Gastrointestinal Surgery Practice Questions

Q: Increased gastric acid secretion occurs in which type of gastric ulcer?

Type III gastric ulcer. Gastric ulcers are classified using the **Johnson Classification**, which categorizes them based on their location and the underlying pathophysiology of acid secretion. ### **Explanation of the Correct Answer** **Type III gastric ulcers** are located in the **prepyloric region** (within 3 cm of the pylorus). Pathophysiologically, these behave similarly to duodenal ulcers. They are associated with **gastric acid hypersecretion** and an increased number of parietal cells. Because the acid output is high, these ulcers are often linked to a higher risk of recurrence and complications like perforation. ### **Explanation of Incorrect Options** * **Type I:** Located on the **lesser curvature** (incisura angularis). This is the most common type. It is associated with **low to normal acid secretion** and is primarily due to a breakdown in mucosal defense. * **Type IV:** Located high on the lesser curvature, near the **gastroesophageal junction**. Like Type I, these are associated with **low to normal acid secretion**. * **Type V:** These are **NSAID-induced ulcers** and can occur anywhere in the stomach. They are not primarily driven by acid hypersecretion but by the inhibition of protective prostaglandins. ### **High-Yield Clinical Pearls for NEET-PG** * **Acid Hypersecretion Types:** Only **Type II** (body of stomach + duodenal ulcer) and **Type III** (prepyloric) are associated with high acid levels. * **Most Common:** Type I is the most frequent gastric ulcer. * **Surgical Management:** Because Types II and III are acid-driven, surgical treatment often requires an acid-reducing procedure (like a vagotomy) in addition to antrectomy. * **Type IV Caution:** These are difficult to manage surgically due to their proximity to the esophagus (Csendes procedure may be used).

Q: What is false regarding wandering spleen?

Treatment of choice is splenectomy only. **Explanation:** **Wandering Spleen** (Splenoptosis) is a rare clinical condition characterized by the migration of the spleen from its normal anatomical position in the left upper quadrant to other parts of the abdomen or pelvis. This occurs due to the **congenital or acquired absence or laxity of the suspensory ligaments** (gastrosplenic and splenorenal ligaments). **Why Option B is False:** The treatment of choice is **not** splenectomy only. In modern surgical practice, **Splenopexy** (surgical fixation of the spleen) is the preferred treatment, especially in children and young adults, to preserve splenic function and avoid the risk of Overwhelming Post-Splenectomy Infection (OPSI). Splenectomy is reserved only for cases where there is **total splenic infarction** or severe thrombosis of the pedicle. **Analysis of Other Options:** * **Option A:** Chronic or intermittent torsion leads to venous congestion, which results in progressive **splenomegaly**. * **Option C:** Because the spleen is attached only by a **long, mobile vascular pedicle**, it is highly prone to twisting (torsion), which can lead to hemorrhagic infarction and acute abdomen. * **Option D:** The spleen remains encapsulated but possesses an abnormally long vascular pedicle (containing the splenic artery and vein), allowing it to "wander." **High-Yield Clinical Pearls for NEET-PG:** * **Most common presentation:** An asymptomatic mobile abdominal mass or acute abdomen due to torsion. * **Diagnostic Modality:** **Contrast-Enhanced CT (CECT)** is the gold standard (shows the absence of the spleen in its fossa and the "whirl sign" of a twisted pedicle). * **Association:** More common in multiparous women (due to ligamentous laxity) and children under 10 years.

Q: Which of the following clinical signs is NOT associated with acute appendicitis?

Cullen's sign. **Explanation:** The correct answer is **Cullen’s sign**, as it is a clinical marker for **retroperitoneal hemorrhage**, most commonly associated with **acute pancreatitis** or a ruptured ectopic pregnancy, rather than acute appendicitis. **1. Why Cullen’s sign is the correct answer:** Cullen’s sign is characterized by periumbilical ecchymosis (bluish discoloration). It occurs when blood tracks from the retroperitoneum to the periumbilical subcutaneous fat via the falciform ligament. It is a sign of severe, often necrotizing, pancreatitis. **2. Analysis of incorrect options (Signs of Appendicitis):** * **Pointing sign:** The patient is asked to point to where the pain began (periumbilical) and where it moved to (Right Iliac Fossa). This shift reflects the progression from visceral to somatic pain. * **Rovsing's sign:** Deep palpation of the Left Iliac Fossa causes pain in the Right Iliac Fossa. This occurs due to the displacement of gas and the stretching of the peritoneum over the inflamed appendix. * **Obturator sign:** Internal rotation of the flexed right hip causes pain. This indicates an inflamed **pelvic appendix** irritating the obturator internus muscle. **Clinical Pearls for NEET-PG:** * **McBurney’s Point:** Located 1/3rd of the distance from the ASIS to the umbilicus; the site of maximum tenderness. * **Psoas Sign:** Pain on extension of the right hip; indicates a **retrocecal appendix**. * **Grey Turner’s Sign:** Ecchymosis in the flanks (also seen in pancreatitis). * **Sherren’s Triangle:** Formed by the umbilicus, ASIS, and pubic symphysis; hyperesthesia here suggests appendicitis.

Q: A patient presents with a history of abdominal pain. On examination, the person is in shock, with severe abdominal tenderness and guarding. There was also one episode of bloody diarrhea. He gives a history of recurrent abdominal pain soon after taking food which persists for about 3 hours after food. He also has a history of myocardial infarction about 5 years back. What is your diagnosis?

Acute thrombotic mesenteric vascular occlusion. **Explanation:** The clinical presentation points toward **Acute Mesenteric Ischemia (AMI)**, specifically **Acute Thrombotic Mesenteric Vascular Occlusion**. 1. **Why it is correct:** The patient has a classic history of **"Intestinal Angina"** (recurrent post-prandial abdominal pain lasting 1–3 hours), which indicates pre-existing atherosclerotic narrowing of the mesenteric vessels. The sudden progression to shock, severe tenderness (indicating bowel infarction/peritonitis), and **bloody diarrhea** (sloughing of ischemic mucosa) are hallmarks of acute occlusion. His history of myocardial infarction confirms a systemic atherosclerotic profile, a major risk factor for mesenteric thrombosis. 2. **Why the others are incorrect:** * **Acute Pancreatitis:** While it causes severe pain and shock, it does not typically present with bloody diarrhea or a specific history of post-prandial "angina" pain. * **Acute Duodenal Ulcer Perforation:** This presents with sudden "board-like" rigidity. While pain may be related to food, it usually improves with food (in DU) and does not cause bloody diarrhea. * **Acute Appendicitis:** This typically presents with migratory pain to the right iliac fossa and fever, not systemic shock and bloody diarrhea in the early stages. **Clinical Pearls for NEET-PG:** * **Classic Triad of AMI:** Severe abdominal pain out of proportion to physical findings (early), gut emptying (vomiting/diarrhea), and a source of emboli (AFib) or thrombus (Atherosclerosis). * **Gold Standard Investigation:** CT Angiography. * **Early Sign on X-ray:** Usually normal; late signs include "Thumbprinting" (mucosal edema) or Pneumatosis intestinalis. * **Most common site:** Superior Mesenteric Artery (SMA).

Q: What is the treatment of choice for fistula in ano?

Fistulotomy. **Explanation:** The primary goal in treating a fistula-in-ano is to eradicate the track while preserving anal sphincter function. **1. Why Fistulotomy is the Correct Answer:** **Fistulotomy** is considered the gold standard and treatment of choice for most simple (low) fistulae. It involves laying the fistula track open by cutting the overlying skin and muscle, allowing the wound to heal by secondary intention from the base upwards. It has a high success rate and a lower risk of fecal incontinence compared to more radical procedures. **2. Analysis of Incorrect Options:** * **Anal Dilatation (Lord’s Procedure):** This is historically used for hemorrhoids or anal fissures to reduce sphincter hypertonia; it has no role in treating a fistulous track. * **Fissurotomy:** This is the surgical treatment for a chronic anal fissure, not a fistula. * **Fistulectomy:** This involves the complete excision of the fistula track. While effective, it creates a larger wound, takes longer to heal, and carries a significantly higher risk of damaging the anal sphincters, leading to incontinence. Therefore, it is generally less preferred than fistulotomy. **3. Clinical Pearls for NEET-PG:** * **Goodsall’s Law:** Predicts the track of the fistula. If the external opening is **anterior** to a transverse line through the anus, the track is straight. If **posterior**, the track is curved and opens in the midline (Exception: Anterior openings >3cm from the anus also follow a curved posterior track). * **Park’s Classification:** Categorizes fistulae into Intersphincteric (most common), Transsphincteric, Suprasphincteric, and Extrasphincteric. * **Seton Placement:** Used for "complex" or "high" fistulae where a fistulotomy would risk major incontinence. * **Most common cause:** Cryptoglandular infection (infection of the anal glands).

Q: A young patient presents with a history of dysphagia, more to liquids than solids. What is the first investigation you will perform?

Barium Swallow. **Explanation:** The clinical presentation of **dysphagia more to liquids than solids** is a classic hallmark of a **motility disorder**, most commonly **Achalasia Cardia**. In contrast, mechanical obstructions (like strictures or malignancy) typically present with dysphagia to solids first, progressing to liquids. **1. Why Barium Swallow is the Correct Answer:** Barium swallow is the **initial investigation of choice** for dysphagia. It provides a "road map" of the esophagus, helping to differentiate between structural and functional causes. In Achalasia, it classically shows the **"Bird’s Beak" appearance** (tapering of the lower esophageal sphincter with proximal dilatation). It is non-invasive and helps the clinician avoid accidental perforation during a subsequent endoscopy if a large diverticulum (like Zenker’s) is present. **2. Why other options are incorrect:** * **Esophagoscopy:** While it is the most important investigation to **rule out malignancy** (pseudo-achalasia) and is mandatory before treatment, it is usually the second step. It is invasive and may miss subtle motility patterns. * **Ultrasound of the chest:** This has no diagnostic role in evaluating the lumen or motility of the esophagus. * **CT Scan of the chest:** This is used for staging esophageal cancer but is not a primary screening tool for dysphagia or motility disorders. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** Esophageal Manometry (shows incomplete relaxation of LES and aperistalsis). * **Most Common Symptom:** Dysphagia to both solids and liquids (paradoxical dysphagia). * **Heller’s Myotomy:** The surgical treatment of choice. * **Rule of Thumb:** For any dysphagia, **Barium Swallow** is the first/initial test, while **Endoscopy** is the best test to rule out cancer.

Q: All of the following are true about Retained Antrum Syndrome except:

Positive Secretin Stimulation Test. **Explanation:** **Retained Antrum Syndrome (RAS)** occurs when a portion of the gastric antrum is inadvertently left behind attached to the duodenal stump following a **Billroth II gastrectomy**. Because this antral tissue is no longer exposed to acidic gastric contents, the G-cells are constantly stimulated to release **Gastrin**, leading to hypergastrinemia and recurrent stomal ulcers. 1. **Why Option C is the correct answer (False statement):** In RAS, the **Secretin Stimulation Test is negative** (gastrin levels decrease or remain stable). In contrast, a **Positive Secretin Test** (paradoxical rise in gastrin >200 pg/mL) is the hallmark of a **Zollinger-Ellison Syndrome (Gastrinoma)**. This is the primary clinical method used to differentiate between the two conditions. 2. **Analysis of other options:** * **Option A:** **Technetium 99m pertechnetate scan** is the diagnostic imaging of choice as it is taken up by the ectopic gastric mucosa in the duodenal stump. * **Option B:** It is specifically seen after **Billroth II** reconstruction because the duodenal stump is excluded from the food stream and acid flow. * **Option D:** The **Calcium Provocation Test** is typically **negative** or shows a minimal rise in RAS, whereas it shows a significant increase in Gastrinoma. **High-Yield Clinical Pearls for NEET-PG:** * **Pathophysiology:** Loss of feedback inhibition of G-cells due to alkaline environment in the duodenum. * **Differential Diagnosis:** Always differentiate RAS from Gastrinoma using the Secretin Test. * **Treatment:** Surgical excision of the residual antral stump (often performed laparoscopically). * **Key Distinction:** * **RAS:** Secretin test (-), Tc-99m scan (+). * **Gastrinoma:** Secretin test (+), Tc-99m scan (-).

Q: All are true about Dieulafoy's lesion except?

Angiographic embolization is the preferred treatment. **Explanation:** Dieulafoy’s lesion is a rare but life-threatening cause of gastrointestinal bleeding. It is characterized by a **large-caliber submucosal artery** that fails to taper as it reaches the mucosa. **1. Why Option A is the Correct Answer (The "Except"):** While angiographic embolization is a valid treatment option, it is **not the preferred or first-line treatment**. The gold standard and preferred initial management for Dieulafoy’s lesion is **Endoscopic Therapy** (e.g., clipping, banding, or thermal coagulation), which has a success rate of over 90%. Angiography or surgery is reserved only for cases where endoscopic management fails. **2. Analysis of Other Options:** * **Option B:** Endoscopic treatment (mechanical clips, bipolar cautery, or epinephrine injection) is indeed the primary modality for both diagnosis and treatment. * **Option C:** The lesion occurs because the abnormally large artery exerts constant **pulsatile pressure** on the overlying mucosa, leading to focal erosion, thinning, and eventually a "pinpoint" ulceration that causes massive bleeding. * **Option D:** By definition, it involves a **persistent submucosal artery** that maintains a diameter of 1–3 mm (much larger than normal capillaries). **Clinical Pearls for NEET-PG:** * **Most Common Location:** Lesser curvature of the **stomach** (within 6 cm of the gastroesophageal junction). * **Clinical Presentation:** Sudden, massive, painless hematemesis or melena in an otherwise asymptomatic patient. * **Diagnosis:** Often difficult because the surrounding mucosa looks normal; "hidden" between bleeding episodes. * **Management Priority:** 1st: Endoscopy; 2nd: Angiographic Embolization; 3rd: Surgical Wedge Resection.

Question 1

Increased gastric acid secretion occurs in which type of gastric ulcer?

Accepted Answer

Type III gastric ulcer

Answer

Type I gastric ulcer

Answer

Type IV gastric ulcer

Answer

Type V gastric ulcer

Question 2

What is false regarding wandering spleen?

Accepted Answer

Treatment of choice is splenectomy only

Answer

Chronic torsion leads to splenomegaly

Answer

Infarction and torsion are common

Answer

It is encapsulated with a long vascular pedicle

Question 3

Which of the following clinical signs is NOT associated with acute appendicitis?

Accepted Answer

Cullen's sign

Answer

Pointing sign

Answer

Rovsing's sign

Answer

Obturator sign

Question 4

Which of the following is NOT a characteristic of malignant gastric ulcers?

Accepted Answer

Ulcer extends beyond the gastric wall.

Answer

Mucosal rugae stop far from the ulcer.

Answer

Eccentric crater.

Answer

Margins are raised.

Question 5

A patient presents with a history of abdominal pain. On examination, the person is in shock, with severe abdominal tenderness and guarding. There was also one episode of bloody diarrhea. He gives a history of recurrent abdominal pain soon after taking food which persists for about 3 hours after food. He also has a history of myocardial infarction about 5 years back. What is your diagnosis?

Accepted Answer

Acute thrombotic mesenteric vascular occlusion

Answer

Acute pancreatitis

Answer

Acute duodenal ulcer perforation

Answer

Acute appendicitis

Question 6

Which of the following statements is FALSE regarding Gastric lymphoma?

Accepted Answer

Total gastrectomy with adjuvant chemotherapy is the treatment of choice.

Answer

Stomach is the most common site.

Answer

It is associated with H. pylori infection.

Answer

The 5-year survival rate after treatment is 60%.

Question 7

What is the treatment of choice for fistula in ano?

Accepted Answer

Fistulotomy

Answer

Anal dilatation

Answer

Fissurotomy

Answer

Fistulectomy

Question 8

A young patient presents with a history of dysphagia, more to liquids than solids. What is the first investigation you will perform?

Accepted Answer

Barium Swallow

Answer

Esophagoscopy

Answer

Ultrasound of the chest

Answer

CT Scan of the chest

Question 9

All of the following are true about Retained Antrum Syndrome except:

Accepted Answer

Positive Secretin Stimulation Test

Answer

Technetium 99m scan is used for diagnosis

Answer

Seen after Billroth II surgery

Answer

Calcium Provocation test is negative

Question 10

All are true about Dieulafoy's lesion except?

Accepted Answer

Angiographic embolization is the preferred treatment

Answer

Endoscopic treatment can be given

Answer

Pulsation of an artery causes ulceration

Answer

It involves a submucosal artery

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

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