Anatomy
1 questionsTo which lymph nodes, the lymph from the umbilicus drain?
UPSC-CMS 2009 - Anatomy UPSC-CMS Practice Questions and MCQs
Question 11: To which lymph nodes, the lymph from the umbilicus drain?
- A. External and internal iliac
- B. Axillary and inguinal (Correct Answer)
- C. Inter aortocaval
- D. Pre and para-aortic
Explanation: ***Axillary and inguinal*** - Lymph above the **transumbilical plane** drains to the **axillary lymph nodes** [1]. - Lymph below the **transumbilical plane** drains to the **superficial inguinal lymph nodes** [1]. *External and internal iliac* - These nodes primarily drain structures within the **pelvis**, such as the bladder, rectum, and reproductive organs. - They are not the direct primary drainage site for the umbilical region. *Inter aortocaval* - **Inter aortocaval lymph nodes** are located between the abdominal aorta and inferior vena cava. - They primarily receive lymph from structures such as the **kidneys** and **testes/ovaries**, not the umbilicus. *Pre and para-aortic* - **Pre-aortic lymph nodes** drain organs supplied by unpaired visceral branches of the aorta, like the gastrointestinal tract. - **Para-aortic lymph nodes** drain organs like the kidneys, adrenal glands, and gonads, not directly the umbilical region.
Internal Medicine
2 questionsThe following are complications of gall stone except
Consider the following prognostic parameters of acute pancreatitis : 1. Rise in blood urea nitrogen over 5 mg/dl 2. Hematocrit decrease over 10% 3. Base deficit more than 4 mmol/L 4. Blood glucose over 10 mmol/L Which of the above parameters are important during initial 48 hours ?
UPSC-CMS 2009 - Internal Medicine UPSC-CMS Practice Questions and MCQs
Question 11: The following are complications of gall stone except
- A. Acute pancreatitis
- B. Cholangitis
- C. Biliary enteric fistula
- D. Haemobilia (Correct Answer)
Explanation: ***Haemobilia*** - **Haemobilia** refers to bleeding into the biliary tree, often caused by trauma, surgery, or vascular malformations, and is **not a direct complication of gallstones**. [1] - While gallstones can lead to inflammation and erosion, they typically do not cause bleeding into the bile ducts as a primary complication. *Acute pancreatitis* - **Gallstones** are a common cause of **acute pancreatitis** when a stone obstructs the ampulla of Vater, leading to reflux of bile into the pancreatic duct or obstruction of the pancreatic duct itself [1]. - This obstruction causes premature activation of pancreatic enzymes and autodigestion of the pancreas. *Cholangitis* - **Cholangitis** is an inflammation of the bile ducts, usually caused by bacterial infection, which is often precipitated by an obstruction of the biliary tree, most commonly by **gallstones** [1]. - The obstruction leads to stasis of bile, allowing bacteria to ascend from the duodenum and proliferate. *Biliary enteric fistula* - A **biliary enteric fistula** (e.g., cholecystoduodenal fistula) is a pathological connection between the gallbladder or bile duct and the gastrointestinal tract, which can occur due to chronic inflammation and erosion caused by **gallstones** [1]. - This can lead to gallstone ileus if the stone passes into the bowel and obstructs it [1].
Question 12: Consider the following prognostic parameters of acute pancreatitis : 1. Rise in blood urea nitrogen over 5 mg/dl 2. Hematocrit decrease over 10% 3. Base deficit more than 4 mmol/L 4. Blood glucose over 10 mmol/L Which of the above parameters are important during initial 48 hours ?
- A. 2 and 3 only
- B. 1, 2 and 3
- C. 1, 3 and 4
- D. 1 and 2 only (Correct Answer)
Explanation: ***1 and 2 only*** - A **rise in blood urea nitrogen over 5 mg/dL** and a **hematocrit decrease over 10%** within the initial 48 hours are significant early indicators of fluid sequestration and systemic inflammation, which are critical prognostic factors in acute pancreatitis [1]. - These parameters are part of common prognostic scoring systems, like the **Modified Glasgow Score** or **Ranson's Criteria**, used to assess the severity and predict outcomes [1]. *2 and 3 only* - While a **hematocrit decrease over 10%** is a relevant early prognostic indicator, a **base deficit more than 4 mmol/L** (indicating metabolic acidosis) typically emerges later or reflects more severe, established organ dysfunction. - Early prognostic assessment focuses on parameters measurable within the first 48 hours that reflect initial systemic impact. *1, 2 and 3* - **Rise in blood urea nitrogen over 5 mg/dL** and **hematocrit decrease over 10%** are valid early indicators, but a **base deficit more than 4 mmol/L** is not included in the standard initial 48-hour prognostic criteria for acute pancreatitis severity assessment for the first two days [1]. - This option incorrectly includes base deficit as a primary early prognostic parameter. *1, 3 and 4* - **Rise in blood urea nitrogen over 5 mg/dL** is a correct early prognostic parameter. However, a **base deficit more than 4 mmol/L** and **blood glucose over 10 mmol/L** are less specifically emphasized as *initial 48-hour* critical parameters in all common scoring systems. - While hyperglycemia can be present, its specific prognostic cutoff often varies, and it typically contributes to overall severity rather than being a standalone early change in the first 48 hours.
Pathology
2 questionsConsider the following: 1. Cholesterolosis 2. Adenomyomatosis 3. Polyposis 4. Cholelithiasis To which of the above does cholecystoses refer to?
The following disorders are predisposing conditions for carcinoma of the colon except
UPSC-CMS 2009 - Pathology UPSC-CMS Practice Questions and MCQs
Question 11: Consider the following: 1. Cholesterolosis 2. Adenomyomatosis 3. Polyposis 4. Cholelithiasis To which of the above does cholecystoses refer to?
- A. 1 and 2 only (Correct Answer)
- B. 1 and 3 only
- C. 1, 2 and 3
- D. 2, 3 and 4
Explanation: ***1 and 2 only*** - **Cholecystoses** is a term used in pathology to describe a group of **non-inflammatory, degenerative changes** in the gallbladder wall, classically comprising two main entities: **cholesterolosis** and **adenomyomatosis**. - **Cholesterolosis** involves the accumulation of cholesterol esters in macrophages within the gallbladder mucosa, creating a characteristic **"strawberry gallbladder"** appearance on gross examination. - **Adenomyomatosis** is characterized by **hyperplasia of the muscularis propria** with epithelial invaginations forming **Rokitansky-Aschoff sinuses**, which are deep diverticula extending into the thickened muscle layer [1]. - These conditions are typically benign, often incidental findings, and distinct from inflammatory or neoplastic processes. *1, 2 and 3* - This option incorrectly includes **polyposis** as a separate category of cholecystoses. - While **cholesterol polyps** and **adenomyomatous polyps** can be manifestations of cholesterolosis and adenomyomatosis respectively, "polyposis" itself is not traditionally classified as a distinct cholecystosis in standard pathology references (Robbins, WHO classification). - Gallbladder polyps represent a heterogeneous group including neoplastic and non-neoplastic lesions, but are not listed as a separate cholecystosis category. *2, 3 and 4* - This option incorrectly includes **cholelithiasis** (gallstones), which is a completely separate condition involving calculi formation within the gallbladder lumen [3]. - Cholelithiasis is an **inflammatory/metabolic condition**, not a degenerative change of the gallbladder wall itself as seen in cholecystoses [2]. - It also incorrectly excludes **cholesterolosis**, which is one of the two classical cholecystoses. *1 and 3 only* - This option incorrectly excludes **adenomyomatosis**, which is one of the two classical and well-established forms of cholecystoses. - It also incorrectly includes **polyposis** as a separate category, which is not supported by standard pathology literature. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 404-405. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, pp. 883-884. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Liver And Biliary System Disease, pp. 403-404.
Question 12: The following disorders are predisposing conditions for carcinoma of the colon except
- A. Villous adenoma
- B. Familial polyposis coli
- C. Escherichia coli (Correct Answer)
- D. Peutz-Jeghers syndrome
Explanation: ***Escherichia coli*** - For this 2009 examination, *Escherichia coli* was not recognized as a direct predisposing condition for **colorectal carcinoma**. - **Note for modern learners:** Recent research (post-2010) has identified that certain E. coli strains, particularly pks+ E. coli producing colibactin toxin, can cause DNA damage and are associated with increased colorectal cancer risk. However, this knowledge was not established at the time of this exam. - In the context of classic predisposing conditions, E. coli remains the correct answer for this historical question. *Villous adenoma* - **Villous adenomas** are a type of colorectal polyp with the highest malignant potential among adenomatous polyps (up to 40% risk) [1]. - These are well-established **precancerous lesions** that can progress to **colorectal cancer**, especially when large (>2 cm) or showing high-grade dysplasia [1]. - This is a major predisposing condition for colorectal carcinoma. *Familial polyposis coli* - Also known as **Familial Adenomatous Polyposis (FAP)**, this autosomal dominant disorder causes hundreds to thousands of adenomatous polyps in the colon and rectum [2]. - Nearly **100% of untreated patients** develop **colorectal cancer** by age 40-50 [2]. - This is one of the most significant hereditary predisposing conditions for colorectal carcinoma. *Peutz-Jeghers syndrome* - This **autosomal dominant** disorder features multiple **hamartomatous polyps** throughout the GI tract and characteristic mucocutaneous pigmentation [3]. - Patients have a **15-fold increased risk** of colorectal cancer and elevated risks for other malignancies (gastric, small bowel, pancreatic, breast, ovarian, lung) [3]. - This is an established hereditary predisposing condition for colorectal carcinoma. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Alimentary System Disease, pp. 371-373. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 821-822. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Gastrointestinal Tract, pp. 813-814.
Surgery
5 questionsA young patient develops high grade fever with chills and rigors, mild jaundice and acute pain in the upper abdomen following cholecystectomy. On examination she was jaundiced, toxic, haemodynamically stable and having vague fullness upper abdomen. What is the most probable diagnosis ?
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 ?
A 50 year old diabetic patient with asymptomatic gallstone (> 3 cm) will be best treated by
Which of the following is not an indication for surgical intervention in acute pancreatitis?
The most common intraperitoneal abscess following peritonitis is
UPSC-CMS 2009 - Surgery UPSC-CMS Practice Questions and MCQs
Question 11: A young patient develops high grade fever with chills and rigors, mild jaundice and acute pain in the upper abdomen following cholecystectomy. On examination she was jaundiced, toxic, haemodynamically stable and having vague fullness upper abdomen. What is the most probable diagnosis ?
- A. Duodenal injury
- B. Acute Pancreatitis
- C. Localised collection of bile in peritoneal cavity (Correct Answer)
- D. Iatrogenic ligation of common bile duct
Explanation: ***Localised collection of bile in peritoneal cavity*** - The combination of **fever with chills and rigors**, **mild jaundice**, and **acute upper abdominal pain** developing post-cholecystectomy, along with a toxic appearance and vague upper abdominal fullness, strongly suggests a **localized bile leak** leading to a bile collection (biloma) and secondary infection. - **Bile leakage** can occur due to clips dislodging, an accessory duct injury, or cystic duct stump leak, and often presents as signs of **peritonitis** and **sepsis** if infected, causing the fever and rigors. *Duodenal injury* - A duodenal injury post-cholecystectomy would typically present with signs of **peritonitis**, **sepsis**, and potentially contents like bile or gastric acid in the drain, but **jaundice** would not be a prominent feature unless a separate biliary injury was also present. - While it could cause abdominal pain and fever, the specific presentation of **jaundice** and **vague fullness** without overt signs of free perforation makes it less likely than a bile collection. *Acute Pancreatitis* - **Acute pancreatitis** post-cholecystectomy is possible due to retained **gallstones** or **iatrogenic trauma** to the pancreatic duct, causing severe epigastric pain radiating to the back, nausea, and vomiting. - While it can cause jaundice in severe cases due to common bile duct compression, the primary abdominal finding is usually diffuse tenderness and rigidity rather than vague fullness, and the pattern of pain is often more characteristic. *Iatrogenic ligation of common bile duct* - **Iatrogenic ligation of the common bile duct** would cause **progressive jaundice**, **acholic stools**, and potentially **cholangitis** (fever, chills, abdominal pain), due to complete obstruction of bile flow. - However, while it explains jaundice and may cause fever, the presence of **rigors**, immediate post-operative onset of **fever**, and vague **abdominal fullness** suggesting a collection makes a bile leak with infection a more direct explanation for the acute picture.
Question 12: 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 ?
- A. 3, 2, 1, 4
- B. 2, 1, 4, 3 (Correct Answer)
- C. 1, 4, 2, 3
- D. 4, 2, 1, 3
Explanation: ***Correct Option: 2, 1, 4, 3*** - The initial and most critical step in managing massive variceal bleeding is **general resuscitation** to stabilize the patient, including securing the airway, establishing IV access, and restoring blood volume. - After initial resuscitation, **infusion of vasopressin** or other vasoactive drugs (e.g., octreotide or somatostatin) is initiated to reduce portal pressure and control bleeding by causing splanchnic vasoconstriction. - Once the patient is stabilized and pharmacological agents are initiated, **endoscopic sclerotherapy** or band ligation is performed to directly control bleeding from the varices. - If initial measures fail, or in cases of chronic, recurrent bleeding not amenable to endoscopy, a **devascularization procedure** (e.g., portosystemic shunts, or surgical devascularization such as splenorenal shunt) becomes necessary as a definitive, but more invasive, treatment. *Incorrect Option: 3, 2, 1, 4* - **Devascularization procedures** are invasive surgical interventions and are generally considered a last resort for definitive management after less invasive methods have failed or are not suitable. - Starting with a devascularization procedure would bypass critical initial steps of **resuscitation** and immediate control of hemorrhage. *Incorrect Option: 1, 4, 2, 3* - This sequence incorrectly places **vasopressin infusion** and **endoscopic sclerotherapy** before **general resuscitation**. - Without proper resuscitation, the patient may not be stable enough to tolerate these interventions, and vital organ perfusion may be compromised, leading to a worse outcome. *Incorrect Option: 4, 2, 1, 3* - This sequence mistakenly places **endoscopic sclerotherapy** before **general resuscitation**, which is incorrect given the urgency of stabilizing a patient with massive bleeding. - While endoscopy is crucial for diagnosis and treatment, it must follow initial **resuscitation** to ensure patient safety and optimize the chances of success.
Question 13: A 50 year old diabetic patient with asymptomatic gallstone (> 3 cm) will be best treated by
- A. Early surgery (Correct Answer)
- B. Bile-salt treatment
- C. Waiting till it becomes symptomatic
- D. ESWL
Explanation: ***Early surgery*** - **Diabetic patients** with gallstones, especially those over 3 cm, have a higher risk of complications like **cholecystitis**, **cholangitis**, and even **gallbladder cancer**, justifying prophylactic cholecystectomy. - The risk of perioperative complications is lower than the risk associated with an acute gallstone event in a diabetic patient. *Bile-salt treatment* - This treatment is primarily used for **small cholesterol gallstones** in patients who are not surgical candidates. - It is ineffective for large gallstones (>3 cm) and calcified stones, and it carries a high recurrence rate. *Waiting till it becomes symptomatic* - In diabetic patients, waiting for symptoms can lead to more severe and **atypical presentations** of complications, which may be harder to manage. - Larger gallstones in diabetic patients pose a significantly increased risk of developing **gallbladder cancer**, making prophylactic removal beneficial. *ESWL (Extracorporeal Shock Wave Lithotripsy)* - **ESWL** is generally reserved for solitary, small (<2 cm), non-calcified gallstones in patients who refuse or are not candidates for surgery. - It is not effective for large gallstones (>3 cm) and carries risks of stone recurrence and fragmentation complications.
Question 14: Which of the following is not an indication for surgical intervention in acute pancreatitis?
- A. Diagnostic dilemma
- B. Pancreatic abscess
- C. Infected pancreatic necrosis
- D. Acute fluid collection (Correct Answer)
Explanation: ***Acute fluid collection*** - **Acute fluid collections** are common in acute pancreatitis and are often **sterile** and resolve spontaneously without intervention. - Early surgical intervention for uncomplicated acute fluid collections is generally **contraindicated** due to high morbidity and mortality. *Diagnostic dilemma* - When the diagnosis of acute pancreatitis is uncertain and other surgical emergencies, such as **perforated viscus** or **ischemic bowel**, cannot be ruled out, surgery may be necessary. - An **exploratory laparotomy** can help confirm the diagnosis and address any concurrent surgical pathology. *Pancreatic abscess* - A **pancreatic abscess** is a localized collection of pus in or near the pancreas, indicating **infected necrotic tissue**. - Surgical drainage and debridement are typically required to control the infection and prevent systemic sepsis. *Infected pancreatic necrosis* - **Infected pancreatic necrosis** is a severe complication of acute pancreatitis with high mortality, often requiring surgical debridement (necrosectomy). - While sterile necrosis may be managed conservatively, **infected necrosis** necessitates intervention to remove the source of infection.
Question 15: The most common intraperitoneal abscess following peritonitis is
- A. Pelvic (Correct Answer)
- B. Paracolic
- C. Subphrenic
- D. Interloop
Explanation: ***Pelvic*** - Due to **gravity**, inflammatory exudates and bacteria tend to accumulate in the lowest part of the peritoneal cavity, which is the **pelvis**. - The **pelvic peritoneum** has an excellent capacity for localizing infection, leading to a high incidence of abscess formation here. *Para colic* - While paracolic gutters can accumulate fluid, they are generally **less dependent** than the pelvis for universal collection of peritoneal fluid. - Abscesses in this region are common but not typically the *most common* overall compared to pelvic abscesses. *Subphrenic* - Subphrenic abscesses occur below the diaphragm, often associated with operations on the **upper abdomen** or liver/spleen injuries. - While a significant complication, they are less common than pelvic abscesses in general peritonitis. *Interloop* - Interloop abscesses form between loops of bowel, often due to localized inflammation and exudate. - These are common but tend to be **smaller** and **more scattered** than the large collections seen in the pelvis, making them less frequently the single most common site for a prominent abscess.