Sleeve Gastrectomy — MCQs

10 questions

Which of the following is the MOST common complication associated with GERD?

Ramesh met an accident with a car and has been in deep coma for the last 15 days. The most suitable route for the administration of protein and calories is by :

A patient underwent a gastrectomy. Which vitamin replacement is required?

All of the following are primarily restrictive operations for morbid obesity, except which of the following?

The major disadvantage of mesenteric angiography in the setting of GI bleeding is:

All of the following are potential complications of untreated GERD, EXCEPT which of the following?

Which of the following is NOT true about ghrelin?

Following complete ileal and partial jejunal resection, the patient is most likely to have-

Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.

Q10

A patient who underwent sleeve gastrectomy on the 3rd postoperative day complains of fever. On examination, the patient is febrile, with a pulse rate of 110 beats per minute. The complete blood count shows leucocytosis. What is the next best step in managing this patient?

Sleeve Gastrectomy Indian Medical PG Practice Questions and MCQs

Question 1: Which of the following is the MOST common complication associated with GERD?

A. Chronic cough
B. Dental erosion
C. None of the options
D. Esophagitis (Correct Answer)

Explanation: ***Esophagitis*** - **Reflux of gastric acid** into the esophagus directly irritates the esophageal lining, leading to inflammation and cellular damage, commonly presenting as esophagitis [1]. - This recurrent irritation causes histological changes such as **basal cell hyperplasia** and **elongation of papillae**, which are hallmarks of reflux-induced injury [1]. *Chronic cough* - While chronic cough can be a symptom of GERD, it is considered an **extraesophageal manifestation** rather than a direct complication of esophageal mucosal damage. - Its prevalence is lower than esophagitis among GERD complications and it's less direct consequence of acid exposure to the esophagus itself. *Dental erosion* - **Acid reflux** can lead to dental erosion due to the direct contact of acidic gastric contents with tooth enamel. - However, this is less common than esophagitis, which is a direct and frequent consequence of **mucosal acid exposure** within the esophagus [1].

Question 2: Ramesh met an accident with a car and has been in deep coma for the last 15 days. The most suitable route for the administration of protein and calories is by :

A. Central venous hyperalimentation
B. Nasogastric tube feeding
C. Jejunostomy tube feeding (Correct Answer)
D. Gastrostomy tube feeding

Explanation: ***Jejunostomy tube feeding*** - For patients in a **deep coma** who need long-term nutritional support, **enteral feeding** is preferred over parenteral if the gut is functional [1]. - A **jejunostomy tube** is suitable when there is a risk of **gastric reflux** and aspiration, which is common in comatose patients, as feeding directly into the jejunum bypasses the stomach. *Central venous hyperalimentation* - This is **parenteral nutrition**, which is generally reserved for patients where the **gastrointestinal tract is not functional** or cannot safely be used [1]. - It carries higher risks of **infection**, **metabolic complications**, and is more expensive than enteral feeding. *Nasogastric tube feeding* - While a common route for short-term enteral feeding, **nasogastric tubes** have a higher risk of **aspiration pneumonia** in patients with an impaired gag reflex or altered consciousness, like those in a deep coma. - Long-term use can also lead to **nasal irritation**, **sinusitis**, or **esophageal erosion**. *Gastrostomy tube feeding* - A **gastrostomy tube** delivers feed directly into the stomach, which can still pose a significant risk of **gastroesophageal reflux** and subsequent **aspiration** in a comatose patient [1]. - This route is typically considered when the patient has intact gastric emptying and a low risk of aspiration [1].

Question 3: A patient underwent a gastrectomy. Which vitamin replacement is required?

A. Vitamin A
B. Vitamin C
C. Vitamin D
D. Vitamin B12 (Correct Answer)

Explanation: ***Vitamin B12*** - **Gastrectomy** removes all or part of the stomach, which is the site of **intrinsic factor** production by parietal cells. - Intrinsic factor is essential for the absorption of **Vitamin B12** (cobalamin) in the terminal ileum; without it, severe B12 deficiency will develop [1]. *Vitamin A* - Vitamin A (retinol) is a **fat-soluble vitamin** primarily absorbed in the small intestine, and its absorption is generally not directly affected by gastrectomy. - Deficiency is usually linked to malabsorption syndromes affecting the small intestine or severe hepatic dysfunction. *Vitamin C* - Vitamin C (ascorbic acid) is a **water-soluble vitamin** absorbed in the small intestine, and its absorption is largely independent of gastric function. - While gastrectomy might impact overall nutrient intake, there's no specific mechanism linking it directly to Vitamin C malabsorption. *Vitamin D* - Vitamin D is a **fat-soluble vitamin** absorbed in the small intestine, and its absorption is primarily dependent on the presence of bile salts and an intact small bowel. - Gastrectomy does not directly impair Vitamin D absorption, although general nutritional deficiencies can occur if dietary intake is insufficient post-surgery.

Question 4: 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 5: The major disadvantage of mesenteric angiography in the setting of GI bleeding is:

A. Transient ischemic attacks
B. High radiation exposure to patient
C. Requires active bleeding for detection (Correct Answer)
D. It does not identify the specific cause of the bleeding

Explanation: ***Requires active bleeding for detection*** - This is the **major disadvantage** of mesenteric angiography in the setting of GI bleeding. - It requires bleeding at a rate of at least **0.5-1 mL/min** to visualize contrast extravasation, which means it will **miss intermittent or slow bleeding** (the most common pattern in GI hemorrhage). - This significant limitation often makes **CT angiography or nuclear medicine scans** more suitable for detecting slower or intermittent bleeds. - The need for active bleeding at the time of the procedure **directly limits its clinical utility** and is why the study may be negative even when bleeding is ongoing at a slower rate. *It does not identify the specific cause of the bleeding* - While mesenteric angiography primarily localizes the bleeding site rather than identifying the underlying pathology, this is a **secondary limitation**. - The angiographic appearance can sometimes **suggest the etiology** (e.g., vascular malformations show characteristic patterns, tumors may show a blush). - The primary goal of the procedure is **localization for therapeutic intervention**, not definitive diagnosis, so this is less of a disadvantage. *High radiation exposure to patient* - Although mesenteric angiography involves **ionizing radiation**, this is a general concern with fluoroscopy-guided procedures, not its major specific disadvantage in GI bleeding. - The diagnostic and therapeutic benefit typically **outweighs the radiation risk** when active bleeding is appropriately suspected. *Transient ischemic attacks* - This is **not a recognized complication** of mesenteric angiography. - TIAs are **neurological events** related to cerebrovascular circulation, not the mesenteric (abdominal) circulation. - This option is medically inaccurate in the context of mesenteric angiography.

Question 6: 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 7: Which of the following is NOT true about ghrelin?

A. Has anorexic effect (Correct Answer)
B. Stimulates growth hormone release
C. Secreted by gastric fundus cells
D. Increases gastric motility

Explanation: ***Has anorexic effect*** - Ghrelin is known as the **"hunger hormone"** because it stimulates appetite and has an **orexigenic effect**, meaning it increases food intake. - Therefore, stating that it has an **anorexic effect** (reduces appetite) is incorrect. *Stimulates growth hormone release* - Ghrelin is a **natural ligand** for the **growth hormone secretagogue receptor (GHSR)**. - This binding leads to the stimulation of **growth hormone (GH)** release from the pituitary gland. *Secreted by gastric fundus cells* - The primary source of ghrelin in the body is the **P/D1 cells** found in the mucosa of the **gastric fundus**. - Smaller amounts are also produced in the small intestine, pancreas, and hypothalamus. *Increases gastric motility* - Ghrelin is involved in regulating stomach function and can **increase gastric motility** and acid secretion. - This action helps to prepare the digestive system for incoming food.

Question 8: Following complete ileal and partial jejunal resection, the patient is most likely to have-

A. Constipation
B. Gastric ulcer
C. Folic acid deficiency
D. Vitamin B12 Deficiency (Correct Answer)

Explanation: ***Vitamin B12 Deficiency*** - The **terminal ileum** is the primary site for **vitamin B12 absorption**, complexed with intrinsic factor [3]. Resection of this segment significantly impairs this process. - Patients with **ileal resection** are highly susceptible to developing **megaloblastic anemia** and neurological complications due to **vitamin B12 deficiency** [3]. *Constipation* - Complete ileal and partial jejunal resection is **more likely to cause diarrhea** rather than constipation, particularly due to malabsorption of bile salts and fats [2]. - **Bile salt malabsorption** in the colon often leads to secretory diarrhea [1]. *Gastric ulcer* - Gastric ulcers are typically associated with *Helicobacter pylori* infection or NSAID use, and are **not a direct consequence** of ileal and jejunal resection. - While short bowel syndrome can sometimes lead to increased gastric acid secretion, peptic ulcer formation is not the most likely or direct complication. *Folic acid deficiency* - **Folic acid** is primarily absorbed in the **jejunum**, and while partial jejunal resection occurred, complete ileal resection is less directly implicated in folate deficiency. - Other sections of the small intestine can often compensate for partial jejunal loss in folate absorption, making B12 deficiency a more immediate and severe concern after complete ileal resection.

Question 9: Statement 1 - A 59-year-old patient presents with flaccid bullae. Histopathology shows a suprabasal acantholytic split. Statement 2 - The row of tombstones appearance is diagnostic of Pemphigus vulgaris.

A. Statements 1 & 2 are correct, 2 is not explaining 1 (Correct Answer)
B. Statements 1 and 2 are correct and 2 is the correct explanation for 1
C. Statements 1 and 2 are incorrect
D. Statement 1 is incorrect

Explanation: ***Correct: Statements 1 & 2 are correct, 2 is not explaining 1*** **Analysis of Statement 1:** - A 59-year-old patient with **flaccid bullae** and **suprabasal acantholytic split** on histopathology is the classic presentation of **Pemphigus vulgaris** - The flaccid (easily ruptured) nature of bullae distinguishes it from tense bullae seen in bullous pemphigoid - The suprabasal location of the split (just above the basal layer) with acantholysis (loss of cell-to-cell adhesion) is pathognomonic - **Statement 1 is CORRECT** ✓ **Analysis of Statement 2:** - The **"row of tombstones" or "tombstone appearance"** is indeed a diagnostic histopathological feature of Pemphigus vulgaris - This appearance results from basal keratinocytes remaining attached to the basement membrane while suprabasal cells separate due to acantholysis - The intact basal cells standing upright resemble a row of tombstones - **Statement 2 is CORRECT** ✓ **Does Statement 2 explain Statement 1?** - Statement 2 describes a **histopathological appearance** (tombstone pattern) that is a **consequence** of the suprabasal split - However, it does NOT explain the **underlying cause** of the flaccid bullae or the suprabasal split - The true explanation involves **IgG autoantibodies against desmoglein 3 (and desmoglein 1)**, which attack intercellular adhesion structures (desmosomes), causing **acantholysis** - Therefore, **Statement 2 does NOT explain Statement 1** ✗ *Incorrect: Statement 2 is the correct explanation for Statement 1* - While both statements describe features of Pemphigus vulgaris, the tombstone appearance is a descriptive finding, not an explanatory mechanism *Incorrect: Statements 1 and 2 are incorrect* - Both statements are medically accurate descriptions of Pemphigus vulgaris features *Incorrect: Statement 1 is incorrect* - Statement 1 correctly describes the cardinal clinical and histopathological features of Pemphigus vulgaris

Question 10: A patient who underwent sleeve gastrectomy on the 3rd postoperative day complains of fever. On examination, the patient is febrile, with a pulse rate of 110 beats per minute. The complete blood count shows leucocytosis. What is the next best step in managing this patient?

A. Re-exploration
B. Broad spectrum antibiotics
C. Abdominal USG to locate the septic focus
D. CECT abdomen (Correct Answer)

Explanation: ***CECT abdomen*** - A **computed tomography (CT) scan** with contrast is the most sensitive and specific imaging modality to detect potential complications like a **leak, abscess**, or other **intra-abdominal pathology** following sleeve gastrectomy. - Given the patient's fever, tachycardia, and leukocytosis on the 3rd postoperative day, there is a strong suspicion of **sepsis** requiring prompt investigation to identify the source. *Broad spectrum antibiotics* - While antibiotics are important in managing potential infection, they are not the *next best step* without identifying the **source of infection**, as this patient is critically ill. - Starting antibiotics empirically without imaging could delay diagnosis of a surgically treatable complication like a **leak** or **abscess**. *Abdominal USG to locate the septic focus* - Abdominal ultrasound has **limited sensitivity** for detecting small leaks or deep-seated collections, especially in obese patients or with overlying bowel gas. - A **CT scan** provides superior anatomical detail and penetration compared to ultrasound for evaluating the surgical site. *Re-exploration* - **Re-exploration is a surgical intervention** and should only be considered after a definitive diagnosis, preferably guided by imaging like a **CECT abdomen**, indicating a need for surgical repair or drainage. - Performing re-exploration without imaging guidance could be an unnecessary and potentially harmful procedure if the diagnosis is incorrect or manageable non-surgically.

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