Gastrointestinal Surgery Practice Questions

Q: What does the X-ray film show?

Perforated abdominal viscus. ***Perforated abdominal viscus*** - X-ray findings in perforated viscus include **free air under the diaphragm** (pneumoperitoneum) on erect chest/abdominal X-ray, which is the hallmark sign - **Rigler's sign** (both sides of bowel wall visible) and **football sign** (large amount of free air outlining abdominal organs) may be seen - Common causes include **perforated peptic ulcer**, perforated appendix, or bowel perforation from trauma or ischemia - This represents a **surgical emergency** requiring immediate intervention *Intestinal obstruction* - Shows **dilated bowel loops** with **air-fluid levels** on erect X-ray - **Absent or reduced gas in distal bowel** in complete obstruction - Does not typically show free intraperitoneal air unless there is associated perforation - Multiple air-fluid levels at different heights distinguish it from perforation *Pneumoperitoneum* - While pneumoperitoneum (free intraperitoneal air) is a **radiological finding**, it is not a diagnosis in itself - It is a **sign** that indicates perforation of a hollow viscus - "Perforated abdominal viscus" is the more complete clinical diagnosis that explains the cause of pneumoperitoneum *Right hydropneumothorax* - Shows **air-fluid level in the pleural space** (thoracic cavity, not abdominal) - Air appears as **radiolucency in upper part** with fluid level below in the pleural cavity - Caused by trauma, infection (empyema with gas-forming organisms), or iatrogenic causes - Would be seen in the **chest**, not abdomen, and would not show subdiaphragmatic free air

Q: The following X-ray abdomen is diagnostic of:

Perforation peritonitis. ***Perforation peritonitis*** - The X-ray image shows widespread **free air under the diaphragm** and dilated loops of bowel with **air-fluid levels**, which are classic signs of **perforation peritonitis**. - **Free intraperitoneal air** (pneumoperitoneum) is a strong indicator of a perforated hollow viscus, leading to peritonitis. *Toxic megacolon* - Characterized by **extreme dilatation of the colon** (typically >6 cm in transverse colon) with loss of haustral markings on plain film, without free air. - While it can lead to perforation, the primary finding here is *free air*, not just colitis and colonic dilation. *Intestinal obstruction* - Identified by multiple **dilated bowel loops proximal to the obstruction**, with **air-fluid levels**, and a relative absence of gas distally. - While there are dilated loops and air-fluid levels, the most prominent finding of **free air under the diaphragm** is not typically associated with an uncomplicated obstruction. *Chronic mesenteric insufficiency* - This condition involves **reduced blood flow to the intestines**, leading to chronic abdominal pain, especially postprandial, and weight loss. - Its radiographic signs are often non-specific or involve bowel wall thickening and pneumatosis, not free air or acute findings of perforation.

Q: Which of the following are correct regarding late dumping? I. It usually occurs during the second hour after meal. II. It lasts for 30-40 minutes. III. Major symptoms are tremor, faintness, prostration IV. It is relieved by lying down. Select the answer using the code given below :

I, II and III. ***I, II and III*** - Late dumping syndrome typically manifests **1 to 3 hours after a meal** (usually around the second hour), triggered by rapid carbohydrate absorption leading to hyperinsulinemia and subsequent hypoglycemia. - The symptoms, which include **tremor, faintness, prostration, sweating, and confusion**, are due to hypoglycemia and usually last for **30-60 minutes**. *I, III and IV* - This option is incorrect because lying down generally **does not relieve symptoms** of late dumping syndrome; instead, consuming a small amount of sugar or glucose is recommended to raise blood glucose levels. - While I and III are correct, the inclusion of IV makes this option incorrect. *II, III and IV* - This option is incorrect because statement IV, suggesting relief by lying down, is **false** for late dumping syndrome. - Additionally, statement I "It usually occurs during the second hour after meal" is an accurate description of late dumping, which this option omits. *I, II and IV* - This option is incorrect because statement IV, which claims symptoms are relieved by lying down, is **inaccurate** for late dumping syndrome. - While I and II are correct, the inclusion of IV makes this option incorrect regarding the characteristic management or relief of late dumping.

Q: While managing oesophageal perforations, which of the following factors favour non-operative management? 1. Perforation by a flexible endoscope 2. Contained perforation without free communication 3. Perforation with a small septic load 4. Perforation of the abdominal oesophagus Select the correct answer using the code given below:

1, 2 and 3. ***1, 2 and 3*** - **Perforation by a flexible endoscope** often results in smaller, less destructive perforations due to the instrument's flexibility, making non-operative management feasible if other favorable conditions are met. - **Contained perforation without free communication** implies that the leak is localized and not actively spreading into surrounding tissues, reducing the risk of widespread mediastinitis or peritonitis. - **Perforation with a small septic load** indicates minimal contamination, which simplifies management and improves the chances of successful non-operative treatment through antibiotics and supportive care. *1, 3 and 4* - This option correctly identifies factors 1 and 3, but **perforation of the abdominal esophagus** is generally treated surgically due to the high risk of widespread peritonitis and severe sepsis. - While smaller perforations are more manageable, the anatomical location in the abdominal cavity predisposes to rapid and severe contamination. *2, 3 and 4* - This option correctly includes factors 2 and 3 that favor non-operative management but incorrectly suggests that **perforation of the abdominal esophagus** is managed non-operatively. - The high risk of peritonitis from an abdominal oesophageal perforation often necessitates surgical intervention to prevent severe complications. *1, 2 and 4* - This option correctly identifies factors 1 and 2 but mistakenly includes **perforation of the abdominal esophagus** as a factor favoring non-operative management. - Abdominal oesophageal perforations are high-risk situations generally requiring early surgical repair to prevent life-threatening complications.

Q: What is the most common cause of perforation of the oesophagus?

Iatrogenic injury. ***Correct: Iatrogenic injury*** - **Iatrogenic injuries** are the most common cause of esophageal perforation, accounting for **50-75%** of all cases. - Most commonly occur during **endoscopic procedures** (upper GI endoscopy, esophageal dilation, biopsy, bougie dilation, pneumatic dilation for achalasia, sclerotherapy). - Other iatrogenic causes include **nasogastric tube insertion**, esophageal stent placement, and intraoperative injuries during thoracic or cervical surgery. - The incidence has increased with the widespread use of therapeutic endoscopy. *Incorrect: Barotrauma* - **Boerhaave syndrome** (spontaneous esophageal rupture from forceful vomiting) is the most common cause of *spontaneous* perforation. - Accounts for only **15-20%** of all esophageal perforations. - Typically occurs after severe vomiting, retching, or Valsalva maneuver causing sudden increase in intra-esophageal pressure. - Most commonly involves the **left posterolateral wall of the lower esophagus**, 3-6 cm above the gastroesophageal junction. *Incorrect: Malignancy* - Esophageal tumors (carcinoma, lymphoma) can **erode through the esophageal wall** leading to perforation. - However, this is a **rare complication** and accounts for a small percentage of perforations. - More commonly, perforation in malignancy occurs during endoscopic intervention rather than spontaneous erosion. *Incorrect: Mediastinitis* - **Mediastinitis** is a **consequence** of esophageal perforation, not a cause. - Results from leakage of esophageal contents (saliva, gastric acid, food particles) into the mediastinum. - Leads to severe infection with high mortality if not promptly treated with antibiotics, drainage, and surgical repair.

Q: Which of the following are features of umbilical hernia in adults? 1. Patients are commonly overweight with a thinned and attenuated midline raphe. 2. Most patients are asymptomatic or present with a painless swelling. 3. Men are affected more than women. 4. Hernia repair can be done by the technique described by Mayo. Select the correct answer using the code given below.

1, 2 and 4. ***1, 2 and 4*** - **Overweight patients** often have increased intra-abdominal pressure and weakened abdominal walls, contributing to the development of an umbilical hernia and a **thinned midline raphe**. - **Most adult umbilical hernias are asymptomatic** or present as painless swellings; patients typically notice a bulge that may increase with coughing or straining. Pain usually indicates **complications** such as incarceration or strangulation. - The **Mayo repair** is a classic technique specifically designed for umbilical hernias, involving the overlapping of the rectus sheath for a strong repair. *2, 3 and 4* - While patients are often **asymptomatic** (statement 2 correct) and the **Mayo repair** is standard (statement 4 correct), statement 3 is incorrect; **women are more commonly affected** by umbilical hernias than men. *1, 2 and 3* - Patients are commonly **overweight** (statement 1 correct) and often **asymptomatic** (statement 2 correct), but statement 3 is incorrect as umbilical hernias are seen **more often in women** than men. *1, 3 and 4* - Patients are commonly **overweight** (statement 1 correct) and the **Mayo repair** is a recognized technique (statement 4 correct), but statement 3 is incorrect because **women are more affected** than men. Statement 2 is also correct as most patients are asymptomatic.

Q: Which one of the following statements is correct about mesenteric cysts?

It presents most commonly as a painless abdominal swelling.. ***It presents most commonly as a painless abdominal swelling.*** - **Mesenteric cysts** typically manifest as a **slowly growing**, **asymptomatic abdominal mass**, which is often discovered incidentally or due to mild pressure symptoms. - Their **painless nature** and gradual enlargement contribute to this common presentation. *Percutaneous aspiration with injection of sclerosant is the preferred treatment option.* - **Simple aspiration** or sclerotherapy of mesenteric cysts is generally **contraindicated** due to the high risk of recurrence and potential for complications like infection or rupture. - The **preferred treatment** for mesenteric cysts is surgical excision to prevent recurrence and complications. *It is more common in males as compared to females.* - While rare overall, mesenteric cysts are **more prevalent in females** than males, although the exact reason for this disparity is not fully understood. - Some studies suggest a **female-to-male ratio** of approximately 2:1. *It occurs most commonly in children less than 18 years of age.* - Mesenteric cysts can occur at any age, but they are **more common in adults**, with the highest incidence typically reported in the third to fifth decades of life. - Although they can be found in children, this is **not the most common age group** for presentation.

Q: Which of the following are tension-free inguinal hernia repairs? 1. Stoppa's repair 2. Lichtenstein's repair 3. Laparoscopic TEP repair 4. Desarda's repair.

1, 2 and 3. ***1, 2 and 3*** - **Stoppa's repair**, **Lichtenstein's repair**, and **Laparoscopic TEP repair** are all considered tension-free methods because they use mesh to reinforce the inguinal floor without putting tension on the surrounding tissues. - The use of mesh in these repairs distributes the tension across a wider area, minimizing pain and recurrence rates compared to traditional tension-based repairs. - **Desarda's repair** is excluded because it is a tissue-based (non-mesh) technique that uses the external oblique aponeurosis, and is NOT classified as a tension-free repair. *2, 3 and 4* - This option incorrectly excludes **Stoppa's repair**, which is a widely recognized tension-free technique using a large prosthetic mesh in the preperitoneal space. - **Desarda's repair** is incorrectly included as it is a tissue-based repair without mesh, not a tension-free technique. *1, 3 and 4* - This option incorrectly excludes **Lichtenstein's repair**, which is the most commonly performed tension-free open mesh repair for inguinal hernias. - It involves placing a prosthetic mesh over the defect without suturing muscle or fascia under tension. - **Desarda's repair** is incorrectly included as it does not use mesh and is not classified as tension-free. *1, 2 and 4* - This option incorrectly excludes **Laparoscopic TEP repair**, which is a minimally invasive tension-free approach utilizing mesh to reinforce the posterior wall of the inguinal canal in the preperitoneal space. - **Desarda's repair** is incorrectly included; while it aims to be physiological and mesh-free, it is a tissue-based technique and not a tension-free repair.

Question 1

What does the X-ray film show?

Accepted Answer

Perforated abdominal viscus

Answer

Right hydropneumothorax

Answer

Intestinal obstruction

Answer

Pneumoperitoneum

Question 2

The following X-ray abdomen is diagnostic of:

Accepted Answer

Perforation peritonitis

Answer

Toxic megacolon

Answer

Intestinal obstruction

Answer

Chronic mesenteric insufficiency

Question 3

All of the following statements regarding this radiological film representing esophagus are true except:

Accepted Answer

Regurgitation of previous day food items is the most common and early presenting symptom

Answer

Squamous cell usually affects the upper two-thirds

Answer

Adenocarcinoma usually affects the lower-third

Answer

Lymph node involvement is a bad prognostic factor

Question 4

Which one of the following statements is not correct regarding Gastric outlet obstruction associated with long standing peptic ulcer disease?

Accepted Answer

Medical therapy has no role in the treatment of this condition.

Answer

Endoscopic biopsy is essential to exclude malignancy.

Answer

Hypochloraemic alkalosis is the usual metabolic abnormality in such cases.

Answer

Operation is frequently required along with a drainage procedure.

Question 5

Which of the following are correct regarding late dumping?
I. It usually occurs during the second hour after meal.
II. It lasts for 30-40 minutes.
III. Major symptoms are tremor, faintness, prostration
IV. It is relieved by lying down.

Select the answer using the code given below :

Accepted Answer

I, II and III

Answer

I, III and IV

Answer

II, III and IV

Answer

I, II and IV

Question 6

While managing oesophageal perforations, which of the following factors favour non-operative management?

1. Perforation by a flexible endoscope

2. Contained perforation without free communication

3. Perforation with a small septic load

4. Perforation of the abdominal oesophagus

Select the correct answer using the code given below:

Accepted Answer

1, 2 and 3

Answer

1, 3 and 4

Answer

2, 3 and 4

Answer

1, 2 and 4

Question 7

What is the most common cause of perforation of the oesophagus?

Accepted Answer

Iatrogenic injury

Answer

Barotrauma

Answer

Malignancy

Answer

Mediastinitis

Question 8

Which of the following are features of umbilical hernia in adults?

1. Patients are commonly overweight with a thinned and attenuated midline raphe.
2. Most patients are asymptomatic or present with a painless swelling.
3. Men are affected more than women.
4. Hernia repair can be done by the technique described by Mayo.

Select the correct answer using the code given below.

Accepted Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 2 and 3

Answer

1, 3 and 4

Question 9

Which one of the following statements is correct about mesenteric cysts?

Accepted Answer

It presents most commonly as a painless abdominal swelling.

Answer

It is more common in males as compared to females.

Answer

It occurs most commonly in children less than 18 years of age.

Answer

Percutaneous aspiration with injection of sclerosant is the preferred treatment option.

Question 10

Which of the following are tension-free inguinal hernia repairs?

1. Stoppa's repair
2. Lichtenstein's repair
3. Laparoscopic TEP repair
4. Desarda's repair.

Accepted Answer

1, 2 and 3

Answer

2, 3 and 4

Answer

1, 3 and 4

Answer

1, 2 and 4

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

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