Gastrointestinal Surgery Practice Questions

Q: A 40-year-old male with a history of progressive dysphagia for liquids presents with a dilated esophagus on barium meal. What is the most likely cause?

Achalasia cardia. ### Explanation **1. Why Achalasia Cardia is the Correct Answer:** Achalasia cardia is a primary esophageal motility disorder characterized by the failure of the Lower Esophageal Sphincter (LES) to relax and the absence of peristalsis. The hallmark clinical feature is **progressive dysphagia**, which classically begins with **liquids** or occurs for both solids and liquids simultaneously (unlike malignancy, which starts with solids). Over time, the functional obstruction leads to massive proximal dilatation of the esophagus, often referred to as a **"Sigmoid Esophagus"** or **"Mega-esophagus."** On a barium meal, this appears as a dilated esophageal body with a smooth, tapered narrowing at the GE junction, known as the **"Bird’s Beak"** or **"Rat-tail"** appearance. **2. Why the Other Options are Incorrect:** * **Options B, C, and D (Malignancies):** In esophageal or gastric cancers, dysphagia is typically **progressive for solids first**, only progressing to liquids in advanced stages. While these can cause proximal dilatation, it is rarely as massive or "mega-esophageal" as seen in long-standing achalasia. Furthermore, the narrowing in malignancy is usually irregular or "shouldered" (Apple-core appearance) rather than the smooth tapering seen in achalasia. **3. Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Esophageal **Manometry** (shows incomplete LES relaxation and aperistalsis). * **Initial Investigation:** Barium Swallow. * **To Rule Out Pseudo-achalasia:** Upper GI Endoscopy (essential to exclude malignancy at the cardia). * **Treatment of Choice:** Laparoscopic Heller’s Myotomy with partial fundoplication (Dor or Toupet). * **Pharmacotherapy:** Isosorbide dinitrate or Nifedipine (least effective, used in surgical non-candidates).

Q: All of the following are causes of pneumoperitoneum except?

Hirschsprung's disease. **Explanation:** **Pneumoperitoneum** refers to the presence of free air within the peritoneal cavity, most commonly caused by the perforation of a hollow viscus. **Why Hirschsprung’s Disease is the correct answer:** Hirschsprung’s disease is a functional bowel obstruction caused by the absence of ganglion cells in the distal colon. While it leads to massive bowel dilatation (**megacolon**), the bowel wall typically remains intact. Therefore, it presents with **pneumatosis intestinalis** (air within the bowel wall) or massive distension, but not pneumoperitoneum, unless a secondary complication like enterocolitis leads to a perforation (which is rare compared to the primary pathology). **Analysis of Incorrect Options:** * **Perforated Peptic Ulcer:** This is the **most common cause** of spontaneous pneumoperitoneum. Gastric or duodenal contents and air escape into the peritoneal cavity. * **Laparoscopic Procedure:** This is a cause of **iatrogenic pneumoperitoneum**. Carbon dioxide (CO2) is intentionally insufflated into the abdomen to create a working space. Residual air can persist for several days post-surgery. * **Perforated Appendix:** While less common than peptic ulcers (due to the appendix often being walled off by the omentum), a free perforation of the appendix can release intraluminal gas into the peritoneum. **NEET-PG High-Yield Pearls:** * **Most sensitive sign:** Air under the right diaphragm on an erect X-ray chest (can detect as little as 1–2 ml of air). * **Left Lateral Decubitus View:** The preferred position if the patient cannot stand; air is seen over the liver shadow. * **Rigler’s Sign:** Seeing both sides of the bowel wall due to free intraperitoneal air. * **Football Sign:** A large radiolucency outlining the entire peritoneal cavity in massive pneumoperitoneum (common in neonates).

Q: What is the most common cause of splenic rupture?

Malaria. **Explanation:** **Splenic rupture** can occur due to trauma or spontaneously in a diseased spleen. In the context of medical causes (non-traumatic/pathological rupture), **Malaria** is the most common cause worldwide, particularly in endemic regions. **Why Malaria is the correct answer:** In Malaria (especially *P. vivax* and *P. falciparum*), the spleen undergoes rapid congestion, hyperplasia, and infarcts. This leads to significant **splenomegaly**, stretching the splenic capsule. The capsule becomes thin and friable, making it highly susceptible to rupture even with trivial trauma or during the acute phase of the infection (spontaneous rupture). **Analysis of Incorrect Options:** * **ITP:** While ITP involves splenic destruction of platelets, the spleen is typically **not enlarged** (non-palpable). A palpable spleen in a suspected ITP case should prompt a search for an alternative diagnosis. * **Thalassemia:** This causes massive splenomegaly due to extramedullary hematopoiesis. While the spleen is large, the chronic nature of the enlargement leads to a thickened, fibrotic capsule which is more resistant to rupture compared to the acute enlargement seen in Malaria. * **Cirrhosis:** Leads to congestive splenomegaly due to portal hypertension. While common, the risk of spontaneous rupture is significantly lower than in acute infectious processes like Malaria or Infectious Mononucleosis. **High-Yield Clinical Pearls for NEET-PG:** 1. **Most common organ injured in blunt trauma abdomen:** Spleen. 2. **Most common cause of spontaneous (pathological) splenic rupture:** Malaria (followed by Infectious Mononucleosis). 3. **Kehr’s Sign:** Referred pain to the left shoulder due to diaphragmatic irritation by splenic blood (classic sign of rupture). 4. **Ballance’s Sign:** Fixed dullness in the left flank and shifting dullness in the right flank, indicating a large perisplenic hematoma.

Q: A 37-year-old woman presents with high fever (39.5°C), nausea, and vomiting. Physical examination reveals increased abdominal pain in the paraumbilical region, rebound tenderness over McBurney's point, and a positive psoas sign. Blood tests show marked leukocytosis. What is the most likely diagnosis?

Appendicitis. ### Explanation **Correct Answer: B. Appendicitis** The clinical presentation is a classic textbook case of **Acute Appendicitis**. The diagnosis is primarily clinical, based on the following findings: * **Paraumbilical pain:** This represents visceral pain from the T10 dermatome as the appendix distends. * **McBurney’s Point Tenderness:** As the parietal peritoneum becomes inflamed, the pain localizes to the Right Iliac Fossa (RIF). * **Psoas Sign:** Pain on extension of the right hip indicates an inflamed appendix in a **retrocecal** position, irritating the iliopsoas muscle. * **Systemic Signs:** High fever, nausea, vomiting, and marked leukocytosis (left shift) are indicative of an acute inflammatory/infectious process. **Why Incorrect Options are Wrong:** * **A. Ectopic Pregnancy:** While it causes RIF pain, it is usually associated with amenorrhea, vaginal bleeding, and hemodynamic instability if ruptured. Fever and high leukocytosis are less common unless there is secondary infection. * **C. Cholecystitis:** Pain is typically localized in the **Right Upper Quadrant (RUQ)** and radiates to the right scapula (Boas' sign). Murphy’s sign would be positive, not McBurney’s. * **D. Nephrolithiasis:** Presents as "loin to groin" colicky pain. While it causes nausea, it rarely presents with high fever or rebound tenderness unless complicated by pyelonephritis. **High-Yield Clinical Pearls for NEET-PG:** * **Alvarado Score (MANTRELS):** A score ≥7 is highly suggestive of appendicitis. * **Most common position:** Retrocecal (75%), followed by Pelvic (20%). * **Rovsing’s Sign:** Pain in the RIF when the Left Iliac Fossa is palpated. * **Investigation of Choice:** Contrast-Enhanced CT (CECT) is the gold standard in adults; Ultrasound is preferred in children and pregnant women.

Q: What is true about a femoral hernia?

Pregnancy is a common cause. **Explanation:** **Why Option B is Correct:** Femoral hernias occur through the femoral canal, which is bounded medially by the lacunar ligament and laterally by the femoral vein. While femoral hernias are more common in females overall (due to a wider pelvis), the most significant physiological factor contributing to their development is **increased intra-abdominal pressure**. Pregnancy is a classic cause as it leads to both increased pressure and hormonal changes that relax pelvic ligaments, widening the femoral ring and predisposed the patient to herniation. **Analysis of Incorrect Options:** * **Option A:** While femoral hernias are more common in women (Female:Male ratio is approx. 4:1), they do **not** occur exclusively in females. In fact, the most common hernia in both sexes remains the indirect inguinal hernia. * **Option C:** Femoral hernias have the **highest risk of strangulation** (approx. 20-40%) among all abdominal wall hernias. This is because the femoral ring is narrow and rigid, particularly due to the sharp edge of the lacunar ligament. * **Option D:** There is no clinical association between femoral hernias and cryptorchidism (undescended testes). Cryptorchidism is more relevant to the development of indirect inguinal hernias due to a patent processus vaginalis. **NEET-PG High-Yield Pearls:** * **Position:** A femoral hernia is felt **below and lateral** to the pubic tubercle (Inguinal hernias are above and medial). * **Laugier’s Hernia:** A rare variant of femoral hernia through the lacunar ligament. * **Cloquet’s Node:** A lymph node located within the femoral canal that can mimic a strangulated femoral hernia (De Garengeot's hernia is when the appendix is in the sac). * **Management:** Because of the high risk of strangulation, all femoral hernias should be repaired surgically (e.g., McVay repair or pre-peritoneal mesh).

Question 1

A 52-year-old male with a known history of peptic ulcer disease presents to the emergency department with sudden-onset severe epigastric pain described as 'like being stabbed', now spreading across the entire abdomen. He is lying completely still, has board-like rigidity on examination, and his vital signs show BP 118/76 mmHg, HR 92/min, RR 18/min, SpO2 98% on room air. He takes NSAIDs regularly for chronic back pain. His erect chest X-ray is shown (Image 1). After establishing IV access, sending bloods, and commencing IV fluids and analgesia, what is the most appropriate next step in management?

Accepted Answer

C. Emergency laparotomy with peritoneal lavage and primary repair

Answer

A. Urgent upper GI endoscopy to identify and clip the bleeding vessel

Answer

B. CT abdomen with IV contrast to confirm the source of perforation before intervention

Answer

D. Nasogastric tube insertion, IV proton pump inhibitor infusion, and conservative management for 24 hours

Question 2

A 70-year-old man with atrial fibrillation presents with severe periumbilical pain out of proportion to physical findings, bloody diarrhoea, and a markedly elevated serum lactate. He is haemodynamically unstable despite initial resuscitation. A CECT abdomen is shown (Image 2). Which of the following best describes the most appropriate operative strategy for this patient?

Accepted Answer

A. Damage control laparotomy with resection of non-viable bowel, leaving bowel in discontinuity, and planned relook at 24–48 hours

Answer

B. Emergency laparotomy with resection of non-viable bowel and primary anastomosis in the same sitting

Answer

C. Emergency catheter-directed thrombolysis via superior mesenteric artery angiography before any surgical intervention

Answer

D. Systemic anticoagulation with unfractionated heparin infusion and reassessment of bowel viability at 6 hours

Question 3

A 55-year-old man with a known history of peptic ulcer disease presents with sudden-onset severe epigastric pain that has now spread across the entire abdomen. On examination, the abdomen is board-like rigid and bowel sounds are absent. He is tachycardic and diaphoretic. His BP is 94/60 mmHg. An erect abdominal X-ray is shown (Image 1). After securing IV access and initiating fluid resuscitation, what is the most appropriate next step in management?

Accepted Answer

A. Proceed to emergency exploratory laparotomy after adequate resuscitation

Answer

B. Perform urgent upper GI endoscopy to identify and treat the bleeding source

Answer

C. Administer IV proton pump inhibitor infusion and arrange urgent CT abdomen

Answer

D. Insert a nasogastric tube for decompression and observe for 24 hours

Question 4

A 40-year-old male with a history of progressive dysphagia for liquids presents with a dilated esophagus on barium meal. What is the most likely cause?

Accepted Answer

Achalasia cardia

Answer

Cancer at the cardia

Answer

Carcinoma of the esophagus

Answer

Carcinoma of the gastric fundus

Question 5

All of the following are causes of pneumoperitoneum except?

Accepted Answer

Hirschsprung's disease

Answer

Perforated peptic ulcer

Answer

Laparoscopic procedure

Answer

Perforated appendix

Question 6

Which of the following statements about duodenal adenocarcinoma is correct?

Accepted Answer

It is the most common small bowel carcinoma.

Answer

It is a periampullary carcinoma.

Answer

Jaundice and anemia are the most common symptoms.

Answer

Local resection is curative.

Question 7

What is the most common cause of splenic rupture?

Accepted Answer

Malaria

Answer

Idiopathic Thrombocytopenic Purpura (ITP)

Answer

Thalassemia

Answer

Cirrhosis

Question 8

A 32-year-old patient presents with diarrhea and flushing. CT scan reveals multiple lesions in the liver. The primary disease is most likely located in which of the following?

Accepted Answer

Small bowel

Answer

Esophagus

Answer

Appendix

Answer

Stomach

Question 9

A 37-year-old woman presents with high fever (39.5°C), nausea, and vomiting. Physical examination reveals increased abdominal pain in the paraumbilical region, rebound tenderness over McBurney's point, and a positive psoas sign. Blood tests show marked leukocytosis. What is the most likely diagnosis?

Accepted Answer

Appendicitis

Answer

Ectopic pregnancy

Answer

Cholecystitis

Answer

Nephrolithiasis

Question 10

What is true about a femoral hernia?

Accepted Answer

Pregnancy is a common cause

Answer

Occurs exclusively in females

Answer

Does not strangulate

Answer

In males, it is associated with cryptorchidism

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?