Gastrointestinal Surgery Practice Questions

Q: When the hernia extends between the layers of abdominal wall muscles and not directly through them, it is called

Spigelian hernia. ***Spigelian hernia*** - A **Spigelian hernia** occurs through a defect in the **Spigelian fascia**, extending between the transverse abdominis and internal oblique muscles. - It typically presents as a bulge between muscular layers, making it often **interparietal** and difficult to diagnose clinically due to its hidden nature. *Amyand's hernia* - This is a rare type of inguinal hernia that contains the **vermiform appendix** within the hernial sac. - It is notable for the potential complication of **appendicitis** within the hernia. *Richter's hernia* - A **Richter's hernia** involves only a portion of the circumference of the bowel wall becoming strangulated within the hernia orifice. - This can lead to **bowel necrosis** without complete obstruction, making diagnosis challenging. *Littre's hernia* - A **Littre's hernia** is characterized by the presence of a **Meckel's diverticulum** within the hernial sac. - It can occur in any hernia type (inguinal, femoral, umbilical) and carries a risk of diverticulitis or perforation.

Q: Which of the following is the MOST reliable intraoperative feature of viable small bowel? 1. Visible peristalsis 2. Flabby intestinal musculature 3. Shiny appearance of small bowel wall 4. Visible pulsation in the mesenteric artery

1. Visible peristalsis. ***Visible peristalsis*** - The presence of **visible peristalsis** is the **MOST reliable indicator** of viable small bowel, demonstrating preserved neuromuscular function and tissue vitality. - Among the classical "3 Ps" of bowel viability (Peristalsis, Pulsation, Pink color), **peristalsis is the most direct indicator** as it confirms functional integrity of the bowel wall itself. - This indicates that the muscle layers of the intestine (longitudinal and circular) are functioning properly with intact innervation. *Shiny appearance of small bowel wall* - A **shiny serosa** is indeed a feature of viable bowel, indicating healthy, well-perfused tissue with an intact mesenteric surface. - However, it is a **less specific indicator** compared to peristalsis, as the appearance can be subjective and may not directly correlate with functional viability. *Visible pulsation in the mesenteric artery* - **Visible pulsation** in the mesenteric artery is one of the classical signs of viability and indicates blood flow to the vessel. - However, arterial pulsation alone **does not guarantee adequate tissue perfusion** or venous drainage, and ischemia can still occur despite pulsatile flow (e.g., venous thrombosis). - Peristalsis is more reliable as it confirms both adequate perfusion AND functional integrity. *Flabby intestinal musculature* - **Flabby intestinal musculature** indicates **non-viable bowel** with loss of tone, suggesting ischemia or necrosis. - Viable bowel typically feels **turgid and elastic** with good tone, not flabby.

Q: The most common metabolic abnormality associated with gastric outlet obstruction is

hypochloraemic alkalosis. ***Hypochloraemic alkalosis*** - Gastric outlet obstruction leads to **persistent vomiting of gastric contents**, rich in **hydrochloric acid (HCl)**. - The loss of HCl causes a decrease in plasma chloride (**hypochloraemia**) and an increase in bicarbonate, leading to **metabolic alkalosis**. - This is the **classic metabolic abnormality** seen in pyloric stenosis and other causes of gastric outlet obstruction. *Hyperchloraemic alkalosis* - This is an incorrect combination of electrolyte and acid-base disturbances; hyperchloraemia typically accompanies **acidosis**, not alkalosis. - Hyperchloraemic alkalosis would imply an excess of chloride and base, which does not result from the vomiting of acidic gastric contents. *Hypochloraemic acidosis* - Hypochloraemia can occur with acidosis (e.g., from severe diarrhea with bicarbonate loss), but the primary acid-base disturbance in gastric outlet obstruction is **alkalosis** due to hydrogen ion loss. - Vomiting primarily causes a loss of acid, leading to an increase in blood pH, not a decrease. *Hyperchloraemic acidosis* - This condition is often seen in situations like **renal tubular acidosis** or with the administration of large amounts of **saline solutions**, where chloride intake is high and bicarbonate is lost or diluted. - It specifically does not occur with the loss of highly acidic gastric contents, which would decrease chloride levels and increase pH.

Q: A patient presents to the emergency department with pain and distension of abdomen and absolute constipation. What is the investigation of choice ?

Plain X-ray abdomen (Erect). ***Plain X-ray abdomen (Erect)*** - An erect plain X-ray of the abdomen is the initial and often diagnostic investigation for **bowel obstruction**, revealing **dilated bowel loops** and **air-fluid levels**. - It helps confirm the presence of obstruction and can sometimes indicate its location and severity, though it does not provide information about the cause. *Ultrasonography* - While ultrasound can detect **bowel dilation** and **peristalsis**, it is limited in visualizing the entire bowel and cannot reliably differentiate between various causes of obstruction. - It is more useful for assessing **extraluminal pathology** or **fluid collections** but less effective as a primary diagnostic tool for bowel obstruction. *Barium meal follow-through* - This study involves oral **barium administration** and serial X-rays to visualize the small bowel, but it is **contraindicated** in suspected bowel obstruction due to the risk of exacerbating the obstruction or causing **barium impaction**. - Its primary role is in evaluating chronic or partial obstructions, or malabsorption, not acute presentations with complete obstruction. *Colonoscopy* - **Colonoscopy** is an invasive procedure primarily used for diagnosis and treatment of **colonic pathology**, such as polyps, strictures, or bleeding. - It is **contraindicated** in acute, complete bowel obstruction due to the risk of **perforation** and is not the initial diagnostic choice for acute abdominal pain and absolute constipation.

Q: Pelvic abscess can present with all symptoms except:

bleeding rectum. ***bleeding rectum*** - A **bleeding rectum** is not a typical presentation of a pelvic abscess. It might suggest other conditions like hemorrhoids, colorectal cancer, or inflammatory bowel disease. - Pelvic abscesses are collections of pus in the pelvic cavity, and while they can cause various gastrointestinal symptoms due to local inflammation and pressure, direct rectal bleeding is generally not among them. *pain abdomen* - **Abdominal pain** is a very common symptom of a pelvic abscess, often localized to the lower abdomen. - This pain is caused by inflammation, pressure, and irritation of surrounding organs and tissues. *diarrhea with mucus discharge* - A pelvic abscess can cause irritation to the adjacent **bowel segments**, leading to changes in bowel habits such as diarrhea. - The presence of **mucus discharge** can also be a sign of bowel irritation or inflammation, which can occur secondary to a nearby abscess. *fever* - **Fever** is a classic systemic sign of infection and inflammation, and thus is almost always present in patients with an abscess, including a pelvic abscess. - The body's inflammatory response to the infection typically elevates body temperature.

Q: All of the following statements regarding gallstones are true except :

They are mostly radio opaque. ***They are mostly radio opaque*** - Only about **10-20% of gallstones** are sufficiently calcified to be visible on a plain abdominal radiograph. - The majority of gallstones, especially **cholesterol stones**, are radiolucent and are best visualized by ultrasound. *They can cause intestinal obstruction* - This statement is true. A large gallstone can erode through the gallbladder wall into the small intestine, typically the duodenum, leading to a gallstone ileus. - **Gallstone ileus** is a rare form of mechanical bowel obstruction caused by a gallstone impaction, usually in the terminal ileum. *They can lead to acute cholangitis by slipping into the common bile duct* - This statement is true. Gallstones can migrate from the gallbladder into the **common bile duct (CBD)**, obstructing bile flow and leading to **choledocholithiasis**. - Obstruction of the CBD by gallstones, especially with superimposed bacterial infection, can cause **acute cholangitis**. *Mixed stones are the commonest type* - This statement is true. **Mixed gallstones**, which contain a combination of cholesterol, calcium salts, and bilirubin, are the most prevalent type of gallstones. - Pure cholesterol stones and pure pigment stones (black or brown) are less common than mixed stones.

Q: All of the following signs are considered in Alvarado score for acute appendicitis except

Rectal tenderness. ***Rectal tenderness*** - While rectal tenderness can be a sign of appendicitis, it is **not included in the Alvarado score**. The Alvarado score focuses on more direct indicators of peritoneal irritation and systemic response. - The score is composed of symptoms like **migratory right iliac fossa pain**, anorexia, nausea/vomiting, and signs like right iliac fossa tenderness, rebound tenderness, elevated temperature, leukocytosis and shift to the left. *Elevated temperature* - An **elevated body temperature** (fever) is a recognized component of the Alvarado score, indicating a systemic inflammatory response. - This sign contributes one point to the total score. *Rebound tenderness* - **Rebound tenderness** in the right lower quadrant is a crucial sign of peritoneal irritation and is explicitly included in the Alvarado score. - This clinical finding contributes one point to the total score. *Right iliac fossa tenderness* - **Tenderness in the right iliac fossa** (RLQ tenderness) is a primary clinical sign of appendicitis and is a significant component of the Alvarado score. - This sign contributes two points to the total score, reflecting its importance.

Q: Which one of the following nerves is vulnerable to injury while conducting an appendicectomy through the McBurney's incision ?

Ilio-inguinal nerve. ***Ilio-inguinal nerve*** - The **ilio-inguinal nerve** runs anterior to the **quadratus lumborum muscle** and enters the **transversus abdominis muscle**, lying between it and the internal oblique muscle. It is especially vulnerable at the lateral edge of the **rectus abdominis.** - **McBurney's incision**, which is an **oblique incision** in the **right lower quadrant**, may damage the ilioinguinal nerve as it exits the deep inguinal ring. *Subcostal nerve* - The **subcostal nerve** is the ventral ramus of **T12**, and it runs inferior to the **12th rib**. - It usually lies significantly superior to the **McBurney’s incision** site, making injury unlikely during this specific procedure. *Lateral cutaneous nerve of the thigh* - The **lateral cutaneous nerve of the thigh** arises from the **lumbar plexus (L2-L3)** and innervates the skin of the lateral thigh. - It traverses near the **anterior superior iliac spine**, which is not typically within the primary field of a **McBurney’s incision**. *Genitofemoral nerve* - The **genitofemoral nerve** originates from the **L1 and L2 spinal nerves** and descends retroperitoneally. - It is located deep and medial to the region of **McBurney’s incision**, making direct injury during this superficial abdominal incision less probable.

Question 1

When the hernia extends between the layers of abdominal wall muscles and not directly through them, it is called

Accepted Answer

Spigelian hernia

Answer

Amyand's hernia

Answer

Richter's hernia

Answer

Littre's hernia

Question 2

Which of the following is the MOST reliable intraoperative feature of viable small bowel?

1. Visible peristalsis
2. Flabby intestinal musculature
3. Shiny appearance of small bowel wall
4. Visible pulsation in the mesenteric artery

Accepted Answer

1. Visible peristalsis

Answer

3. Shiny appearance of small bowel wall

Answer

2. Flabby intestinal musculature

Answer

4. Visible pulsation in the mesenteric artery

Question 3

Which of the following statements about peptic ulcers is correct?

Accepted Answer

Anteriorly located duodenal ulcers are 'more prone for perforation'.

Answer

It is more commonly seen in females.

Answer

The most common location is the third part of duodenum.

Answer

There is no risk of malignancy in gastric ulcers.

Question 4

The most common metabolic abnormality associated with gastric outlet obstruction is

Accepted Answer

hypochloraemic alkalosis

Answer

hyperchloraemic alkalosis

Answer

hypochloraemic acidosis

Answer

hyperchloraemic acidosis

Question 5

A patient presents to the emergency department with pain and distension of abdomen and absolute constipation. What is the investigation of choice ?

Accepted Answer

Plain X-ray abdomen (Erect)

Answer

Ultrasonography

Answer

Barium meal follow-through

Answer

Colonoscopy

Question 6

Consider the following with reference to the management of portal hypertension :

1. Infusion of vasopressin
2. General resuscitation
3. Devascularisation procedure
4. Endoscopic sclerotherapy What is the appropriate sequence in the line of management in the event of massive variceal bleeding in portal hypertension ?

Accepted Answer

2, 1, 4, 3

Answer

3, 2, 1, 4

Answer

1, 4, 2, 3

Answer

4, 2, 1, 3

Question 7

Pelvic abscess can present with all symptoms except:

Accepted Answer

bleeding rectum

Answer

pain abdomen

Answer

diarrhea with mucus discharge

Answer

fever

Question 8

All of the following statements regarding gallstones are true except :

Accepted Answer

They are mostly radio opaque

Answer

They can cause intestinal obstruction

Answer

They can lead to acute cholangitis by slipping into the common bile duct

Answer

Mixed stones are the commonest type

Question 9

All of the following signs are considered in Alvarado score for acute appendicitis except

Accepted Answer

Rectal tenderness

Answer

Elevated temperature

Answer

Rebound tenderness

Answer

Right iliac fossa tenderness

Question 10

Which one of the following nerves is vulnerable to injury while conducting an appendicectomy through the McBurney's incision ?

Accepted Answer

Ilio-inguinal nerve

Answer

Subcostal nerve

Answer

Lateral cutaneous nerve of the thigh

Answer

Genitofemoral nerve

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?