Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery Indian Medical PG Practice Questions and MCQs

Question 1091: Which of the following signs of acute appendicitis is characterized by pain in the right lower quadrant upon palpation of the left lower quadrant?

A. Psoas sign
B. Rovsing's (Correct Answer)
C. Obturator sign
D. McBurney's point tenderness

Explanation: ***Rovsing's sign*** - **Rovsing's sign** is characterized by pain in the **right lower quadrant** when the **left lower quadrant** is palpated. - This occurs due to the movement of gas/contents in the colon, causing pressure on the inflamed appendix and producing **referred pain** in the RLQ. - It is a reliable clinical sign with good specificity for acute appendicitis. *Psoas sign* - The **psoas sign** is elicited by **pain on right hip extension** when the patient lies on their left side. - This indicates irritation of the **psoas muscle** by an inflamed **retrocecal appendix**. - This is not related to left lower quadrant palpation. *Obturator sign* - The **obturator sign** involves pain on **internal rotation of the flexed right hip**. - This suggests irritation of the **obturator internus muscle** by a **pelvic appendix**. - This is not elicited by abdominal palpation but by hip manipulation. *McBurney's point tenderness* - **McBurney's point** is located at the junction of the **lateral one-third and medial two-thirds** of a line from the anterior superior iliac spine to the umbilicus. - Direct tenderness at this point is highly suggestive of appendicitis. - However, this involves **direct palpation of the RLQ**, not left-sided palpation causing right-sided pain.

Question 1092: A 25 year old man presents with a 3-day history of pain in the right lower abdomen and vomiting. The patient's general condition is satisfactory, and clinical examination reveals a tender lump in the right iliac fossa. What is the most appropriate management in this case?

A. Immediate appendicectomy
B. Ochsner-Sherren regimen (Correct Answer)
C. External drainage
D. Exploratory laparotomy

Explanation: ***Ochsner-Sherren regimen*** - The presence of a **tender lump** in the right iliac fossa combined with a 3-day history strongly suggests a contained appendix mass or abscess. The **Ochsner-Sherren regimen** is appropriate here. - This conservative management includes **IV fluids**, **antibiotics**, **nil by mouth (NBM)**, **nasogastric aspiration**, and pain control, aiming to resolve the inflammation before interval appendectomy (typically after 6-8 weeks). *Immediate appendicectomy* - This is indicated for **uncomplicated acute appendicitis**, where there is no evidence of a contained mass or abscess. - Performing surgery on a mature appendix mass can be technically difficult, increasing the risk of **perforation** and **complications**. *Exploratory laparotomy* - This is a more extensive surgical procedure, typically reserved for cases with **diffuse peritonitis**, **haemodynamic instability**, or suspicion of other serious intra-abdominal pathology that requires immediate wide exploration. - Given the stable condition and localized findings, it is not the initial appropriate approach. *External drainage* - **External drainage** is specifically used for a well-formed **appendix abscess** that is amenable to percutaneous (image-guided) drainage. - While it's an option for some abscesses, the Ochsner-Sherren regimen is the initial conservative step for an appendix mass, with drainage considered if the mass progresses to a drainable abscess.

Question 1093: What condition is caused by a gallstone impacting and causing intestinal obstruction?

A. Hepatitis
B. Gallstone ileus (Correct Answer)
C. Obstructive jaundice
D. Raynaud's pentad

Explanation: ***Gallstone ileus*** - **Gallstone ileus** occurs when a **gallstone erodes through the gallbladder wall** into the adjacent small intestine, creating a **cholecystoenteric fistula**. - The displaced gallstone then travels down the bowel and causes **mechanical obstruction**, most commonly in the **terminal ileum** due to its narrow lumen. - This is the **correct answer** as it specifically describes intestinal obstruction caused by an impacted gallstone. *Incorrect: Raynaud's pentad* - **Raynaud's pentad** is an incorrect term; the related clinical entity is **Reynolds' pentad**. - **Reynolds' pentad** describes the combination of **Charcot's triad** (right upper quadrant pain, fever, jaundice) with **hypotension** and **altered mental status**, indicating **acute suppurative cholangitis**. - This represents a **biliary tract complication**, not intestinal obstruction. *Incorrect: Hepatitis* - **Hepatitis** refers to **inflammation of the liver parenchyma**, which can be caused by viral infections, alcohol, drugs, or autoimmune conditions. - Gallstones do not directly cause hepatitis; they may cause **biliary obstruction** or **cholangitis**, but these are distinct conditions affecting the biliary tree rather than causing hepatocellular inflammation characteristic of hepatitis. - This is **not related to intestinal obstruction**. *Incorrect: Obstructive jaundice* - **Obstructive jaundice** occurs when there is a **blockage in the bile ducts**, preventing bile flow from the liver to the intestine, leading to **bilirubin accumulation**. - This condition is typically caused by a gallstone in the **common bile duct (choledocholithiasis)**, which obstructs the **biliary system**, not the intestinal lumen. - While caused by gallstones, this represents **biliary obstruction**, not **intestinal obstruction**.

Question 1094: What is the most common cause of small intestine obstruction?

A. Postoperative adhesions (Correct Answer)
B. Idiopathic adhesions
C. Tumors
D. Intussusception

Explanation: ***Postoperative adhesions*** - **Postoperative adhesions** are by far the most common cause of **small bowel obstruction** in developed countries, leading to fibrous bands that can kink or strangulate the bowel. - The risk of adhesion formation increases with the number and complexity of prior **abdominal surgeries**. *Intussusception* - **Intussusception** is a condition where one segment of the intestine telescopes into another, which is more common in **children** than adults. - While it can cause obstruction, it is a relatively rare cause of small bowel obstruction in the general adult population. *Idiopathic adhesions* - While adhesions can occur, very few are truly **idiopathic**; most have an identifiable cause, such as prior surgery or inflammation. - They are not considered the most prevalent cause compared to those clearly linked to previous surgical interventions. *Tumors* - **Tumors**, both primary and metastatic, can cause small bowel obstruction by stricturing the lumen or compressing it externally. - Though a significant cause, tumors are less common than postoperative adhesions for acute small bowel obstructions.

Question 1095: In which type of hernia can the cecum be found as part of the hernia contents?

A. Incisional hernia
B. Hiatus hernia
C. Sliding hernia (Correct Answer)
D. Rolling hernia

Explanation: ***Sliding hernia*** - A **sliding hernia** occurs when a **retroperitoneal organ** (such as cecum, sigmoid colon, or bladder) **forms part of the wall of the hernia sac** itself - The **cecum**, being retroperitoneal on the right side, characteristically "slides" into **right-sided inguinal hernias** - The peritoneal covering of the organ becomes part of the sac wall, distinguishing it from hernias where organs are simply contained within the sac - **Key distinguishing feature:** The organ is not just herniated content but actually forms the sac wall *Rolling hernia* - A **paraesophageal hernia** where the **gastric fundus** herniates through the diaphragmatic hiatus alongside the esophagus - The gastroesophageal junction remains in normal position - Involves only upper GI structures, not abdominal organs like the cecum *Incisional hernia* - Develops through weakened fascia at previous **surgical incision sites** - Can contain various abdominal contents including cecum, but the cecum does **not form part of the sac wall** as in sliding hernias - Lacks the specific anatomical relationship characteristic of sliding hernias *Hiatus hernia* - Protrusion of **stomach** through the esophageal hiatus into the thoracic cavity - Involves only gastroesophageal structures - Does not involve intestinal organs like the cecum

Question 1096: What condition is characterized by obstruction and dilatation of the large intestine in the absence of any mechanical obstruction?

A. Ogilvie syndrome (Correct Answer)
B. Hirschsprung disease
C. Chagas disease
D. Toxic megacolon

Explanation: ***Ogilvie syndrome*** - It is characterized by **acute colonic pseudo-obstruction**, involving massive dilation of the colon without a mechanical obstruction. - This condition most often occurs in severely ill, hospitalized patients and is thought to be due to an imbalance in the **autonomic nervous system** regulation of the colon. *Hirschsprung disease* - This is a **congenital condition** characterized by the absence of **ganglion cells** in the distal colon, leading to a functional obstruction. - It typically presents in neonates and infants with symptoms like failure to pass meconium, abdominal distension, and vomiting. *Chagas disease* - Caused by the parasite **Trypanosoma cruzi**, it can lead to chronic complications, including **cardiomyopathy** and **megacolon**. - The megacolon in Chagas disease results from destruction of the **myenteric plexus**, not an acute pseudo-obstruction. *Toxic megacolon* - This is an **acute complication** of **inflammatory bowel disease** (ulcerative colitis or Crohn's disease) or infectious colitis. - It involves severe colonic dilation with systemic toxicity, but occurs in the setting of severe mucosal inflammation, not pseudo-obstruction.

Question 1097: At what age do symptoms of midgut volvulus most commonly present?

A. 1 week (Correct Answer)
B. 2-3 days
C. 2-3 weeks
D. Within 24 hours

Explanation: ***1 week*** - **Midgut volvulus** is a surgical emergency where the intestine twists around the **superior mesenteric artery**, typically due to **intestinal malrotation**. - Approximately **50% of cases present within the first week of life**, making this the most common timeframe for symptom onset. - Classic presentation includes **bilious vomiting** in a neonate, which requires urgent surgical evaluation. - The volvulus causes arterial occlusion leading to **bowel ischemia** and potential necrosis if not promptly treated. *Within 24 hours* - While some cases present within the first 24 hours of life, this represents a subset of cases rather than the typical presentation timeframe. - The teaching emphasizes that 50% present in the **first week**, not specifically the first day. *2-3 days* - This falls within the first week and represents a reasonable timeframe for presentation. - However, when considering the **most typical** presentation period, the first week as a whole is the more accurate teaching point. *2-3 weeks* - While 75% of cases present within the **first month of life**, the peak incidence is earlier. - Presentation at 2-3 weeks is possible but less common than presentation in the first week. - Most standard references emphasize the **first week** as the critical period for presentation.

Question 1098: A patient after a heavy meal and episode of forceful vomiting presents with severe epigastric pain. On examination, there is tenderness and rigidity in the upper abdomen. X-ray shows pneumomediastinum. What is the most likely cause?

A. Spontaneous rupture of the esophagus (Correct Answer)
B. Penetrating injury to the esophagus
C. Perforation of a peptic ulcer
D. Rupture of an emphysematous bulla

Explanation: ***Spontaneous rupture of the esophagus*** - The combination of **post-emetic epigastric pain**, upper abdominal tenderness/rigidity, and **pneumomediastinum** is characteristic of Boerhaave syndrome, which is a **spontaneous transmural esophageal rupture**. - This rupture often occurs after a heavy meal or forceful vomiting, leading to a sudden increase in **intra-esophageal pressure**. *Penetrating injury to the esophagus* - While a penetrating injury could cause esophageal rupture and pneumomediastinum, the clinical scenario describes a **spontaneous event** following a meal, not trauma. - Absence of an external wound, trauma history, or foreign body ingestion makes this less likely. *Perforation of a peptic ulcer* - A perforated peptic ulcer would typically cause **severe, sudden onset epigastric pain** and **peritonitis**, but it would lead to **pneumoperitoneum** (free air in the abdomen) rather than pneumomediastinum. - While it could cause referred pain to the chest, the direct finding of air in the mediastinum points away from an isolated abdominal perforation. *Rupture of an emphysematous bulla* - Rupture of an emphysematous bulla would cause a **pneumothorax** or **pneumomediastinum**, but it would not typically present with severe epigastric pain and abdominal signs. - There would usually be a history of **lung disease** or smoking, and respiratory symptoms would be more prominent.

Question 1099: A patient presents with abdominal pain. On physical examination there was abdominal guarding and tenderness. A plain erect chest X-ray reveals air under diaphragm. Probable diagnosis is

A. Perforated abdominal viscus (Correct Answer)
B. Acute myocardial infarction
C. Aortic dissection
D. None of the options

Explanation: ***Perforated abdominal viscus*** - The presence of **abdominal guarding** and **tenderness** indicates peritoneal irritation, while **air under the diaphragm** on an erect chest X-ray (**pneumoperitoneum**) is a classic sign of a perforated hollow abdominal organ. - This combination strongly suggests a **perforated abdominal viscus**, such as a **perforated peptic ulcer** or perforated diverticulitis, leading to the leakage of air and intestinal contents into the peritoneal cavity. *Acute myocardial infarction* - Acute myocardial infarction primarily presents with **chest pain**, radiation to the arm/jaw, and shortness of breath, not typically severe abdominal pain with guarding. - While it can cause some epigastric discomfort, it would not explain the **pneumoperitoneum** seen on the chest X-ray. *Aortic dissection* - Aortic dissection typically causes **sudden, severe tearing chest or back pain**, often radiating to the back. - There is no direct link between aortic dissection and **air under the diaphragm** unless there's a co-existing, unrelated issue, which is not suggested by the primary symptoms. *None of the options* - Given the clear clinical and radiological findings of **pneumoperitoneum** and **peritoneal signs**, a perforated abdominal viscus is the most fitting diagnosis among the choices provided. - This option is incorrect as there is a highly probable diagnosis among the given choices.

Question 1100: Where does spontaneous esophageal rupture (Boerhaave syndrome) most commonly occur?

A. Below the diaphragmatic aperture
B. Pharyngoesophageal junction
C. At the crossing of the arch of aorta
D. Above the diaphragmatic aperture (Correct Answer)

Explanation: ***Above the diaphragmatic aperture*** - Boerhaave syndrome, or spontaneous esophageal rupture, most commonly occurs in the **distal esophagus**, just above the diaphragmatic aperture. - This region is particularly susceptible due to increased **intraluminal pressure** during forceful vomiting, combined with a lack of muscular support and a thinner esophageal wall. - The rupture typically occurs in the **left posterolateral wall** of the lower third of the esophagus, approximately **2-5 cm above the gastroesophageal junction**. *Below the diaphragmatic aperture* - Ruptures below the diaphragmatic aperture are less common in Boerhaave syndrome, as the **lower esophageal sphincter** and surrounding diaphragmatic crura provide more support. - While other forms of esophageal injury can occur here, a spontaneous rupture due to vomiting is less typical in this location. *Pharyngoesophageal junction* - Ruptures at the pharyngoesophageal junction are known as **Zenker's diverticulum ruptures** or other types of perforation, typically not Boerhaave syndrome. - This area is prone to tears from instrumentation or foreign bodies but not usually from the extreme pressure of forceful vomiting (which affects the distal esophagus more). *At the crossing of the arch of aorta* - The mid-esophagus at the level of the aortic arch is not a common site for Boerhaave syndrome. - Although the esophagus is constricted here, the primary stress during forceful vomiting is concentrated in the **distal esophagus**.

Practice by Chapter

Esophageal Disorders

Practice Questions

Gastric Disorders

Practice Questions

Small Intestine Pathology

Practice Questions

Appendicitis

Practice Questions

Inflammatory Bowel Disease

Practice Questions

Intestinal Obstruction

Practice Questions

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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