Gastrointestinal Surgery Practice Questions

Q: A patient presents with acute appendicitis. What is NOT to be done?

Check for visual acuity. ***Check for visual acuity*** - **Visual acuity** assessment is not relevant to the diagnosis or management of **acute appendicitis**. - This examination is typically performed in cases of suspected eye injury, vision changes, or neurological issues that affect vision. - In the context of acute appendicitis, checking visual acuity would be inappropriate and waste valuable time. *Give antibiotics* - **Antibiotics** are crucial in managing **acute appendicitis** to prevent progression to perforation and reduce postoperative infection risk. - They are typically administered preoperatively and continued postoperatively, especially in cases of complicated appendicitis. - Broad-spectrum antibiotics covering **gram-negative organisms and anaerobes** are standard practice. *Do primary survey* - A **primary survey** (ABCDE approach) is essential in any emergent patient presentation to assess and manage immediate **life-threatening conditions**. - While appendicitis itself may not be immediately life-threatening, ensuring patient stability and ruling out other serious conditions is critical. - This is standard emergency medicine practice and should always be performed. *Perform appendectomy* - **Appendectomy** (surgical removal of the appendix) is the definitive treatment for **acute appendicitis**. - This is the standard of care and should be performed once the diagnosis is confirmed and the patient is stable. - Either open or laparoscopic approach can be used depending on clinical factors and surgeon expertise.

Q: In which of the following conditions is Alvarado score indicated?

Appendicitis. ***Appendicitis*** - The Alvarado score, also known as the MANTRELS score, is a clinical scoring system used to assess the likelihood of **acute appendicitis**. - It considers symptoms (e.g., **migratory right iliac fossa pain**, **anorexia**, **nausea/vomiting**), signs (e.g., **tenderness in the right iliac fossa**, **rebound tenderness**), and laboratory findings (e.g., **leukocytosis**, **shift to the left of neutrophils**). *Pancreatitis* - Pancreatitis is typically diagnosed and managed using criteria such as the **Ranson criteria** or **APACHE II score** for severity assessment, and imaging like CT scans. - The Alvarado score is not applicable for the diagnosis or severity assessment of pancreatitis. *Cholangitis* - Cholangitis is an infection of the bile ducts which is usually diagnosed clinically using the **Charcot's triad** (fever, jaundice, right upper quadrant pain) or **Reynold's pentad** (Charcot's triad plus altered mental status and hypotension). - The Alvarado score has no role in the evaluation of cholangitis. *Cholecystitis* - Cholecystitis, inflammation of the gallbladder, is primarily diagnosed based on clinical symptoms (e.g., **right upper quadrant pain**, **fever**, **leukocytosis**), Murphy's sign, and imaging (ultrasound). - The Alvarado score is specifically designed for appendicitis and is not used for cholecystitis.

Q: A 60-year-old man presents with foul breath and regurgitates food eaten 3 days ago. What is the most likely diagnosis?

Zenker's Diverticulum. ***Zenker's Diverticulum*** - This condition presents with a classic triad of **dysphagia**, **regurgitation of undigested food**, and **foul breath (halitosis)** due to food retention in the diverticulum. - The regurgitation of food eaten several days ago is highly characteristic, indicating significant pooling and decomposition within the **pharyngeal pouch**. *Achalasia cardia* - Characterized by **dysphagia for both solids and liquids** and regurgitation, but the regurgitated food is typically fresh or only recently ingested, not from several days prior. - The primary pathology is the **failure of the lower esophageal sphincter (LES) to relax** and loss of peristalsis in the esophageal body. *Carcinoma esophagus* - Often presents with **progressive dysphagia** (first for solids, then for liquids) and significant **weight loss**. - While regurgitation can occur, it's usually of recently ingested food and rarely associated with the severe halitosis from long-standing food decomposition seen in Zenker's. *Loss of tone of upper esophageal sphincter* - This condition would more likely lead to **regurgitation of stomach contents** into the pharynx, rather than the retention of food in a pouch. - It could contribute to **reflux symptoms** but does not explain the formation of a diverticulum or the prolonged food retention leading to foul breath.

Q: Hamman's sign is seen in which of the following conditions?

Oesophageal perforation. ***Oesophageal perforation*** - **Hamman's sign** is a classic auscultatory finding of a crunching, rasping sound synchronous with the heartbeat, indicative of **mediastinal emphysema** (air in the mediastinum). - Oesophageal perforation allows air to escape into the mediastinum, leading to mediastinal emphysema and thus Hamman's sign. *Acute oesophagitis* - This condition involves inflammation of the oesophagus, often causing symptoms like **dysphagia** and **odynophagia**. - It typically does not involve air leakage into the mediastinum, and therefore, **Hamman's sign is not expected**. *Corrosive burns of oesophagus* - Corrosive injuries cause chemical burns to the oesophageal lining, leading to inflammation, strictures, or in severe cases, perforation. - While perforation is a possibility in severe cases, the primary presentation is typically related to direct tissue damage and inflammation, not consistently with **mediastinal emphysema** unless perforation has occurred. *Benign strictures of oesophagus* - Benign strictures are narrowings of the oesophagus, usually caused by chronic inflammation or reflux. - They primarily cause **dysphagia** due to mechanical obstruction and are not associated with **air leakage into the mediastinum** or Hamman's sign.

Q: Forrest classification is used for evaluating:

Upper GI bleeding. ***Upper GI bleeding*** - The **Forrest classification** is a widely used endoscopic classification system that assesses the status of bleeding from a peptic ulcer. - It helps predict the risk of **rebleeding** and guides treatment decisions, ranging from active bleeding requiring urgent intervention to signs of recent hemorrhage or no visible signs of bleeding. *Familial adenomatous polyposis* - This is a **hereditary syndrome** characterized by the development of hundreds to thousands of adenomatous polyps in the colon and rectum. - Its evaluation primarily involves **genetic testing**, colonoscopy surveillance, and screening for extracolonic manifestations. *Liver transplantation* - The evaluation for liver transplantation involves complex scoring systems like the **MELD (Model for End-Stage Liver Disease) score** or Child-Pugh score. - These scores assess the severity of liver disease and predict short-term mortality to prioritize patients for transplantation. *Lower GI bleeding* - Lower GI bleeding typically originates distal to the ligament of Treitz and is evaluated using different techniques like **colonoscopy**, angiography, or capsule endoscopy. - Specific classification systems for lower GI bleeding are not commonly referred to as the Forrest classification.

Q: Best site for taking biopsy for HSV esophagitis is:

Edge of ulcer. ***Edge of ulcer*** - The **edge of the ulcer** is the preferred site for biopsy in HSV esophagitis because it is where the **actively replicating viral particles** and **cytopathic effects** are most likely to be found. - This area allows for the detection of characteristic **ground-glass nuclei**, **Cowdry type A inclusions**, and **multinucleated giant cells** indicative of HSV infection. *Base of ulcer* - While the base of the ulcer might show inflammatory changes, it is less likely to contain actively replicating virus or viable host cells exhibiting the classic **cytopathic changes** seen in HSV. - The base often consists of **necrotic debris** and granulation tissue, making a definitive diagnosis more difficult. *Adjacent indurated area around ulcer* - An indurated area around an ulcer could suggest chronic inflammation or other pathologies, but for acute HSV infection, it is less likely to yield diagnostic viral effects. - This region may show secondary inflammatory changes rather than the primary viral effects at the site of invasion. *Surrounding normal mucosa* - The normal mucosa surrounding the ulcer is unlikely to show any direct histological evidence of HSV infection. - Biopsying this area would not be diagnostic as the virus primarily affects and ulcerates the epithelial lining.

Q: Claw sign seen in?

Intussusception. ***Intussusception*** - The **claw sign** is a characteristic radiological finding in **intussusception**, seen on barium enema or ultrasound - It represents the **intussusceptum** (the invaginated bowel segment) within the **intussuscipiens** (the receiving bowel segment), creating a claw-like appearance at the margins - The claw-like projections are formed by the opposing walls of the intussusception *Malrotation* - Malrotation presents with **midgut volvulus** and shows the **whirl sign** (twisted mesentery) on imaging - May show **duodenal obstruction** with double bubble sign, not claw sign - The claw sign is not a feature of malrotation *Volvulus* - **Volvulus** typically presents with a **"coffee bean sign"** (sigmoid volvulus) or **"whirl sign"** (cecal/midgut volvulus) on imaging - These signs indicate twisted bowel loops around the mesentery - The **claw sign** is not associated with volvulus; it is specific to the telescoping of bowel segments seen in intussusception *Both* - This option is incorrect as the **claw sign** is specific to **intussusception** only - While intussusception, malrotation, and volvulus can all cause bowel obstruction, their radiographic signs are distinct and diagnostically important

Q: Alvarado score is used for

Acute appendicitis. ***Acute appendicitis*** - The **Alvarado score**, also known as the MANTRELS score, is a clinical prediction rule used to assist in the diagnosis of **acute appendicitis**. - It assigns points based on symptoms (migratory pain, anorexia, nausea/vomiting), signs (tenderness in the right iliac fossa, rebound tenderness), and laboratory findings (elevated temperature, leukocytosis, left shift of neutrophils). *Acute epididymitis* - Diagnosis typically relies on clinical findings like **unilateral testicular pain and swelling**, often associated with dysuria or urethral discharge. - While it has scoring systems (like the Epididymitis Severity Score), the **Alvarado score** is not used for its diagnosis. *Acute pancreatitis* - Diagnosed based on characteristic **epigastric pain**, elevated serum amylase or lipase levels, and imaging findings. - Severity is often assessed using scoring systems like **Ranson's criteria** or APACHE II, not the Alvarado score. *Acute cholecystitis* - Diagnosed by symptoms such as **right upper quadrant pain**, fever, and leukocytosis, often with **positive Murphy's sign** and imaging evidence (e.g., gallbladder wall thickening on ultrasound). - The **Alvarado score** is not relevant to the diagnosis or severity assessment of acute cholecystitis.

Q: Dohlman surgery in Zenker's diverticulum is:-

Endoscopic electrocautery technique. ***Endoscopic electrocautery technique*** - The **Dohlman procedure** (Dohlman-Mattsson procedure, 1960) is an **endoscopic electrosurgical technique** that uses **diathermy/electrocautery** to divide the cricopharyngeal muscle (the septum between the esophagus and the diverticulum). - This method creates a common cavity between the esophagus and the diverticulum, allowing food to pass freely and preventing pooling. - It is one of the **classic endoscopic approaches** for treating Zenker's diverticulum and remains widely used. *Endoscopic suturing of pouch* - Endoscopic suturing is not the primary technique for the Dohlman procedure. - The goal is to **divide the septum**, not to suture or reduce the pouch itself. *Laser division of pouch* - **Laser division** of the cricopharyngeal muscle is another endoscopic approach, often called **endoscopic laser diverticulostomy**. - While effective, this is a **different technique** from the Dohlman procedure, which specifically uses electrocautery. *Endoscopic stapling of septum* - **Endoscopic stapling** (using an endoscopic stapler to divide the septum) is associated with the **Collard-Peracchia technique** or endoscopic stapling diverticulostomy. - While this is a modern and effective approach, it is **not the Dohlman procedure**, which historically and traditionally refers to the electrocautery technique.

Q: A middle aged man complains of upper abdominal pain after a heavy meal. There is tenderness in the upper abdomen and on X-ray, widening of the mediastinum is seen with air in the mediastinum. What is the diagnosis?

Spontaneous perforation of the esophagus. ***Spontaneous perforation of the esophagus*** - The combination of **upper abdominal pain after a heavy meal** (suggestive of regurgitation/vomiting), **tenderness in the upper abdomen**, and **widening of the mediastinum with air in the mediastinum (pneumomediastinum)** points strongly to spontaneous esophageal rupture, also known as **Boerhaave syndrome**. - This condition results from a sudden increase in intra-esophageal pressure, often due to forceful vomiting, leading to a full-thickness tear in the esophageal wall. *Perforated peptic ulcer* - While it causes **severe upper abdominal pain** and tenderness, a perforated peptic ulcer primarily leads to **pneumoperitoneum** (free air under the diaphragm) rather than pneumomediastinum. - The abdominal symptoms would be more generalized and severe, and the X-ray findings would typically show free air in the abdominal cavity, not the mediastinum. *Rupture of emphysematous bulla* - This would generally cause **pneumothorax** and/or **subcutaneous emphysema**, and potentially pneumomediastinum, but typically without the profound abdominal pain and tenderness associated with a gastrointestinal event. - It would not be directly linked to a heavy meal or suggest a primary esophageal pathology. *Foreign body in esophagus* - A foreign body could cause pain and dysphagia, and potentially lead to perforation if sharp or impacted for too long, but the primary presentation would likely involve difficulty swallowing or a sensation of obstruction. - The immediate presence of **pneumomediastinum** and severe abdominal pain after a meal makes acute perforation more likely than a simple foreign body impaction without prior perforation.

Question 1

A patient presents with acute appendicitis. What is NOT to be done?

Accepted Answer

Check for visual acuity

Answer

Give antibiotics

Answer

Do primary survey

Answer

Perform appendectomy

Question 2

In which of the following conditions is Alvarado score indicated?

Accepted Answer

Appendicitis

Answer

Pancreatitis

Answer

Cholangitis

Answer

Cholecystitis

Question 3

A 60-year-old man presents with foul breath and regurgitates food eaten 3 days ago. What is the most likely diagnosis?

Accepted Answer

Zenker's Diverticulum

Answer

Achalasia cardia

Answer

Carcinoma esophagus

Answer

Loss of tone of upper esophageal sphincter

Question 4

Hamman's sign is seen in which of the following conditions?

Accepted Answer

Oesophageal perforation

Answer

Acute oesophagitis

Answer

Corrosive burns of oesophagus

Answer

Benign strictures of oesophagus

Question 5

Forrest classification is used for evaluating:

Accepted Answer

Upper GI bleeding

Answer

Familial adenomatous polyposis

Answer

Liver transplantation

Answer

Lower GI bleeding

Question 6

Best site for taking biopsy for HSV esophagitis is:

Accepted Answer

Edge of ulcer

Answer

Base of ulcer

Answer

Adjacent indurated area around ulcer

Answer

Surrounding normal mucosa

Question 7

Claw sign seen in?

Accepted Answer

Intussusception

Answer

Malrotation

Answer

Volvulus

Answer

Both

Question 8

Alvarado score is used for

Accepted Answer

Acute appendicitis

Answer

Acute epididymitis

Answer

Acute pancreatitis

Answer

Acute cholecystitis

Question 9

Dohlman surgery in Zenker's diverticulum is:-

Accepted Answer

Endoscopic electrocautery technique

Answer

Endoscopic suturing of pouch

Answer

Laser division of pouch

Answer

Endoscopic stapling of septum

Question 10

A middle aged man complains of upper abdominal pain after a heavy meal. There is tenderness in the upper abdomen and on X-ray, widening of the mediastinum is seen with air in the mediastinum. What is the diagnosis?

Accepted Answer

Spontaneous perforation of the esophagus

Answer

Perforated peptic ulcer

Answer

Rupture of emphysematous bulla

Answer

Foreign body in esophagus

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?