Prevention of Ileus — MCQs

10 questions

All are causes of mechanical intestinal obstruction except which of the following?

Most important early postoperative complication of ileostomy:

A 50-year-old patient with renal insufficiency was recently operated on for pyelolithotomy. Which drug is the most appropriate choice for post-operative analgesia?

Which of the following is not a prokinetic?

What is the treatment of choice for a post-operative abscess?

In surgical stress all hormones are increased except:

Following complete ileal and partial jejunal resection, the patient is most likely to have-

Which Benzodiazepine decreases post-operative nausea & vomiting:-

A meta-analysis comparing ERAS versus traditional perioperative care shows 30% reduction in length of stay and 50% reduction in complications without increase in readmission rates. However, implementation costs are 20% higher initially. As a department head, how should you evaluate the adoption of ERAS protocol?

Q10

A hospital is designing an ERAS protocol for gynecological oncology surgery. Literature shows conflicting evidence about routine nasogastric tube (NGT) placement versus no NGT. Considering ERAS principles and risk-benefit analysis, which approach would be most appropriate and why?

Prevention of Ileus Indian Medical PG Practice Questions and MCQs

Question 1: All are causes of mechanical intestinal obstruction except which of the following?

A. Intussusception
B. Bands
C. Mesenteric vascular occlusion (Correct Answer)
D. Gall stones

Explanation: ***Mesenteric vascular occlusion*** - This condition causes **ischemic bowel injury** due to impaired blood flow, leading to **paralytic ileus** rather than a physical blockage. - While it results in intestinal dysfunction, it does not involve a **mechanical obstruction** by a physical barrier. *Gall stones* - Large **gallstones** can erode through the gallbladder wall into the small intestine, leading to a condition called **gallstone ileus**. - This creates a **physical obstruction** within the lumen of the small bowel. *Intussusception* - **Intussusception** involves one segment of the intestine telescoping into an adjacent segment. - This creates a **mechanical blockage** of the intestinal lumen. *Bands* - Internal **fibrous bands** or adhesions, often from previous surgeries, can constrict and obstruct the bowel lumen. - These bands represent a direct **physical impediment** to the passage of intestinal contents.

Question 2: Most important early postoperative complication of ileostomy:

A. Necrosis (Correct Answer)
B. Prolapse
C. Obstruction
D. Diarrhea

Explanation: ***Necrosis*** - Stomal **necrosis** can occur early postoperatively due to issues with **blood supply** to the ileum, often caused by excessive tension on the mesentery or improper creation of the stoma. - This complication can lead to severe issues like perforation and sepsis if not promptly identified and managed. *Obstruction* - While **obstruction** can occur after ileostomy, it is typically a **delayed complication** often caused by adhesions, internal herniation, or food bolus impaction. - Early postoperative obstruction is less common unless there's an immediate surgical issue like a twisted loop or stricture. *Prolapse* - **Stoma prolapse**, where the bowel telescopes out through the stoma, is usually a **late complication** that develops over time due to weakened abdominal wall muscles or increased intra-abdominal pressure. - It is rarely seen in the immediate postoperative period without predisposing factors. *Diarrhea* - **High-output stoma** (sometimes referred to as diarrhea in general terms) is a common early postoperative issue, but it is considered a **physiological response** rather than a complication. - This is due to the lack of colonic absorption, leading to unformed stools and potential electrolyte imbalances, but it's not a direct surgical complication in the same way necrosis is.

Question 3: A 50-year-old patient with renal insufficiency was recently operated on for pyelolithotomy. Which drug is the most appropriate choice for post-operative analgesia?

A. Diclofenac sodium
B. Naproxen
C. Indomethacin
D. Acetaminophen (Correct Answer)
E. Ketorolac

Explanation: ***Acetaminophen*** - **Acetaminophen** is primarily metabolized in the liver, with minimal renal excretion, making it a safer option for patients with **renal insufficiency**. - It provides effective **analgesia** without the adverse renal effects associated with NSAIDs. *Diclofenac sodium* - **Diclofenac** is a non-steroidal anti-inflammatory drug (**NSAID**) that can impair renal function, especially in patients with pre-existing **renal insufficiency**, by inhibiting prostaglandin synthesis. - Its use can lead to further **kidney damage** or exacerbate existing renal impairment. *Naproxen* - **Naproxen** is an **NSAID** that carries a significant risk of causing acute kidney injury in patients with **compromised renal function**. - It reduces renal blood flow and glomerular filtration rate, making it unsuitable for this patient. *Indomethacin* - **Indomethacin** is a potent **NSAID** known for its adverse renal effects, including acute renal failure. - It should be avoided in patients with **renal insufficiency** due to its potential to further decline kidney function. *Ketorolac* - **Ketorolac** is a potent **NSAID** commonly used for post-operative pain but is **contraindicated** in patients with renal insufficiency. - It has significant nephrotoxic potential and can cause acute renal failure, especially in patients with pre-existing kidney disease.

Question 4: Which of the following is not a prokinetic?

A. Macrolides
B. D2 blocker
C. 5HT4 agonist
D. Loperamide derivative (Correct Answer)

Explanation: **Loperamide derivative** - **Loperamide** is an **opioid receptor agonist** that acts on the mu-opioid receptors in the gut, primarily to **decrease gastrointestinal motility** and treat diarrhea. - Its mechanism of action directly opposes that of prokinetic agents, which aim to increase GI motility. *Macrolides* - Certain macrolide antibiotics, particularly **erythromycin**, act as **motilin receptor agonists** at low doses. - This agonism leads to increased gastric motility and can be used as a prokinetic in conditions like gastroparesis. *D2 blocker* - **Dopamine D2 receptor antagonists** (e.g., **metoclopramide**, **domperidone**) block the inhibitory effect of dopamine on cholinergic smooth muscle. - This blockade enhances acetylcholine release, leading to increased gastrointestinal motility and prokinetic effects. *5HT4 agonist* - **Serotonin 5-HT4 receptor agonists** (e.g., **cisapride**, **prucalopride**) stimulate the release of acetylcholine and other excitatory neurotransmitters in the enteric nervous system. - This action promotes increased gastrointestinal motility, making them effective prokinetic agents.

Question 5: What is the treatment of choice for a post-operative abscess?

A. Hydration
B. IV antibiotics
C. Image guided aspiration (Correct Answer)
D. Reexploration

Explanation: ***Image-guided aspiration*** - This is often the **first-line treatment** for a post-operative abscess, especially if it is well-localized. - It involves **draining the pus** under imaging guidance, relieving pressure and removing the infectious material. *Hydration* - While important for overall patient management, especially in cases of infection or sepsis, **hydration alone does not treat an abscess**. - It is a supportive measure but does not address the **localized collection of pus**. *IV antibiotics* - Antibiotics are typically indicated as an **adjunct to drainage**, especially in cases of systemic infection or cellulitis. - However, **antibiotics alone are often insufficient** to resolve an abscess as they have difficulty penetrating the necrotic core and thick capsule. *Reexploration* - **Surgical reexploration** is a more invasive option usually reserved for abscesses that are **large, multiloculated, not amenable to percutaneous drainage**, or when initial drainage attempts fail. - It carries greater risks and is not the initial treatment of choice for every post-operative abscess.

Question 6: In surgical stress all hormones are increased except:

A. Insulin (Correct Answer)
B. Epinephrine
C. ACTH
D. Cortisol

Explanation: ***Insulin*** - While other **stress hormones** increase, **insulin** levels typically **decrease** or remain stable due to increased **insulin resistance** during surgical stress. - This physiological response aims to maintain **blood glucose** levels for energy during heightened metabolic demands. *Epinephrine* - **Epinephrine** (adrenaline) is a key **catecholamine** released during surgical stress, leading to a "fight or flight" response. - It increases **heart rate**, **blood pressure**, and promotes **gluconeogenesis** to supply quick energy. *ACTH* - **Adrenocorticotropic hormone (ACTH)** is released from the **pituitary gland** in response to surgical stress. - **ACTH** stimulates the adrenal cortex to produce **cortisol**, a critical stress hormone. *Cortisol* - **Cortisol** levels significantly rise during surgical stress, mediated by **ACTH** release. - It plays a crucial role in **modulating inflammation**, **glucose metabolism**, and maintaining **hemodynamic stability**.

Question 7: Following complete ileal and partial jejunal resection, the patient is most likely to have-

A. Constipation
B. Gastric ulcer
C. Folic acid deficiency
D. Vitamin B12 Deficiency (Correct Answer)

Explanation: ***Vitamin B12 Deficiency*** - The **terminal ileum** is the primary site for **vitamin B12 absorption**, complexed with intrinsic factor [3]. Resection of this segment significantly impairs this process. - Patients with **ileal resection** are highly susceptible to developing **megaloblastic anemia** and neurological complications due to **vitamin B12 deficiency** [3]. *Constipation* - Complete ileal and partial jejunal resection is **more likely to cause diarrhea** rather than constipation, particularly due to malabsorption of bile salts and fats [2]. - **Bile salt malabsorption** in the colon often leads to secretory diarrhea [1]. *Gastric ulcer* - Gastric ulcers are typically associated with *Helicobacter pylori* infection or NSAID use, and are **not a direct consequence** of ileal and jejunal resection. - While short bowel syndrome can sometimes lead to increased gastric acid secretion, peptic ulcer formation is not the most likely or direct complication. *Folic acid deficiency* - **Folic acid** is primarily absorbed in the **jejunum**, and while partial jejunal resection occurred, complete ileal resection is less directly implicated in folate deficiency. - Other sections of the small intestine can often compensate for partial jejunal loss in folate absorption, making B12 deficiency a more immediate and severe concern after complete ileal resection.

Question 8: Which Benzodiazepine decreases post-operative nausea & vomiting:-

A. Midazolam (Correct Answer)
B. Diazepam
C. Lorazepam
D. All of the options

Explanation: ***Midazolam*** - **Midazolam** is a commonly used benzodiazepine in anesthesia that has been shown to have **antiemetic properties** and can decrease the incidence of **postoperative nausea and vomiting (PONV)**. - Its mechanism may involve its sedative and anxiolytic effects, indirectly reducing the triggers for nausea. *Diazepam* - While **diazepam** is a benzodiazepine with sedative and anxiolytic effects, it is not primarily known for reducing PONV. - Its longer duration of action compared to midazolam can also contribute to unwanted **postoperative sedation**. *Lorazepam* - **Lorazepam** is another benzodiazepine used for anxiolysis and sedation but is not a primary agent for the prevention of PONV. - Like diazepam, its prolonged effects can lead to **delayed recovery** and drowsiness, which may not be desirable in the postoperative period. *All of the options* - While all listed drugs are benzodiazepines, only **midazolam** is consistently recognized and utilized for its ability to reduce PONV in the perioperative setting. - The other benzodiazepines do not demonstrate the same consistent benefit in PONV reduction and may have other side effects that limit their utility for this specific purpose.

Question 9: A meta-analysis comparing ERAS versus traditional perioperative care shows 30% reduction in length of stay and 50% reduction in complications without increase in readmission rates. However, implementation costs are 20% higher initially. As a department head, how should you evaluate the adoption of ERAS protocol?

A. Reject ERAS due to higher initial costs affecting hospital budget
B. Wait for more evidence before implementation
C. Adopt ERAS based on superior clinical outcomes and likely long-term cost savings from reduced complications (Correct Answer)
D. Implement ERAS only for low-risk patients to minimize costs

Explanation: ***Adopt ERAS based on superior clinical outcomes and likely long-term cost savings from reduced complications*** - Significant reductions in **length of stay (30%)** and **complications (50%)** provide strong evidence for the clinical superiority of **ERAS protocols** over traditional care. - The initial 20% cost increase is often offset by **long-term savings** gained from fewer hospital days and reduced management of postoperative complications. *Reject ERAS due to higher initial costs affecting hospital budget* - Focusing solely on **upfront costs** ignores the substantial economic benefit derived from **resource optimization** and beds being freed faster. - High-value healthcare prioritizes **outcomes per dollar spent**, and ERAS typically demonstrates a high **return on investment**. *Wait for more evidence before implementation* - Current **meta-analysis data** already provides high-level evidence regarding its efficacy in improving **surgical recovery**. - Delaying implementation based on sufficient existing evidence prevents patients from accessing safer, **evidence-based clinical pathways**. *Implement ERAS only for low-risk patients to minimize costs* - **ERAS protocols** are designed to be multi-modal and often provide the greatest absolute benefit to **high-risk patients** who are prone to complications. - Restricting the protocol limits the overall **scale of improvement** in hospital-wide metrics like **readmission rates** and total surgical volume.

Question 10: A hospital is designing an ERAS protocol for gynecological oncology surgery. Literature shows conflicting evidence about routine nasogastric tube (NGT) placement versus no NGT. Considering ERAS principles and risk-benefit analysis, which approach would be most appropriate and why?

A. Selective NGT placement only for symptomatic patients with postoperative nausea/vomiting (Correct Answer)
B. Routine NGT placement as it prevents aspiration and monitors gastric output
C. No NGT placement but prophylactic antiemetics to all patients
D. NGT placement in all cases but removal within 6 hours postoperatively

Explanation: ***Selective NGT placement only for symptomatic patients with postoperative nausea/vomiting*** - **ERAS protocols** advocate against routine nasogastric decompression as it does not reduce the risk of **postoperative ileus** or **anastomotic leakage**. - Reserving **NGT placement** for patients who develop clinical symptoms like persistent vomiting or **gastric distension** minimizes risks and improves patient comfort. *Routine NGT placement as it prevents aspiration and monitors gastric output* - Studies show that routine usage actually increases **pulmonary complications** such as **pneumonia** and atelectasis due to interference with coughing. - It delays the return of **bowel function** and prolongs the time until a patient can tolerate an **oral diet**. *No NGT placement but prophylactic antiemetics to all patients* - While **prophylactic antiemetics** are a standard part of ERAS, this option incorrectly implies an absolute prohibition of NGT even when symptoms occur. - Clinical guidelines require the flexibility to use an **NGT as a rescue therapy** for patients with severe, refractory **gastric distension**. *NGT placement in all cases but removal within 6 hours postoperatively* - Even short-term placement can cause unnecessary **pharyngeal trauma** and severe **patient discomfort** during the immediate recovery phase. - Starting with an NGT in every patient contradicts the **evidence-based medicine** that suggests most oncology patients do not require decompression at all.

Want unlimited practice?

Get full access to all questions, explanations, and performance tracking.

Start For Free