Gastrointestinal Surgery — MCQs
On this page
Which of the following statements about volvulus is false?
Total gastrectomy is the only accepted treatment for which of the following conditions?
A 75-year-old woman with chronic atrial fibrillation presented to the hospital with a 2-day history of colicky abdominal pain. Physical examination revealed hypoactive bowel sounds and diffuse abdominal tenderness. Laboratory tests showed a white cell count of 19,400 per cubic millimeter with 92% neutrophils, a blood urea nitrogen level of 42 mg/dL, and a serum creatinine level of 3.0 mg/dL. What is the most probable diagnosis in this patient?
What is the most important cause of abdominal distension in intestinal obstruction?
A 35-year-old lady presented with retrosternal burning pain, epigastric pain, and regurgitation for 6 years. What is the most preferred treatment option?
A 72-year-old patient presents with an intractable type I ulcer along the incisura and significant scarring along the entire length of the lesser curvature. Select the appropriate surgical procedure for this patient.
Retractile mesenteris may be seen in which of the following conditions?
What is the investigation of choice for Zenker's diverticulum?
What is a mucocele of the appendix?
Which of the following is a known complication of a stoma (e.g., colostomy)?
Gastrointestinal Surgery Indian Medical PG Practice Questions and MCQs
Question 631: Which of the following statements about volvulus is false?
- A. More common in psychiatric patients
- B. Sigmoid volvulus is more common than caecal volvulus
- C. Lower GI endoscopy is contraindicated in sigmoid volvulus (Correct Answer)
- D. Volvulus of the caecum is managed by conservative methods
Explanation: ### Explanation **1. Why Option C is the correct (False) statement:** In **Sigmoid Volvulus**, lower GI endoscopy (specifically rigid or flexible sigmoidoscopy) is **not contraindicated**; in fact, it is the **initial treatment of choice** for non-gangrenous cases. Sigmoidoscopy allows for detorsion of the twisted loop and decompression of the proximal colon. A flatus tube is typically left in situ to prevent immediate recurrence. It is only contraindicated if there are signs of gangrene or perforation (peritonitis). **2. Analysis of other options:** * **Option A (True):** Volvulus is more common in psychiatric patients and those in nursing homes. This is often due to chronic constipation, use of psychotropic drugs (which affect gut motility), and a high-fiber diet leading to a redundant sigmoid colon. * **Option B (True):** Sigmoid volvulus is the most common site of volvulus (approx. 75-80%), followed by the caecum. * **Option D (True/Clinical Context):** While the definitive treatment for caecal volvulus is surgery (caecopexy or right hemicolectomy), initial management in a stable patient involves conservative stabilization (IV fluids, NPO). However, unlike sigmoid volvulus, **endoscopic detorsion is rarely successful in caecal volvulus**, making surgery the primary requirement. *Note: In the context of this specific MCQ, Option C is the most definitively false statement.* **3. Clinical Pearls for NEET-PG:** * **X-ray Sign (Sigmoid):** "Coffee bean sign" or "Omega sign" with the convexity pointing towards the Right Upper Quadrant. * **X-ray Sign (Caecal):** "Comma sign" with the convexity pointing towards the Left Lower Quadrant. * **Barium Enema:** Shows a characteristic "Bird’s beak" or "Ace of Spades" appearance. * **Definitive Treatment:** Since recurrence after endoscopic decompression is high (40-50%), a definitive elective sigmoid resection is recommended after the acute episode is resolved.
Question 632: Total gastrectomy is the only accepted treatment for which of the following conditions?
- A. Cancer located in the proximal stomach (Correct Answer)
- B. Cancer located in the distal stomach
- C. Ulcerating lesion in the body of the stomach
- D. Polyploidy lesion in the antrum of the stomach
Explanation: **Explanation:** The surgical management of gastric adenocarcinoma is primarily determined by the **location of the tumor** and the need to achieve **R0 resection** (microscopically negative margins). **Why Option A is Correct:** For cancers located in the **proximal third** of the stomach (cardia or fundus), a **Total Gastrectomy** is mandatory. To ensure an adequate proximal margin (typically 5 cm in diffuse types and 3 cm in intestinal types) and to perform a complete D2 lymphadenectomy, the entire stomach must be removed. Reconstructive surgery, usually a Roux-en-Y esophagojejunostomy, is then performed. **Why Other Options are Incorrect:** * **B. Cancer in the distal stomach:** For tumors in the antrum or pylorus, a **Subtotal Gastrectomy** (removing approximately 80% of the stomach) is the treatment of choice. It offers similar survival rates to total gastrectomy with better functional outcomes and nutritional status. * **C. Ulcerating lesion in the body:** If the lesion is benign (Peptic Ulcer Disease), conservative management or highly selective vagotomy is preferred. If malignant, the extent of resection depends on the specific location within the body; however, subtotal gastrectomy is often sufficient for mid-body lesions. * **D. Polyploidy lesion in the antrum:** These are often benign or early-stage lesions. If benign, endoscopic mucosal resection (EMR) or simple excision is sufficient. If malignant, a distal/subtotal gastrectomy is performed, not a total gastrectomy. **High-Yield Clinical Pearls for NEET-PG:** * **Standard of Care:** Total gastrectomy is indicated for proximal tumors, linitis plastica, and hereditary diffuse gastric cancer (prophylactic). * **Margins:** A minimum of **5 cm** proximal margin is recommended for gastric cancer. * **Reconstruction:** **Roux-en-Y** is the most common reconstruction after total gastrectomy to prevent biliary reflux esophagitis. * **Lymphadenectomy:** **D2 lymphadenectomy** is the current standard surgical procedure for curable gastric cancer.
Question 633: A 75-year-old woman with chronic atrial fibrillation presented to the hospital with a 2-day history of colicky abdominal pain. Physical examination revealed hypoactive bowel sounds and diffuse abdominal tenderness. Laboratory tests showed a white cell count of 19,400 per cubic millimeter with 92% neutrophils, a blood urea nitrogen level of 42 mg/dL, and a serum creatinine level of 3.0 mg/dL. What is the most probable diagnosis in this patient?
- A. Portal vein thrombosis
- B. Mesenteric ischemia (Correct Answer)
- C. Intestinal perforation
- D. Lynch syndrome
Explanation: **Explanation:** The clinical presentation is classic for **Acute Mesenteric Ischemia (AMI)**. The patient has a significant predisposing factor—**chronic atrial fibrillation**—which is the most common cause of mesenteric arterial embolism (usually affecting the Superior Mesenteric Artery). **Why Mesenteric Ischemia is Correct:** The hallmark of AMI is "pain out of proportion to physical findings." In an elderly patient with an embolic source (AFib), sudden onset colicky pain followed by leukocytosis and signs of metabolic stress (elevated BUN/Creatinine suggesting dehydration or prerenal azotemia) strongly points toward intestinal ischemia. As the bowel becomes gangrenous, tenderness becomes more diffuse and bowel sounds decrease. **Why Other Options are Incorrect:** * **Portal vein thrombosis:** Usually presents with features of portal hypertension (ascites, variceal bleeding) or vague abdominal pain, but is less likely to cause acute colicky pain and high leukocytosis in the absence of underlying cirrhosis or prothrombotic states. * **Intestinal perforation:** While a complication of ischemia, primary perforation usually presents with sudden, sharp pain and "board-like" rigidity (peritonitis) rather than a 2-day history of colicky pain. * **Lynch syndrome:** This is a hereditary non-polyposis colorectal cancer (HNPCC) syndrome. It presents with a family history of cancers (colon, endometrial) and is not an acute surgical emergency. **Clinical Pearls for NEET-PG:** * **Gold Standard Investigation:** CT Angiography (CTA) is the investigation of choice. * **Most Common Site:** Superior Mesenteric Artery (SMA) due to its narrow take-off angle from the aorta. * **Laboratory Marker:** Elevated **Serum Lactate** is a sensitive but late marker indicating bowel infarction. * **Classic Triad:** Postprandial pain, weight loss, and abdominal bruit (seen in *chronic* mesenteric ischemia).
Question 634: What is the most important cause of abdominal distension in intestinal obstruction?
- A. Bacterial activity
- B. Diffusion from the blood
- C. Swallowed air (Correct Answer)
- D. Products of digestion
Explanation: In intestinal obstruction, abdominal distension is a hallmark clinical feature. The accumulation of gas and fluid proximal to the site of obstruction leads to this distension. **Why "Swallowed Air" is the correct answer:** The primary source of gas in an obstructed bowel is **swallowed air (aerophagia)**, accounting for approximately **70-80%** of the total gas volume. Swallowed air is predominantly composed of nitrogen (which is poorly absorbed by the intestinal mucosa) and oxygen. Because nitrogen remains in the lumen, it contributes significantly to the progressive distension seen in clinical practice. **Analysis of Incorrect Options:** * **Bacterial activity:** While bacteria produce gases like methane, hydrogen, and hydrogen sulfide through the fermentation of undigested food, this accounts for only about **10-15%** of the total gas volume. * **Diffusion from the blood:** Gases like CO₂ can diffuse from the bloodstream into the bowel lumen, but this contributes a negligible amount (approx. **5%**) to the overall distension. * **Products of digestion:** The chemical interaction of gastric acid and pancreatic bicarbonate produces CO₂, but most of this is rapidly absorbed or neutralized, making it a minor contributor to luminal volume. **NEET-PG High-Yield Pearls:** * **Composition of Gas:** Nitrogen is the most abundant gas in the obstructed bowel because it is not easily absorbed. * **Fluid Accumulation:** Distension is further aggravated by the failure of the bowel to reabsorb 8–10 liters of daily secretions (saliva, gastric juice, bile, pancreatic juice). * **Clinical Sign:** In high small bowel obstruction, distension may be minimal or limited to the epigastrium; in distal large bowel obstruction, distension is typically massive and peripheral. * **Radiology:** The "Step-ladder pattern" on an erect X-ray abdomen is characteristic of small bowel obstruction.
Question 635: A 35-year-old lady presented with retrosternal burning pain, epigastric pain, and regurgitation for 6 years. What is the most preferred treatment option?
- A. Lifestyle modification
- B. Standard dose PPI
- C. Laparoscopic Nissen's fundoplication (Correct Answer)
- D. Dietary modification
Explanation: **Explanation:** The patient presents with classic symptoms of **Gastroesophageal Reflux Disease (GERD)**—retrosternal burning (heartburn), epigastric pain, and regurgitation—persisting for a significant duration (**6 years**). **Why Laparoscopic Nissen’s Fundoplication is the correct answer:** While medical management is the first line for acute GERD, **surgery is the preferred treatment for chronic, long-standing GERD** (especially >5 years) or when symptoms are refractory to medical therapy. Laparoscopic Nissen’s Fundoplication (a 360° wrap) is the **gold standard surgical procedure**. It reinforces the lower esophageal sphincter (LES) by wrapping the gastric fundus around the distal esophagus, effectively preventing reflux and addressing the underlying anatomical/functional defect. **Why other options are incorrect:** * **A & D (Lifestyle/Dietary modification):** These are initial conservative measures (e.g., weight loss, avoiding late meals). While helpful, they are insufficient as a primary "treatment" for a patient with a 6-year history of symptomatic disease. * **B (Standard dose PPI):** Proton Pump Inhibitors (PPIs) are the medical mainstay. However, for a 35-year-old with a 6-year history, long-term PPI use carries risks (osteoporosis, B12 deficiency) and does not "cure" the mechanical reflux; it only reduces acidity. Surgery is preferred for young patients who face a lifetime of medication. **Clinical Pearls for NEET-PG:** * **Indications for Surgery in GERD:** Persistent symptoms despite PPIs, patient preference (to avoid lifelong meds), complications like Barrett’s esophagus (though surgery doesn't always reverse it), or extra-esophageal manifestations (asthma, aspiration). * **Pre-op Workup:** **24-hour pH monitoring** is the gold standard for diagnosis; **Esophageal Manometry** is mandatory before surgery to rule out motility disorders like Achalasia. * **Alternative Wraps:** **Toupet** (270° posterior) or **Thal** (anterior) wraps are used if esophageal motility is poor to prevent post-operative dysphagia.
Question 636: A 72-year-old patient presents with an intractable type I ulcer along the incisura and significant scarring along the entire length of the lesser curvature. Select the appropriate surgical procedure for this patient.
- A. Vagotomy and antrectomy
- B. Antrectomy alone (Correct Answer)
- C. Vagotomy and pyloroplasty
- D. Vagotomy and gastrojejunostomy
Explanation: **Explanation:** The management of gastric ulcers differs significantly from duodenal ulcers because the primary pathophysiology is often a **mucosal defense defect** rather than acid hypersecretion. **1. Why Antrectomy alone is correct:** This patient has a **Type I Gastric Ulcer** (located at the incisura angularis). According to the Johnson Classification, Type I ulcers are associated with low-to-normal acid output. Therefore, a vagotomy (which reduces acid) is generally unnecessary. The standard surgical treatment for a Type I ulcer is a **distal gastrectomy (antrectomy)** including the ulcer itself, followed by a Billroth I or II reconstruction. In this specific case, the "significant scarring along the lesser curvature" necessitates a formal resection to ensure the ulcer is removed and to rule out occult malignancy, which is a high risk in gastric ulcers. **2. Why other options are incorrect:** * **Vagotomy and Antrectomy (A):** This is the treatment of choice for **Type II** (body + duodenal) and **Type III** (prepyloric) ulcers, which are associated with acid hypersecretion. It is considered "over-treatment" for a Type I ulcer. * **Vagotomy and Pyloroplasty (C):** This is typically used for perforated duodenal ulcers or as an emergency procedure for bleeding. It does not address the gastric ulcer itself, which must be resected due to the risk of malignancy. * **Vagotomy and Gastrojejunostomy (D):** This is a drainage procedure used when there is gastric outlet obstruction or when the patient is too unstable for resection. It does not remove the ulcer or the scarred tissue. **Clinical Pearls for NEET-PG:** * **Johnson Classification:** Type I (Incisura - most common), Type II (Body + Duodenal), Type III (Prepyloric), Type IV (High on lesser curve/GE junction), Type V (NSAID induced - anywhere). * **Acid Status:** Types II and III are **hypersecretory** (require vagotomy); Types I and IV are **hyposecretory**. * **Rule of Thumb:** All gastric ulcers must be biopsied or resected to exclude **gastric adenocarcinoma**, unlike duodenal ulcers which are almost never malignant.
Question 637: Retractile mesenteris may be seen in which of the following conditions?
- A. Ormond's disease (Correct Answer)
- B. Gardner's disease
- C. Turner's syndrome
- D. Down's syndrome
Explanation: **Explanation:** **Retractile Mesenteritis** (also known as Sclerosing Mesenteritis) is a rare, idiopathic inflammatory condition characterized by chronic inflammation, fat necrosis, and eventual fibrosis of the mesenteric adipose tissue. **Why Option A is Correct:** **Ormond’s disease** (Idiopathic Retroperitoneal Fibrosis) is part of a spectrum of fibro-inflammatory disorders now often classified under **IgG4-related diseases**. Both Ormond’s disease and Retractile Mesenteritis share a common pathophysiology involving the proliferation of fibrous tissue. In many clinical cases, these two conditions coexist or represent different anatomical manifestations of the same systemic fibrotic process. **Why the Other Options are Incorrect:** * **B. Gardner’s Syndrome:** This is a variant of Familial Adenomatous Polyposis (FAP) characterized by intestinal polyps, osteomas, and soft tissue tumors (like **Desmoid tumors**). While desmoid tumors can occur in the mesentery, they are distinct neoplastic entities, not the inflammatory/fibrotic process seen in retractile mesenteritis. * **C. Turner’s Syndrome:** A chromosomal anomaly (45, XO) associated with webbed neck, coarctation of the aorta, and streak ovaries. It has no association with mesenteric fibrosis. * **D. Down’s Syndrome:** A trisomy 21 condition associated with GI anomalies like duodenal atresia and Hirschsprung’s disease, but not retractile mesenteritis. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Often presents as vague abdominal pain, a palpable mass, or intestinal obstruction. * **Imaging Sign:** On CT, it may show the **"Fat Ring Sign"** (preservation of fat around mesenteric vessels) or a **"Tumoral Pseudocapsule."** * **Histology:** Shows a triad of fat necrosis, chronic inflammation, and fibrosis. * **Association:** Always look for **IgG4-related systemic disease** if multiple fibrotic sites (e.g., Riedel’s thyroiditis, Autoimmune pancreatitis) are mentioned.
Question 638: What is the investigation of choice for Zenker's diverticulum?
- A. Barium swallow (Correct Answer)
- B. Endoscopy
- C. Esophageal manometry
- D. CT scan
Explanation: ### Explanation **Zenker’s Diverticulum (ZD)** is a pulsion pseudodiverticulum occurring through **Killian’s dehiscence**, a weak area between the thyropharyngeus and cricopharyngeus muscles. **1. Why Barium Swallow is the Correct Answer:** Barium swallow is the **investigation of choice** because it provides a definitive diagnosis by visualizing the location, size, and shape of the pouch. It typically shows a posterior midline pouch at the level of the C5-C6 vertebrae. It is non-invasive and provides the necessary anatomical detail required for surgical planning without the risks associated with instrumentation. **2. Why Other Options are Incorrect:** * **Endoscopy:** This is generally **avoided or contraindicated** as the initial step. The endoscope can easily enter the diverticulum instead of the esophagus, leading to an accidental **perforation** of the thin-walled pouch. * **Esophageal Manometry:** While ZD is caused by incoordination of the upper esophageal sphincter, manometry is technically difficult to perform in these patients and is not required for diagnosis. * **CT Scan:** While it may show a fluid-filled sac, it is not the gold standard and lacks the functional/mucosal detail provided by barium studies. **3. High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Characterized by dysphagia, **halitosis** (foul breath due to undigested food), and **regurgitation** of undigested food. * **Boyce’s Sign:** A gurgling sound heard on the side of the neck when pressure is applied to the diverticulum. * **Treatment:** Small pouches may be treated with a cricopharyngeal myotomy; larger pouches require diverticulectomy or endoscopic stapling (Dohlman’s procedure). * **Complication:** The most common serious complication is aspiration pneumonia.
Question 639: What is a mucocele of the appendix?
- A. A benign tumor
- B. A low-grade malignancy
- C. A retention cyst
- D. All of the above (Correct Answer)
Explanation: **Explanation:** A **mucocele of the appendix** is a clinical descriptive term referring to the abnormal accumulation of mucus within the appendiceal lumen, causing progressive cystic dilatation. It is not a single pathological entity but rather a manifestation of several different underlying conditions. **Why "All of the above" is correct:** The term encompasses a spectrum of pathologies categorized by the cause of the obstruction and the nature of the epithelium: 1. **Retention Cyst (Option C):** This is a non-neoplastic mucocele caused by an obstruction of the appendiceal outflow (often by a fecalith), leading to mucus accumulation behind the blockage. The epithelium remains normal. 2. **Benign Tumors (Option A):** Mucinous cystadenomas are benign neoplastic growths where the epithelium undergoes villous hyperplasia, producing excessive mucus. 3. **Low-grade Malignancy (Option B):** This refers to **LAMN (Low-grade Appendiceal Mucinous Neoplasm)**. While it lacks the aggressive features of frank adenocarcinoma, it has the potential to rupture and cause **Pseudomyxoma Peritonei**, thus carrying malignant potential. **Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Often asymptomatic (incidental finding) or presents like chronic appendicitis. A palpable mass in the Right Iliac Fossa (RIF) may be present. * **Radiological Sign:** On CT scan, it appears as a well-encapsulated cystic mass. The presence of **"onion skin"** appearance (layering of mucus) is highly suggestive. * **Surgical Management:** Extreme care must be taken during surgery (usually an appendectomy or cecectomy) to avoid **intraoperative rupture**. Spillage of the contents into the peritoneal cavity can lead to **Pseudomyxoma Peritonei** (the "Jelly Belly" syndrome). * **Association:** There is a known association between appendiceal mucoceles and **ovarian mucinous tumors**; hence, the ovaries should always be inspected.
Question 640: Which of the following is a known complication of a stoma (e.g., colostomy)?
- A. Prolapse
- B. Stenosis
- C. Retraction
- D. All of the above (Correct Answer)
Explanation: ### Explanation Stoma complications are a high-yield topic in surgical exams, categorized into **early** (within 30 days) and **late** (after 30 days) complications. The correct answer is **D (All of the above)** because prolapse, stenosis, and retraction are well-documented sequelae of stoma formation. * **Prolapse (Option A):** This is a late complication where the bowel protrudes through the stoma site. It is more common in loop colostomies than end stomas. It occurs due to an oversized fascial opening or increased intra-abdominal pressure. * **Stenosis (Option B):** This refers to the narrowing of the stoma outlet. It often results from chronic ischemia, peristomal skin infections, or excessive scarring during healing. It can lead to obstructive symptoms. * **Retraction (Option C):** This occurs when the stoma sinks below the skin level. It is often caused by excessive tension on the bowel limb, poor mobilization of the mesentery, or weight gain (increased subcutaneous fat). It leads to poor appliance fitting and skin excoriation. **Clinical Pearls for NEET-PG:** * **Most common early complication:** Skin excoriation/dermatitis (due to leakage). * **Most common late complication:** Parastomal hernia. * **Necrosis:** Usually occurs within the first 24 hours due to compromised blood supply; if it extends below the fascial level, immediate re-operation is required. * **Ideal Stoma Site:** Should be placed through the **rectus abdominis muscle** to reduce the risk of herniation and away from bony prominences or skin folds.
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
Practice Questions
Anorectal Disorders
Practice Questions
Colorectal Neoplasms
Practice Questions
Gastrointestinal Stomas
Practice Questions
Bariatric Surgery Principles
Practice Questions
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free