Gastrointestinal Surgery Practice Questions

Q: What is the most common cause of perforation of the oesophagus?

Iatrogenic injury. ***Correct: Iatrogenic injury*** - **Iatrogenic injuries** are the most common cause of esophageal perforation, accounting for **50-75%** of all cases. - Most commonly occur during **endoscopic procedures** (upper GI endoscopy, esophageal dilation, biopsy, bougie dilation, pneumatic dilation for achalasia, sclerotherapy). - Other iatrogenic causes include **nasogastric tube insertion**, esophageal stent placement, and intraoperative injuries during thoracic or cervical surgery. - The incidence has increased with the widespread use of therapeutic endoscopy. *Incorrect: Barotrauma* - **Boerhaave syndrome** (spontaneous esophageal rupture from forceful vomiting) is the most common cause of *spontaneous* perforation. - Accounts for only **15-20%** of all esophageal perforations. - Typically occurs after severe vomiting, retching, or Valsalva maneuver causing sudden increase in intra-esophageal pressure. - Most commonly involves the **left posterolateral wall of the lower esophagus**, 3-6 cm above the gastroesophageal junction. *Incorrect: Malignancy* - Esophageal tumors (carcinoma, lymphoma) can **erode through the esophageal wall** leading to perforation. - However, this is a **rare complication** and accounts for a small percentage of perforations. - More commonly, perforation in malignancy occurs during endoscopic intervention rather than spontaneous erosion. *Incorrect: Mediastinitis* - **Mediastinitis** is a **consequence** of esophageal perforation, not a cause. - Results from leakage of esophageal contents (saliva, gastric acid, food particles) into the mediastinum. - Leads to severe infection with high mortality if not promptly treated with antibiotics, drainage, and surgical repair.

Q: Which of the following are features of umbilical hernia in adults? 1. Patients are commonly overweight with a thinned and attenuated midline raphe. 2. Most patients are asymptomatic or present with a painless swelling. 3. Men are affected more than women. 4. Hernia repair can be done by the technique described by Mayo. Select the correct answer using the code given below.

1, 2 and 4. ***1, 2 and 4*** - **Overweight patients** often have increased intra-abdominal pressure and weakened abdominal walls, contributing to the development of an umbilical hernia and a **thinned midline raphe**. - **Most adult umbilical hernias are asymptomatic** or present as painless swellings; patients typically notice a bulge that may increase with coughing or straining. Pain usually indicates **complications** such as incarceration or strangulation. - The **Mayo repair** is a classic technique specifically designed for umbilical hernias, involving the overlapping of the rectus sheath for a strong repair. *2, 3 and 4* - While patients are often **asymptomatic** (statement 2 correct) and the **Mayo repair** is standard (statement 4 correct), statement 3 is incorrect; **women are more commonly affected** by umbilical hernias than men. *1, 2 and 3* - Patients are commonly **overweight** (statement 1 correct) and often **asymptomatic** (statement 2 correct), but statement 3 is incorrect as umbilical hernias are seen **more often in women** than men. *1, 3 and 4* - Patients are commonly **overweight** (statement 1 correct) and the **Mayo repair** is a recognized technique (statement 4 correct), but statement 3 is incorrect because **women are more affected** than men. Statement 2 is also correct as most patients are asymptomatic.

Q: Which one of the following statements is correct about mesenteric cysts?

It presents most commonly as a painless abdominal swelling.. ***It presents most commonly as a painless abdominal swelling.*** - **Mesenteric cysts** typically manifest as a **slowly growing**, **asymptomatic abdominal mass**, which is often discovered incidentally or due to mild pressure symptoms. - Their **painless nature** and gradual enlargement contribute to this common presentation. *Percutaneous aspiration with injection of sclerosant is the preferred treatment option.* - **Simple aspiration** or sclerotherapy of mesenteric cysts is generally **contraindicated** due to the high risk of recurrence and potential for complications like infection or rupture. - The **preferred treatment** for mesenteric cysts is surgical excision to prevent recurrence and complications. *It is more common in males as compared to females.* - While rare overall, mesenteric cysts are **more prevalent in females** than males, although the exact reason for this disparity is not fully understood. - Some studies suggest a **female-to-male ratio** of approximately 2:1. *It occurs most commonly in children less than 18 years of age.* - Mesenteric cysts can occur at any age, but they are **more common in adults**, with the highest incidence typically reported in the third to fifth decades of life. - Although they can be found in children, this is **not the most common age group** for presentation.

Q: Which of the following are tension-free inguinal hernia repairs? 1. Stoppa's repair 2. Lichtenstein's repair 3. Laparoscopic TEP repair 4. Desarda's repair.

1, 2 and 3. ***1, 2 and 3*** - **Stoppa's repair**, **Lichtenstein's repair**, and **Laparoscopic TEP repair** are all considered tension-free methods because they use mesh to reinforce the inguinal floor without putting tension on the surrounding tissues. - The use of mesh in these repairs distributes the tension across a wider area, minimizing pain and recurrence rates compared to traditional tension-based repairs. - **Desarda's repair** is excluded because it is a tissue-based (non-mesh) technique that uses the external oblique aponeurosis, and is NOT classified as a tension-free repair. *2, 3 and 4* - This option incorrectly excludes **Stoppa's repair**, which is a widely recognized tension-free technique using a large prosthetic mesh in the preperitoneal space. - **Desarda's repair** is incorrectly included as it is a tissue-based repair without mesh, not a tension-free technique. *1, 3 and 4* - This option incorrectly excludes **Lichtenstein's repair**, which is the most commonly performed tension-free open mesh repair for inguinal hernias. - It involves placing a prosthetic mesh over the defect without suturing muscle or fascia under tension. - **Desarda's repair** is incorrectly included as it does not use mesh and is not classified as tension-free. *1, 2 and 4* - This option incorrectly excludes **Laparoscopic TEP repair**, which is a minimally invasive tension-free approach utilizing mesh to reinforce the posterior wall of the inguinal canal in the preperitoneal space. - **Desarda's repair** is incorrectly included; while it aims to be physiological and mesh-free, it is a tissue-based technique and not a tension-free repair.

Q: When the hernia extends between the layers of abdominal wall muscles and not directly through them, it is called

Spigelian hernia. ***Spigelian hernia*** - A **Spigelian hernia** occurs through a defect in the **Spigelian fascia**, extending between the transverse abdominis and internal oblique muscles. - It typically presents as a bulge between muscular layers, making it often **interparietal** and difficult to diagnose clinically due to its hidden nature. *Amyand's hernia* - This is a rare type of inguinal hernia that contains the **vermiform appendix** within the hernial sac. - It is notable for the potential complication of **appendicitis** within the hernia. *Richter's hernia* - A **Richter's hernia** involves only a portion of the circumference of the bowel wall becoming strangulated within the hernia orifice. - This can lead to **bowel necrosis** without complete obstruction, making diagnosis challenging. *Littre's hernia* - A **Littre's hernia** is characterized by the presence of a **Meckel's diverticulum** within the hernial sac. - It can occur in any hernia type (inguinal, femoral, umbilical) and carries a risk of diverticulitis or perforation.

Q: Which of the following is the MOST reliable intraoperative feature of viable small bowel? 1. Visible peristalsis 2. Flabby intestinal musculature 3. Shiny appearance of small bowel wall 4. Visible pulsation in the mesenteric artery

1. Visible peristalsis. ***Visible peristalsis*** - The presence of **visible peristalsis** is the **MOST reliable indicator** of viable small bowel, demonstrating preserved neuromuscular function and tissue vitality. - Among the classical "3 Ps" of bowel viability (Peristalsis, Pulsation, Pink color), **peristalsis is the most direct indicator** as it confirms functional integrity of the bowel wall itself. - This indicates that the muscle layers of the intestine (longitudinal and circular) are functioning properly with intact innervation. *Shiny appearance of small bowel wall* - A **shiny serosa** is indeed a feature of viable bowel, indicating healthy, well-perfused tissue with an intact mesenteric surface. - However, it is a **less specific indicator** compared to peristalsis, as the appearance can be subjective and may not directly correlate with functional viability. *Visible pulsation in the mesenteric artery* - **Visible pulsation** in the mesenteric artery is one of the classical signs of viability and indicates blood flow to the vessel. - However, arterial pulsation alone **does not guarantee adequate tissue perfusion** or venous drainage, and ischemia can still occur despite pulsatile flow (e.g., venous thrombosis). - Peristalsis is more reliable as it confirms both adequate perfusion AND functional integrity. *Flabby intestinal musculature* - **Flabby intestinal musculature** indicates **non-viable bowel** with loss of tone, suggesting ischemia or necrosis. - Viable bowel typically feels **turgid and elastic** with good tone, not flabby.

Q: The most common metabolic abnormality associated with gastric outlet obstruction is

hypochloraemic alkalosis. ***Hypochloraemic alkalosis*** - Gastric outlet obstruction leads to **persistent vomiting of gastric contents**, rich in **hydrochloric acid (HCl)**. - The loss of HCl causes a decrease in plasma chloride (**hypochloraemia**) and an increase in bicarbonate, leading to **metabolic alkalosis**. - This is the **classic metabolic abnormality** seen in pyloric stenosis and other causes of gastric outlet obstruction. *Hyperchloraemic alkalosis* - This is an incorrect combination of electrolyte and acid-base disturbances; hyperchloraemia typically accompanies **acidosis**, not alkalosis. - Hyperchloraemic alkalosis would imply an excess of chloride and base, which does not result from the vomiting of acidic gastric contents. *Hypochloraemic acidosis* - Hypochloraemia can occur with acidosis (e.g., from severe diarrhea with bicarbonate loss), but the primary acid-base disturbance in gastric outlet obstruction is **alkalosis** due to hydrogen ion loss. - Vomiting primarily causes a loss of acid, leading to an increase in blood pH, not a decrease. *Hyperchloraemic acidosis* - This condition is often seen in situations like **renal tubular acidosis** or with the administration of large amounts of **saline solutions**, where chloride intake is high and bicarbonate is lost or diluted. - It specifically does not occur with the loss of highly acidic gastric contents, which would decrease chloride levels and increase pH.

Q: A patient presents to the emergency department with pain and distension of abdomen and absolute constipation. What is the investigation of choice ?

Plain X-ray abdomen (Erect). ***Plain X-ray abdomen (Erect)*** - An erect plain X-ray of the abdomen is the initial and often diagnostic investigation for **bowel obstruction**, revealing **dilated bowel loops** and **air-fluid levels**. - It helps confirm the presence of obstruction and can sometimes indicate its location and severity, though it does not provide information about the cause. *Ultrasonography* - While ultrasound can detect **bowel dilation** and **peristalsis**, it is limited in visualizing the entire bowel and cannot reliably differentiate between various causes of obstruction. - It is more useful for assessing **extraluminal pathology** or **fluid collections** but less effective as a primary diagnostic tool for bowel obstruction. *Barium meal follow-through* - This study involves oral **barium administration** and serial X-rays to visualize the small bowel, but it is **contraindicated** in suspected bowel obstruction due to the risk of exacerbating the obstruction or causing **barium impaction**. - Its primary role is in evaluating chronic or partial obstructions, or malabsorption, not acute presentations with complete obstruction. *Colonoscopy* - **Colonoscopy** is an invasive procedure primarily used for diagnosis and treatment of **colonic pathology**, such as polyps, strictures, or bleeding. - It is **contraindicated** in acute, complete bowel obstruction due to the risk of **perforation** and is not the initial diagnostic choice for acute abdominal pain and absolute constipation.

Question 1

What is the most common cause of perforation of the oesophagus?

Accepted Answer

Iatrogenic injury

Answer

Barotrauma

Answer

Malignancy

Answer

Mediastinitis

Question 2

Which of the following are features of umbilical hernia in adults?

1. Patients are commonly overweight with a thinned and attenuated midline raphe.
2. Most patients are asymptomatic or present with a painless swelling.
3. Men are affected more than women.
4. Hernia repair can be done by the technique described by Mayo.

Select the correct answer using the code given below.

Accepted Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 2 and 3

Answer

1, 3 and 4

Question 3

Which one of the following statements is correct about mesenteric cysts?

Accepted Answer

It presents most commonly as a painless abdominal swelling.

Answer

It is more common in males as compared to females.

Answer

It occurs most commonly in children less than 18 years of age.

Answer

Percutaneous aspiration with injection of sclerosant is the preferred treatment option.

Question 4

Which of the following are tension-free inguinal hernia repairs?

1. Stoppa's repair
2. Lichtenstein's repair
3. Laparoscopic TEP repair
4. Desarda's repair.

Accepted Answer

1, 2 and 3

Answer

2, 3 and 4

Answer

1, 3 and 4

Answer

1, 2 and 4

Question 5

When the hernia extends between the layers of abdominal wall muscles and not directly through them, it is called

Accepted Answer

Spigelian hernia

Answer

Amyand's hernia

Answer

Richter's hernia

Answer

Littre's hernia

Question 6

Which of the following is the MOST reliable intraoperative feature of viable small bowel?

1. Visible peristalsis
2. Flabby intestinal musculature
3. Shiny appearance of small bowel wall
4. Visible pulsation in the mesenteric artery

Accepted Answer

1. Visible peristalsis

Answer

3. Shiny appearance of small bowel wall

Answer

2. Flabby intestinal musculature

Answer

4. Visible pulsation in the mesenteric artery

Question 7

Which of the following statements about peptic ulcers is correct?

Accepted Answer

Anteriorly located duodenal ulcers are 'more prone for perforation'.

Answer

It is more commonly seen in females.

Answer

The most common location is the third part of duodenum.

Answer

There is no risk of malignancy in gastric ulcers.

Question 8

The most common metabolic abnormality associated with gastric outlet obstruction is

Accepted Answer

hypochloraemic alkalosis

Answer

hyperchloraemic alkalosis

Answer

hypochloraemic acidosis

Answer

hyperchloraemic acidosis

Question 9

A patient presents to the emergency department with pain and distension of abdomen and absolute constipation. What is the investigation of choice ?

Accepted Answer

Plain X-ray abdomen (Erect)

Answer

Ultrasonography

Answer

Barium meal follow-through

Answer

Colonoscopy

Question 10

Consider the following with reference to the management of portal hypertension :

1. Infusion of vasopressin
2. General resuscitation
3. Devascularisation procedure
4. Endoscopic sclerotherapy What is the appropriate sequence in the line of management in the event of massive variceal bleeding in portal hypertension ?

Accepted Answer

2, 1, 4, 3

Answer

3, 2, 1, 4

Answer

1, 4, 2, 3

Answer

4, 2, 1, 3

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?