Gastrointestinal Surgery Practice Questions

Q: Which of the following is not done in carcinoma esophagus?

pH - metry/monitoring. ***pH - metry/monitoring*** - **pH metry/monitoring** is primarily used to diagnose **gastroesophageal reflux disease (GERD)**, which is not a direct diagnostic tool for esophageal carcinoma itself. - While GERD is a risk factor for **Barrett's esophagus** and subsequently adenocarcinoma of the esophagus, pH monitoring does not directly identify or stage the cancer. *CT chest* - **CT (Computed Tomography) chest** is routinely performed in esophageal carcinoma to assess the **local extent** of the tumor and identify potential **lymph node involvement** or **metastasis** to other organs. - It is crucial for **staging** the disease and guiding treatment decisions such as resectability. *PET scan* - A **PET (Positron Emission Tomography) scan** is highly useful for detecting **distant metastases** and identifying **occult disease** not visible on CT, especially in cases of suspected advanced esophageal carcinoma. - It helps in **accurate staging** and avoiding futile surgery in patients with metastatic disease. *Biopsy* - **Biopsy**, typically performed during endoscopy, is the **gold standard** for confirming the diagnosis of esophageal carcinoma by obtaining tissue for **histopathological examination**. - It identifies the cell type (e.g., adenocarcinoma, squamous cell carcinoma) and grade of the tumor, which is essential for treatment planning.

Q: 20 yr old female diagnosed previously with adenocarcinoma stomach and on examination following is seen;

Sister Mary joseph nodule. ***Sister Mary Joseph nodule*** - A **Sister Mary Joseph nodule** is a **metastatic lesion** to the umbilicus, often originating from an intra-abdominal malignancy such as **gastric adenocarcinoma**. - Its presence in a patient with a known history of **adenocarcinoma of the stomach** strongly suggests metastatic spread. *Infected umbilical hernia* - An **infected umbilical hernia** would typically present with signs of local infection such as **erythema**, **pain**, **tenderness**, and possibly **purulent discharge**. - While it might cause a lump, it does not explain the association with a prior diagnosis of gastric adenocarcinoma. *Umbilical granuloma* - An **umbilical granuloma** is a benign, inflamed overgrowth of tissue that presents as a **red, moist lump** at the umbilicus, often seen in infants. - It is not associated with malignancy and would not typically be found in a 20-year-old female in the context of gastric cancer. *Irish node* - An **Irish node** refers to a **left axillary lymph node metastasis** from gastric cancer. - While it signifies metastatic gastric cancer, it is distinct from an umbilical metastasis.

Q: Surgery is indicated in Ulcerative Colitis in all except?

Colonic polyp. ***Colonic polyp*** - **Colonic polyps** in ulcerative colitis (UC) are often managed with **endoscopic polypectomy** and surveillance; surgery (colectomy) for polyps is typically reserved for those with **high-grade dysplasia** or **colorectal cancer**. - Simple polyps themselves, without high-grade dysplasia or malignancy, do not independently warrant surgical intervention in UC. *Toxic megacolon* - **Toxic megacolon** is a severe and life-threatening complication of UC characterized by rapid **colonic dilation** and systemic toxicity, which carries a high risk of perforation and mortality. - Urgent surgical intervention, often **subtotal colectomy**, is indicated to prevent perforation and manage sepsis. *Colonic obstruction* - Although uncommon in UC, **colonic obstruction** can occur due to strictures, fibrosis, or malignant transformation, causing symptoms like abdominal pain, distension, and vomiting. - When medically refractory or associated with significant symptoms or suspicion of malignancy, surgery is often required to relieve the obstruction. *Failure of medical management* - **Chronic medically refractory UC** is one of the most common indications for elective colectomy, accounting for approximately 20-30% of surgical cases. - When patients fail to respond to maximal medical therapy including corticosteroids, immunomodulators, and biologics, or experience steroid-dependent disease with unacceptable side effects, surgical intervention with **proctocolectomy** may be required for definitive management.

Q: In gastric outlet obstruction in a peptic ulcer patient, the site of obstruction is most likely to be:

Pylorus. ***Pylorus*** - The **pylorus** is the most common site of obstruction in gastric outlet obstruction caused by **peptic ulcer disease**. This is due to **scarring** and **inflammation** from chronic ulcers in or near this region. - Obstruction at the pylorus impedes the normal flow of digested food from the stomach into the **duodenum**. *Duodenum* - While ulcers can occur in the **duodenum** (specifically the duodenal bulb), they are less likely to cause a complete obstruction of the gastric outlet. - **Duodenal ulcers** are more common than gastric ulcers, but rarely lead to severe narrowing causing outlet obstruction. *Antrum* - The **gastric antrum** is part of the stomach leading up to the pylorus. Although ulcers can occur here, obstruction is less common compared to the **pylorus** itself. - Obstruction due to antral pathology typically occurs closer to the **pyloric sphincter**. *Fundus* - The **fundus** is the upper, dome-shaped part of the stomach. It is very rarely the site of obstruction in the context of gastric outlet obstruction from peptic ulcer disease. - Obstructions in the fundus are usually associated with other pathologies, such as **tumors** or **gastric volvulus**, not peptic ulcers causing outlet obstruction.

Q: A patient who underwent gastrectomy develops sweating and diarrhea within 20 minutes after eating. What could be the cause?

Early dumping syndrome. ***Early dumping syndrome*** - Occurs **15-30 minutes after eating** in patients who have undergone **gastric surgery**, such as gastrectomy, due to rapid emptying of hyperosmolar chyme into the small intestine. - Symptoms include **sweating**, **diarrhea**, **nausea**, **cramping**, and **tachycardia** due to fluid shifts and hormonal responses. *Late dumping syndrome* - Typically occurs **1-3 hours after eating**, not within 20 minutes. - It is characterized by **hypoglycemia** due to an exaggerated insulin response to the rapid absorption of glucose, leading to symptoms like weakness, confusion, and tremor. *Hyperglycemia* - While a rapid influx of glucose can initially cause hyperglycemia, the symptoms described (sweating, diarrhea) are more indicative of the systemic effects of rapid gastric emptying rather than simple hyperglycemia itself. - Hyperglycemia post-meal is a normal physiological response, and the constellation of symptoms points to a post-surgical complication. *Hypoglycemia* - Hypoglycemia is characteristic of **late dumping syndrome**, occurring hours after a meal, not within 20 minutes. - The symptoms of early dumping syndrome are primarily driven by fluid shifts and neurovascular responses, not low blood glucose.

Q: A patient presents with acute appendicitis. What is NOT to be done?

Check for visual acuity. ***Check for visual acuity*** - **Visual acuity** assessment is not relevant to the diagnosis or management of **acute appendicitis**. - This examination is typically performed in cases of suspected eye injury, vision changes, or neurological issues that affect vision. - In the context of acute appendicitis, checking visual acuity would be inappropriate and waste valuable time. *Give antibiotics* - **Antibiotics** are crucial in managing **acute appendicitis** to prevent progression to perforation and reduce postoperative infection risk. - They are typically administered preoperatively and continued postoperatively, especially in cases of complicated appendicitis. - Broad-spectrum antibiotics covering **gram-negative organisms and anaerobes** are standard practice. *Do primary survey* - A **primary survey** (ABCDE approach) is essential in any emergent patient presentation to assess and manage immediate **life-threatening conditions**. - While appendicitis itself may not be immediately life-threatening, ensuring patient stability and ruling out other serious conditions is critical. - This is standard emergency medicine practice and should always be performed. *Perform appendectomy* - **Appendectomy** (surgical removal of the appendix) is the definitive treatment for **acute appendicitis**. - This is the standard of care and should be performed once the diagnosis is confirmed and the patient is stable. - Either open or laparoscopic approach can be used depending on clinical factors and surgeon expertise.

Q: In which of the following conditions is Alvarado score indicated?

Appendicitis. ***Appendicitis*** - The Alvarado score, also known as the MANTRELS score, is a clinical scoring system used to assess the likelihood of **acute appendicitis**. - It considers symptoms (e.g., **migratory right iliac fossa pain**, **anorexia**, **nausea/vomiting**), signs (e.g., **tenderness in the right iliac fossa**, **rebound tenderness**), and laboratory findings (e.g., **leukocytosis**, **shift to the left of neutrophils**). *Pancreatitis* - Pancreatitis is typically diagnosed and managed using criteria such as the **Ranson criteria** or **APACHE II score** for severity assessment, and imaging like CT scans. - The Alvarado score is not applicable for the diagnosis or severity assessment of pancreatitis. *Cholangitis* - Cholangitis is an infection of the bile ducts which is usually diagnosed clinically using the **Charcot's triad** (fever, jaundice, right upper quadrant pain) or **Reynold's pentad** (Charcot's triad plus altered mental status and hypotension). - The Alvarado score has no role in the evaluation of cholangitis. *Cholecystitis* - Cholecystitis, inflammation of the gallbladder, is primarily diagnosed based on clinical symptoms (e.g., **right upper quadrant pain**, **fever**, **leukocytosis**), Murphy's sign, and imaging (ultrasound). - The Alvarado score is specifically designed for appendicitis and is not used for cholecystitis.

Q: Howship-Romberg sign is seen in

Obturator hernia. ***Obturator hernia*** - The **Howship-Romberg sign** is characterized by **medial thigh pain** on hip extension, adduction, and internal rotation, which is indicative of an obturator hernia. - This symptom arises from compression of the **obturator nerve** as it passes through the obturator canal alongside the hernia sac. *Spigelian hernia* - A Spigelian hernia presents as a **ventrolateral abdominal wall defect**, typically between the rectus abdominis muscle and linea semilunaris. - It usually causes localized pain and a palpable lump but does not involve **obturator nerve compression**. *Femoral hernia* - A femoral hernia manifests as a bulge in the **groin region** below the inguinal ligament, often presenting as an emergent strangulated hernia. - While it can cause groin pain, it does not typically involve the **obturator nerve** or present with the **Howship-Romberg sign**. *Inguinal hernia* - Inguinal hernias are common, presenting as a bulge in the groin, either **direct or indirect**, above the inguinal ligament. - Symptoms include a palpable mass and discomfort, but not the specific **medial thigh pain** associated with obturator nerve compression.

Q: A 60-year-old man presents with foul breath and regurgitates food eaten 3 days ago. What is the most likely diagnosis?

Zenker's Diverticulum. ***Zenker's Diverticulum*** - This condition presents with a classic triad of **dysphagia**, **regurgitation of undigested food**, and **foul breath (halitosis)** due to food retention in the diverticulum. - The regurgitation of food eaten several days ago is highly characteristic, indicating significant pooling and decomposition within the **pharyngeal pouch**. *Achalasia cardia* - Characterized by **dysphagia for both solids and liquids** and regurgitation, but the regurgitated food is typically fresh or only recently ingested, not from several days prior. - The primary pathology is the **failure of the lower esophageal sphincter (LES) to relax** and loss of peristalsis in the esophageal body. *Carcinoma esophagus* - Often presents with **progressive dysphagia** (first for solids, then for liquids) and significant **weight loss**. - While regurgitation can occur, it's usually of recently ingested food and rarely associated with the severe halitosis from long-standing food decomposition seen in Zenker's. *Loss of tone of upper esophageal sphincter* - This condition would more likely lead to **regurgitation of stomach contents** into the pharynx, rather than the retention of food in a pouch. - It could contribute to **reflux symptoms** but does not explain the formation of a diverticulum or the prolonged food retention leading to foul breath.

Q: Hamman's sign is seen in which of the following conditions?

Oesophageal perforation. ***Oesophageal perforation*** - **Hamman's sign** is a classic auscultatory finding of a crunching, rasping sound synchronous with the heartbeat, indicative of **mediastinal emphysema** (air in the mediastinum). - Oesophageal perforation allows air to escape into the mediastinum, leading to mediastinal emphysema and thus Hamman's sign. *Acute oesophagitis* - This condition involves inflammation of the oesophagus, often causing symptoms like **dysphagia** and **odynophagia**. - It typically does not involve air leakage into the mediastinum, and therefore, **Hamman's sign is not expected**. *Corrosive burns of oesophagus* - Corrosive injuries cause chemical burns to the oesophageal lining, leading to inflammation, strictures, or in severe cases, perforation. - While perforation is a possibility in severe cases, the primary presentation is typically related to direct tissue damage and inflammation, not consistently with **mediastinal emphysema** unless perforation has occurred. *Benign strictures of oesophagus* - Benign strictures are narrowings of the oesophagus, usually caused by chronic inflammation or reflux. - They primarily cause **dysphagia** due to mechanical obstruction and are not associated with **air leakage into the mediastinum** or Hamman's sign.

Question 1

Which of the following is not done in carcinoma esophagus?

Accepted Answer

pH - metry/monitoring

Answer

CT chest

Answer

PET scan

Answer

Biopsy

Question 2

20 yr old female diagnosed previously with adenocarcinoma stomach and on examination following is seen;

Accepted Answer

Sister Mary joseph nodule

Answer

Infected umbilical hernia

Answer

Umbilical granuloma

Answer

Irish node

Question 3

Surgery is indicated in Ulcerative Colitis in all except?

Accepted Answer

Colonic polyp

Answer

Toxic megacolon

Answer

Colonic obstruction

Answer

Failure of medical management

Question 4

In gastric outlet obstruction in a peptic ulcer patient, the site of obstruction is most likely to be:

Accepted Answer

Pylorus

Answer

Duodenum

Answer

Antrum

Answer

Fundus

Question 5

A patient who underwent gastrectomy develops sweating and diarrhea within 20 minutes after eating. What could be the cause?

Accepted Answer

Early dumping syndrome

Answer

Late dumping syndrome

Answer

Hyperglycemia

Answer

Hypoglycemia

Question 6

A patient presents with acute appendicitis. What is NOT to be done?

Accepted Answer

Check for visual acuity

Answer

Give antibiotics

Answer

Do primary survey

Answer

Perform appendectomy

Question 7

In which of the following conditions is Alvarado score indicated?

Accepted Answer

Appendicitis

Answer

Pancreatitis

Answer

Cholangitis

Answer

Cholecystitis

Question 8

Howship-Romberg sign is seen in

Accepted Answer

Obturator hernia

Answer

Spigelian hernia

Answer

Femoral hernia

Answer

Inguinal hernia

Question 9

A 60-year-old man presents with foul breath and regurgitates food eaten 3 days ago. What is the most likely diagnosis?

Accepted Answer

Zenker's Diverticulum

Answer

Achalasia cardia

Answer

Carcinoma esophagus

Answer

Loss of tone of upper esophageal sphincter

Question 10

Hamman's sign is seen in which of the following conditions?

Accepted Answer

Oesophageal perforation

Answer

Acute oesophagitis

Answer

Corrosive burns of oesophagus

Answer

Benign strictures of oesophagus

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

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