General Surgery Principles — MCQs

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: Hyperacute rejection is due to which of the following mechanisms?

Preformed antibodies. **Explanation:** **Hyperacute Rejection** is an immediate, irreversible immunological reaction occurring within minutes to hours after organ transplantation. **1. Why Option A is Correct:** The mechanism is a **Type II Hypersensitivity reaction**. It is mediated by **preformed circulating antibodies** (IgG) in the recipient’s blood. These antibodies are directed against donor antigens (typically ABO blood group antigens or HLA Class I antigens). Upon reperfusion, these antibodies bind to the donor vascular endothelium, activating the **complement system**. This leads to rapid endothelial damage, platelet aggregation, and diffuse intravascular thrombosis, resulting in the "blue graft" appearance and graft necrosis. **2. Why Other Options are Incorrect:** * **Option B:** Cytotoxic T lymphocyte (CD8+) mediated injury is the hallmark of **Acute Cellular Rejection**, which typically occurs days to weeks after transplant. * **Option C:** Endothelitis (inflammation of the vessel wall) is a feature of **Acute Antibody-Mediated Rejection**, but it is caused by *recipient* antibodies against donor tissue, not donor antibodies. * **Option D:** Macrophages play a role in chronic inflammation and delayed-type hypersensitivity but are not the primary mediators of the rapid vascular collapse seen in hyperacute rejection. **3. High-Yield Clinical Pearls for NEET-PG:** * **Prevention:** Hyperacute rejection is prevented by **Cross-matching** (mixing recipient serum with donor lymphocytes) and ABO compatibility testing. * **Treatment:** There is no effective treatment once it starts; the graft must be **surgically removed**. * **Risk Factors:** Previous blood transfusions, multiple pregnancies, or prior organ transplants (all of which sensitize the recipient). * **Pathology:** Characterized by **Fibrinoid necrosis** of capillaries and "starry sky" appearance due to neutrophilic infiltration.

Q: Bochdalek hernia occurs through which anatomical structure?

Diaphragm. **Explanation:** **Bochdalek hernia** is the most common type of **Congenital Diaphragmatic Hernia (CDH)**, accounting for approximately 85-90% of cases. It occurs due to the failure of the **pleuroperitoneal membrane** to fuse with the septum transversum and dorsal mesentery of the esophagus during embryonic development (usually between the 8th and 10th week). This results in a posterolateral defect in the **diaphragm**, most commonly on the **left side** (80-85%), allowing abdominal viscera to herniate into the thoracic cavity. **Analysis of Incorrect Options:** * **B. Lumbar triangle:** Hernias through the superior lumbar triangle (Grynfeltt-Lesshaft) or inferior lumbar triangle (Petit) are types of lumbar hernias, not diaphragmatic. * **C. Femoral region:** This is the site for femoral hernias, which occur through the femoral canal, medial to the femoral vein. * **D. Obturator canal:** This is the site for obturator hernias, which typically present with the Howship-Romberg sign (pain in the medial thigh). **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic:** **B**ochdalek is **B**ack and **B**ad (Posterolateral, associated with severe pulmonary hypoplasia). **M**orgagni is **M**edial/Anterior. * **Clinical Triad:** Scaphoid abdomen, respiratory distress, and shifted heart sounds. * **Radiology:** Chest X-ray shows air-filled bowel loops in the hemithorax and a mediastinal shift. * **Management:** Initial stabilization involves **intubation** (avoid bag-mask ventilation to prevent bowel distension) and **nasogastric suction**. Surgery is not an emergency; it is performed after stabilizing pulmonary hypertension.

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: Splenectomy is done to tide over the acute crises of uncontrollable:

ITP. **Explanation:** **1. Why ITP is the Correct Answer:** Immune Thrombocytopenic Purpura (ITP) is an autoimmune condition where IgG autoantibodies coat platelets, leading to their premature destruction by splenic macrophages. In **acute, life-threatening crises** (such as intracranial or gastrointestinal hemorrhage) where medical management (steroids, IVIG, or platelet transfusions) fails to stabilize the patient, an **emergency splenectomy** is performed. Removing the spleen eliminates both the primary site of platelet destruction and a major source of autoantibody production, leading to a rapid rise in platelet counts. **2. Why Other Options are Incorrect:** * **TTP (Thrombotic Thrombocytopenic Purpura):** The pathophysiology involves a deficiency of the ADAMTS13 enzyme, leading to microthrombi. The primary treatment is **Plasmapheresis (Plasma Exchange)**. Splenectomy is not indicated for acute crises and is rarely considered even in refractory cases. * **HUS (Hemolytic Uremic Syndrome):** This is primarily a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury (often Shiga-toxin mediated). Treatment is supportive (dialysis, fluids); splenectomy has no role in its management. **3. Clinical Pearls for NEET-PG:** * **Indications for Splenectomy in ITP:** Failure of medical therapy (steroids are 1st line), contraindications to steroids, or emergency life-threatening bleeding. * **Vaccination Protocol:** For elective splenectomy, vaccinate **2 weeks before** surgery. For emergency splenectomy (like in acute ITP crisis), vaccinate **2 weeks after** surgery. * **Target Organisms:** *S. pneumoniae* (most common), *H. influenzae*, and *N. meningitidis*. * **Post-Splenectomy Blood Picture:** Look for **Howell-Jolly bodies** (most characteristic), Pappenheimer bodies, Heinz bodies, and target cells.

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?

Q5Easy

Splenectomy is done to tide over the acute crises of uncontrollable:

General Surgery Principles Indian Medical PG Practice Questions and MCQs

Question 1: All of the following are causes of pneumoperitoneum except?

A. Perforated peptic ulcer
B. Laparoscopic procedure
C. Perforated appendix
D. Hirschsprung's disease (Correct Answer)

Explanation: **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).

Question 2: Hyperacute rejection is due to which of the following mechanisms?

A. Preformed antibodies (Correct Answer)
B. Cytotoxic T lymphocyte mediated injury
C. Endothelitis caused by donor antibodies
D. Circulating macrophage mediated injury

Explanation: **Explanation:** **Hyperacute Rejection** is an immediate, irreversible immunological reaction occurring within minutes to hours after organ transplantation. **1. Why Option A is Correct:** The mechanism is a **Type II Hypersensitivity reaction**. It is mediated by **preformed circulating antibodies** (IgG) in the recipient’s blood. These antibodies are directed against donor antigens (typically ABO blood group antigens or HLA Class I antigens). Upon reperfusion, these antibodies bind to the donor vascular endothelium, activating the **complement system**. This leads to rapid endothelial damage, platelet aggregation, and diffuse intravascular thrombosis, resulting in the "blue graft" appearance and graft necrosis. **2. Why Other Options are Incorrect:** * **Option B:** Cytotoxic T lymphocyte (CD8+) mediated injury is the hallmark of **Acute Cellular Rejection**, which typically occurs days to weeks after transplant. * **Option C:** Endothelitis (inflammation of the vessel wall) is a feature of **Acute Antibody-Mediated Rejection**, but it is caused by *recipient* antibodies against donor tissue, not donor antibodies. * **Option D:** Macrophages play a role in chronic inflammation and delayed-type hypersensitivity but are not the primary mediators of the rapid vascular collapse seen in hyperacute rejection. **3. High-Yield Clinical Pearls for NEET-PG:** * **Prevention:** Hyperacute rejection is prevented by **Cross-matching** (mixing recipient serum with donor lymphocytes) and ABO compatibility testing. * **Treatment:** There is no effective treatment once it starts; the graft must be **surgically removed**. * **Risk Factors:** Previous blood transfusions, multiple pregnancies, or prior organ transplants (all of which sensitize the recipient). * **Pathology:** Characterized by **Fibrinoid necrosis** of capillaries and "starry sky" appearance due to neutrophilic infiltration.

Question 3: Bochdalek hernia occurs through which anatomical structure?

A. Diaphragm (Correct Answer)
B. Lumbar triangle
C. Femoral region
D. Obturator canal

Explanation: **Explanation:** **Bochdalek hernia** is the most common type of **Congenital Diaphragmatic Hernia (CDH)**, accounting for approximately 85-90% of cases. It occurs due to the failure of the **pleuroperitoneal membrane** to fuse with the septum transversum and dorsal mesentery of the esophagus during embryonic development (usually between the 8th and 10th week). This results in a posterolateral defect in the **diaphragm**, most commonly on the **left side** (80-85%), allowing abdominal viscera to herniate into the thoracic cavity. **Analysis of Incorrect Options:** * **B. Lumbar triangle:** Hernias through the superior lumbar triangle (Grynfeltt-Lesshaft) or inferior lumbar triangle (Petit) are types of lumbar hernias, not diaphragmatic. * **C. Femoral region:** This is the site for femoral hernias, which occur through the femoral canal, medial to the femoral vein. * **D. Obturator canal:** This is the site for obturator hernias, which typically present with the Howship-Romberg sign (pain in the medial thigh). **High-Yield Clinical Pearls for NEET-PG:** * **Mnemonic:** **B**ochdalek is **B**ack and **B**ad (Posterolateral, associated with severe pulmonary hypoplasia). **M**orgagni is **M**edial/Anterior. * **Clinical Triad:** Scaphoid abdomen, respiratory distress, and shifted heart sounds. * **Radiology:** Chest X-ray shows air-filled bowel loops in the hemithorax and a mediastinal shift. * **Management:** Initial stabilization involves **intubation** (avoid bag-mask ventilation to prevent bowel distension) and **nasogastric suction**. Surgery is not an emergency; it is performed after stabilizing pulmonary hypertension.

Question 4: 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?

A. Ectopic pregnancy
B. Appendicitis (Correct Answer)
C. Cholecystitis
D. Nephrolithiasis

Explanation: ### 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.

Question 5: Splenectomy is done to tide over the acute crises of uncontrollable:

A. ITP (Correct Answer)
B. TTP
C. HUS
D. All of the above

Explanation: **Explanation:** **1. Why ITP is the Correct Answer:** Immune Thrombocytopenic Purpura (ITP) is an autoimmune condition where IgG autoantibodies coat platelets, leading to their premature destruction by splenic macrophages. In **acute, life-threatening crises** (such as intracranial or gastrointestinal hemorrhage) where medical management (steroids, IVIG, or platelet transfusions) fails to stabilize the patient, an **emergency splenectomy** is performed. Removing the spleen eliminates both the primary site of platelet destruction and a major source of autoantibody production, leading to a rapid rise in platelet counts. **2. Why Other Options are Incorrect:** * **TTP (Thrombotic Thrombocytopenic Purpura):** The pathophysiology involves a deficiency of the ADAMTS13 enzyme, leading to microthrombi. The primary treatment is **Plasmapheresis (Plasma Exchange)**. Splenectomy is not indicated for acute crises and is rarely considered even in refractory cases. * **HUS (Hemolytic Uremic Syndrome):** This is primarily a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury (often Shiga-toxin mediated). Treatment is supportive (dialysis, fluids); splenectomy has no role in its management. **3. Clinical Pearls for NEET-PG:** * **Indications for Splenectomy in ITP:** Failure of medical therapy (steroids are 1st line), contraindications to steroids, or emergency life-threatening bleeding. * **Vaccination Protocol:** For elective splenectomy, vaccinate **2 weeks before** surgery. For emergency splenectomy (like in acute ITP crisis), vaccinate **2 weeks after** surgery. * **Target Organisms:** *S. pneumoniae* (most common), *H. influenzae*, and *N. meningitidis*. * **Post-Splenectomy Blood Picture:** Look for **Howell-Jolly bodies** (most characteristic), Pappenheimer bodies, Heinz bodies, and target cells.

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