UPSC-CMS 2009 Practice Questions

Q: To which lymph nodes, the lymph from the umbilicus drain?

Axillary and inguinal. ***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.

Q: The following are complications of gall stone except

Haemobilia. ***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].

Q: 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 ?

1 and 2 only. ***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.

Q: A 50 year old diabetic patient with asymptomatic gallstone (> 3 cm) will be best treated by

Early surgery. ***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 ( 3 cm) and carries risks of stone recurrence and fragmentation complications.

Q: Which of the following is not an indication for surgical intervention in acute pancreatitis?

Acute fluid collection. ***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.

Q: The most common intraperitoneal abscess following peritonitis is

Pelvic. ***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.

Question 1

To which lymph nodes, the lymph from the umbilicus drain?

Accepted Answer

Axillary and inguinal

Answer

External and internal iliac

Answer

Inter aortocaval

Answer

Pre and para-aortic

Question 2

The following are complications of gall stone except

Accepted Answer

Haemobilia

Answer

Acute pancreatitis

Answer

Cholangitis

Answer

Biliary enteric fistula

Question 3

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 ?

Accepted Answer

1 and 2 only

Answer

2 and 3 only

Answer

1, 2 and 3

Answer

1, 3 and 4

Question 4

Consider the following:

1. Cholesterolosis
2. Adenomyomatosis
3. Polyposis
4. Cholelithiasis

To which of the above does cholecystoses refer to?

Accepted Answer

1 and 2 only

Answer

1 and 3 only

Answer

1, 2 and 3

Answer

2, 3 and 4

Question 5

The following disorders are predisposing conditions for carcinoma of the colon except

Accepted Answer

Escherichia coli

Answer

Villous adenoma

Answer

Familial polyposis coli

Answer

Peutz-Jeghers syndrome

Question 6

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 ?

Accepted Answer

Localised collection of bile in peritoneal cavity

Answer

Duodenal injury

Answer

Acute Pancreatitis

Answer

Iatrogenic ligation of common bile duct

Question 7

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 ?

Accepted Answer

2, 1, 4, 3

Answer

3, 2, 1, 4

Answer

1, 4, 2, 3

Answer

4, 2, 1, 3

Question 8

A 50 year old diabetic patient with asymptomatic gallstone (> 3 cm) will be best treated by

Accepted Answer

Early surgery

Answer

Bile-salt treatment

Answer

Waiting till it becomes symptomatic

Answer

ESWL

Question 9

Which of the following is not an indication for surgical intervention in acute pancreatitis?

Accepted Answer

Acute fluid collection

Answer

Diagnostic dilemma

Answer

Pancreatic abscess

Answer

Infected pancreatic necrosis

Question 10

The most common intraperitoneal abscess following peritonitis is

Accepted Answer

Pelvic

Answer

Paracolic

Answer

Subphrenic

Answer

Interloop

UPSC-CMS 2009

Anatomy

Internal Medicine

Pathology

Surgery