Gastrointestinal Surgery — MCQs
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A 55 year old woman presented with history of recurrent episodes of right upper abdominal pain for the last one year. She presented to emergency with history of jaundice and fever for 2 days. On examination, the patient appeared toxic and had a blood pressure of 100/60 mmHg. She was started on intravenous antibiotics. Ultrasound of the abdomen showed presence of stones in the common bile duct. What would be the best treatment option for her -
All of the following are true about Nissen Fundoplication except which of the following?
Which of the following is true about Mallory-Weiss tear -
Under what guidelines is treatment started for a patient presenting with appendicular mass on a CT scan?
A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -
What is the commonest site of peptic ulcer?
Among pathological lead points, the commonest cause of intussusception is -
All of the following are surgical options in the management of esophageal carcinoma except -
Which of the following statements is MOST accurate regarding Zenker diverticulum?
Pulled up cecum is seen in which condition?
Gastrointestinal Surgery Indian Medical PG Practice Questions and MCQs
Question 1101: A 55 year old woman presented with history of recurrent episodes of right upper abdominal pain for the last one year. She presented to emergency with history of jaundice and fever for 2 days. On examination, the patient appeared toxic and had a blood pressure of 100/60 mmHg. She was started on intravenous antibiotics. Ultrasound of the abdomen showed presence of stones in the common bile duct. What would be the best treatment option for her -
- A. Open bile duct surgery for stone removal
- B. Lithotripsy for bile duct stones
- C. Laparoscopic cholecystectomy (gallbladder removal)
- D. Endoscopic Retrograde Cholangiopancreatography (ERCP) and bile duct stone extraction (Correct Answer)
Explanation: ***Endoscopic Retrograde Cholangiopancreatography (ERCP) and bile duct stone extraction*** - The patient presents with **Reynolds' pentad** (Charcot's triad - right upper abdominal pain, jaundice, fever - plus hypotension and toxic appearance/altered mental status), indicating severe acute **cholangitis with septic shock** due to common bile duct stones. - **ERCP with stone extraction** is the most appropriate initial treatment in this unstable patient to achieve rapid biliary decompression and remove the obstruction, which is life-saving in septic cholangitis. - This minimally invasive approach provides urgent drainage while minimizing surgical stress in a critically ill patient. *Laparoscopic cholecystectomy (gallbladder removal)* - While cholecystectomy addresses gallbladder stones, it does not directly remove **common bile duct stones** causing the current acute cholangitis. - Performing cholecystectomy alone in an acutely septic patient would not resolve the immediate life-threatening biliary obstruction. - Cholecystectomy can be considered later (interval cholecystectomy) after stabilization and ERCP. *Open bile duct surgery for stone removal* - This is a more invasive procedure with higher morbidity and mortality compared to ERCP for initial management of common bile duct stones, especially in an acutely ill, hemodynamically unstable patient. - **Open surgery** is typically reserved for cases where ERCP fails or is not feasible, or for complex cases requiring biliary reconstruction. *Lithotripsy for bile duct stones* - **Lithotripsy** (fragmenting stones) is not appropriate for initial management of acute cholangitis with sepsis, as it does not provide immediate biliary drainage. - It might be considered as an adjunct for very large or impacted stones during ERCP, but it's not the primary immediate treatment in this emergency setting.
Question 1102: All of the following are true about Nissen Fundoplication except which of the following?
- A. It is done for GERD
- B. Upper part of stomach is plicated around the lower esophagus
- C. It is done for paraesophageal hiatus hernia
- D. Reinforcement is done only in the posterior half (Correct Answer)
Explanation: ***Reinforcement is done only in the posterior half*** - This statement is incorrect because the **Nissen fundoplication** typically involves a **360-degree wrap** of the gastric fundus around the lower esophagus. - A 360-degree wrap provides complete reinforcement to prevent reflux, unlike a partial wrap which might be used in other procedures but not a standard Nissen. *It is done for GERD* - **Nissen fundoplication** is a common surgical procedure performed to treat severe **Gastroesophageal Reflux Disease (GERD)** that is refractory to medical management. - The procedure aims to strengthen the **lower esophageal sphincter (LES)** and prevent the reflux of stomach contents into the esophagus. *Upper part of stomach is plicated around the lower esophagus* - Specifically, the **fundus** (upper part) of the stomach is wrapped around the distal esophagus to create a functional valve. - This wrap helps to reinforce the LES and prevent stomach acid from flowing back up into the esophagus. *It is done for paraesophageal hiatus hernia* - **Nissen fundoplication** is often performed concurrently with the repair of a **hiatal hernia**, especially a **paraesophageal hernia**, to anchor the stomach in its correct anatomical position and prevent recurrence. - Repair of the hernia alone may not be sufficient to prevent reflux, making the fundoplication an important additional step.
Question 1103: Which of the following is true about Mallory-Weiss tear -
- A. It is a mucosal tear not extending through the muscle layer (Correct Answer)
- B. It is more common in women than men
- C. It is common in young individuals
- D. It is associated with achalasia cardia
Explanation: ***It is a mucosal tear not extending through the muscle layer*** - A **Mallory-Weiss tear** is defined as a longitudinal tear in the **mucosa** of the distal esophagus or proximal stomach. - These tears typically do not extend through the **muscularis propria** layer, distinguishing them from a Boerhaave syndrome, which is a full-thickness rupture. *It is more common in women than men* - Mallory-Weiss tears show a **male predominance** with a male-to-female ratio of approximately 2-4:1. - Risk factors like **alcohol use disorder** and forceful vomiting are more common in males, contributing to this gender distribution. *It is common in young individuals* - Mallory-Weiss tears are more common in **middle-aged to older individuals**, typically between 40 and 60 years old. - The condition is rare in young children or teenagers. *It is associated with achalasia cardia* - While both conditions affect the esophagus, there is **no direct causal association** between Mallory-Weiss tears and **achalasia cardia**. - Achalasia is a motility disorder, whereas Mallory-Weiss tears are caused by sudden increases in intra-abdominal pressure.
Question 1104: Under what guidelines is treatment started for a patient presenting with appendicular mass on a CT scan?
- A. Ochsner Sherren Regimen (Correct Answer)
- B. Conservative management and discharge
- C. Kocher's Regimen
- D. Immediate Laparotomy
Explanation: ***Ochsner Sherren Regimen*** - The **Ochsner Sherren regimen** is a conservative management approach specifically used for patients presenting with an **appendicular mass** (a palpable mass formed by the inflamed appendix, omentum, and small bowel loops). - This regimen involves **nil by mouth**, **intravenous fluids**, **antibiotics**, and **analgesia**, with close observation to allow the inflammation to subside before potential interval appendectomy. *Conservative management and discharge* - While the Ochsner Sherren regimen is a form of conservative management, simply stating "conservative management and discharge" is incomplete and potentially dangerous for a patient with an **appendicular mass**. - **Discharge** is not appropriate without a period of observation and specific medical interventions like antibiotics, as there's a risk of abscess formation or perforation. *Kocher's Regimen* - **Kocher's regimen** is not a recognized treatment protocol for an appendicular mass. - The term "Kocher" is more commonly associated with a **surgical incision** (Kocher incision for cholecystectomy) or a **maneuver** (Kocher maneuver for duodenal mobilization). *Immediate Laparotomy* - **Immediate laparotomy** is generally contraindicated in the presence of a well-formed **appendicular mass**. - Operating on a friable, inflamed mass can disrupt the natural containment, leading to widespread peritonitis and increased morbidity. The Ochsner Sherren regimen aims to cool down the inflammation first.
Question 1105: A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -
- A. Proceed to laparotomy and appendicectomy (Correct Answer)
- B. Intravenous antibiotics
- C. Continue Ochsner Sherren regimen with close monitoring
- D. Continue conservative management
Explanation: ***Proceed to laparotomy and appendicectomy*** - A **rising pulse rate, tachycardia, and fever** indicate **worsening sepsis** or **perforation** of the appendicular mass, necessitating urgent surgical intervention. - Continuing conservative management in the face of these signs carries a high risk of **morbidity and mortality** from peritonitis or widespread sepsis. *Continue Ochsner Sherren regimen with close monitoring* - The Ochsner Sherren regimen is a **conservative approach** for a stable appendicular mass, which is no longer the case with signs of deterioration. - **Clinical worsening** (tachycardia, rising fever, increased pulse) signifies failure of conservative management and requires a shift to surgical intervention. *Continue conservative management* - Continuing conservative management despite **signs of deterioration** (rising pulse, tachycardia, fever) would lead to further progression of the disease and potential life-threatening complications. - These symptoms suggest that the infection is **not contained** and is likely spreading, indicating the need for immediate surgical treatment. *Intravenous antibiotics* - While intravenous antibiotics are part of the initial conservative management, they are **insufficient** alone for an appendicular mass showing signs of deterioration. - The worsening clinical picture suggests a **failed antibiotic response** or a more severe underlying issue (e.g., abscess rupture) that requires surgical drainage or removal.
Question 1106: What is the commonest site of peptic ulcer?
- A. Second part of the duodenum
- B. Distal third of the stomach
- C. Pylorus of the stomach
- D. First part of the duodenum (Correct Answer)
Explanation: ***First part of the duodenum*** - The **duodenal bulb** (first part of the duodenum) is the most common location for peptic ulcers due to its proximity to the pylorus, where it's exposed to **acidic chyme** and susceptible to **H. pylori infection**. - The **mucosal defenses** in the duodenum are often less robust compared to the stomach, making it more vulnerable to acid-pepsin aggression. *Second part of the duodenum* - Ulcers in the **second part of the duodenum** are relatively rare compared to the first part. - This section receives bile and pancreatic secretions which help to **neutralize stomach acid**, providing greater protection. *Distal third of the stomach* - Ulcers in the **distal third of the stomach** are less common than in the first part of the duodenum. - While **gastric ulcers** do occur, they are more frequently found in the **antrum or lesser curvature** of the stomach. *Pylorus of the stomach* - Ulcers can occur in the **pylorus**, but they are not as frequent as those in the **duodenal bulb**. - Pyloric ulcers are considered a type of **gastric ulcer** and can be associated with gastric outlet obstruction.
Question 1107: Among pathological lead points, the commonest cause of intussusception is -
- A. Submucous lipoma
- B. Meckel's diverticulum (Correct Answer)
- C. Polyp
- D. Hypertrophy of submucous peyer's patches
Explanation: ***Meckel's diverticulum*** - Among **pathological lead points** specifically, **Meckel's diverticulum** is the most common cause of intussusception. - It is a true congenital diverticulum that can act as a lead point when it becomes inverted, inflamed, or has associated ectopic tissue or tumors. - While overall intussusception in children is mostly idiopathic, when a **pathological lesion** is identified, Meckel's diverticulum is the leading cause. - Seen in approximately 2% of the population, it follows the "rule of 2s" and is the most frequent anatomical abnormality causing pathological intussusception in pediatric patients. *Hypertrophy of submucous Peyer's patches* - **Peyer's patch hypertrophy** is the most common cause of intussusception **overall** in children (90% of cases), typically following viral infections. - However, this represents **idiopathic intussusception**, not a true pathological lead point, as no discrete anatomical lesion is identified. - The question specifically asks for pathological lead points, which excludes this idiopathic mechanism. *Submucous lipoma* - A **submucous lipoma** can serve as a pathological lead point for intussusception, but is much rarer. - More commonly seen in adults rather than children. - While it is a true pathological lesion, it is less frequent than Meckel's diverticulum as a lead point. *Polyp* - **Polyps** (adenomatous, hamartomatous, or inflammatory) can act as pathological lead points. - More common in adults and in specific syndromes (e.g., Peutz-Jeghers syndrome). - Less frequent than Meckel's diverticulum among pathological causes in the pediatric population.
Question 1108: All of the following are surgical options in the management of esophageal carcinoma except -
- A. Ivor Lewis Approach
- B. McKeown's Approach
- C. Transhiatal removal
- D. Sistrunk operation (Correct Answer)
Explanation: ***Sistrunk operation*** - The **Sistrunk operation** is a surgical procedure specifically designed for the removal of a **thyroglossal duct cyst**, not for esophageal carcinoma. - This procedure involves excising the cyst along with the central portion of the hyoid bone and the tract leading to the foramen cecum to prevent recurrence. *Ivor Lewis Approach* - The **Ivor Lewis approach** is a common and established surgical technique for **esophagectomy**, involving both abdominal and right thoracic incisions for tumor resection and reconstruction. - It is often used for tumors in the mid to distal esophagus. *Mckeown's Approach* - The **McKeown's approach** is another well-known surgical technique for **esophagectomy**, typically used for more proximal esophageal tumors. - This involves three incisions: abdominal, right thoracic, and cervical, allowing for extensive lymphadenectomy. *Transhiatal removal* - **Transhiatal esophagectomy** is a surgical option for esophageal cancer that involves abdominal and cervical incisions without a thoracic incision. - This approach is often favored in patients with significant comorbidities who may not tolerate a full thoracotomy.
Question 1109: Which of the following statements is MOST accurate regarding Zenker diverticulum?
- A. It is a pulsion diverticulum (Correct Answer)
- B. It is between superior and middle constrictor
- C. It projects posteriorly
- D. It is commonly seen in older adults
Explanation: ***It is a pulsion diverticulum*** - A **Zenker diverticulum** is formed by the herniation of the **pharyngeal mucosa** through a weak point in the posterior pharyngeal wall, driven by increased intraluminal pressure (**pulsion**). - This contrasts with **traction diverticula**, which are caused by external pulling forces on the esophageal wall. *It is between superior and middle constrictor* - **Zenker diverticulum** occurs in **Killian's triangle**, a weak area between the **cricopharyngeus muscle** (part of the inferior constrictor) and the **thyropharyngeus muscle** (also part of the inferior constrictor). - The superior and middle constrictor muscles are located more superiorly in the pharynx, and diverticula in this region are rare. *It projects posteriorly* - Although it originates from the **posterior pharyngeal wall**, the **Zenker diverticulum** typically projects **left laterally** or **inferiorly** into the neck as it enlarges. - Its initial herniation is posterior, but subsequent growth and gravitational forces lead to its characteristic downward and often left-sided displacement. *It is commonly seen in older adults* - While it most commonly affects **older adults**, this statement describes an **epidemiological characteristic** rather than a fundamental pathophysiological feature of the diverticulum's formation. - The question asks for the **most accurate statement** regarding its nature, and its classification as a pulsion diverticulum directly addresses its pathological mechanism.
Question 1110: Pulled up cecum is seen in which condition?
- A. Cecal carcinoma
- B. Intussusception
- C. Colon carcinoma
- D. Ileocecal tuberculosis (TB) (Correct Answer)
Explanation: ***Ileocecal tuberculosis (TB)*** - **Ileocecal tuberculosis** commonly causes **fibrosis** and stricture formation in the ileocecal region, which can lead to the **retraction or pulling up of the cecum**. - This "pulled-up cecum" is a characteristic radiographic finding, often associated with a **patulous ileocecal valve** and inflammatory changes. *Cecal carcinoma* - While cecal carcinoma can cause a mass and involve the cecum, it does not typically lead to a "pulled-up" appearance. - Carcinoma usually presents as a **filling defect** or an **obstructing lesion** rather than retraction. *Intussusception* - **Intussusception** involves the telescoping of one part of the intestine into another, usually presenting as a **target sign** on imaging. - This condition does not cause a *pulled-up cecum*; instead, it involves the distal segment invaginating into the proximal segment. *Colon carcinoma* - **Colon carcinoma** can manifest as an **apple-core lesion** or an obstructing mass, but like cecal carcinoma, it generally does not cause the cecum to be pulled upwards. - The pathology is primarily one of **luminal narrowing** or mass obstruction.
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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