UPSC-CMS 2016 — Surgery
15 Previous Year Questions with Answers & Explanations
Tumours of anterior mediastinum include the following except:
Nottingham prognostic Index is used for:
In gallstone ileus, obstruction most frequently occurs at:
The commonest major surgical complication following Whipple procedure is:
A 60 year old male presents with bleeding per rectum. Proctoscopy reveals 2nd degree hemorrhoids. The treatment of choice is:
Pott's puffy tumour is a:
Hyperchloremic acidosis is a common complication of:
Bisgaard treatment refers to that of:
The most common cause of intestinal obstruction is:
A 30 year old lady sustained chest injury in an accident and presented with massive haemothorax on right side. Tube thoracostomy drained 1800 ml of blood. What is the most appropriate treatment?
UPSC-CMS 2016 - Surgery UPSC-CMS Practice Questions and MCQs
Question 1: Tumours of anterior mediastinum include the following except:
- A. Lymphoma
- B. Germ cell tumour
- C. Thymoma
- D. Schwannoma (Correct Answer)
Explanation: ***Schwannoma*** - **Schwannomas** (neurilemmomas) are typically found in the **posterior mediastinum**, arising from **peripheral nerves** or nerve roots. - They are usually benign and grow slowly, presenting with symptoms due to compression of surrounding structures. *Lymphoma* - **Lymphoma** is a common tumor of the **anterior mediastinum**, often presenting as an **anterior mediastinal mass**. - Both Hodgkin and non-Hodgkin lymphomas can involve mediastinal lymph nodes. *Germ cell tumour* - **Germ cell tumors**, including **teratomas** and **seminomas**, frequently occur in the **anterior mediastinum**. - They arise from ectopic germ cell rests that migrate aberrantly during embryonic development. *Thymoma* - **Thymomas** are the most common primary tumor of the **anterior mediastinum**, originating from the **thymus gland**. - They are often associated with **myasthenia gravis** and other paraneoplastic syndromes.
Question 2: Nottingham prognostic Index is used for:
- A. Cancer stomach
- B. Cancer breast (Correct Answer)
- C. Cancer colon
- D. Cancer lung
Explanation: ***Cancer breast*** - The **Nottingham Prognostic Index (NPI)** is a well-established tool used specifically for assessing the prognosis of **early invasive breast cancer**. - It combines three key pathological features: **tumor size**, **lymph node status**, and **histological grade**, to provide a prognostic score. *Cancer stomach* - Prognostic indices for gastric cancer typically involve factors like **tumor depth (T stage)**, **lymph node involvement (N stage)**, **metastasis (M stage)**, and **histological type**. - The NPI is not validated or used for gastric cancer. *Cancer colon* - Prognosis in colorectal cancer is primarily determined by the **Dukes' staging system** or the **TNM staging system**, which consider tumor invasion depth, lymph node spread, and distant metastasis. - The NPI is not applicable to colorectal cancer. *Cancer lung* - Lung cancer prognosis depends heavily on the **TNM staging system**, differentiating between **non-small cell lung cancer** and **small cell lung cancer**, and considering factors like tumor size, nodal involvement, and metastases. - There is no role for the NPI in assessing lung cancer prognosis.
Question 3: In gallstone ileus, obstruction most frequently occurs at:
- A. Jejunum
- B. Duodenum
- C. Terminal ileum (Correct Answer)
- D. Proximal ileum
Explanation: ***Terminal ileum*** - In gallstone ileus, the **terminal ileum** (particularly at the **ileocecal valve region**) is the most common site of obstruction, accounting for **60-70%** of cases. - This occurs because the terminal ileum is the **narrowest portion of the small bowel**, creating a natural anatomical bottleneck where large gallstones become impacted. - The **ileocecal valve** represents the point of transition from small to large bowel, and its relatively fixed position and narrow caliber make it the classic site of obstruction. *Proximal ileum* - While gallstones can cause obstruction in the proximal or mid-ileum, this is **less frequent** than terminal ileum obstruction. - The proximal ileum has a relatively wider lumen compared to the terminal ileum, allowing larger stones to pass through more easily. *Jejunum* - The **jejunum** has the widest lumen of the small bowel, making obstruction at this site uncommon. - Gallstones typically pass through the jejunum without causing impaction. *Duodenum* - Duodenal obstruction by a gallstone is called **Bouveret's syndrome** and represents a rare variant (1-4% of gallstone ileus cases). - This occurs when a large stone impacts in the duodenal bulb or pylorus after eroding through a cholecystoduodenal fistula.
Question 4: The commonest major surgical complication following Whipple procedure is:
- A. Disruption of gastric anastomosis
- B. Disruption of pancreatic anastomosis (Correct Answer)
- C. Biliary peritonitis
- D. GI bleeding
Explanation: ***Disruption of pancreatic anastomosis*** - **Pancreatic fistula** resulting from the disruption of the pancreatic anastomosis is the most frequent and most serious complication, occurring in 5-20% of cases. - Leakage of pancreatic fluids can lead to severe **intra-abdominal infection**, hemorrhage, and multi-organ failure. *Disruption of gastric anastomosis* - While possible, leak from the **gastric or duodenal anastomosis** is less common than pancreatic fistula. - This complication typically leads to peritonitis or abscess formation but generally has a lower morbidity compared to pancreatic leaks. *Biliary peritonitis* - **Bile leaks** from the hepaticojejunostomy are less common than pancreatic leaks and generally have a lower risk of severe systemic complications. - They primarily cause **peritonitis** and sometimes require percutaneous drainage or re-operation. *GI bleeding* - Gastrointestinal bleeding can occur post-Whipple, either from the **anastomotic sites**, stress ulcers, or coagulation issues. - While serious, it is typically less common and often more manageable than the sequelae of a pancreatic fistula.
Question 5: A 60 year old male presents with bleeding per rectum. Proctoscopy reveals 2nd degree hemorrhoids. The treatment of choice is:
- A. Cryotherapy
- B. Sclerotherapy
- C. Banding (Correct Answer)
- D. Surgery
Explanation: ***Banding*** - **Rubber band ligation** is the preferred treatment for **second-degree hemorrhoids** because it is effective, minimally invasive, and can be done in an outpatient setting. - The bands cause the hemorrhoid tissue to necrose and fall off within a few days, alleviating symptoms. *Cryotherapy* - **Cryotherapy** involves freezing the hemorrhoid tissue, but it is rarely used due to a **higher risk of complications** such as pain, prolonged discharge, and incomplete tissue destruction. - It is generally considered less effective and associated with more discomfort and potential for recurrence compared to other treatments. *Sclerotherapy* - **Sclerotherapy** involves injecting a chemical solution into the hemorrhoid to cause fibrosis and shrinkage, primarily used for **first-degree hemorrhoids**. - While it can be effective for smaller hemorrhoids, it is less effective than banding for **second-degree hemorrhoids** and has a higher recurrence rate for this grade. *Surgery* - **Surgical hemorrhoidectomy** is typically reserved for **third- and fourth-degree hemorrhoids** or those that have failed other less invasive treatments. - While highly effective, surgery is more invasive, carries **higher risks of complications**, and requires a longer recovery period, making it overtreatment for second-degree hemorrhoids.
Question 6: Pott's puffy tumour is a:
- A. Tuberculosis of the skull bone
- B. Subperiosteal abscess associated with osteomyelitis of frontal bone (Correct Answer)
- C. Fungating scrotal malignancy
- D. Squamous cell cancer of scalp
Explanation: ***Subperiosteal abscess associated with osteomyelitis of frontal bone*** - **Pott's puffy tumor** is a rare but serious complication of **frontal sinusitis**, characterized by an overlying edema and subperiosteal abscess. - It arises from **osteomyelitis of the frontal bone**, which can erode through the bone and lead to an intracranial abscess. *Tuberculosis of the skull bone* - While tuberculosis can affect bones, a **tuberculosis of the skull** would typically present with a more chronic course and different imaging findings, not the characteristic acute, localized swelling of Pott's puffy tumor. - **Pott's puffy tumor** is specifically associated with bacterial sinusitis, not mycobacterial infection. *Fungating scrotal malignancy* - This option refers to a **malignant tumor of the scrotum** and is entirely unrelated to skull pathology or infection. - The clinical presentation and location are completely different from Pott's puffy tumor. *Squamous cell cancer of scalp* - A **squamous cell cancer of the scalp** is a type of skin malignancy, which would present as a growing lesion and potentially ulcerate, but would not typically involve the deeper bone in the characteristic way of Pott's puffy tumor. - It does not involve a **subperiosteal abscess** or underlying osteomyelitis of the frontal bone.
Question 7: Hyperchloremic acidosis is a common complication of:
- A. Ureterosigmoidostomy (Correct Answer)
- B. Ileostomy
- C. Vomiting
- D. Diarrhoea
Explanation: ***Ureterosigmoidostomy*** - This procedure directly connects the ureters to the sigmoid colon, allowing for the **reabsorption of urinary chloride and ammonium** by the colonic mucosa in exchange for bicarbonate secretion. - The mechanism involves **active reabsorption of chloride** from urine coupled with bicarbonate loss into the bowel lumen, leading to **hyperchloremic metabolic acidosis**. - This is the **classic urological cause** of hyperchloremic acidosis and the most specific answer in a surgical context. *Ileostomy* - **Ileostomy** typically leads to significant loss of fluids and electrolytes, including sodium and potassium, through the stoma. - While it can cause dehydration and electrolyte imbalances, it is more commonly associated with **hypokalemia, hyponatremia, and dehydration** rather than hyperchloremic acidosis. *Vomiting* - **Protracted vomiting** primarily results in the loss of gastric acid (HCl), leading to **hypochloremia** and **metabolic alkalosis** (not acidosis). - The loss of hydrogen ions from the stomach causes the kidneys to retain bicarbonate to maintain pH balance, resulting in elevated serum HCO3-. *Diarrhoea* - Severe **diarrhea** causes the loss of **bicarbonate-rich fluids** from the gastrointestinal tract, which can indeed lead to **normal anion gap metabolic acidosis** (hyperchloremic acidosis). - However, in the context of **surgical/urological complications**, **ureterosigmoidostomy** is the more specific and classic answer, as it involves a unique mechanism of **direct chloride reabsorption from urine** rather than simple bicarbonate loss. - Diarrhea-induced acidosis is also typically an acute medical condition rather than a surgical complication.
Question 8: Bisgaard treatment refers to that of:
- A. An ischaemic ulcer
- B. Venous ulcer (Correct Answer)
- C. An in-growing toe nail
- D. Ruptured tendo achillis
Explanation: ***Venous ulcer*** - **Bisgaard treatment** is a historical surgical technique specifically developed for the management of **chronic venous ulcers**. - This treatment aims to improve venous return and reduce venous hypertension by surgically addressing incompetent perforator veins and superficial venous reflux. *An ischaemic ulcer* - **Ischaemic ulcers** are caused by arterial insufficiency and require interventions to improve arterial blood flow, such as revascularization. - Bisgaard treatment is not appropriate for ischaemic ulcers as it does not address the underlying **arterial occlusive disease**. *An in-growing toe nail* - An **ingrown toenail** is a common podiatric condition typically treated with local procedures like nail avulsion or matrixectomy. - Bisgaard treatment is a complex vascular surgical procedure and bears no relevance to the treatment of an ingrown toenail. *Ruptured tendo achillis* - A **ruptured Achilles tendon** is an orthopaedic injury that requires surgical repair or conservative management involving immobilization. - Bisgaard treatment is exclusively for venous ulcer disease and has no role in the management of tendon injuries.
Question 9: The most common cause of intestinal obstruction is:
- A. Inflammatory abdominal conditions
- B. Bands and adhesions (Correct Answer)
- C. Obstructed hernia
- D. Gastrointestinal malignancy
Explanation: ***Bands and adhesions*** - **Post-surgical adhesions** are the most common cause of small bowel obstruction, often forming after abdominal surgeries due to tissue healing. - These fibrous bands can **constrict or kink** the bowel, leading to a mechanical blockage. *Inflammatory abdominal conditions* - Conditions like **Crohn's disease** or **diverticulitis** can cause obstruction, but they are less frequent than adhesions as a primary cause. - Obstruction due to inflammation often involves **strictures** or inflammation-induced narrowing of the lumen. *Obstructed hernia* - **Hernias** (inguinal, femoral, umbilical, incisional) can become obstructed or strangulated, causing acute obstruction. - While a significant cause, the overall incidence is lower than that of adhesions, especially looking at all cases of intestinal obstruction. *Gastrointestinal malignancy* - **Colorectal cancer** is a common cause of large bowel obstruction, and other GI malignancies can cause small bowel obstruction. - Malignancy-related obstructions typically involve **tumor growth** causing luminal narrowing, but adhesions remain the leading cause overall.
Question 10: A 30 year old lady sustained chest injury in an accident and presented with massive haemothorax on right side. Tube thoracostomy drained 1800 ml of blood. What is the most appropriate treatment?
- A. Clamp the chest tube to cause the tamponade
- B. Put one more chest tube
- C. Resuscitation and prepare for urgent thoracotomy (Correct Answer)
- D. Correction of hypovolemic shock
Explanation: ***Resuscitation and prepare for urgent thoracotomy*** - A **massive hemothorax**, defined as draining >1500 ml of blood initially or >200 ml/hour for 2-4 hours, indicates significant ongoing bleeding requiring surgical intervention. - Urgent **thoracotomy** is necessary to identify and control the source of hemorrhage in such cases. *Clamp the chest tube to cause the tamponade* - Clamping the chest tube in a massive hemothorax can lead to **cardiac tamponade** or worsening **respiratory distress** by trapping blood in the pleural space. - This action would dangerously increase **intrathoracic pressure** and is contraindicated as it prevents proper drainage and exacerbates hypovolemic shock. *Put one more chest tube* - While additional chest tubes might be considered for inadequate drainage in certain situations, a massive hemothorax (1800 ml) signifies a major vascular injury, making multiple tubes insufficient to control the bleeding. - The priority is to stop the bleeding surgically, not just to drain more blood, which would only accelerate **exsanguination**. *Correction of hypovolemic shock* - **Resuscitation** is a critical initial step, but it is not the definitive treatment for a massive hemothorax with ongoing bleeding. - Without addressing the source of the bleeding via **thoracotomy**, simply managing the **hypovolemic shock** would be futile as the patient would continue to bleed out.