UPSC-CMS 2017 Practice Questions

Q: In endoscopic retrograde cholangiopancreatography endoscope used is:

Side viewing. ***Side viewing*** - **Side-viewing endoscopes** are specifically designed for ERCP, allowing the endoscopist to visualize the **ampulla of Vater** en face for precise cannulation [1]. - The side-viewing optic facilitates the passage of accessories like **catheters, guidewires**, and **sphincterotomes** into the bile and pancreatic ducts [1]. *End viewing* - **End-viewing endoscopes** (like standard gastroscopes or colonoscopes) have the camera directly at the tip, providing a straight-ahead view. - This design makes cannulation of the **ampulla of Vater** challenging, as it would be viewed tangentially, not directly. *Front viewing* - This term is synonymous with **end-viewing** and describes the typical orientation of standard gastrointestinal endoscopes. - While suitable for examining the lumen of organs, it lacks the specialized optics needed for the complex angulation and cannulation required in **ERCP**. *Rigid* - **Rigid endoscopes** are generally used for procedures where flexibility is not required, such as laparoscopy or cystoscopy [2]. - They are unsuitable for **ERCP**, which requires a highly flexible instrument to navigate the esophagus, stomach, duodenum, and access the **ampulla of Vater**.

Q: Oliguria is defined as:

Less than 400 ml of urine excreted in a day. ***Less than 400 ml of urine excreted in a day*** - **Oliguria** is medically defined as a daily urine output that is **less than 400 ml** in adults. [1] - This level of urine production is often insufficient to effectively excrete metabolic waste products. [1] *600 ml to 700 ml of urine excreted in a day* - This range of urine output is generally considered within the **normal limits**, not oliguric. - Normal daily urine production for an adult typically ranges from **800 to 2000 ml**. *More than 900 ml of urine excreted in a day* - An output of **more than 900 ml** per day for an adult indicates normal urine production, well above the threshold for oliguria. - This level suggests adequate kidney function in terms of fluid excretion. *Absence of urine production* - The complete absence of urine production is known as **anuria**, which is a more severe condition than oliguria. [1] - Anuria is typically defined as **less than 50 ml of urine** per day. [1]

Q: Which of the following is NOT correct for ‘strawberry gall bladder’?

It is a malignant condition of gall bladder. ***It is a malignant condition of gall bladder*** - **Strawberry gallbladder**, also known as **cholesterolosis**, is a **benign** condition where cholesterol esters accumulate in the macrophages within the lamina propria of the gallbladder wall. - It is **not cancerous** and does not lead to malignancy. *It may be associated with cholesterol Stones* - **Cholesterolosis** is often associated with a higher incidence of **cholesterol gallstones (cholelithiasis)**, as both conditions involve abnormal cholesterol metabolism [1]. - The accumulation of cholesterol in the gallbladder wall can sometimes precede or coincide with the formation of cholesterol stones within the lumen [1]. *Simple cholecystectomy is the treatment of choice* - For symptomatic **cholesterolosis**, especially when associated with pain or recurrent biliary colic, **cholecystectomy** (surgical removal of the gallbladder) is the standard and effective treatment. - Asymptomatic cases generally do not require treatment. *It has submucous aggregation of cholesterol crystals* - The characteristic appearance of **"strawberry gallbladder"** is due to the macroscopic visualization of yellow, lipid-laden macrophages aggregated within the **lamina propria** (a layer beneath the mucous membrane), appearing as tiny yellow flecks against a red mucosal background. - These aggregates contain **cholesterol esters**, which can crystallize. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Liver and Gallbladder, p. 882.

Q: All the following are features of Polycystic disease of kidneys EXCEPT:

Erythrocytosis. ***Erythrocytosis*** - While other renal conditions like **renal cell carcinoma** can cause erythrocytosis due to increased **erythropoietin** production, it is generally **not a typical feature** of Polycystic Kidney Disease (PKD). - Patients with PKD usually have **normal or even low erythropoietin levels** despite compromised kidney function, and anemia is more common, particularly as **renal failure progresses**. *Renal failure* - **Progressive cyst growth** leads to replacement of normal kidney parenchyma, inevitably culminating in **end-stage renal disease** [1] in the majority of patients. - This is a hallmark feature, often necessitating **dialysis or transplant** later in life for individuals with autosomal dominant polycystic kidney disease (ADPKD) [2]. *Haematuria* - **Gross or microscopic hematuria** is a common symptom in PKD, often resulting from **cyst rupture** [1], bleeding into a cyst, or the passage of a calculus due to urinary stasis. - It can be a presenting symptom and can cause significant pain and anxiety for patients. *Hypertension* - **Hypertension** is an early and frequent complication of PKD, often preceding any significant decline in glomerular filtration rate. - It is primarily caused by activation of the **renin-angiotensin-aldosterone system (RAAS)** [3] due to arterial compression and ischemia from expanding cysts. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Kidney, pp. 951-955. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 544-545. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 520-521.

Q: Which one of the following is the most important selection criteria for obesity surgery?

BMI > 40. ***BMI > 40*** - A **Body Mass Index (BMI) greater than 40 kg/m²** is generally the primary and most significant criterion for considering obesity surgery. - This category of obesity, often referred to as **morbid obesity**, carries severe health risks that surgery is deemed necessary to mitigate. *BMI 35 without any co-morbid disease* - While a **BMI of 35 kg/m²** is considered severe obesity, standing alone without significant comorbidities, it is not typically the strongest indication for bariatric surgery. - Surgery is usually recommended for this group if there are also **obesity-related comorbidities** like diabetes or hypertension. *BMI 30 with co-morbid disease* - A **BMI of 30 kg/m²** falls into the category of obesity class I, and while comorbidities are present, bariatric surgery is generally not recommended at this stage. - Lifestyle interventions, medication, and non-surgical approaches are typically tried first for individuals with a BMI of 30, even with comorbidities. *BMI 30* - A **BMI of 30 kg/m²** without any mention of comorbidities is considered obesity class I. - This level is usually managed through lifestyle modifications, diet, exercise, and sometimes pharmacotherapy, rather than surgical intervention.

Q: A 45 year old underwent surgery for rectal prolapse. At present, he complains of sexual dysfunction which is probably due to the injury of:

Pelvic autonomic nerves. ***Pelvic autonomic nerves*** - Surgical procedures in the **pelvic region**, such as for rectal prolapse, carry a risk of damaging the **pelvic autonomic nerves**, which are crucial for sexual function. - Injury to these nerves can lead to various forms of **sexual dysfunction**, including erectile dysfunction in men, due to impaired nerve signaling to the genital organs. *Urinary bladder* - While the urinary bladder is anatomically close to the rectum, direct injury to the bladder itself during rectal prolapse surgery typically leads to **urinary symptoms** (e.g., incontinence, retention), not primarily sexual dysfunction. - Though bladder dysfunction can indirectly impact sexual activity, it's not the direct cause of primary sexual dysfunction following injury in this context. *Rectum* - The surgery is performed on the rectum, and while complications can occur, direct injury to the rectal wall itself primarily results in issues such as **fecal incontinence, bleeding, or infection**. - The rectum's primary role is in digestion and defecation, and its injury does not directly cause sexual dysfunction unrelated to nerve damage. *Inferior mesenteric artery* - The **inferior mesenteric artery (IMA)** supplies blood to the distal colon and rectum, and its injury during surgery would primarily lead to **ischemia or necrosis** of the supplied bowel segments. - While a severely compromised blood supply could have systemic effects, direct injury to the IMA is not a direct or common cause of sexual dysfunction.

Q: A 40 year old man, with a history of a reducible left groin swelling of two years, comes with severe pain over left groin. The swelling is now non-reducible and is very tender to touch. The most probable treatment plan for this patient would be:

Prepare for emergency surgery. ***Prepare for emergency surgery*** - The sudden onset of **severe pain**, non-reducibility, and tenderness in a pre-existing reducible groin swelling strongly suggests **incarceration** or **strangulation** of a hernia. - **Strangulation** is a surgical emergency due to the risk of **ischemic bowel injury**, requiring immediate surgical intervention. *Hot fomentation of groin area* - This offers no therapeutic benefit for an incarcerated or strangulated hernia and may delay necessary surgical intervention, leading to **worse patient outcomes**. - It would be inappropriate for a condition that poses a risk of **bowel necrosis**. *Oral antibiotics* - While infection could be a secondary complication of bowel necrosis, antibiotics alone will not resolve the mechanical obstruction or relieve the **ischemia**. - They do not address the primary problem of **hernia incarceration** or strangulation. *Continue conservative management* - Conservative management is suitable for **reducible hernias** that are asymptomatic or mildly symptomatic, but not for acute, painful, and non-reducible hernias. - Continuing conservative management in this setting would lead to **bowel strangulation** and potential **peritonitis** or sepsis.

Q: During laparoscopic inguinal hernia repair, in the ‘triangle of doom’, the following are true EXCEPT:

Cord structures on lateral side. ***Cord structures on lateral side*** - This statement is somewhat **ambiguous** and is considered the EXCEPT answer in this context. - The **spermatic cord** contains multiple structures, and different components form **both boundaries** of the triangle of doom: - The **vas deferens** (a cord structure) forms the **medial** boundary - The **gonadal vessels** (testicular artery and pampiniform plexus, also cord structures) form the **lateral** boundary - In the context of this question, "cord structures" likely refers to the **bulk of the cord or vas deferens**, which is positioned **medially**, making the lateral positioning statement incorrect as commonly taught. *Vas deferens on medial side* - The **vas deferens** forms the **medial border** of the triangle of doom. - This is a key anatomical landmark used to identify the triangle during laparoscopic inguinal hernia repair. *Base by iliac vessels* - The **external iliac artery and vein** form the **base (inferior border)** of the triangle of doom. - These are the most dangerous structures in this region—injury can lead to catastrophic hemorrhage. *Dangerous area for dissection* - The triangle of doom is aptly named because it contains **critical vascular structures** including the **external iliac vessels** and **deep circumflex iliac artery**. - **Aggressive dissection, stapling, or tack placement** in this area can cause life-threatening vascular injury or damage to the **femoral branch of the genitofemoral nerve**.

Q: All are rare types of lateral hernia of abdominal wall, EXCEPT:

Inferior lumbar. ***Inferior lumbar*** - While still considered rare, **inferior lumbar hernias** (also known as **Petit's hernias**) are relatively more common among the listed lateral hernias. - They occur through the **inferior lumbar triangle** (Petit's triangle), bounded by the latissimus dorsi, external oblique, and iliac crest. - Among lumbar hernias, inferior lumbar hernias comprise approximately **20-25%** of cases, making them less rare than superior lumbar hernias. *Spigelian* - **Spigelian hernias** are rare lateral hernias occurring through the **Spigelian aponeurosis** (fascia of transversus abdominis muscle lateral to the rectus abdominis). - Account for only **0.12-2%** of all abdominal wall hernias. - Often **interparietal** (between muscle layers), making clinical diagnosis difficult. *Obturator* - **Obturator hernias** are extremely rare, accounting for **0.05-0.4%** of all hernias. - Protrude through the **obturator canal** in the pelvis. - More common in elderly, emaciated women and often present as small bowel obstruction. - **Note:** Technically a pelvic hernia rather than an abdominal wall hernia, but included in rare lateral hernia classifications. *Superior lumbar* - **Superior lumbar hernias** (also known as **Grynfeltt-Lesshaft hernias**) are the rarest type, comprising only **1-2%** of all abdominal wall hernias. - Occur through the **superior lumbar triangle** (Grynfeltt's triangle), bounded by the 12th rib, erector spinae, and internal oblique. - More prone to incarceration than inferior lumbar hernias.

Q: A 35 year old female had laparoscopic ventral hernia repair using polypropylene mesh in January 2015. In June 2015, she is again admitted with features of subacute intestinal obstruction and is managed conservatively. She continues to have recurrent colicky pain after that. Most probably she is suffering from:

Bowel adhesion to mesh. ***Bowel adhesion to mesh*** - The patient's history of **laparoscopic ventral hernia repair** using polypropylene mesh, followed by recurrent colicky pain and a subacute intestinal obstruction, strongly suggests **adhesion formation involving the mesh and bowel**. - **Polypropylene mesh** is known to induce an inflammatory response, leading to scar tissue formation and potential adhesion to nearby organs, which can cause chronic pain and obstruction. *Recurrence of hernia* - While hernia recurrence is possible, the presentation primarily with **recurrent colicky pain** and a single episode of **subacute intestinal obstruction** is less characteristic of a simple recurrence, which often presents with a palpable bulge or more direct obstructive symptoms. - The conservative management of the obstruction episode further suggests a non-strangulated or irreducible recurrence, which would typically warrant surgical intervention if severely symptomatic. *New hernia* - A new hernia is unlikely given the history of a recent repair at a different site, unless specified. - The symptoms are more directly attributable to complications related to the previous surgery and the implanted mesh. *Acute appendicitis* - **Acute appendicitis** typically presents with right lower quadrant pain, fever, and leukocytosis, which are not described in the patient's symptoms of recurrent colicky pain and subacute obstruction. - The onset of symptoms months after a hernia repair, and their chronic, recurrent nature, makes acute appendicitis an improbable diagnosis.

Question 1

In endoscopic retrograde cholangiopancreatography endoscope used is:

Accepted Answer

Side viewing

Answer

End viewing

Answer

Front viewing

Answer

Rigid

Question 2

Oliguria is defined as:

Accepted Answer

Less than 400 ml of urine excreted in a day

Answer

600 ml to 700 ml of urine excreted in a day

Answer

More than 900 ml of urine excreted in a day

Answer

Absence of urine production

Question 3

Which of the following is NOT correct for ‘strawberry gall bladder’?

Accepted Answer

It is a malignant condition of gall bladder

Answer

It may be associated with cholesterol Stones

Answer

Simple cholecystectomy is the treatment of choice

Answer

It has submucous aggregation of cholesterol crystals

Question 4

All the following are features of Polycystic disease of kidneys EXCEPT:

Accepted Answer

Erythrocytosis

Answer

Renal failure

Answer

Haematuria

Answer

Hypertension

Question 5

Which one of the following is the most important selection criteria for obesity surgery?

Accepted Answer

BMI > 40

Answer

BMI 35 without any co-morbid disease

Answer

BMI 30 with co-morbid disease

Answer

BMI 30

Question 6

A 45 year old underwent surgery for rectal prolapse. At present, he complains of sexual dysfunction which is probably due to the injury of:

Accepted Answer

Pelvic autonomic nerves

Answer

Urinary bladder

Answer

Rectum

Answer

Inferior mesenteric artery

Question 7

A 40 year old man, with a history of a reducible left groin swelling of two years, comes with severe pain over left groin. The swelling is now non-reducible and is very tender to touch. The most probable treatment plan for this patient would be:

Accepted Answer

Prepare for emergency surgery

Answer

Hot fomentation of groin area

Answer

Oral antibiotics

Answer

Continue conservative management

Question 8

During laparoscopic inguinal hernia repair, in the ‘triangle of doom’, the following are true EXCEPT:

Accepted Answer

Cord structures on lateral side

Answer

Vas deferens on medial side

Answer

Base by iliac vessels

Answer

Dangerous area for dissection

Question 9

All are rare types of lateral hernia of abdominal wall, EXCEPT:

Accepted Answer

Inferior lumbar

Answer

Spigelian

Answer

Obturator

Answer

Superior lumbar

Question 10

A 35 year old female had laparoscopic ventral hernia repair using polypropylene mesh in January 2015. In June 2015, she is again admitted with features of subacute intestinal obstruction and is managed conservatively. She continues to have recurrent colicky pain after that. Most probably she is suffering from:

Accepted Answer

Bowel adhesion to mesh

Answer

Recurrence of hernia

Answer

New hernia

Answer

Acute appendicitis

UPSC-CMS 2017

Internal Medicine

Pathology

Surgery