Adjustable Gastric Banding — MCQs
A young girl hospitalised with anorexia nervosa is on treatment. Even after taking adequate food according to the recommended diet plan for last 1 week, there is no gain in weight. What is the next step in management:
All of the following are primarily restrictive operations for morbid obesity, except which of the following?
All of the following are potential complications of untreated GERD, EXCEPT which of the following?
Which of the following is a common consequence of gastrectomy?
Which of the following surgeries is contraindicated below 12 years of age?
A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?
Postmortem examination of the stomach is done after:
Dumping syndrome can occur after
What is true about carcinoma of the esophagus?
In patients with osteoarthritis of the knee joint, atrophy occurs most commonly in which muscle?
Adjustable Gastric Banding Indian Medical PG Practice Questions and MCQs
Question 1: A young girl hospitalised with anorexia nervosa is on treatment. Even after taking adequate food according to the recommended diet plan for last 1 week, there is no gain in weight. What is the next step in management:
- A. Increase the caloric intake from 1500 kcal to 2000 kcal per day
- B. Increase fluid intake
- C. Increase the dose of anxiolytics
- D. Observe patient for 2 hours after meal (Correct Answer)
Explanation: ***Observe patient for 2 hours after meal*** - Patients with **anorexia nervosa** often engage in compensatory behaviors like **purging** or extensive exercise, which would counteract the effects of increased caloric intake and lead to a lack of weight gain despite consuming an "adequate" diet. - Observing the patient post-meal helps identify these behaviors and ensures that the ingested calories are actually being retained and utilized for weight restoration. *Increase the caloric intake from 1500 kcal to 2000 kcal per day* - Increasing caloric intake is a valid long-term strategy but is not the immediate next step when there's **no weight gain despite adequate intake**; the primary concern is identifying *why* the initial intake isn't leading to weight gain. - Doing so without addressing potential compensatory behaviors might only increase patient distress or lead to more intense purging/exercise. *Increase fluid intake* - While adequate **hydration** is important, it does not directly address the issue of **lack of weight gain** in anorexia nervosa, which is fundamentally a caloric deficit problem. - Increased fluid intake would not provide the necessary calories for weight restoration. *Increase the dose of anxiolytics* - Anxiolytics may help manage **anxiety** related to eating, but they do not directly promote **weight gain** or prevent compensatory behaviors. - This step does not address the core issue of why the recommended diet is not leading to weight gain.
Question 2: All of the following are primarily restrictive operations for morbid obesity, except which of the following?
- A. Laparoscopic adjustable gastric banding
- B. Roux-en-Y operation (Correct Answer)
- C. Vertical band gastroplasty
- D. Duodenal switch operation
Explanation: **Roux-en-Y operation** - The **Roux-en-Y gastric bypass** is considered a **malabsorptive as well as a restrictive procedure** because it creates a small gastric pouch and bypasses a significant portion of the small intestine. - This dual mechanism leads to greater weight loss compared to purely restrictive surgeries. *Vertical band gastroplasty* - **Vertical band gastroplasty** is a **purely restrictive procedure** that creates a small pouch and restricts outflow, but does not involve nutrient malabsorption. - It is less commonly performed now due to higher rates of weight regain and complications compared to other bariatric surgeries. *Laparoscopic adjustable gastric banding* - **Laparoscopic adjustable gastric banding** is a **purely restrictive procedure** where an inflatable band is placed around the upper part of the stomach to create a small pouch. - This limits the amount of food that can be consumed at one time and slows gastric emptying, but does not alter nutrient absorption. *Switch duodenal operation* - The **duodenal switch operation** (biliopancreatic diversion with duodenal switch) is primarily a **malabsorptive procedure** with a restrictive component. - While it includes creation of a small gastric pouch, its most significant effect on weight loss comes from bypassing a large portion of the small intestine, leading to **significant malabsorption**.
Question 3: All of the following are potential complications of untreated GERD, EXCEPT which of the following?
- A. Esophageal adenocarcinoma
- B. Esophageal stricture
- C. Barrett's esophagus
- D. Esophageal varices (Correct Answer)
Explanation: ***Esophageal varices*** - **Esophageal varices** are dilated veins in the lower esophagus, almost exclusively caused by **portal hypertension** from conditions like cirrhosis. - They are not a direct complication of **gastroesophageal reflux disease (GERD)**; GERD deals with acid reflux, not increased portal venous pressure. *Esophageal adenocarcinoma* - **Esophageal adenocarcinoma** can develop from **Barrett's esophagus**, which is a metaplastic change in the esophageal lining caused by chronic acid exposure from GERD [1]. - Therefore, untreated GERD can progress through Barrett's esophagus to develop into this type of cancer [1]. *Esophageal stricture* - Chronic inflammation and injury from untreated GERD can lead to **fibrosis** and subsequent narrowing of the esophagus, known as an **esophageal stricture** [1]. - This stricture can cause difficulty swallowing and food impaction. *Barrett's esophagus* - **Barrett's esophagus** is a precancerous condition where the normal squamous epithelium of the esophagus is replaced by columnar epithelium due to chronic acid reflux from GERD [1]. - It is a significant risk factor for esophageal adenocarcinoma and directly results from long-standing GERD [1].
Question 4: Which of the following is a common consequence of gastrectomy?
- A. Calcium deficiency
- B. Iron deficiency (Correct Answer)
- C. Steatorrhoea
- D. Fluid loss
Explanation: ***Iron deficiency*** - Gastrectomy often leads to **achlorhydria** or hypochlorhydria, reducing the conversion of **ferric iron** (Fe3+) to its more absorbable ferrous form (Fe2+). - Additionally, bypassing the duodenum, a primary site of iron absorption, further contributes to **iron malabsorption**. *Calcium deficiency* - While gastrectomy can contribute to calcium malabsorption due to reduced gastric acidity and faster transit, **iron deficiency** is typically a more direct and common initial consequence. - **Vitamin D deficiency**, often co-occurring with gastrectomy, is a more direct cause of **calcium malabsorption**. *Steatorrhoea* - **Steatorrhoea** (fat malabsorption) is more commonly associated with conditions affecting the **pancreas** or **small intestine** (e.g., celiac disease, chronic pancreatitis) rather than primarily gastrectomy unless there is significant bile salt malabsorption or rapid gastric emptying affecting nutrient mixing. - Although rapid transit post-gastrectomy can sometimes impair fat digestion, it's not the most common direct consequence compared to iron deficiency. *Fluid loss* - **Fluid loss** is usually an acute post-surgical complication or related to conditions causing vomiting or diarrhea, and not a common long-term consequence of gastrectomy itself. - While **dumping syndrome** can occur after gastrectomy, causing osmotic fluid shifts into the intestine, generalized chronic fluid loss is not a primary recognized long-term sequela.
Question 5: Which of the following surgeries is contraindicated below 12 years of age?
- A. SMR (Correct Answer)
- B. Rhinoplasty
- C. Septoplasty
- D. Antral puncture
Explanation: ***SMR (Submucous Resection of the septum)*** - SMR procedure involves removing a significant portion of the **septal cartilage and bone**, which is crucial for nasal growth. - Performing SMR before 12 years of age can lead to severe **facial growth disturbances**, such as a saddle nose deformity, due to interference with the septal growth plate. *Rhinoplasty* - While rhinoplasty is generally delayed until nasal growth is complete (around 15-16 years old for girls, 16-17 for boys), it is not absolutely contraindicated structurally before 12 in the same way SMR is. - The concern is primarily about final aesthetic outcome and patient maturity, not direct damage to major growth centers. *Septoplasty* - **Septoplasty** can be performed in younger children for severe nasal obstruction, especially if it significantly impacts breathing or sleep. - It involves reshaping or repositioning the **septal cartilage and bone** with minimal removal, preserving growth potential. *Antral puncture* - **Antral puncture** (or antral lavage) is a procedure to drain the maxillary sinus and can be performed at any age when indicated for sinusitis. - It does not interfere with facial growth as it targets the sinus cavity walls and does not involve the nasal septum.
Question 6: A 55-year-old male, known smoker, complains of calf pain while walking. He experiences calf pain while walking but can continue walking with effort. Which grade of claudication does this patient fall under?
- A. Grade I (Mild claudication)
- B. Grade II (Moderate claudication) (Correct Answer)
- C. Grade III (Severe claudication)
- D. Grade IV (Ischemic rest pain)
Explanation: ***Grade II (Moderate claudication)*** - **Grade II claudication** is characterized by **intermittent claudication** where the patient experiences pain while walking but can **continue walking with effort**. - This level of claudication reflects a moderate degree of peripheral arterial disease, where blood flow is sufficiently compromised to cause pain with exertion but not severe enough to force immediate cessation of activity. - The patient in this scenario can continue ambulation despite discomfort, which is the defining feature of this grade. *Grade I (Mild claudication)* - **Grade I claudication** involves discomfort or pain that the patient can **tolerate without significantly altering their gait or pace**. - In this stage, the pain is minimal, and the patient may perceive it as a dull ache or mild fatigue rather than true pain. - Walking can continue without significant effort or limitation. *Grade III (Severe claudication)* - **Grade III claudication** is marked by pain that is **severe enough to stop the patient from walking within a short distance** (typically less than 200 meters). - The pain forces the patient to rest and recover before they can resume walking. - This represents significant functional limitation in daily activities. *Grade IV (Ischemic rest pain)* - **Grade IV**, also known as **critical limb ischemia**, involves **pain even at rest**, especially in the feet or toes, often worsening at night when the limb is elevated. - This stage indicates severe arterial obstruction and is frequently associated with **ulcers, non-healing wounds, or gangrene**. - This represents advanced peripheral arterial disease requiring urgent intervention. **Note:** This grading system is a simplified clinical classification. The standard medical classifications for peripheral arterial disease are the **Fontaine classification** (Stages I-IV) and **Rutherford classification** (Categories 0-6).
Question 7: Postmortem examination of the stomach is done after:
- A. Double ligation (Correct Answer)
- B. Triple ligation
- C. Single ligation
- D. Cut open
Explanation: ***Double ligation*** - **Double ligation** of the esophagus minimizes spillage of stomach contents during organ removal and dissection, preserving the integrity of the collected sample. - This technique helps prevent contamination of other organs and the examination area, which is crucial for accurate **postmortem analysis**. *Triple ligation* - While technically more secure, **triple ligation** is generally not considered necessary for routine postmortem stomach removal due to the practicality of the procedure. - The added effort and time for a third ligature provide minimal additional benefit beyond **double ligation** in preventing spillage. *Single ligation* - **Single ligation** of the esophagus is insufficient and carries a high risk of stomach content spillage during organ manipulation. - This method is inadequate for ensuring the **integrity of the gastric sample** and preventing contamination of other organs. *Cut open* - Simply **cutting open** the stomach or esophagus prior to removal and proper isolation would lead to immediate and extensive spillage of stomach contents. - This approach would severely compromise the postmortem examination by contaminating other organs and making it difficult to assess the **gastric contents accurately**.
Question 8: Dumping syndrome can occur after
- A. Whipple's operation
- B. Nissen fundoplication
- C. Heller's operation
- D. Billroth-II operation (Correct Answer)
Explanation: ***Billroth-II operation*** - This procedure involves a **gastrojejunostomy** where the stomach is connected directly to the jejunum, bypassing the duodenum. This design allows for rapid emptying of gastric contents into the small intestine. - The rapid transit of **hyperosmolar chyme** into the small bowel draws fluid into the lumen, leading to symptoms like abdominal pain, bloating, diarrhea, and vasomotor symptoms (e.g., palpitations, sweating) [1]. *Whipple's operation* - While it involves extensive gastrointestinal reconstruction, a **Whipple's operation** (pancreaticoduodenectomy) typically includes a gastrojejunostomy that is less prone to severe dumping than a Billroth II, as it often preserves a significant portion of the duodenum or creates a more controlled gastric outflow. - The primary aim of a Whipple is to resect the head of the pancreas, duodenum, gallbladder, and bile duct, with subsequent reconstruction involving multiple anastomoses, but usually not one specifically designed to rapidly empty into the jejunum without duodenal transit. *Nissen fundoplication* - This procedure is performed to treat **gastroesophageal reflux disease (GERD)** by wrapping the top of the stomach (fundus) around the lower esophagus to strengthen the lower esophageal sphincter. - It aims to prevent reflux, not to alter the rate of gastric emptying in a way that typically causes dumping syndrome. *Heller's operation* - **Heller's myotomy** is a surgical procedure to treat **achalasia**, a disorder where the lower esophageal sphincter fails to relax properly. It involves cutting the muscle fibers of the lower esophageal sphincter to facilitate the passage of food into the stomach. - This operation addresses a motility issue of the esophagus and generally does not affect gastric emptying in a manner that leads to dumping syndrome.
Question 9: What is true about carcinoma of the esophagus?
- A. The most common site is the lower end.
- B. Both adenocarcinoma and squamous cell carcinoma occur. (Correct Answer)
- C. The commonest histology is adenocarcinoma.
- D. It is more common in females.
Explanation: **Explanation:** Carcinoma of the esophagus is a significant topic in surgical oncology. The correct answer is **Option B** because esophageal cancer primarily manifests in two distinct histological types: **Squamous Cell Carcinoma (SCC)** and **Adenocarcinoma (EAC)**. While their risk factors and primary locations differ, both are recognized as the major pathological variants of the disease. **Analysis of Options:** * **Option A & C:** Historically, SCC was the most common type globally and typically occurred in the **middle third** of the esophagus. However, in Western countries, the incidence of Adenocarcinoma (usually involving the **lower third**) is rising due to GERD and Barrett’s esophagus. Globally, SCC remains more prevalent, making "Adenocarcinoma" or "Lower end" incorrect as absolute "most common" statements without geographic context. * **Option D:** Esophageal cancer shows a strong **male predominance** (often 3:1 or higher), largely due to higher rates of smoking and alcohol consumption (for SCC) and central obesity/GERD (for EAC) in men. **High-Yield Clinical Pearls for NEET-PG:** * **Most common type (Worldwide/India):** Squamous Cell Carcinoma. * **Most common type (Western world):** Adenocarcinoma. * **Risk Factors:** SCC is associated with smoking, alcohol, and achalasia cardia; EAC is strongly linked to **Barrett’s Esophagus** (metaplasia). * **Investigation of Choice:** Upper GI Endoscopy with biopsy. * **Staging:** Contrast-enhanced CT (CECT) for distant spread; **Endoscopic Ultrasound (EUS)** is the most accurate for T and N staging. * **Lymphatic Spread:** The esophagus lacks a serosa, leading to early mediastinal spread.
Question 10: In patients with osteoarthritis of the knee joint, atrophy occurs most commonly in which muscle?
- A. Quadriceps only (Correct Answer)
- B. Hamstrings only
- C. Both quadriceps and hamstrings
- D. Gastrocnemius
Explanation: In patients with osteoarthritis (OA) of the knee, muscle atrophy is a hallmark clinical finding, and the **Quadriceps femoris** is the most commonly and severely affected muscle group. ### Why Quadriceps only is the correct answer: The primary mechanism is **Arthrogenic Muscle Inhibition (AMI)**. Pain, swelling, and joint laxity associated with OA trigger a presynaptic inhibition of the alpha-motoneurons supplying the quadriceps. This prevents the muscle from being fully activated, leading to disuse atrophy. The quadriceps (specifically the *Vastus Medialis Obliquus*) is highly sensitive to joint effusion; even a small amount of intra-articular fluid can inhibit its contraction. This creates a vicious cycle: weak quadriceps fail to absorb shock during gait, leading to increased joint loading and accelerated cartilage degeneration. ### Why other options are incorrect: * **Hamstrings only:** While hamstrings may show some weakness due to overall decreased activity, they do not undergo the same level of reflex inhibition as the extensors. In fact, hamstrings often become relatively "overactive" to stabilize the joint, which can lead to flexion contractures. * **Both quadriceps and hamstrings:** Although generalized limb wasting can occur in advanced stages, the atrophy is significantly disproportionate. The quadriceps waste earlier and more profoundly than the hamstrings. * **Gastrocnemius:** This muscle is primarily involved in ankle plantarflexion. While it crosses the knee joint, it is not the primary stabilizer affected by the neuro-mechanical changes of knee OA. ### High-Yield Clinical Pearls for NEET-PG: * **Vastus Medialis Obliquus (VMO):** This is the first component of the quadriceps to show visible wasting in knee pathologies. * **Quadriceps Lag:** A clinical sign where the patient can passively straighten the knee but cannot maintain active extension, often due to quadriceps weakness/atrophy. * **Management:** Strengthening the quadriceps is the most effective non-pharmacological intervention to reduce pain and improve function in knee OA.
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