Bariatric Surgery — MCQs
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A 43-year-old male presented with a submandibular region mass, diagnosed as acinic cell carcinoma after ultrasound and biopsy. Following staging and attempted excision, the patient noticed deviation of his tongue to the affected side post-surgery. Which of the following nerves is most likely to have been damaged?
Tietz syndrome is:
Endoscopic ultrasound is extremely useful in staging which tumor?
A hernia where the sac contains only a portion of the circumference of the intestine is called:
What is the most common cause of a cold abscess of the chest wall?
Which of the following are bariatric surgical procedures?
All of the following are true about Bariatric surgery except:
What is the epithelial lining of the glottis/ true vocal cords?
Which of the following is NOT seen in neurofibromatosis?
Which of the following is NOT true about gynecomastia?
Bariatric Surgery Indian Medical PG Practice Questions and MCQs
Question 41: A 43-year-old male presented with a submandibular region mass, diagnosed as acinic cell carcinoma after ultrasound and biopsy. Following staging and attempted excision, the patient noticed deviation of his tongue to the affected side post-surgery. Which of the following nerves is most likely to have been damaged?
- A. Lingual nerve
- B. Auriculotemporal nerve
- C. Hypoglossal nerve (Correct Answer)
- D. Facial Nerve
Explanation: **Explanation:** The clinical presentation describes a classic injury to the **Hypoglossal nerve (CN XII)** during submandibular gland surgery. **1. Why the Correct Answer is Right:** The hypoglossal nerve provides motor innervation to all intrinsic and extrinsic muscles of the tongue (except the palatoglossus). The **genioglossus muscle** is the primary muscle responsible for tongue protrusion. When one hypoglossal nerve is damaged, the genioglossus on the healthy side acts unopposed, pushing the tongue toward the **affected (paralyzed) side** upon protrusion. In submandibular gland excision or radical neck dissection for carcinomas (like acinic cell carcinoma), the nerve is at risk as it lies deep to the submandibular gland within the submandibular triangle. **2. Why Incorrect Options are Wrong:** * **Lingual Nerve:** This nerve provides general sensation to the anterior 2/3rd of the tongue. Injury would result in loss of touch/temperature sensation and taste (via chorda tympani), but not motor deviation. * **Auriculotemporal Nerve:** A branch of the mandibular nerve (V3) that carries secretomotor fibers to the parotid gland. Injury leads to **Frey’s Syndrome** (gustatory sweating), typically after parotid surgery, not tongue deviation. * **Facial Nerve:** While the marginal mandibular branch of the facial nerve is frequently injured in submandibular surgery, it results in **drooping of the corner of the mouth**, not tongue deviation. **3. Clinical Pearls for NEET-PG:** * **Rule of Tongue Deviation:** "The tongue licks the wound" (deviates toward the side of the CN XII lesion). * **Nerves at risk in Submandibular Gland Excision:** 1. **Marginal Mandibular Nerve:** Most common; causes angle of mouth deviation. 2. **Lingual Nerve:** Causes sensory loss. 3. **Hypoglossal Nerve:** Causes motor loss/deviation. * **Acinic Cell Carcinoma:** The second most common malignant salivary gland tumor in adults (after Mucoepidermoid carcinoma) and the most common in children.
Question 42: Tietz syndrome is:
- A. Costochondritis of the second rib (Correct Answer)
- B. Costochondritis of the fourth rib
- C. Superficial thrombophlebitis of the breast
- D. Fibroadenoma of the breast
Explanation: **Explanation:** **Tietze Syndrome** (often referred to as costochondritis) is a benign, inflammatory condition characterized by painful swelling of the costochondral or costosternal joints. 1. **Why Option A is correct:** The hallmark of Tietze syndrome is localized pain and palpable swelling of the upper costal cartilages. It most commonly involves the **second costochondral junction** (followed by the third). Unlike general costochondritis, Tietze syndrome specifically presents with **visible/palpable swelling** and is usually unilateral. 2. **Why the other options are incorrect:** * **Option B:** While costochondritis can involve the fourth rib, the classic description and most frequent site for Tietze syndrome is the second rib. * **Option C:** Superficial thrombophlebitis of the breast or anterior chest wall is known as **Mondor’s Disease**. It presents as a "cord-like" structure and is a common differential in breast surgery questions. * **Option D:** Fibroadenoma is a benign breast tumor ("breast mouse") and is unrelated to the thoracic cage or costal cartilages. **High-Yield Clinical Pearls for NEET-PG:** * **Tietze vs. Costochondritis:** The presence of **swelling** is the key differentiator; costochondritis has pain without swelling. * **Mondor’s Disease:** Often associated with trauma, tight clothing, or surgery; it is self-limiting and treated with NSAIDs. * **Differential Diagnosis:** In a surgical or emergency setting, always rule out myocardial infarction or pleurisy before diagnosing Tietze syndrome. * **Management:** Treatment is conservative, involving rest, NSAIDs, or local steroid injections in refractory cases.
Question 43: Endoscopic ultrasound is extremely useful in staging which tumor?
- A. Colon cancer
- B. Esophageal cancer (Correct Answer)
- C. Stomach cancer
- D. Pancreatic head cancer
Explanation: **Explanation:** Endoscopic Ultrasound (EUS) is the **gold standard for the local staging (T and N staging)** of esophageal cancer. Its superiority lies in its ability to visualize the individual layers of the esophageal wall (mucosa, submucosa, muscularis propria, and adventitia) with high-frequency sound waves. This allows for precise determination of the depth of tumor invasion (**T-stage**) and the identification of regional lymphadenopathy (**N-stage**), which is critical for deciding between primary surgery and neoadjuvant chemoradiotherapy. **Analysis of Options:** * **Esophageal Cancer (Correct):** EUS has an accuracy of 85-90% for T-staging and is the most sensitive tool for identifying periesophageal lymph nodes. * **Colon Cancer:** EUS is not used for colon cancer; instead, **Endorectal Ultrasound (ERUS)** or MRI is the standard for staging rectal cancer. For the colon, CT and colonoscopy are preferred. * **Stomach Cancer:** While EUS is useful for gastric cancer staging, it is less accurate than in the esophagus due to the larger lumen and technical difficulty in visualizing the entire stomach wall. CT is often the primary staging modality. * **Pancreatic Head Cancer:** EUS is excellent for detecting small pancreatic masses and performing **FNA (Fine Needle Aspiration)**, but **Contrast-Enhanced CT (CECT)** remains the primary modality for staging resectability (vascular invasion). **High-Yield Clinical Pearls for NEET-PG:** 1. **T-Staging:** EUS is the most accurate modality for T-staging in esophageal and gastric cancers. 2. **M-Staging:** PET-CT is the investigation of choice for detecting distant metastasis (M-stage) in esophageal cancer. 3. **Barrett’s Esophagus:** EUS is used to screen for early invasive adenocarcinoma in patients with high-grade dysplasia. 4. **Contraindication:** EUS may be limited in cases of high-grade malignant strictures where the scope cannot pass.
Question 44: A hernia where the sac contains only a portion of the circumference of the intestine is called:
- A. Richter's hernia (Correct Answer)
- B. Littre's hernia
- C. Spigelian hernia
- D. Lumbar hernia
Explanation: **Explanation** **Richter’s Hernia (Correct Answer):** Richter’s hernia occurs when only a **portion of the circumference** of the antimesenteric border of the bowel becomes incarcerated within the hernial sac. Because the entire lumen is not compromised, patients may not present with classic signs of intestinal obstruction (like vomiting or absolute constipation), which often leads to a dangerous delay in diagnosis. However, the trapped portion can rapidly undergo ischemia and gangrene, leading to perforation. It is most commonly seen in femoral and obturator hernias. **Analysis of Incorrect Options:** * **Littre’s Hernia:** This refers to a hernia where the sac contains a **Meckel’s diverticulum**. It is a common "distractor" for Richter’s hernia in exams. * **Spigelian Hernia:** This is an acquired ventral hernia occurring through the **linea semilunaris** (at the level of the arcuate line), where the aponeurosis of the transversus abdominis muscle is weakest. * **Lumbar Hernia:** These occur through the posterior abdominal wall. Examples include **Petit’s hernia** (inferior lumbar triangle) and **Grynfeltt-Lesshaft hernia** (superior lumbar triangle). **Clinical Pearls for NEET-PG:** * **Richter’s Hernia:** High risk of "silent" strangulation. Always suspect in cases of localized abdominal pain without obstructive symptoms. * **Maydl’s Hernia:** A "W-shaped" hernia where two loops of bowel are in the sac, but the intervening loop inside the abdomen is the one that becomes strangulated. * **Amyand’s Hernia:** Hernia sac containing the **Appendix**. * **Pantaloon Hernia:** Coexistence of direct and indirect inguinal hernias on the same side.
Question 45: What is the most common cause of a cold abscess of the chest wall?
- A. Pott's spine (Correct Answer)
- B. TB abscesses of the chest wall
- C. TB of the ribs
- D. Intercostal lymphadenitis
Explanation: ### Explanation A **cold abscess** of the chest wall is a collection of tuberculous pus that lacks the typical signs of acute inflammation (heat, redness, or pain). **1. Why Pott’s Spine is the Correct Answer:** The most common cause of a cold abscess appearing on the chest wall is **Pott’s spine (Tuberculosis of the thoracic vertebrae)**. The infection originates in the vertebral bodies and tracks forward along the **intercostal nerves and vessels**. The pus follows the path of least resistance through the neurovascular bundle, eventually piercing the deep fascia to present as a fluctuant, non-tender swelling on the lateral or anterior chest wall. **2. Analysis of Incorrect Options:** * **TB Abscesses of the chest wall:** This is a general descriptive term for the presentation, not the underlying anatomical source. * **TB of the ribs:** While tuberculosis can affect the ribs directly, it is a much rarer primary source compared to the spine. * **Intercostal lymphadenitis:** TB of the internal mammary or intercostal lymph nodes can lead to a cold abscess (often presenting near the sternum), but statistically, it is less common than spinal origin. **3. NEET-PG High-Yield Pearls:** * **Presentation:** A cold abscess is "cold" because it lacks a pyogenic response. It is often fluctuant and may have a "cross-fluctuation" sign if it communicates with a deeper collection. * **Management:** The gold standard is **Antitubercular Therapy (ATT)**. If the abscess is large or threatening to skin, **aspiration** (using a Z-track technique to prevent sinus formation) is preferred over incision and drainage. * **Common Sites:** Besides the chest wall, cold abscesses from Pott’s spine often track down the psoas muscle to present in the groin (**Psoas Abscess**).
Question 46: Which of the following are bariatric surgical procedures?
- A. Vertical banded gastroplasty
- B. Roux-en Y gastric bypass
- C. Biliopancreatic diversion
- D. All the above (Correct Answer)
Explanation: **Explanation:** Bariatric surgery (metabolic surgery) includes a variety of procedures designed to induce weight loss by altering the anatomy of the gastrointestinal tract. These procedures are broadly classified based on their mechanism of action: **Restrictive**, **Malabsorptive**, or a **Combination (Hybrid)**. * **Vertical Banded Gastroplasty (VBG):** This is a purely **restrictive** procedure. It involves using staples and a band to create a small pouch in the upper stomach, limiting food intake. While historically popular, it is less common now due to the superiority of the Sleeve Gastrectomy. * **Roux-en-Y Gastric Bypass (RYGB):** This is a **hybrid** procedure (both restrictive and malabsorptive). It involves creating a small gastric pouch and bypassing the duodenum and proximal jejunum. It is currently considered the "Gold Standard" for bariatric surgery. * **Biliopancreatic Diversion (BPD):** This is primarily a **malabsorptive** procedure. It involves a subtotal gastrectomy and a long limb bypass, significantly limiting the absorption of fats and calories. The Scopinaro procedure is a well-known variant. Since all three options represent established surgical techniques for weight loss, **Option D** is the correct answer. **High-Yield Clinical Pearls for NEET-PG:** * **Indications:** BMI >40 kg/m² or BMI >35 kg/m² with comorbidities (e.g., Type 2 Diabetes, OSA). * **Most Common Procedure:** Laparoscopic Sleeve Gastrectomy (Restrictive). * **Most Common Complication (RYGB):** Nutritional deficiencies (Iron, B12, Calcium, Vitamin D) and Dumping Syndrome. * **Internal Hernia:** A specific complication of RYGB occurring through **Petersen’s space**. * **Ghrelin:** Levels decrease significantly after Sleeve Gastrectomy because the gastric fundus (the primary site of ghrelin production) is removed.
Question 47: All of the following are true about Bariatric surgery except:
- A. Indication for Bariatric surgery is patients that have a BMI of 35 Kg/m2 or more with comorbidity
- B. Most commonly performed procedure now-a-days is Roux-en-Y gastric bypass
- C. Laparoscopic adjustable gastric banding is considered safe and reversible
- D. Most common cause of death within 30 days of bariatric surgery is peritonitis secondary to anastomotic leak (Correct Answer)
Explanation: The correct answer is **D** because it is a false statement. While anastomotic leak is a serious complication, the **most common cause of death within 30 days of bariatric surgery is Pulmonary Embolism (PE)**. ### Explanation of Options: * **Option D (Incorrect Statement/Correct Answer):** Clinical data shows that Pulmonary Embolism accounts for approximately 30-50% of perioperative mortality. While peritonitis from an anastomotic leak is the second most common cause of death, it is not the first. * **Option A (True):** According to standard guidelines (IFSO/ASMBS), bariatric surgery is indicated for patients with a BMI ≥40 kg/m² or a **BMI ≥35 kg/m² with associated comorbidities** (e.g., Type 2 Diabetes, Hypertension, OSA). Note: Recent guidelines have lowered these thresholds, but NEET-PG often follows these classic criteria. * **Option B (True):** Globally and historically, the **Roux-en-Y Gastric Bypass (RYGB)** has been the "gold standard." However, in recent years, Sleeve Gastrectomy has become more frequent; nonetheless, RYGB remains a primary benchmark procedure in surgical textbooks. * **Option C (True):** Gastric banding is a restrictive procedure that does not involve cutting the stomach or intestines, making it **reversible** and associated with lower immediate perioperative mortality compared to bypass. ### High-Yield Clinical Pearls for NEET-PG: * **Most common complication overall:** Wound infection (in open cases) or nutritional deficiencies (long-term). * **Most common cause of death:** Pulmonary Embolism. * **Dumping Syndrome:** Most commonly seen after RYGB due to rapid gastric emptying into the jejunum. * **Internal Hernia:** Specifically, **Petersen’s Hernia** is a known complication after RYGB where the bowel herniates through the mesenteric defect. * **Ghrelin:** Levels decrease significantly after Sleeve Gastrectomy because the gastric fundus (the primary site of ghrelin production) is removed.
Question 48: What is the epithelial lining of the glottis/ true vocal cords?
- A. Stratified squamous non-keratinized (Correct Answer)
- B. Stratified squamous keratinized
- C. Ciliated columnar
- D. Non-ciliated columnar
Explanation: **Explanation:** The respiratory tract is predominantly lined by **pseudostratified ciliated columnar epithelium** (respiratory epithelium). However, areas subjected to significant mechanical stress or friction undergo a protective adaptation to **stratified squamous non-keratinized epithelium**. **1. Why Option A is correct:** The **true vocal cords (glottis)** are responsible for phonation. During speech and coughing, the vocal folds undergo high-frequency vibration and rapid contact (mechanical stress). To withstand this constant friction without damage, the epithelium transitions from respiratory type to stratified squamous non-keratinized epithelium. This provides a durable, multi-layered protective barrier. **2. Why other options are incorrect:** * **Option B (Keratinized):** Keratinization is a feature of the skin (epidermis) to prevent desiccation. Mucosal surfaces like the vocal cords remain moist and do not require a keratin layer. * **Options C & D (Columnar):** While ciliated columnar epithelium lines most of the larynx (supraglottis and subglottis), it is too fragile for the high-impact zone of the true vocal cords. **Clinical Pearls for NEET-PG:** * **The "Transition Zone":** The vocal cords are one of the few sites in the upper respiratory tract where this epithelial change occurs. Another high-yield site is the **epiglottis** (lingual surface and upper part of the laryngeal surface). * **Pathology Link:** Because the true vocal cords are lined by squamous epithelium, the most common malignancy of the larynx is **Squamous Cell Carcinoma (SCC)**. * **Reinke’s Space:** This is the potential space between the epithelium and the vocal ligament. Accumulation of fluid here leads to **Reinke’s edema**, commonly seen in smokers.
Question 49: Which of the following is NOT seen in neurofibromatosis?
- A. Meningioma
- B. Lisch nodule
- C. Axillary freckling
- D. Shagreen patch (Correct Answer)
Explanation: **Explanation:** The correct answer is **D. Shagreen patch**. This is because Shagreen patches are pathognomonic for **Tuberous Sclerosis**, not Neurofibromatosis. A Shagreen patch is a connective tissue nevus (leathery, "orange-peel" textured skin) typically found on the lower back. **Analysis of Options:** * **Option A (Meningioma):** Central nervous system tumors are a hallmark of Neurofibromatosis. While more common in **NF-2** (often associated with bilateral acoustic neuromas), meningiomas can occur in both types. * **Option B (Lisch nodules):** These are melanocytic hamartomas of the iris. They are the most common ocular finding in **NF-1** and are present in nearly all affected adults. * **Option C (Axillary freckling):** Also known as **Crowe’s sign**, this is a highly specific clinical marker for **NF-1**. It refers to freckling in the axillary or inguinal regions. **High-Yield Clinical Pearls for NEET-PG:** * **NF-1 (von Recklinghausen Disease):** Chromosome **17**. Diagnostic criteria include ≥6 Café-au-lait spots, Lisch nodules, Axillary freckling, Optic gliomas, and Sphenoid dysplasia. * **NF-2 (MISME Syndrome):** Chromosome **22**. Characterized by bilateral vestibular schwannomas, meningiomas, and juvenile posterior subcapsular lenticular opacities. * **Tuberous Sclerosis (TSC):** Remember the triad of **Epiloia** (Epilepsy, Low IQ, Adenoma sebaceum). Key skin findings include **Ash-leaf spots** (earliest sign), **Shagreen patches**, and **Periungual fibromas** (Koenen tumors).
Question 50: Which of the following is NOT true about gynecomastia?
- A. Can be drug-induced
- B. Associated with Klinefelter's syndrome
- C. Seen in cryptorchidism
- D. None of the above (Correct Answer)
Explanation: **Explanation:** Gynecomastia is the benign proliferation of glandular breast tissue in males, primarily caused by an imbalance between estrogen and androgen action. The question asks to identify the incorrect statement; however, all options provided are clinically accurate associations with gynecomastia, making **"None of the above"** the correct choice. 1. **Drug-induced (Option A):** This is a very common cause. High-yield drugs associated with gynecomastia include **S**pironolactone, **D**igoxin, **C**imetidine, **K**etoconazole, and **E**strogens (Mnemonic: **"Some Drugs Create Knockers"**). 2. **Klinefelter’s Syndrome (Option B):** This is the most common chromosomal cause (47, XXY). Patients have primary testicular failure (low testosterone) and elevated gonadotropins, leading to increased peripheral conversion to estrogen. These patients have a **20-50 times higher risk** of developing male breast cancer. 3. **Cryptorchidism (Option C):** Undescended testes are associated with testicular dysgenesis and an increased risk of germ cell tumors (especially seminomas). These conditions can disrupt the hormonal axis or produce hCG, leading to secondary gynecomastia. **High-Yield Clinical Pearls for NEET-PG:** * **Physiological Gynecomastia:** Occurs in three peaks: Neonatal (maternal estrogens), Pubertal (most common, usually resolves in 2 years), and Senile (aging). * **Grading:** Uses the **Simon Scale** (Grade I to III) to determine surgical management. * **Treatment:** The medical drug of choice is **Tamoxifen** (SERM). Surgery (Subcutaneous mastectomy/liposuction) is indicated if the condition is long-standing (>1 year) or causes significant psychological distress. * **True vs. Pseudo-gynecomastia:** True gynecomastia involves glandular tissue (firm, concentric), while pseudo-gynecomastia is merely fat deposition (soft, seen in obesity).
Practice by Chapter
Pathophysiology of Obesity
Practice Questions
Patient Selection and Preoperative Evaluation
Practice Questions
Restrictive Procedures
Practice Questions
Malabsorptive Procedures
Practice Questions
Sleeve Gastrectomy
Practice Questions
Roux-en-Y Gastric Bypass
Practice Questions
Biliopancreatic Diversion
Practice Questions
Adjustable Gastric Banding
Practice Questions
Revisional Bariatric Surgery
Practice Questions
Postoperative Management
Practice Questions
Nutritional Considerations
Practice Questions
Metabolic Effects of Bariatric Surgery
Practice Questions
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