Gastrointestinal Surgery Practice Questions

Q: Gastric conduit after oesophageal resection is based upon:

Right Gastroepiploic artery. ***Right Gastroepiploic artery*** - The **right gastroepiploic artery** is the primary arterial supply preserved when fashioning a gastric conduit for esophageal replacement. - This artery provides the main blood supply to the **greater curvature of the stomach**, which forms the basis of the conduit, ensuring its viability. *Short gastric vessels and Vasa brevia* - The **short gastric vessels** are typically ligated and divided during gastric conduit creation to mobilize the stomach for upward transposition. - These vessels supply the fundus and upper part of the greater curvature, which are often either resected or lose their primary blood supply, making them unsuitable as the sole basis for the conduit. *Left gastric artery* - The **left gastric artery** is usually ligated during oesophageal resection to facilitate gastric mobilization and conduit creation. - It supplies the lesser curvature and upper part of the stomach, but its division is necessary to free the stomach for transposition into the chest or neck. *Right gastric artery* - The **right gastric artery** supplies the lesser curvature of the stomach and is often ligated or preserved with care, but it is not the primary vessel relied upon for the blood supply of the gastric conduit. - Its contribution to the overall conduit's blood supply is secondary to the robust flow from the right gastroepiploic artery.

Q: A 45 year old female patient presents with a painless firm abdominal swelling of size 10 x 8 cm near the umbilicus. The swelling is reducible and shows no fixation to deeper structures. The most probable clinical diagnosis in this patient is

Umbilical hernia. ***Umbilical hernia*** - An **umbilical hernia** presents as a swelling near the umbilicus, is often **painless**, and tends to be **reducible**, especially in adults where it can be acquired. - The patient's age and the location and characteristics of the swelling (painless, firm, reducible, unfixed near the umbilicus) are highly consistent with an umbilical hernia, which commonly affects middle-aged women. *Incisional hernia* - An **incisional hernia** develops at the site of a previous surgical incision, which is not mentioned in the patient's history. - While it can be reducible, its location near the umbilicus without a history of abdominal surgery makes it less likely than an umbilical hernia. *Inguinal hernia* - An **inguinal hernia** occurs in the **groin region**, above the inguinal ligament, and not typically near the umbilicus. - While also often **reducible**, its anatomical location differentiates it from the described swelling. *Femoral hernia* - A **femoral hernia** presents as a swelling in the **upper thigh**, inferior to the inguinal ligament, and is more common in women. - The described swelling's location near the umbilicus rules out a femoral hernia.

Q: A 35 year old male patient with enteric fever presents to the emergency with sudden onset of generalised abdominal pain, abdominal distension, nausea, vomiting and constipation for last 48 hours. On examination, patient is dehydrated with PR = 110/min and BP = 100/60 mm Hg. There is generalised tenderness, rebound tenderness present and board like rigidity on per abdomen examination. The most likely complication of enteric fever in this patient is

Small bowel perforation. ***Small bowel perforation*** - The sudden onset of **generalised abdominal pain**, **distension**, **rebound tenderness**, and **board-like rigidity** in a patient with enteric fever strongly indicate **peritoneal irritation** due to perforation. - **Enteric fever** (typhoid) commonly causes **Peyer's patch hyperplasia and necrosis**, leading to full-thickness bowel wall damage and perforation, typically in the **ileum**. *Cholecystitis* - While cholecystitis can occur with enteric fever, it usually presents with **right upper quadrant pain**, **fever**, and **leukocytosis**, not generalized abdominal pain or peritoneal signs. - It does not typically cause **board-like rigidity** or signs of **perforation**. *Small bowel enteritis* - Small bowel enteritis causes **crampy abdominal pain**, **diarrhea**, and **vomiting**, but usually without the severe peritoneal signs like generalized tenderness and board-like rigidity. - It does not typically lead to systemic signs of shock and severe peritonitis as seen in this patient. *Small bowel obstruction* - Small bowel obstruction presents with **abdominal pain**, **distension**, **vomiting**, and **constipation**, but usually with **hyperactive bowel sounds** initially, progressing to absent. - The presence of **rebound tenderness** and **board-like rigidity** points more towards peritonitis from perforation rather than uncomplicated obstruction.

Q: Which of the following statements with regard to Enteric perforation are correct? 1. Salmonella typhi is the causative organism for Enteric fever 2. Enteric perforation characteristically occurs during the third week of illness 3. Typhoid ulcers are placed transversely to the long axis of the gut 4. Terminal ileum is the most common site for enteric perforation

1, 2 and 4. ***1, 2 and 4*** * **Salmonella typhi** is indeed the causative organism for **enteric fever**, often known as typhoid fever. * **Enteric perforation** characteristically occurs during the **third week of illness** due to progressive ulceration of **Peyer's patches** [1]. * The **terminal ileum** is the **most common site** for enteric perforation because it has the highest concentration of **Peyer's patches**, which are target sites for Salmonella typhi [1]. *2, 3 and 4* * While enteric perforation typically occurs in the third week and the terminal ileum is the most common site, the statement about **typhoid ulcers** being placed transversely is incorrect. * **Typhoid ulcers** are characteristically oriented **longitudinally** along the long axis of the gut, following the orientation of the underlying Peyer's patches [1]. *1, 3 and 4* * Although Salmonella typhi is the causative organism and the terminal ileum is the most common site, the statement about **typhoid ulcers** being placed **transversely** is incorrect. * Perforation typically occurs during the **third week of illness**, which is an important clinical detail missed in this option [1]. *1, 2 and 3* * **Salmonella typhi** is the causative organism for enteric fever, and perforation does occur during the **third week of illness** [1]. * However, the statement that **typhoid ulcers** are placed **transversely** is incorrect; they are **longitudinal** in orientation.

Q: Which of the following is NOT a classical symptom of acute appendicitis ?

Constipation. ***Constipation*** - While patients with appendicitis may experience altered bowel habits, **constipation is not a classic or defining symptom**; **diarrhea** can even be present. - The primary symptoms relate to inflammation and irritation of the appendix, not typically leading to significant constipation. *Periumbilical colic* - This is a very common early symptom, often described as a **vague, dull pain around the umbilicus** as the appendix initially becomes inflamed. - The pain later **migrates to the right lower quadrant** as the inflammation localizes to the parietal peritoneum. *Anorexia* - **Loss of appetite** is a highly characteristic and almost universal symptom in patients with acute appendicitis. - It often precedes the onset of abdominal pain and is considered a significant diagnostic indicator. *Nausea* - **Nausea and vomiting** are very common symptoms, often following the onset of abdominal pain. - These gastrointestinal symptoms are due to the visceral irritation caused by the inflamed appendix.

Q: Which one of the following is given a score of two in Alvarado score?

Leukocytosis. ***Leukocytosis*** - A **leukocyte count greater than 10,000/mm³** (leukocytosis) is assigned a score of **two points** in the Alvarado score. [2] - This parameter reflects the systemic inflammatory response often associated with acute appendicitis. [1] *Anorexia* - **Anorexia**, or loss of appetite, is a common symptom in acute appendicitis but is only assigned **one point** in the Alvarado score. - It is a non-specific symptom that can be present in numerous conditions. *Pyrexia* - **Pyrexia** (fever) is another indicator of inflammation, but in the Alvarado score, a **fever of 37.3°C or higher** is given only **one point**. - This symptom, while important, does not carry the same weight as a significant elevation in white blood cell count. *Rebound tenderness* - **Rebound tenderness** is a sign of peritoneal irritation and is given **one point** in the Alvarado score. [1] - While strongly correlated with appendicitis, it is a clinical finding rather than a laboratory marker.

Q: An air fluid level with dilated oesophagus and “bird beak” appearance in a barium swallow is diagnostic of:

Achalasia cardia. ***Achalasia cardia*** - The classic radiographic features of achalasia on a barium swallow include a **dilated esophagus** with proximal food retention (leading to an **air-fluid level**) and a characteristic narrowing at the gastroesophageal junction, creating a **"bird-beak" appearance**. - This appearance is due to the failure of the lower esophageal sphincter to relax during swallowing, combined with absent esophageal peristalsis. *Carcinoma oesophagus* - Oesophageal carcinoma typically presents as an **irregular, constricting lesion** or a **filling defect** on barium swallow, often with mucosal irregularity or shelf-like margins, rather than a smooth "bird beak." - While it can cause dysphagia and possibly proximal dilation, the specific "bird beak" morphology is not characteristic of cancer. *Barrett's oesophagus* - Barrett's esophagus is a histological diagnosis involving **metaplastic changes** in the esophageal lining, usually due to chronic GERD. - It does not have a distinct radiographic appearance on barium swallow, though it might be associated with reflux changes or **ulcerations**, but not a "bird beak" sign. *Hiatus hernia* - Hiatus hernias are characterized by the **protrusion of a portion of the stomach into the chest cavity** through the esophageal hiatus of the diaphragm. - On a barium swallow, this appears as an **accumulation of barium above the diaphragm**, often with a wide opening at the esophagogastric junction, which is distinct from the narrowed "bird beak" of achalasia.

Q: Which one of the following statements is not correct regarding trichobezoar ( hair balls)?

It is usually associated with pyloric stenosis.. ***It is usually associated with pyloric stenosis.*** - **Trichobezoars** are generally not associated with **pyloric stenosis**. The two conditions have distinct etiologies and pathophysiologies. - While both can present with gastric outlet obstruction symptoms, the presence of a hairball does not imply an underlying congenital or acquired narrowing of the pylorus. *It is associated usually with psychiatric illness.* - **Trichobezoars** are highly associated with **trichophagia** (compulsive hair eating), which is often a symptom of underlying psychiatric conditions like **trichotillomania** or **pica**. - These conditions involve an irresistible urge to pull out one's hair and/or consume non-nutritive substances, including hair. *It is more common in females.* - **Trichobezoars** are indeed more commonly found in **females**, especially young females [1]. - This increased prevalence is often linked to the higher incidence of **trichotillomania** and **trichophagia** in females. *It is more common in young.* - **Trichobezoars** are observed more frequently in **children and adolescents**, particularly among young girls [1]. - The behaviors of **trichotillomania** and **trichophagia** often develop during childhood or early adolescence [1].

Q: Match List-I with List-II and select the correct answer using the code given below the Lists: **List-I (Procedure)** A. Highly selective vagotomy B. Vagotomy with gastrojejunostomy C. Subtotal gastrectomy D. Nissen's fundoplication **List-II (Complication)** 1. Metabolic bone disease 2. Post-prandial gas bloat 3. Lesser curve necrosis 4. Diarrhea **Code:**

A→3 B→4 C→1 D→2. ***A→3 B→4 C→1 D→2*** - **Highly selective vagotomy** involves careful dissection along the **lesser curve** of the stomach, which can lead to **lesser curve necrosis** due to devascularization during the procedure. - **Vagotomy with gastrojejunostomy** disrupts vagal innervation leading to altered gut motility and bacterial overgrowth, causing **diarrhea** as a common complication. - **Subtotal gastrectomy** removes significant gastric tissue affecting absorption of **calcium** and **vitamin D**, leading to **metabolic bone disease**. - **Nissen's fundoplication** creates a 360° wrap that can cause inability to belch and **post-prandial gas bloat** syndrome. *A→2 B→4 C→1 D→3* - Incorrectly associates **highly selective vagotomy** with gas bloat, which is primarily seen with **fundoplication procedures**. - Mismatches **Nissen's fundoplication** with lesser curve necrosis, when lesser curve necrosis specifically occurs during **vagotomy procedures**. *A→2 B→1 C→4 D→3* - Wrongly links **vagotomy with gastrojejunostomy** to metabolic bone disease, which is characteristic of **gastric resection procedures**. - Incorrectly associates **subtotal gastrectomy** with diarrhea as primary complication rather than the more specific **metabolic bone disease**. *A→3 B→1 C→4 D→2* - Mismatches **vagotomy with gastrojejunostomy** with metabolic bone disease, when this complication is specific to **gastric resection**. - Incorrectly links **subtotal gastrectomy** with diarrhea instead of its more characteristic long-term complication of **metabolic bone disease**.

Question 1

Gastric conduit after oesophageal resection is based upon:

Accepted Answer

Right Gastroepiploic artery

Answer

Short gastric vessels and Vasa brevia

Answer

Left gastric artery

Answer

Right gastric artery

Question 2

A 45 year old female patient presents with a painless firm abdominal swelling of size 10 x 8 cm near the umbilicus. The swelling is reducible and shows no fixation to deeper structures. The most probable clinical diagnosis in this patient is

Accepted Answer

Umbilical hernia

Answer

Incisional hernia

Answer

Inguinal hernia

Answer

Femoral hernia

Question 3

A 35 year old male patient with enteric fever presents to the emergency with sudden onset of generalised abdominal pain, abdominal distension, nausea, vomiting and constipation for last 48 hours. On examination, patient is dehydrated with PR = 110/min and BP = 100/60 mm Hg. There is generalised tenderness, rebound tenderness present and board like rigidity on per abdomen examination. The most likely complication of enteric fever in this patient is

Accepted Answer

Small bowel perforation

Answer

Cholecystitis

Answer

Small bowel enteritis

Answer

Small bowel obstruction

Question 4

Which of the following statements with regard to Enteric perforation are correct?

1. Salmonella typhi is the causative organism for Enteric fever
2. Enteric perforation characteristically occurs during the third week of illness
3. Typhoid ulcers are placed transversely to the long axis of the gut
4. Terminal ileum is the most common site for enteric perforation

Accepted Answer

1, 2 and 4

Answer

2, 3 and 4

Answer

1, 3 and 4

Answer

1, 2 and 3

Question 5

Which of the following is NOT a classical symptom of acute appendicitis ?

Accepted Answer

Constipation

Answer

Periumbilical colic

Answer

Anorexia

Answer

Nausea

Question 6

Which one of the following is given a score of two in Alvarado score?

Accepted Answer

Leukocytosis

Answer

Anorexia

Answer

Pyrexia

Answer

Rebound tenderness

Question 7

An air fluid level with dilated oesophagus and “bird beak” appearance in a barium swallow is diagnostic of:

Accepted Answer

Achalasia cardia

Answer

Carcinoma oesophagus

Answer

Barrett's oesophagus

Answer

Hiatus hernia

Question 8

Which one of the following statements is not correct regarding trichobezoar ( hair balls)?

Accepted Answer

It is usually associated with pyloric stenosis.

Answer

It is associated usually with psychiatric illness.

Answer

It is more common in females.

Answer

It is more common in young.

Question 9

What is the treatment of choice in a patient with Crohn’s disease, where inflamed appendix was found on exploration?

Accepted Answer

Ileo–colic resection and anastomosis

Answer

Appendectomy

Answer

Closing the abdomen and starting medical treatment

Answer

Right hemicolectomy

Question 10

Match List-I with List-II and select the correct answer using the code given below the Lists:

**List-I (Procedure)**
A. Highly selective vagotomy
B. Vagotomy with gastrojejunostomy
C. Subtotal gastrectomy
D. Nissen's fundoplication

**List-II (Complication)**
1. Metabolic bone disease
2. Post-prandial gas bloat
3. Lesser curve necrosis
4. Diarrhea

**Code:**

Accepted Answer

A→3  B→4  C→1  D→2

Answer

A→3  B→1  C→4  D→2

Answer

A→2  B→1  C→4  D→3

Answer

A→2  B→4  C→1  D→3

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

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