Gastrointestinal Surgery — MCQs
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Which one of the following parts of intussusception is most susceptible to ischaemia and perforation?
What is the treatment of choice in a patient with Crohn’s disease, where inflamed appendix was found on exploration?
Match List-I with List-II and select the correct answer using the code given below the Lists: **List-I (Procedure)** A. Highly selective vagotomy B. Vagotomy with gastrojejunostomy C. Subtotal gastrectomy D. Nissen's fundoplication **List-II (Complication)** 1. Metabolic bone disease 2. Post-prandial gas bloat 3. Lesser curve necrosis 4. Diarrhea **Code:**
In a patient of gastric outlet obstruction nutritional support is best delivered by:
Mousseau-Barbin Tube (M.B.Tube) is used for:
The most common cause of intestinal obstruction is:
In gallstone ileus, obstruction most frequently occurs at:
A 48 year old male with the history of chronic duodenal ulcer presented in surgical emergency with the complaints of sudden severe pain in the abdomen. At presentation: Pulse = 120/m, BP = 90/60 mm of Hg Abdomen: Tenderness (+), Rigidity (+), Guarding (+) Respiratory Rate: 20/m X-ray: Gas under right dome of diaphragm The probable diagnosis is:
Which of the following is NOT a tissue repair surgery for inguinal hernia repair?
Valentino's syndrome is:
Gastrointestinal Surgery Indian Medical PG Practice Questions and MCQs
Question 1001: Which one of the following parts of intussusception is most susceptible to ischaemia and perforation?
- A. Apex (Correct Answer)
- B. Neck
- C. Intussuscipiens
- D. Intussusceptum
Explanation: ***Apex*** - The **apex** is the **leading edge** (distal tip) of the intussusceptum that protrudes furthest into the intussuscipiens. - It is the **most distal point** from its blood supply and experiences the **greatest degree of vascular compromise**. - The apex suffers from **pressure necrosis** due to compression against the intussuscipiens and maximal venous congestion. - This makes it the **most susceptible site for ischemia, necrosis, and perforation** in intussusception. - Clinically, when perforation occurs, it is **most commonly at the apex**. *Neck* - The **neck** is the constricted point where the intussusceptum enters the intussuscipiens. - While the neck does compress the **mesentery and blood vessels**, causing venous outflow obstruction that affects the entire intussusceptum, it is not itself the most susceptible site for perforation. - The neck causes the ischemia, but the apex suffers the most from it. *Intussuscipiens* - The **intussuscipiens** is the **outer receiving segment** that engulfs the intussusceptum. - Its blood supply remains relatively intact as it is not invaginated. - It is **not susceptible** to ischemia in the same way as the invaginated segment. *Intussusceptum* - The **intussusceptum** refers to the **entire invaginated inner segment**. - While the whole intussusceptum can become ischemic, the question asks for the **specific part** most susceptible. - Within the intussusceptum, the **apex is the most vulnerable point** for ischemia and perforation.
Question 1002: What is the treatment of choice in a patient with Crohn’s disease, where inflamed appendix was found on exploration?
- A. Appendectomy
- B. Closing the abdomen and starting medical treatment
- C. Right hemicolectomy
- D. Ileo–colic resection and anastomosis (Correct Answer)
Explanation: ***Ileo-colic resection and anastomosis*** - This is the treatment of choice when an inflamed appendix is found during exploration in a patient with Crohn's disease, as the disease typically affects the **terminal ileum** and **right colon**. - The inflamed appendix is often a manifestation of Crohn's disease involving the **cecal base** and surrounding bowel. - **Ileo-colic resection** ensures removal of the diseased segment, including the inflamed appendix and involved bowel, thereby preventing future complications such as **fistulas** (risk up to 65% with simple appendectomy) and **strictures**. - If the cecal base is involved with Crohn's disease, simple appendectomy is contraindicated due to poor healing and high fistula risk. *Appendectomy* - Performing a simple appendectomy in the context of Crohn's disease carries a high risk of **fistula formation** and **poor wound healing** due to the underlying inflammatory process. - When the disease involves the **base of the appendix** and surrounding **cecum** (which is common), appendectomy alone is insufficient and dangerous. - Appendectomy may only be considered safe if the cecal base is completely **normal and uninvolved**, which is uncommon in this clinical scenario. *Closing the abdomen and starting medical treatment* - While medical treatment is crucial for managing Crohn's disease, an **inflamed appendix** found during exploration suggests an acute process that requires **surgical intervention**. - Delaying surgery by closing the abdomen could lead to complications such as **perforation** and **peritonitis**, especially if inflammation is severe. - Medical therapy alone is insufficient for acute complications requiring exploration. *Right hemicolectomy* - Right hemicolectomy is a more extensive resection than necessary for most cases of ileocecal Crohn's disease with appendiceal involvement. - **Ileo-colic resection** (removing terminal ileum, cecum, and ascending colon up to the hepatic flexure) is adequate and preferred as it is less extensive while addressing the pathology. - Right hemicolectomy would be reserved for more extensive colonic involvement beyond the typical ileocecal distribution.
Question 1003: Match List-I with List-II and select the correct answer using the code given below the Lists: **List-I (Procedure)** A. Highly selective vagotomy B. Vagotomy with gastrojejunostomy C. Subtotal gastrectomy D. Nissen's fundoplication **List-II (Complication)** 1. Metabolic bone disease 2. Post-prandial gas bloat 3. Lesser curve necrosis 4. Diarrhea **Code:**
- A. A→2 B→1 C→4 D→3
- B. A→2 B→4 C→1 D→3 (Correct Answer)
- C. A→3 B→1 C→4 D→2
- D. A→3 B→4 C→1 D→2
Explanation: ***A→2 B→4 C→1 D→3*** - **Highly selective vagotomy** (HSV) aims to reduce gastric acid secretion by denervating only the parietal cell mass, sparing the antrum and pylorus. A potential complication due to altered gastric motility and emptying can be **post-prandial gas bloat** or fullness. - **Vagotomy with gastrojejunostomy** involves severing the vagus nerve, which can lead to altered gastrointestinal motility and malabsorption. **Diarrhea** is a common complication due to accelerated transit time and bacterial overgrowth. - **Subtotal gastrectomy** involves the removal of a significant portion of the stomach. This procedure can lead to malabsorption of nutrients, including calcium and vitamin D, resulting in **metabolic bone disease**. - **Nissen's Fundoplication** is a procedure to treat gastroesophageal reflux disease (GERD) by wrapping the gastric fundus around the lower esophageal sphincter. **Lesser curve necrosis** is a rare but severe complication that can occur due to devascularization during the procedure. *A→2 B→1 C→4 D→3* - This option incorrectly associates vagotomy with gastrojejunostomy with metabolic bone disease and subtotal gastrectomy with diarrhea. While diarrhea can occur after gastrectomy, metabolic bone disease is a more specific and significant long-term complication of subtotal gastrectomy due to malabsorption. - Furthermore, this option suggests that metabolic bone disease is a complication of vagotomy with gastrojejunostomy, which is not a primary or common complication of this procedure. *A→3 B→1 C→4 D→2* - This option incorrectly links highly selective vagotomy with lesser curve necrosis and vagotomy with gastrojejunostomy with metabolic bone disease. Lesser curve necrosis is a specific complication linked to Nissen's fundoplication, not HSV. - It also misassociates subtotal gastrectomy with diarrhea as the primary unique complication, and Nissen's fundoplication with post-prandial gas bloat, which is more typical of vagotomy. *A→3 B→4 C→1 D→2* - This option incorrectly pairs highly selective vagotomy with lesser curve necrosis, similar to one of the previous incorrect options. Lesser curve necrosis is a known specific complication of Nissen's fundoplication, not vagotomy. - It also incorrectly links Nissen's fundoplication with post-prandial gas bloat, which is a symptom more commonly associated with procedures that affect gastric emptying, such as vagotomy, rather than fundoplication.
Question 1004: In a patient of gastric outlet obstruction nutritional support is best delivered by:
- A. Enteral nutrition by Ryles tube
- B. Jejunostomy (Correct Answer)
- C. Gastrostomy
- D. Parenteral nutrition
Explanation: ***Jejunostomy*** - In **gastric outlet obstruction**, the stomach cannot empty properly, making gastric feeding routes (like Ryles tube or gastrostomy) ineffective. - A **jejunostomy** allows direct delivery of **enteral nutrition** into the jejunum, bypassing the obstructed stomach and duodenum. *Enteral nutrition by Ryles tube* - A **Ryles tube** delivers nutrition into the stomach, which is obstructed in this condition, leading to **stasis** and **vomiting**. - This method would be ineffective and potentially dangerous due to the inability of gastric contents to pass beyond the obstruction. *Gastrostomy* - A **gastrostomy** involves placing a tube directly into the stomach, which is still part of the obstructed system. - Feeding via gastrostomy would lead to accumulation of feed in the stomach, mimicking the issues with oral feeding or a Ryles tube. *Parenteral nutrition* - **Parenteral nutrition** is a viable option for nutritional support but is generally considered a second-line therapy after **enteral routes** fail or are contraindicated. - **Enteral feeding**, when possible (as with jejunostomy), is preferred due to lower cost, reduced risk of infection, and better maintenance of gut integrity.
Question 1005: Mousseau-Barbin Tube (M.B.Tube) is used for:
- A. Advanced cancer oropharynx
- B. All of these
- C. Advanced cancer stomach
- D. Advanced cancer oesophagus (Correct Answer)
Explanation: ***Advanced cancer oesophagus*** - The **Mousseau-Barbin tube** is a type of **endoscopic stent** used for palliative management of **dysphagia** caused by advanced **oesophageal cancer**. - It provides a lumen through obstructed oesophageal segments, allowing patients to swallow food and liquids more easily. *Advanced cancer oropharynx* - While dysphagia can be a symptom of oropharyngeal cancer, the Mousseau-Barbin tube is specifically designed for placement within the **oesophagus**. - Management for advanced oropharyngeal cancer often involves other interventions like **radiotherapy**, **chemotherapy**, or **surgical resection**. *All of these* - This option is incorrect because the Mousseau-Barbin tube has a specific application for the **oesophagus**. - It is not routinely used for cancers of the oropharynx or stomach due to differences in anatomical location and disease progression. *Advanced cancer stomach* - Advanced stomach cancer, particularly in the distal stomach, would not typically benefit from an oesophageal stent. - Gastric outlet obstruction can occur, but specific **gastric stents** or **surgical bypasses** are used for this.
Question 1006: The most common cause of intestinal obstruction is:
- A. Inflammatory abdominal conditions
- B. Bands and adhesions (Correct Answer)
- C. Obstructed hernia
- D. Gastrointestinal malignancy
Explanation: ***Bands and adhesions*** - **Post-surgical adhesions** are the most common cause of small bowel obstruction, often forming after abdominal surgeries due to tissue healing. - These fibrous bands can **constrict or kink** the bowel, leading to a mechanical blockage. *Inflammatory abdominal conditions* - Conditions like **Crohn's disease** or **diverticulitis** can cause obstruction, but they are less frequent than adhesions as a primary cause. - Obstruction due to inflammation often involves **strictures** or inflammation-induced narrowing of the lumen. *Obstructed hernia* - **Hernias** (inguinal, femoral, umbilical, incisional) can become obstructed or strangulated, causing acute obstruction. - While a significant cause, the overall incidence is lower than that of adhesions, especially looking at all cases of intestinal obstruction. *Gastrointestinal malignancy* - **Colorectal cancer** is a common cause of large bowel obstruction, and other GI malignancies can cause small bowel obstruction. - Malignancy-related obstructions typically involve **tumor growth** causing luminal narrowing, but adhesions remain the leading cause overall.
Question 1007: In gallstone ileus, obstruction most frequently occurs at:
- A. Jejunum
- B. Duodenum
- C. Terminal ileum (Correct Answer)
- D. Proximal ileum
Explanation: ***Terminal ileum*** - In gallstone ileus, the **terminal ileum** (particularly at the **ileocecal valve region**) is the most common site of obstruction, accounting for **60-70%** of cases. - This occurs because the terminal ileum is the **narrowest portion of the small bowel**, creating a natural anatomical bottleneck where large gallstones become impacted. - The **ileocecal valve** represents the point of transition from small to large bowel, and its relatively fixed position and narrow caliber make it the classic site of obstruction. *Proximal ileum* - While gallstones can cause obstruction in the proximal or mid-ileum, this is **less frequent** than terminal ileum obstruction. - The proximal ileum has a relatively wider lumen compared to the terminal ileum, allowing larger stones to pass through more easily. *Jejunum* - The **jejunum** has the widest lumen of the small bowel, making obstruction at this site uncommon. - Gallstones typically pass through the jejunum without causing impaction. *Duodenum* - Duodenal obstruction by a gallstone is called **Bouveret's syndrome** and represents a rare variant (1-4% of gallstone ileus cases). - This occurs when a large stone impacts in the duodenal bulb or pylorus after eroding through a cholecystoduodenal fistula.
Question 1008: A 48 year old male with the history of chronic duodenal ulcer presented in surgical emergency with the complaints of sudden severe pain in the abdomen. At presentation: Pulse = 120/m, BP = 90/60 mm of Hg Abdomen: Tenderness (+), Rigidity (+), Guarding (+) Respiratory Rate: 20/m X-ray: Gas under right dome of diaphragm The probable diagnosis is:
- A. Acute appendicitis
- B. Perforation Peritonitis (Correct Answer)
- C. Acute Pancreatitis
- D. Acute Myocardial infarction
Explanation: ***Perforation Peritonitis*** - The patient's history of **chronic duodenal ulcer**, sudden severe abdominal pain, signs of **peritonitis** (**tenderness, rigidity, guarding**), and especially the X-ray finding of **gas under the right dome of the diaphragm** (indicating **pneumoperitoneum**) are all classic for a perforated viscus. - The **tachycardia** (Pulse = 120/m) and **hypotension** (BP = 90/60 mm Hg) further suggest a systemic inflammatory response syndrome (SIRS) or even **septic shock** due to peritonitis. *Acute appendicitis* - This typically presents with peri-umbilical pain migrating to the right lower quadrant, with localized tenderness and guarding, not diffuse peritonitis. - **Gas under the diaphragm** is not a feature of uncomplicated appendicitis but occurs with perforation of a hollow viscus. *Acute Pancreatitis* - While it can cause severe abdominal pain and signs of peritonitis, the pain often radiates to the back and is associated with elevated pancreatic enzymes. - **Gas under the diaphragm** is not a typical finding in acute pancreatitis unless there's a complication like colonic perforation. *Acute Myocardial infarction* - Though an MI can present with epigastric pain, it would not typically cause **diffuse abdominal tenderness, rigidity, guarding**, or **pneumoperitoneum**. - The primary symptoms would generally involve chest discomfort, and diagnostic tests would show cardiac enzyme elevation and EKG changes.
Question 1009: Which of the following is NOT a tissue repair surgery for inguinal hernia repair?
- A. Bassini's repair
- B. Shouldice repair
- C. Stoppa's repair (Correct Answer)
- D. Desarda repair
Explanation: ***Stoppa's repair*** - Stoppa's repair is a type of **giant prosthetic reinforcement of the visceral sac (GPRVS)**, which involves placing a large sheet of **synthetic mesh** in the preperitoneal space to buttress the entire myopectineal orifice. - This technique is primarily a **mesh repair** and thus not considered a pure tissue repair method. *Bassini's repair* - This is a classic **tissue repair** method where the conjoint tendon is sutured to the inguinal ligament, reinforcing the posterior wall of the inguinal canal. - It involves using the patient's own tissues without the implantation of synthetic mesh. *Shouldice repair* - Considered a gold standard among **tissue repairs**, it involves a multi-layered reconstruction of the posterior wall of the inguinal canal by approximating the transversalis fascia, conjoint tendon, and iliopubic tract. - The Shouldice repair also avoids the use of mesh. *Desarda repair* - This is a newer **tissue repair** method that utilizes a strip of the external oblique aponeurosis to create a new posterior wall for the inguinal canal. - It is promoted as a tension-free repair that does not use foreign mesh materials.
Question 1010: Valentino's syndrome is:
- A. Pain over left shoulder in left hypochondriac collection
- B. Pain on per-vaginal examination in pelvic abscess
- C. Pain in right iliac fossa in perforated peptic ulcer (Correct Answer)
- D. Pain over left groin in perirenal collection
Explanation: ***Pain in right iliac fossa in perforated peptic ulcer*** - **Valentino's syndrome** (also known as **Valentino's sign**) specifically describes the clinical presentation of **right iliac fossa (RIF) pain** in patients with a **perforated peptic ulcer**. - This occurs when gastric or duodenal contents from the perforation track down along the **right paracolic gutter** due to gravity and peritoneal fluid flow, accumulating in the RIF and causing **localized peritonitis**. - This can **mimic acute appendicitis** clinically, making it an important differential diagnosis. - Named after Rudolph Valentino, the famous actor who died from complications of a perforated gastric ulcer. *Pain over left shoulder in left hypochondriac collection* - This describes **Kehr's sign**, which is referred pain to the left shoulder due to **diaphragmatic irritation** from blood or fluid in the left upper quadrant (e.g., splenic rupture, subphrenic abscess). - Caused by irritation of the phrenic nerve (C3-C5), which also supplies sensation to the shoulder. - This is **not** Valentino's syndrome. *Pain on per-vaginal examination in pelvic abscess* - Cervical excitation pain or adnexal tenderness on vaginal examination suggests **pelvic pathology** such as pelvic inflammatory disease, ectopic pregnancy, or pelvic abscess. - This finding is unrelated to Valentino's syndrome, which involves upper GI perforation with RIF pain. *Pain over left groin in perirenal collection* - Groin pain from perirenal pathology may occur with conditions like renal calculi, pyelonephritis, or perinephric abscess. - This is not associated with Valentino's syndrome, which has a specific anatomical pattern related to peptic ulcer perforation.
Practice by Chapter
Esophageal Disorders
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Gastric Disorders
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Small Intestine Pathology
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Appendicitis
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Inflammatory Bowel Disease
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Intestinal Obstruction
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Gastrointestinal Bleeding
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Diverticular Disease
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Anorectal Disorders
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Colorectal Neoplasms
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Gastrointestinal Stomas
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Bariatric Surgery Principles
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