Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery Indian Medical PG Practice Questions and MCQs

Question 1151: Hernia containing Meckel's diverticulum is a?

A. Littre hernia (Correct Answer)
B. Maydl's hernia
C. Hernia of Winslow
D. Pantaloon hernia

Explanation: ***Littre hernia*** - A **Littre hernia** is explicitly defined as a hernia that contains a **Meckel's diverticulum**. - This specific type of hernia can occur in various locations, including inguinal, femoral, or umbilical hernias. *Maydl's hernia* - A **Maydl's hernia**, also known as a W-hernia or retrograde incarceration, involves two loops of bowel within the hernia sac, with a segment of incarcerated bowel forming a 'W' outside the sac. - This typically involves an incarcerated bowel segment undergoing strangulation. *Hernia of Winslow* - A **hernia of Winslow** refers to the protrusion of abdominal contents, usually small bowel, through the **foramen of Winslow** (epiploic foramen) into the lesser sac. - This is an internal hernia type, distinct from external abdominal wall hernias. *Pantaloon hernia* - A **pantaloon hernia** (or saddlebag hernia) is a combined direct and indirect inguinal hernia. - It occurs when the hernia sac straddles the inferior epigastric vessels.

Question 1152: Which of the following is true about Zenker's diverticulum?

A. It is asymptomatic
B. Occurs in the mid-esophagus
C. It occurs in children
D. Treatment options typically include surgical interventions such as diverticulectomy or cricopharyngeal myotomy. (Correct Answer)

Explanation: ***Correct Option D: Treatment options typically include surgical interventions such as diverticulectomy or cricopharyngeal myotomy*** - **Zenker's diverticulum** is a false diverticulum that usually requires **surgical intervention** due to its progressive nature and potential complications. - **Diverticulectomy** (surgical removal) and **cricopharyngeal myotomy** (cutting the cricopharyngeal muscle) reduce symptoms and prevent further food accumulation. - Other treatment modalities include **endoscopic stapling diverticulostomy** and **flexible endoscopic septum division**. *Incorrect Option A: It is asymptomatic* - **Zenker's diverticulum** is usually **symptomatic**, causing **dysphagia**, **regurgitation of undigested food**, and **halitosis**. - Symptoms often worsen over time as the diverticulum grows and retains more food particles. *Incorrect Option B: Occurs in the mid-esophagus* - **Zenker's diverticulum** is a **pharyngoesophageal diverticulum** that occurs in the posterior hypopharynx, specifically in **Killian's triangle**, above the upper esophageal sphincter. - Diverticula in the mid-esophagus are typically **traction diverticula**, which are true diverticula involving all layers of the esophageal wall. *Incorrect Option C: It occurs in children* - **Zenker's diverticulum** is rare in children and is primarily a condition of **older adults**, typically presenting after the age of 60. - It results from **cricopharyngeal muscle dysfunction** and increased intraluminal pressure over many years.

Question 1153: Gangrene of the intestine is seen in all the following conditions, except:

A. Shock
B. Mesenteric artery thrombosis
C. Tricuspid Valve Endocarditis (Correct Answer)
D. Volvulus

Explanation: ***Tricuspid Valve Endocarditis*** - While vegetations from **tricuspid valve endocarditis** can embolize, they typically affect the **pulmonary circulation** (e.g., pulmonary embolism, septic pulmonary infarcts) due to the venous drainage pattern. - Embolization from the right side of the heart to the systemic circulation (like the mesenteric arteries) is rare unless there's a **patent foramen ovale** or similar intracardiac shunt. - Therefore, tricuspid endocarditis does **NOT** typically cause intestinal gangrene. *Shock* - **Hypoperfusion** during shock leads to a severe reduction in blood flow to the intestines, causing **ischemia**. - Prolonged or severe ischemia can result in **intestinal gangrene** due to tissue death. - This is known as **non-occlusive mesenteric ischemia (NOMI)**. *Mesenteric artery thrombosis* - A **thrombus** in the mesenteric artery directly blocks blood supply to a segment of the intestine. - This abrupt cessation of blood flow leads rapidly to **ischemia and infarction**, resulting in gangrene. - Accounts for approximately 25-30% of acute mesenteric ischemia cases. *Volvulus* - **Volvulus** involves the twisting of a loop of intestine around its mesentery, which constricts and obstructs the mesenteric blood vessels. - This vascular compromise quickly leads to **ischemia and gangrene** of the twisted bowel segment. - Common sites include sigmoid colon and cecum.

Question 1154: In a patient with gastric carcinoma involving the antrum with extensive perigastric and distant lymph node involvement (para-aortic nodes) and poor performance status, what is the most appropriate surgical management option?

A. None of the options
B. Gastrojejunostomy
C. Total radical gastrectomy
D. Palliative gastrectomy (Correct Answer)

Explanation: ***Palliative gastrectomy*** - This option is appropriate when gastric cancer has **distant lymph node metastases (para-aortic nodes - M1 disease)** and poor performance status, indicating **non-curable disease** - The goal is to alleviate symptoms like bleeding, obstruction, or pain to improve **quality of life**, not to achieve cure - **Palliative gastrectomy** removes the primary tumor to prevent complications such as bleeding or obstruction, even when cure is not achievable - Surgery should only be considered if the patient is symptomatic and has adequate performance status to tolerate the procedure *Total radical gastrectomy* - This is the standard curative approach for **resectable gastric cancer**, including those with regional (perigastric) lymph node involvement (N1-N3 disease) - Involves complete tumor resection with clear margins and **D2 lymphadenectomy** for adequate staging and potential cure - However, in this case with **distant nodal metastases (M1 disease)** and poor performance status, radical surgery would not achieve cure and carries high morbidity without proportional survival benefit - Regional lymph node involvement alone does NOT preclude curative surgery, but distant nodal spread and poor performance status do *Gastrojejunostomy* - This bypass procedure relieves **gastric outlet obstruction** without removing the tumor - Indicated when there is pyloric or distal gastric obstruction causing symptoms - Less morbid than gastrectomy but does not address bleeding from the tumor or significant tumor burden - May be preferred over gastrectomy if the patient has very poor performance status and only obstructive symptoms *None of the options* - Incorrect, as one of the surgical options (palliative gastrectomy) is appropriate for this clinical scenario - The choice between palliative resection and bypass depends on symptoms, performance status, and goals of care

Question 1155: The triad of diverticulosis, gallstones, and hiatus hernia is termed as:

A. Saint's triad (Correct Answer)
B. Whipple's triad
C. Murphy's triad
D. Beck's triad

Explanation: ***Saint's triad*** - This specific combination of **diverticulosis, gallstones, and hiatus hernia** is traditionally known as **Saint's triad**. - It describes the co-occurrence of three common age-related gastrointestinal conditions often seen together. *Beck's triad (hypotension, muffled heart sounds, jugular venous distention)* - **Beck's triad** is characteristic of **cardiac tamponade**, a life-threatening condition where fluid accumulates around the heart, impairing its function. - The presented triad of gastrointestinal conditions is unrelated to cardiac tamponade. *Whipple's triad (neuroglycopenic symptoms, hypoglycemia, improvement after glucose administration)* - **Whipple's triad** is used to diagnose **insulinoma** or other causes of **hypoglycemia** in non-diabetic individuals. - It specifically refers to symptoms related to low blood sugar and their resolution upon glucose administration, not gastrointestinal anatomical issues. *Murphy's triad (abdominal pain, fever, vomiting)* - **Murphy's triad** describes the classical symptoms of **acute appendicitis**. - These are clinical signs of acute inflammation within the abdomen, distinctly different from the chronic anatomical conditions listed in the question.

Question 1156: Which of the following statements about duodenal diverticula is false?

A. Can cause acute pancreatitis
B. Most common site is periampullary region
C. Whenever found, should be treated due to increased risk of complications (Correct Answer)
D. Most are asymptomatic

Explanation: ***Can cause acute pancreatitis*** - This statement is **true**, not false. Duodenal diverticula, especially **periampullary diverticula**, can obstruct the pancreatic duct, leading to bile stasis and **acute pancreatitis**. - They can also cause **cholangitis** and recurrent choledocholithiasis through similar mechanisms of obstruction at the ampulla of Vater. *Most are asymptomatic* - This statement is **true**. The vast majority of duodenal diverticula are **asymptomatic** and are often discovered incidentally during imaging or endoscopy. - Only a small percentage of individuals with duodenal diverticula will develop complications. *Most common site is periampullary region* - This statement is **true**. Duodenal diverticula are most frequently found in the **second part of the duodenum**, often in the **periampullary** region (around the ampulla of Vater). - These are typically **extraluminal pseudodiverticula** which herniate through the duodenal wall. *Whenever found, should be treated due to increased risk of complications* - This statement is **false**. Given that most duodenal diverticula are **asymptomatic** and do not cause problems, prophylactic treatment is generally **not recommended**. - Treatment, typically surgical intervention, is reserved for diverticula that are causing **symptoms** or **complications** such as bleeding, perforation, obstruction, or recurrent pancreatitis/cholangitis.

Question 1157: All of the following can be used as endoscopic sclerosants in the treatment of variceal bleeding, except -

A. Alcohol
B. Acetic acid (Correct Answer)
C. Polydochanol
D. Cyanoacrylate

Explanation: ***Acetic acid*** - **Acetic acid** is not typically used for endoscopic variceal sclerotherapy due to its potent corrosive nature and high risk of tissue damage. - While it has been explored in experimental settings for superficial lesions (e.g., cervical disease), it is not a standard sclerosant for esophageal varices. *Polydochanol* - **Polydochanol** (or Aethoxysclerol®) is a commonly used sclerosing agent for esophageal varices. - It works by inducing **endothelial damage** and subsequent thrombosis and fibrosis within the varix. *Cyanoacrylate* - **Cyanoacrylate** glue is particularly effective for large **gastric varices** due to its ability to rapidly polymerize and achieve immediate hemostasis. - It directly occludes the varix, preventing rebleeding, and is often preferred for gastric varices where conventional sclerotherapy might be less effective. *Alcohol* - **Absolute alcohol** (ethanol) is a traditional and effective sclerosant for esophageal varices, causing rapid **dehydration** and protein denaturation within the vessel wall. - It leads to immediate thrombosis and subsequent fibrosis of the targeted varices.

Question 1158: What is the most common cause of intestinal obstruction?

A. Ileocaecal tuberculosis
B. Carcinoma colon
C. Intussusception
D. Adhesions (Correct Answer)

Explanation: ***Adhesions*** - **Post-surgical adhesions** are by far the leading cause of **small bowel obstruction** in adults, accounting for approximately 60-80% of cases. - They form as fibrous bands between tissue surfaces after surgery, which can later constrict or twist the bowel. *Ileocaecal tuberculosis* - While it can cause intestinal obstruction due to **stricture formation** and inflammation, it is a much rarer cause, particularly in developed countries. - This condition is more common in immunocompromised individuals or endemic areas. *Carcinoma colon* - **Colorectal cancer** is a common cause of **large bowel obstruction**, but it is less frequent as a cause of overall intestinal obstruction compared to adhesions. - The obstruction typically develops gradually as the tumor grows and narrows the bowel lumen. *Intussusception* - This is a more common cause of intestinal obstruction in **infants and young children**, where one part of the intestine telescopes into another. - In adults, it is a relatively rare cause of obstruction and is often associated with a **lead point** such as a tumor or polyp.

Question 1159: All are causes of mechanical intestinal obstruction except which of the following?

A. Intussusception
B. Bands
C. Mesenteric vascular occlusion (Correct Answer)
D. Gall stones

Explanation: ***Mesenteric vascular occlusion*** - This condition causes **ischemic bowel injury** due to impaired blood flow, leading to **paralytic ileus** rather than a physical blockage. - While it results in intestinal dysfunction, it does not involve a **mechanical obstruction** by a physical barrier. *Gall stones* - Large **gallstones** can erode through the gallbladder wall into the small intestine, leading to a condition called **gallstone ileus**. - This creates a **physical obstruction** within the lumen of the small bowel. *Intussusception* - **Intussusception** involves one segment of the intestine telescoping into an adjacent segment. - This creates a **mechanical blockage** of the intestinal lumen. *Bands* - Internal **fibrous bands** or adhesions, often from previous surgeries, can constrict and obstruct the bowel lumen. - These bands represent a direct **physical impediment** to the passage of intestinal contents.

Question 1160: A 60-year-old diabetic man is admitted to the hospital with a diagnosis of acute cholecystitis. The white blood cell count is 28,000, and a plain film of the abdomen and computed tomography scan show evidence of intramural gas in the gallbladder. What is the most likely diagnosis?

A. Emphysematous gallbladder (Correct Answer)
B. Acalculous cholecystitis
C. Cholangiohepatitis
D. Sclerosing cholangitis

Explanation: ***Emphysematous gallbladder*** - The presence of **intramural gas** in the gallbladder wall, along with signs of **acute cholecystitis** and a high WBC count in a diabetic patient, is highly characteristic of emphysematous cholecystitis. - This severe form of cholecystitis is caused by gas-forming organisms, often seen in older, diabetic, or immunocompromised patients. *Acalculous cholecystitis* - This condition is **acute inflammation of the gallbladder** without the presence of gallstones, often seen in critically ill patients. - While it can be severe, it does not typically present with **intramural gas** as a primary diagnostic feature unless complicated by gas-forming organisms, which would then lead to emphysematous cholecystitis. *Cholangiohepatitis* - This refers to inflammation of the **bile ducts and liver parenchyma**, often presenting with fever, jaundice, and RUQ pain, but less commonly with gallbladder wall thickening or intramural gas. - Diagnosis usually requires evidence of **intrahepatic or extrahepatic bile duct dilation** or stones, which are not described here. *Sclerosing cholangitis* - This is a chronic, progressive cholestatic liver disease characterized by **inflammation and fibrosis of the bile ducts**, leading to strictures. - It presents with symptoms like **pruritus, fatigue, and jaundice**, and a diagnosis is typically made by cholangiography showing "beading" of the bile ducts; it does not involve intramural gallbladder gas.

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

Practice Questions

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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