Under what guidelines is treatment started for a patient presenting with appendicular mass on a CT scan?
A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -
What is the appropriate management for a patient with a carcinoid tumor of the appendix larger than 2 cm?
What is the primary indication for the Nigro Regimen?
A 35 year old male came with jaundice, palpable mass in the right hypochondrium not associated with pain. The probable diagnosis is -
A 60-year-old male presented with jaundice, pale stools, dark urine, and a mass in the epigastric region. Which of the following diagnoses is least likely to be the cause of these symptoms?
A 65 year old male presents with CA prostate. The tumour is limited to the capsule and it is palpable on PR examination. The patient is diagnosed as stage T2a. What is the most appropriate treatment option?
Which of the following stoma is formed in Hartmann's procedure?
Most common site of colorectal carcinoma?
Which of the following characteristics is most accurate about Boerhaave syndrome?
NEET-PG 2015 - Surgery NEET-PG Practice Questions and MCQs
Question 21: Under what guidelines is treatment started for a patient presenting with appendicular mass on a CT scan?
- A. Ochsner Sherren Regimen (Correct Answer)
- B. Conservative management and discharge
- C. Kocher's Regimen
- D. Immediate Laparotomy
Explanation: ***Ochsner Sherren Regimen*** - The **Ochsner Sherren regimen** is a conservative management approach specifically used for patients presenting with an **appendicular mass** (a palpable mass formed by the inflamed appendix, omentum, and small bowel loops). - This regimen involves **nil by mouth**, **intravenous fluids**, **antibiotics**, and **analgesia**, with close observation to allow the inflammation to subside before potential interval appendectomy. *Conservative management and discharge* - While the Ochsner Sherren regimen is a form of conservative management, simply stating "conservative management and discharge" is incomplete and potentially dangerous for a patient with an **appendicular mass**. - **Discharge** is not appropriate without a period of observation and specific medical interventions like antibiotics, as there's a risk of abscess formation or perforation. *Kocher's Regimen* - **Kocher's regimen** is not a recognized treatment protocol for an appendicular mass. - The term "Kocher" is more commonly associated with a **surgical incision** (Kocher incision for cholecystectomy) or a **maneuver** (Kocher maneuver for duodenal mobilization). *Immediate Laparotomy* - **Immediate laparotomy** is generally contraindicated in the presence of a well-formed **appendicular mass**. - Operating on a friable, inflamed mass can disrupt the natural containment, leading to widespread peritonitis and increased morbidity. The Ochsner Sherren regimen aims to cool down the inflammation first.
Question 22: A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -
- A. Proceed to laparotomy and appendicectomy (Correct Answer)
- B. Intravenous antibiotics
- C. Continue Ochsner Sherren regimen with close monitoring
- D. Continue conservative management
Explanation: ***Proceed to laparotomy and appendicectomy*** - A **rising pulse rate, tachycardia, and fever** indicate **worsening sepsis** or **perforation** of the appendicular mass, necessitating urgent surgical intervention. - Continuing conservative management in the face of these signs carries a high risk of **morbidity and mortality** from peritonitis or widespread sepsis. *Continue Ochsner Sherren regimen with close monitoring* - The Ochsner Sherren regimen is a **conservative approach** for a stable appendicular mass, which is no longer the case with signs of deterioration. - **Clinical worsening** (tachycardia, rising fever, increased pulse) signifies failure of conservative management and requires a shift to surgical intervention. *Continue conservative management* - Continuing conservative management despite **signs of deterioration** (rising pulse, tachycardia, fever) would lead to further progression of the disease and potential life-threatening complications. - These symptoms suggest that the infection is **not contained** and is likely spreading, indicating the need for immediate surgical treatment. *Intravenous antibiotics* - While intravenous antibiotics are part of the initial conservative management, they are **insufficient** alone for an appendicular mass showing signs of deterioration. - The worsening clinical picture suggests a **failed antibiotic response** or a more severe underlying issue (e.g., abscess rupture) that requires surgical drainage or removal.
Question 23: What is the appropriate management for a patient with a carcinoid tumor of the appendix larger than 2 cm?
- A. Right hemicolectomy (Correct Answer)
- B. Appendicectomy
- C. Appendicectomy + abdominal CT scan
- D. Appendicectomy + 24 hrs urinary HIAA
Explanation: ***Right hemicolectomy*** - Carcinoid tumors of the appendix larger than **2 cm** are considered at high risk for **lymph node metastasis** and recurrence. - A **right hemicolectomy** provides adequate margins and allows for lymph node dissection, which is essential for staging and definitive treatment in such cases. *Appendicectomy* - An **appendicectomy** alone is typically sufficient for carcinoid tumors of the appendix that are **less than 1 cm** and localized to the tip. - For larger tumors, appendicectomy carries an unacceptably high risk of **incomplete resection** and metastatic disease. *Appendicectomy + abdominal CT scan* - While an **abdominal CT scan** is useful for assessing local spread and distant metastases, it does not address the need for a more extensive surgical resection for a **large primary tumor**. - A simple **appendicectomy** in this scenario would be inadequate as definitive treatment. *Appendicectomy + 24 hrs urinary HIAA* - **24-hour urinary 5-hydroxyindoleacetic acid (5-HIAA)** is a biomarker used to detect and monitor **carcinoid syndrome**, which occurs in a minority of patients with carcinoid tumors. - Measuring 5-HIAA is primarily for assessing systemic symptoms rather than determining the primary surgical management of the **tumor size**.
Question 24: What is the primary indication for the Nigro Regimen?
- A. Anal Carcinoma (Correct Answer)
- B. Rectal Carcinoma
- C. Sigmoid Colon Carcinoma
- D. Duodenal Carcinoma
Explanation: ***Anal Carcinoma*** - The **Nigro Regimen** is a standard treatment protocol involving concurrent **chemotherapy** (5-fluorouracil and mitomycin C) and **radiation therapy** for anal carcinoma. - Its primary goal is to achieve **organ preservation** and avoid the need for abdominoperineal resection, which would result in a permanent colostomy. *Rectal Carcinoma* - Treatment for **rectal carcinoma** often involves surgery (e.g., low anterior resection), radiation, and chemotherapy, but the specific **Nigro Regimen** is not the primary protocol. - While some chemotherapy drugs might overlap, the combined regimen and indications are distinct. *Sigmoid Colon Carcinoma* - **Sigmoid colon carcinoma** is typically treated primarily with **surgical resection**, often followed by adjuvant chemotherapy based on staging. - The Nigro Regimen is specifically designed for tumors in the **anal canal**, not the more proximal colon. *Duodenal Carcinoma* - **Duodenal carcinoma** is a rare gastrointestinal cancer usually managed with surgical resection, such as a **Whipple procedure**, and sometimes adjuvant chemotherapy. - This type of cancer is anatomically and etiologically distinct from anal carcinoma, making the Nigro Regimen irrelevant.
Question 25: A 35 year old male came with jaundice, palpable mass in the right hypochondrium not associated with pain. The probable diagnosis is -
- A. Hepatocellular carcinoma
- B. Choledochal cyst
- C. Acute cholecystitis
- D. Pancreatic head carcinoma (Correct Answer)
Explanation: ***Pancreatic head carcinoma*** - **Pancreatic head carcinoma** classically presents with **painless progressive jaundice**, which is the hallmark feature of malignant biliary obstruction. - The **palpable mass in the right hypochondrium** represents a **palpable, non-tender gallbladder** known as **Courvoisier's sign** - indicating distal common bile duct obstruction with gallbladder distension. - **Courvoisier's law** states: "A palpable gallbladder in the presence of jaundice is unlikely to be due to stones and suggests malignant obstruction of the biliary tree." - The **absence of pain** is characteristic, as the obstruction develops gradually, unlike acute inflammatory conditions. *Hepatocellular carcinoma* - **Hepatocellular carcinoma (HCC)** can present with a palpable hepatic mass and hepatomegaly in the right hypochondrium. - However, jaundice in HCC is typically a **late feature** occurring with massive liver involvement, extensive hepatic replacement by tumor, or portal vein thrombosis - not early painless jaundice. - HCC more commonly presents with abdominal pain, weight loss, and symptoms of chronic liver disease rather than painless obstructive jaundice. *Acute cholecystitis* - **Acute cholecystitis** presents with severe **right upper quadrant pain** (Murphy's sign positive), fever, and leukocytosis. - The **absence of pain** in this patient makes acute cholecystitis very unlikely. - While a tender palpable gallbladder may be present, painless presentation is not characteristic. *Choledochal cyst* - **Choledochal cysts** can present with the classic triad of **jaundice, abdominal pain, and palpable mass**. - However, they are **more common in children and young females** (80% present before age 10). - The presentation usually includes **episodic abdominal pain** due to recurrent cholangitis or pancreatitis, making the painless presentation less typical. - In a 35-year-old male with painless jaundice, pancreatic malignancy is more likely.
Question 26: A 60-year-old male presented with jaundice, pale stools, dark urine, and a mass in the epigastric region. Which of the following diagnoses is least likely to be the cause of these symptoms?
- A. Biliary Cancer
- B. Periampullary Cancer
- C. Pancreatic Cancer
- D. Chronic Cholecystitis (Correct Answer)
Explanation: ***Chronic Cholecystitis*** - While chronic cholecystitis can cause epigastric pain, it rarely presents with **jaundice**, **pale stools**, and **dark urine** because it typically does not obstruct the common bile duct. - The presence of a palpable **epigastric mass** is also not a common feature of chronic cholecystitis. *Biliary Cancer* - **Biliary cancer**, particularly choledochal cancer, can cause **obstructive jaundice**, leading to **pale stools** (lack of bilirubin) and **dark urine** (conjugated bilirubin in urine). - A mass in the **epigastric region** could represent an enlarged gallbladder due to distal obstruction (Courvoisier's sign) or the tumor itself. *Periampullary Cancer* - **Periampullary cancers**, which arise near the ampulla of Vater, characteristically cause **obstructive jaundice**, presenting with **pale stools** and **dark urine**. - A mass in the **epigastric region** might be the tumor or a dilated gallbladder due to bile duct obstruction. *Pancreatic cancer* - **Pancreatic head cancer** frequently obstructs the common bile duct, resulting in **jaundice**, **pale stools**, and **dark urine**. - An **epigastric mass** can be the palpable tumor itself or an enlarged, distended gallbladder.
Question 27: A 65 year old male presents with CA prostate. The tumour is limited to the capsule and it is palpable on PR examination. The patient is diagnosed as stage T2a. What is the most appropriate treatment option?
- A. External beam radiation therapy
- B. Androgen deprivation therapy (ADT)
- C. Active surveillance
- D. Surgical removal of the prostate (Radical prostatectomy) (Correct Answer)
Explanation: ***Surgical removal of the prostate (Radical prostatectomy)*** - **Radical prostatectomy** is the **definitive treatment of choice** for **localized prostate cancer (T2a)** in patients with **good life expectancy (>10 years)**. - For a **65-year-old patient** with tumor confined to the prostate, **surgical removal offers excellent disease control** and potential cure. - This is the **preferred option** when the patient is **medically fit for surgery** and has adequate life expectancy. *External beam radiation therapy* - **External beam radiation therapy (EBRT)** is also an effective treatment for **localized T2a prostate cancer** with comparable long-term survival outcomes. - However, **radical prostatectomy is generally preferred** in younger, healthier patients as it: - Provides definitive pathological staging - Allows for immediate assessment of surgical margins - Preserves radiation as a salvage option if needed - EBRT is better suited for patients who are **not surgical candidates** due to comorbidities or patient preference. *Active surveillance* - **Active surveillance** is appropriate for **very low-risk prostate cancer** (T1c, PSA <10, Gleason ≤6). - For **T2a disease** (palpable tumor), the risk of progression is significant, making active surveillance **not the most appropriate first-line option**. - Would be considered only in patients with limited life expectancy or significant comorbidities. *Androgen deprivation therapy (ADT)* - **ADT** is used for **advanced, locally advanced, or metastatic prostate cancer** to reduce testosterone and slow tumor growth. - It is **not curative** and not appropriate as **monotherapy for localized T2a disease**. - May be used as adjuvant therapy with radiation in higher-risk cases, but not as primary treatment alone.
Question 28: Which of the following stoma is formed in Hartmann's procedure?
- A. End Colostomy (Correct Answer)
- B. End Ileostomy
- C. Loop Ileostomy
- D. Caecostomy
Explanation: ***End Colostomy*** - Hartmann's procedure involves resection of a diseased segment of the **colon**, typically the sigmoid colon, with the creation of a **proximal colostomy** and closure of the distal rectal stump. - The proximal end of the colon is brought out through the abdominal wall to form a **stoma**, which is a type of end colostomy. *End Ileostomy* - An end ileostomy involves bringing the **ileum** (small intestine) to the abdominal wall, which is not part of the standard Hartmann's procedure. - This is typically performed after a **total colectomy** or in cases of severe Crohn's disease affecting the colon. *Loop Ileostomy* - A loop ileostomy involves bringing a **loop of the ileum** to the surface of the abdomen, creating two openings that are then joined together. - This is often a **temporary diversion** and does not involve resection of the colon in the same manner as Hartmann's procedure. *Caecostomy* - A caecostomy is a stoma created from the **cecum**, the beginning of the large intestine. - This is typically performed for various reasons such as **bowel decompression** or management of fecal incontinence, and is not a component of Hartmann's procedure.
Question 29: Most common site of colorectal carcinoma?
- A. Ascending Colon
- B. Descending Colon
- C. Rectum
- D. Sigmoid Colon (Correct Answer)
Explanation: ***Sigmoid Colon*** - The **sigmoid colon** is the most common site for colorectal carcinoma, accounting for approximately **25%** of all cases. - This higher incidence is potentially due to its role in stool storage, leading to longer contact time with potential carcinogens. *Rectum* - While the rectum is a common site, it accounts for about **15-20%** of colorectal cancers, making it less frequent than the sigmoid colon. - Rectal cancers often present with **hematochezia** and changes in bowel habits. *Ascending Colon* - The **ascending colon** is less frequently affected, around **10-15%** of cases. - Tumors here are often associated with **iron deficiency anemia** due to chronic blood loss. *Descending Colon* - The **descending colon** is also less commonly affected, making up approximately **5-10%** of colorectal cancers. - Tumors in this segment may present with **obstruction** due to the narrower lumen.
Question 30: Which of the following characteristics is most accurate about Boerhaave syndrome?
- A. Most cases follow a bout of heavy eating or drinking
- B. Perforation of the esophagus due to barotrauma (Correct Answer)
- C. Sudden severe chest pain is an early manifestation
- D. Most common site is left posterolateral aspect 3 - 5 cms above the gastroesophageal junction
Explanation: ***Perforation of the esophagus due to barotrauma*** - **Boerhaave syndrome** is a spontaneous esophageal rupture caused by a sudden increase in **intraesophageal pressure** against a closed glottis, leading to barotrauma. - This typically occurs during forceful **vomiting** or **retching**, expelling gastric contents through the weakened esophageal wall. *Sudden severe chest pain is an early manifestation* - While **sudden, severe chest pain** is a hallmark symptom, it is a manifestation of the syndrome rather than its defining characteristic or cause. - The chest pain is a direct result of the esophageal tear and the leakage of gastric contents into the mediastinum, causing irritation and inflammation. *Most cases follow a bout of heavy eating or drinking* - **Heavy eating or drinking** (especially alcohol) can precipitate vomiting, which is the direct cause of the rupture, but it is not the syndrome's most accurate characteristic. - The actual mechanism is the severe increase in transesophageal pressure during forceful emesis, not simply the consumption itself. *Most common site is left posteromedial aspect 3 - 5 cms above the gastroesophageal junction* - This statement accurately pinpoints the **most common anatomical location** of the esophageal tear in Boerhaave syndrome due to the inherent weakness at this site. - However, it describes the **localization** of the injury rather than the fundamental characteristic of the syndrome, which is the perforation itself due to barotrauma.