, can cause **obstructive jaundice**, leading to **pale stools** (lack of bilirubin) and **dark urine** (conjugated bilirubin in urine). - A mass in the **epigastric region** could represent an enlarged gallbladder due to distal obstruction (Courvoisier's sign) or the tumor itself. *Periampullary Cancer* - **Periampullary cancers**, which arise near the ampulla of Vater, characteristically cause **obstructive jaundice**, presenting with **pale stools** and **dark urine**. - A mass in the **epigastric region** might be the tumor or a dilated gallbladder due to bile duct obstruction. *Pancreatic cancer* - **Pancreatic head cancer** frequently obstructs the common bile duct, resulting in **jaundice**, **pale stools**, and **dark urine**. - An **epigastric mass** can be the palpable tumor itself or an enlarged, distended gallbladder.
Question 1098: Which of the following statements about Gallbladder carcinoma is true?
- A. Carries a good prognosis
- B. Gallstones may be a predisposing factor (Correct Answer)
- C. Commonly squamous cell carcinoma
- D. Jaundice is rare
Explanation: ***Gallstones may be a predisposing factor*** - The chronic inflammation and irritation caused by **gallstones (cholelithiasis)** are considered major risk factors for the development of gallbladder carcinoma. - Approximately 70-90% of patients with gallbladder carcinoma also have **cholelithiasis**, suggesting a strong association. *Carries a good prognosis* - Gallbladder carcinoma generally has a **poor prognosis** due to its asymptomatic nature in early stages and aggressive local invasion. - Most cases are diagnosed at an advanced stage, leading to a **low 5-year survival rate**. *Commonly squamous cell carcinoma* - The vast majority of gallbladder carcinomas are **adenocarcinomas** (around 90%), arising from the glandular epithelium. - **Squamous cell carcinoma** is rare, accounting for only a small percentage of cases. *Jaundice is rare* - **Jaundice** is a common symptom in advanced gallbladder carcinoma, often indicating obstruction of the biliary ducts. - It arises when the tumor invades or compresses the **common bile duct**, leading to bilirubin backup.
Question 1099: Which of the following stoma is formed in Hartmann's procedure?
- A. End Colostomy (Correct Answer)
- B. End Ileostomy
- C. Loop Ileostomy
- D. Caecostomy
Explanation: ***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.