A 56-year-old man is brought to the emergency department for the evaluation of a 3-day history of left lower abdominal pain. During this period, the patient has also had a low-grade fever and has not had a bowel movement. He has a history of constipation. He underwent a cholecystectomy at the age of 53 years. He has smoked one pack of cigarettes daily for the last 30 years. His temperature is 38.8°C (101.8°F), pulse is 80/min, respirations are 18/min, and blood pressure is 130/84 mm Hg. Cardiopulmonary examination shows no abnormalities. Abdominal examination shows left lower quadrant tenderness with no guarding or rebound. There is no edema of his lower extremities. CT of the abdomen with contrast shows segmental wall thickening of the descending colon with multiple diverticula, surrounding fat stranding, and a 5.5-cm, low-attenuating pelvic fluid collection. Intravenous fluids and bowel rest are started. Treatment with intravenous morphine, ciprofloxacin, and metronidazole is begun. Which of the following is the most appropriate next step in the management of this patient?
Q1022
A 25-year-old man presents to his gastroenterologist for trouble swallowing. The patient states that whenever he eats solids, he regurgitates them back up. Given this patient's suspected diagnosis, the gastroenterologist performs a diagnostic test. Several hours later, the patient presents to the emergency department with chest pain and shortness of breath. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 60/min, respirations are 12/min, and oxygen saturation is 99% on room air. On physical exam, the patient demonstrates a normal cardiopulmonary exam. His physical exam demonstrates no tenderness of the neck, a normal oropharynx, palpable crepitus above the clavicles, and minor lymphadenopathy. Which of the following is the best next step in management?
Q1023
A 52-year-old woman comes to the emergency department because of epigastric abdominal pain that started after her last meal and has become progressively worse over the past 6 hours. She has had intermittent pain similar to this before, but it has never lasted this long. Her temperature is 39°C (102.2°F). Examination shows a soft abdomen with normal bowel sounds. The patient has sudden inspiratory arrest during right upper quadrant palpation. Her alkaline phosphatase, total bilirubin, amylase, and aspartate aminotransferase levels are within the reference ranges. Abdominal imaging is most likely to show which of the following findings?
Q1024
Distal ileum was removed in a 20-year-old girl. Which absorption deficiency will be seen?
Q1025
Which of the following is not done in carcinoma esophagus?
Q1026
32-year-old man presented with fever and pain in upper right hypochondrium after food intake. Investigation of choice?
Q1027
Surgery is indicated in Ulcerative Colitis in all except?
Q1028
In gastric outlet obstruction in a peptic ulcer patient, the site of obstruction is most likely to be:
Q1029
A patient who underwent gastrectomy develops sweating and diarrhea within 20 minutes after eating. What could be the cause?
Q1030
Portosystemic shunt is not seen in -
Gastrointestinal Surgery Indian Medical PG Practice Questions and MCQs
Question 1021: A 56-year-old man is brought to the emergency department for the evaluation of a 3-day history of left lower abdominal pain. During this period, the patient has also had a low-grade fever and has not had a bowel movement. He has a history of constipation. He underwent a cholecystectomy at the age of 53 years. He has smoked one pack of cigarettes daily for the last 30 years. His temperature is 38.8°C (101.8°F), pulse is 80/min, respirations are 18/min, and blood pressure is 130/84 mm Hg. Cardiopulmonary examination shows no abnormalities. Abdominal examination shows left lower quadrant tenderness with no guarding or rebound. There is no edema of his lower extremities. CT of the abdomen with contrast shows segmental wall thickening of the descending colon with multiple diverticula, surrounding fat stranding, and a 5.5-cm, low-attenuating pelvic fluid collection. Intravenous fluids and bowel rest are started. Treatment with intravenous morphine, ciprofloxacin, and metronidazole is begun. Which of the following is the most appropriate next step in the management of this patient?
A. Observation and serial CT scans
B. Segmental colonic resection
C. CT-guided percutaneous abscess drainage (Correct Answer)
D. Colonoscopy
Explanation: ***CT-guided percutaneous abscess drainage***
- The imaging finding of a **5.5-cm, low-attenuating pelvic fluid collection** in a patient with diverticulitis strongly indicates a **diverticular abscess**.
- **Abscesses greater than 3 cm** associated with diverticulitis typically require **percutaneous drainage** in addition to antibiotics and bowel rest, as spontaneous resolution is unlikely.
*Observation and serial CT scans*
- While observation is appropriate for **uncomplicated diverticulitis** or small abscesses (<3 cm), a **5.5-cm abscess** warrants more aggressive intervention.
- Simply observing without draining a large abscess can lead to **sepsis** or abscess rupture.
*Segmental colonic resection*
- **Surgical resection** is usually reserved for cases of **perforated diverticulitis** with diffuse peritonitis, recurrent diverticulitis, or complicated diverticulitis that fails conservative management including drainage.
- It is not the immediate next step for a drainable abscess without signs of diffuse peritonitis.
*Colonoscopy*
- **Colonoscopy** is generally contraindicated during an acute episode of diverticulitis due to the **risk of perforation**.
- It is typically performed several weeks after resolution of the acute inflammation to rule out malignancy or other colonic pathology.
Question 1022: A 25-year-old man presents to his gastroenterologist for trouble swallowing. The patient states that whenever he eats solids, he regurgitates them back up. Given this patient's suspected diagnosis, the gastroenterologist performs a diagnostic test. Several hours later, the patient presents to the emergency department with chest pain and shortness of breath. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 60/min, respirations are 12/min, and oxygen saturation is 99% on room air. On physical exam, the patient demonstrates a normal cardiopulmonary exam. His physical exam demonstrates no tenderness of the neck, a normal oropharynx, palpable crepitus above the clavicles, and minor lymphadenopathy. Which of the following is the best next step in management?
A. Barium swallow
B. Gastrografin swallow (Correct Answer)
C. Urgent surgery
D. Ultrasound
Explanation: ***Gastrografin swallow***
- This patient likely has an **esophageal perforation** following a diagnostic procedure, possibly **endoscopy or manometry** for suspected achalasia given the dysphagia, regurgitation, and subsequent symptoms.
- A **Gastrografin swallow** is the best initial diagnostic step because it is water-soluble, allowing for detection of a leak without causing severe complications if aspirated into the lungs or mediastinum.
*Barium swallow*
- This is generally not recommended for suspected esophageal perforation as **barium** is a corrosive agent that can cause a severe inflammatory reaction known as **mediastinitis** if it leaks into the mediastinum.
- While it offers superior mucosal detail, the risks associated with extravasation outweigh its benefits in this emergent setting.
*Urgent surgery*
- While **surgical repair** is the definitive treatment for significant esophageal perforations, it should only be performed after definitive diagnosis and localization of the perforation.
- Performing surgery without imaging confirmation would be inappropriate and potentially lead to unnecessary intervention or missing the actual site of injury.
*Ultrasound*
- **Ultrasound** has limited utility in diagnosing esophageal perforation due to the location of the esophagus behind the trachea and sternum, making it largely inaccessible to acoustic waves.
- It also cannot effectively detect the leakage of contrast material from the esophageal lumen.
Question 1023: A 52-year-old woman comes to the emergency department because of epigastric abdominal pain that started after her last meal and has become progressively worse over the past 6 hours. She has had intermittent pain similar to this before, but it has never lasted this long. Her temperature is 39°C (102.2°F). Examination shows a soft abdomen with normal bowel sounds. The patient has sudden inspiratory arrest during right upper quadrant palpation. Her alkaline phosphatase, total bilirubin, amylase, and aspartate aminotransferase levels are within the reference ranges. Abdominal imaging is most likely to show which of the following findings?
A. Enlargement of the pancreas with peripancreatic fluid
B. Gallstone in the cystic duct (Correct Answer)
C. Fistula formation between the gallbladder and bowel
D. Dilated common bile duct with intrahepatic biliary dilatation
Explanation: ***Gallstone in the cystic duct***
- The patient presents with classic symptoms of **acute cholecystitis**: postprandial epigastric pain worsening over hours, fever (39°C), and a **positive Murphy's sign** (sudden inspiratory arrest during right upper quadrant palpation). In acute cholecystitis, a **gallstone** typically obstructs the **cystic duct**, leading to inflammation of the gallbladder.
- The **normal liver enzymes (AST, total bilirubin, alkaline phosphatase)** and **normal amylase** rule out choledocholithiasis, cholangitis, hepatitis, and pancreatitis. Therefore, imaging would confirm the presence of a gallstone in the cystic duct and associated gallbladder inflammation.
*Enlargement of the pancreas with peripancreatic fluid*
- This finding suggests **acute pancreatitis**, which is unlikely given the **normal amylase levels** in this patient.
- While gallstones can cause pancreatitis (gallstone pancreatitis), the specific obstructive symptoms and normal amylase point away from an active pancreatic inflammation.
*Fistula formation between the gallbladder and bowel*
- **Fistula formation** between the gallbladder and bowel (e.g., cholecystoenteric fistula) is a complication of chronic or severe cholecystitis and is usually associated with recurrent infections, not the acute presentation described.
- This complication can lead to gallstone ileus, and patients often have a history of chronic cholecystitis rather than a first severe episode of acute pain.
*Dilated common bile duct with intrahepatic biliary dilatation*
- This finding would suggest **obstructive jaundice** due to a blockage in the common bile duct, such as a **choledocholithiasis** or stricture.
- The patient's **normal total bilirubin and alkaline phosphatase levels** make significant common bile duct obstruction highly unlikely.
Question 1024: Distal ileum was removed in a 20-year-old girl. Which absorption deficiency will be seen?
A. Bile salts (Correct Answer)
B. Iron
C. Copper
D. Zinc
Explanation: ***Bile salts***
- The **distal ileum** is the primary site for the active reabsorption of **bile salts** back into the enterohepatic circulation.
- Their malabsorption leads to **fat malabsorption** and steatorrhea, and can lead to gallstones due to changes in bile composition.
*Iron*
- The majority of **iron absorption** primarily occurs in the **duodenum** and proximal jejunum, not the distal ileum.
- Iron deficiency would typically result from issues higher up in the small intestine or from chronic blood loss.
*Copper*
- **Copper absorption** mainly occurs in the **stomach** and **duodenum**.
- Deficiency typically arises from dietary inadequacy or specific genetic disorders, not distal ileal resection.
*Zinc*
- **Zinc absorption** occurs throughout the **small intestine**, with significant absorption in the **jejunum**.
- While some zinc is absorbed in the ileum, its primary absorption site is not limited to or predominantly in the distal ileum, making malabsorption less likely with isolated distal ileum removal.
Question 1025: Which of the following is not done in carcinoma esophagus?
A. pH - metry/monitoring (Correct Answer)
B. CT chest
C. PET scan
D. Biopsy
Explanation: ***pH - metry/monitoring***
- **pH metry/monitoring** is primarily used to diagnose **gastroesophageal reflux disease (GERD)**, which is not a direct diagnostic tool for esophageal carcinoma itself.
- While GERD is a risk factor for **Barrett's esophagus** and subsequently adenocarcinoma of the esophagus, pH monitoring does not directly identify or stage the cancer.
*CT chest*
- **CT (Computed Tomography) chest** is routinely performed in esophageal carcinoma to assess the **local extent** of the tumor and identify potential **lymph node involvement** or **metastasis** to other organs.
- It is crucial for **staging** the disease and guiding treatment decisions such as resectability.
*PET scan*
- A **PET (Positron Emission Tomography) scan** is highly useful for detecting **distant metastases** and identifying **occult disease** not visible on CT, especially in cases of suspected advanced esophageal carcinoma.
- It helps in **accurate staging** and avoiding futile surgery in patients with metastatic disease.
*Biopsy*
- **Biopsy**, typically performed during endoscopy, is the **gold standard** for confirming the diagnosis of esophageal carcinoma by obtaining tissue for **histopathological examination**.
- It identifies the cell type (e.g., adenocarcinoma, squamous cell carcinoma) and grade of the tumor, which is essential for treatment planning.
Question 1026: 32-year-old man presented with fever and pain in upper right hypochondrium after food intake. Investigation of choice?
A. Ultrasound (Correct Answer)
B. CT scan
C. ERCP (Endoscopic Retrograde Cholangiopancreatography)
D. MRCP (Magnetic Resonance Cholangiopancreatography)
Explanation: ***Ultrasound***
- **Ultrasound** is the initial and often definitive investigation for suspected **gallbladder pathology** like cholecystitis, especially given the symptoms of fever and **right upper quadrant pain post-meals**.
- It effectively visualizes **gallstones**, gallbladder wall thickening, and **pericholecystic fluid**, which are key indicators of cholecystitis.
*CT scan*
- A **CT scan** is generally not the first-line investigation for acute cholecystitis due to **radiation exposure** and its **lower sensitivity** for gallstones compared to ultrasound.
- While it can identify complications like abscesses or perforations, it is usually reserved for **ambiguous ultrasound findings** or suspected complications.
*ERCP (Endoscopic Retrograde Cholangiopancreatography)*
- **ERCP** is an **invasive procedure** primarily used therapeutically for the removal of **bile duct stones** or for stent placement in cases of obstruction.
- It carries risks of **pancreatitis** and perforation, making it unsuitable as an initial diagnostic tool for simple cholecystitis.
*MRCP (Magnetic Resonance Cholangiopancreatography)*
- **MRCP** is a **non-invasive imaging technique** that provides detailed images of the **biliary and pancreatic ducts** without radiation, primarily useful for confirming suspected bile duct stones or strictures.
- While excellent for ductal anatomy, it is **not typically the first choice** for acute cholecystitis, as ultrasound is quicker, cheaper, and sufficient for initial diagnosis.
Question 1027: Surgery is indicated in Ulcerative Colitis in all except?
A. Colonic polyp (Correct Answer)
B. Toxic megacolon
C. Colonic obstruction
D. Failure of medical management
Explanation: ***Colonic polyp***
- **Colonic polyps** in ulcerative colitis (UC) are often managed with **endoscopic polypectomy** and surveillance; surgery (colectomy) for polyps is typically reserved for those with **high-grade dysplasia** or **colorectal cancer**.
- Simple polyps themselves, without high-grade dysplasia or malignancy, do not independently warrant surgical intervention in UC.
*Toxic megacolon*
- **Toxic megacolon** is a severe and life-threatening complication of UC characterized by rapid **colonic dilation** and systemic toxicity, which carries a high risk of perforation and mortality.
- Urgent surgical intervention, often **subtotal colectomy**, is indicated to prevent perforation and manage sepsis.
*Colonic obstruction*
- Although uncommon in UC, **colonic obstruction** can occur due to strictures, fibrosis, or malignant transformation, causing symptoms like abdominal pain, distension, and vomiting.
- When medically refractory or associated with significant symptoms or suspicion of malignancy, surgery is often required to relieve the obstruction.
*Failure of medical management*
- **Chronic medically refractory UC** is one of the most common indications for elective colectomy, accounting for approximately 20-30% of surgical cases.
- When patients fail to respond to maximal medical therapy including corticosteroids, immunomodulators, and biologics, or experience steroid-dependent disease with unacceptable side effects, surgical intervention with **proctocolectomy** may be required for definitive management.
Question 1028: In gastric outlet obstruction in a peptic ulcer patient, the site of obstruction is most likely to be:
A. Pylorus (Correct Answer)
B. Duodenum
C. Antrum
D. Fundus
Explanation: ***Pylorus***
- The **pylorus** is the most common site of obstruction in gastric outlet obstruction caused by **peptic ulcer disease**. This is due to **scarring** and **inflammation** from chronic ulcers in or near this region.
- Obstruction at the pylorus impedes the normal flow of digested food from the stomach into the **duodenum**.
*Duodenum*
- While ulcers can occur in the **duodenum** (specifically the duodenal bulb), they are less likely to cause a complete obstruction of the gastric outlet.
- **Duodenal ulcers** are more common than gastric ulcers, but rarely lead to severe narrowing causing outlet obstruction.
*Antrum*
- The **gastric antrum** is part of the stomach leading up to the pylorus. Although ulcers can occur here, obstruction is less common compared to the **pylorus** itself.
- Obstruction due to antral pathology typically occurs closer to the **pyloric sphincter**.
*Fundus*
- The **fundus** is the upper, dome-shaped part of the stomach. It is very rarely the site of obstruction in the context of gastric outlet obstruction from peptic ulcer disease.
- Obstructions in the fundus are usually associated with other pathologies, such as **tumors** or **gastric volvulus**, not peptic ulcers causing outlet obstruction.
Question 1029: A patient who underwent gastrectomy develops sweating and diarrhea within 20 minutes after eating. What could be the cause?
A. Late dumping syndrome
B. Hyperglycemia
C. Early dumping syndrome (Correct Answer)
D. Hypoglycemia
Explanation: ***Early dumping syndrome***
- Occurs **15-30 minutes after eating** in patients who have undergone **gastric surgery**, such as gastrectomy, due to rapid emptying of hyperosmolar chyme into the small intestine.
- Symptoms include **sweating**, **diarrhea**, **nausea**, **cramping**, and **tachycardia** due to fluid shifts and hormonal responses.
*Late dumping syndrome*
- Typically occurs **1-3 hours after eating**, not within 20 minutes.
- It is characterized by **hypoglycemia** due to an exaggerated insulin response to the rapid absorption of glucose, leading to symptoms like weakness, confusion, and tremor.
*Hyperglycemia*
- While a rapid influx of glucose can initially cause hyperglycemia, the symptoms described (sweating, diarrhea) are more indicative of the systemic effects of rapid gastric emptying rather than simple hyperglycemia itself.
- Hyperglycemia post-meal is a normal physiological response, and the constellation of symptoms points to a post-surgical complication.
*Hypoglycemia*
- Hypoglycemia is characteristic of **late dumping syndrome**, occurring hours after a meal, not within 20 minutes.
- The symptoms of early dumping syndrome are primarily driven by fluid shifts and neurovascular responses, not low blood glucose.
Question 1030: Portosystemic shunt is not seen in -
A. Anorectum
B. Gastro Esophageal
C. Spleen (Correct Answer)
D. Liver
Explanation: ***Spleen***
- The **spleen** is drained by the **splenic vein**, which is a major tributary of the portal venous system.
- The spleen itself is **not a site of portosystemic anastomoses** - there are no natural connections between portal and systemic veins at the spleen.
- While splenic vein thrombosis or splenomegaly can contribute to **portal hypertension**, which then causes shunts to develop at other anatomical sites, the spleen itself does not have portosystemic shunts.
*Anorectum*
- The **anorectal junction** is a **classic site** for portosystemic shunts.
- The **superior rectal vein** (draining into the portal system via the inferior mesenteric vein) anastomoses with the **middle and inferior rectal veins** (draining into the systemic system).
- In **portal hypertension**, these anastomoses enlarge, forming **rectal varices and hemorrhoids**.
*Gastroesophageal Junction*
- The **gastroesophageal junction** is another **major site** for portosystemic shunts.
- The **left gastric vein** (portal system) anastomoses with the **esophageal veins** (systemic system via azygos vein).
- This leads to the formation of **esophageal varices** in portal hypertension, which can cause life-threatening bleeding.
*Liver*
- While the liver is the organ through which portal blood normally flows, and portosystemic shunts **bypass the liver**, the term "portosystemic shunt site" refers to the anatomical locations where portal and systemic veins naturally anastomose.
- In liver cirrhosis and portal hypertension, **intrahepatic vascular changes** occur, but the major extrahepatic portosystemic anastomoses develop at other specific anatomical sites (gastroesophageal, anorectal, umbilical, and retroperitoneal regions).
