Gastrointestinal Surgery — MCQs

A 20-year-old man presents with severe right lower quadrant abdominal pain, nausea, and anorexia. The abdominal pain started around his umbilicus and has now migrated to the right lower quadrant. Physical examination reveals exquisite tenderness at McBurney's point. This patient is diagnosed with acute appendicitis. What is the recommended treatment for this condition?

Q758Medium

Which of the following is NOT a complication of trichobezoars?

Q759Easy

What is the investigation of choice for the diagnosis of colon cancer?

Q760Easy

What is the commonest cause of acute mesenteric adenitis?

Gastrointestinal Surgery Indian Medical PG Practice Questions and MCQs

Question 751: Which of the following statements is NOT true regarding hyperplastic ileocecal tuberculosis?

A. Presents as a mass in the right iliac fossa.
B. The ileocecal region is a common site.
C. X-ray may show the cecum being drawn in from the ileum.
D. Conservative management is the treatment of choice. (Correct Answer)

Explanation: **Explanation:** Abdominal tuberculosis primarily presents in two forms: **Ulcerative** (common in immunocompromised patients) and **Hyperplastic** (common in patients with high resistance). **Why Option D is the correct answer (The False Statement):** Hyperplastic ileocecal tuberculosis is characterized by an intense inflammatory response leading to excessive fibrosis and thickening of the bowel wall. This results in a narrowed lumen and a rigid, tumor-like mass. Because this condition frequently leads to **intestinal obstruction**, medical management (ATT) alone is often insufficient. **Surgical intervention** (such as a Right Hemicolectomy or Limited Ileocecal Resection) followed by Antitubercular Therapy (ATT) is the treatment of choice to resolve the mechanical obstruction. **Analysis of Incorrect Options:** * **Option A:** True. The hallmark clinical presentation is a firm, non-tender, mobile **mass in the right iliac fossa**, often mimicking Crohn’s disease or Cecal Carcinoma. * **Option B:** True. The **ileocecal region** is the most common site for intestinal TB due to the high density of lymphoid tissue (Peyer’s patches), physiological stasis, and increased rate of absorption in this area. * **Option C:** True. Radiologically, fibrosis causes the cecum to shrink and become pulled up. On Barium studies, this is seen as the **"Stierlin’s Sign"** (rapid emptying of the inflamed segment) or the **"Goose-neck deformity"** (loss of the ileocecal angle). **High-Yield Clinical Pearls for NEET-PG:** * **Sterling’s Sign:** Seen in Ulcerative TB (Barium fails to rest in the inflamed cecum). * **Fleischner Sign:** Thickened, wide-open ileocecal valve. * **Conical Cecum:** Characteristic finding in Hyperplastic TB where the cecum is shrunken and pulled out of the iliac fossa. * **Investigation of Choice:** Colonoscopy with biopsy (shows granulomas).

Question 752: Physiological gastrectomy is defined as:

A. Ligation of all major arteries (Correct Answer)
B. Antrectomy
C. Resection of the upper one-third of the stomach
D. Ligation of four out of five major arteries

Explanation: **Explanation:** **Physiological Gastrectomy** refers to the ligation of all major arteries supplying the stomach. Unlike a surgical gastrectomy, where the organ is physically removed, a physiological gastrectomy renders the stomach "functionally" absent or significantly impaired in its secretory capacity by inducing controlled ischemia. 1. **Why Option A is Correct:** The stomach has a remarkably rich collateral blood supply from five major arteries (Left and Right Gastrics, Left and Right Gastro-epiploics, and Short Gastrics). Because of this extensive intramural plexus, the stomach can survive even if four out of five major vessels are ligated. However, when **all major arteries** are ligated, the blood flow is reduced to a level that causes profound mucosal ischemia, leading to a total cessation of acid secretion (achlorhydria). This mimics the physiological effect of removing the stomach, hence the term. 2. **Why Other Options are Incorrect:** * **Antrectomy (B):** This is the surgical removal of the antrum. While it reduces acid by removing G-cells, it is a partial anatomical resection, not a "physiological" gastrectomy. * **Resection of the upper one-third (C):** This describes a proximal gastrectomy, which is an anatomical procedure. * **Ligation of four out of five arteries (D):** Due to the robust collateral circulation, the stomach remains viable and functional if even one major vessel (like the left gastric artery) is preserved. **High-Yield Clinical Pearls for NEET-PG:** * The stomach is the most vascular organ in the GI tract; it is nearly impossible to cause gangrene of the stomach by ligating a single vessel. * **Left Gastric Artery** is the largest and most important artery of the stomach. * In cases of gastric mobilization (e.g., Esophagectomy/Gastric pull-up), the stomach can survive solely on the **Right Gastro-epiploic artery**.

Question 753: In cases of upper GI bleed associated with stress gastritis, which of the following statements is NOT true?

A. Surgery should be performed if transfusion requirements exceed 6 units.
B. Vagotomy may be added.
C. Surgery involves anterior gastrotomy with ligation of bleeding ulcers and superficial erosions. (Correct Answer)
D. Total gastrectomy is rarely indicated.

Explanation: **Explanation:** Stress gastritis (Stress-Related Mucosal Disease) typically involves diffuse, superficial erosions throughout the gastric body and fundus, rather than a single focal ulcer. **Why Option C is NOT true:** The correct surgical approach for refractory bleeding in stress gastritis is **subtotal or near-total gastrectomy**. A simple anterior gastrotomy with ligation of bleeding points is generally **ineffective** because the bleeding is diffuse and multifocal. Attempting to ligate individual erosions often leads to immediate re-bleeding from adjacent areas of the friable mucosa. **Analysis of other options:** * **Option A:** Surgery is indicated in massive UGI bleeds when medical management (PPIs, endoscopic therapy) fails, typically defined as a transfusion requirement exceeding 6 units of blood in 24 hours. * **Option B:** Vagotomy is often added to gastrectomy procedures to decrease acid secretion and reduce the risk of recurrent ulceration in the gastric remnant. * **Option D:** Total gastrectomy is considered a "last resort" due to high morbidity and mortality. It is rarely indicated unless subtotal gastrectomy fails to control life-threatening hemorrhage. **Clinical Pearls for NEET-PG:** * **Prophylaxis:** The best treatment for stress gastritis is prevention (IV PPIs or H2 blockers) in high-risk ICU patients (e.g., ventilation >48h, coagulopathy). * **Location:** Stress ulcers (Curling’s in burns, Cushing’s in CNS trauma) primarily affect the **acid-producing mucosa** (fundus and body). * **Surgical Choice:** If surgery is mandatory, **Subtotal Gastrectomy** is the procedure of choice. Total gastrectomy is reserved for salvage.

Question 754: What is the most common benign tumor of the esophagus?

A. Lipoma
B. Leiomyoma (Correct Answer)
C. Hamartoma
D. Hemangioma

Explanation: **Explanation:** **Leiomyoma** is the most common benign tumor of the esophagus, accounting for approximately 60–70% of all benign esophageal neoplasms. These tumors arise from the smooth muscle cells of the muscularis propria (most commonly in the lower two-thirds of the esophagus). They are typically slow-growing, intramural, and extramucosal. On barium swallow, they present with a characteristic "smooth filling defect" or "crescent sign," and on endoscopy, they appear as a firm mass with intact overlying mucosa. **Analysis of Incorrect Options:** * **Lipoma (A):** These are rare, slow-growing submucosal tumors composed of adipose tissue. While they can occur in the GI tract, they are far less common than leiomyomas in the esophagus. * **Hamartoma (C):** These are disorganized growths of native tissue. While common in the lungs (pulmonary hamartoma), they are extremely rare in the esophagus. * **Hemangioma (D):** These are rare vascular tumors. They are clinically significant due to the risk of hematemesis but do not approach the prevalence of leiomyomas. **Clinical Pearls for NEET-PG:** * **Most common site:** Lower 2/3rd of the esophagus (where smooth muscle predominates). * **Diagnosis:** Endoscopic Ultrasound (EUS) is the gold standard for diagnosis. * **Biopsy Warning:** Pre-operative endoscopic biopsy is generally **avoided** if surgery is planned, as it causes scarring between the tumor and mucosa, making surgical extirpation difficult and increasing the risk of mucosal perforation. * **Treatment:** Surgical **enucleation** (usually via VATS or laparoscopy) is the treatment of choice for symptomatic tumors or those >5 cm.

Question 755: The most likely cause of fluctuating jaundice in a middle-aged or elderly man is:

A. Periampullary carcinoma (Correct Answer)
B. Liver fluke infestation
C. Choledochal cyst
D. Carcinoma of the head of pancreas

Explanation: **Explanation:** **Periampullary carcinoma** is the classic cause of **fluctuating jaundice**. This phenomenon occurs due to the unique nature of the tumor, which arises near the Ampulla of Vater. As the tumor grows, it obstructs the common bile duct (CBD), causing jaundice. However, the central part of the tumor often undergoes **necrosis and sloughing**, which temporarily relieves the obstruction and allows bile to flow, leading to a decrease in bilirubin levels. This cycle of growth and sloughing results in the characteristic "fluctuating" pattern. **Why other options are incorrect:** * **Carcinoma of the head of pancreas:** Typically presents with **progressive, painless, obstructive jaundice**. Unlike periampullary tumors, these do not slough off to relieve obstruction; the jaundice is persistent and worsening. * **Choledochal cyst:** Usually presents in children or young adults with the classic triad of jaundice, pain, and a palpable right-upper quadrant mass. While jaundice can be intermittent, it is not the most likely cause in the elderly. * **Liver fluke infestation:** Causes biliary obstruction and cholangitis, but the jaundice is generally persistent or recurrent due to inflammation/stones, not fluctuating due to tumor necrosis. **High-Yield Clinical Pearls for NEET-PG:** * **Silver Stool (Thomas’ Sign):** Pathognomonic for periampullary carcinoma. It is a combination of acholic (white) stool due to biliary obstruction and melena (black) due to tumor bleeding. * **Courvoisier’s Law:** In a patient with obstructive jaundice, if the gallbladder is palpable, the obstruction is unlikely to be due to a stone (as stones cause a fibrotic, non-distensible gallbladder). * **Double Duct Sign:** Seen on imaging (ERCP/MRCP) in both pancreatic head and periampullary cancers, representing simultaneous dilatation of the CBD and the pancreatic duct.

Question 756: What are the causes of paralytic ileus?

A. Pancreatitis and pneumonia
B. Peritonitis or abscess
C. Pneumonia involving the viscera
D. All of the above (Correct Answer)

Explanation: **Explanation:** Paralytic ileus is a state of functional intestinal obstruction where there is a failure of peristalsis without a physical mechanical barrier. The underlying pathophysiology involves an imbalance in the autonomic nervous system (increased sympathetic activity), inflammatory mediators, and electrolyte disturbances that inhibit smooth muscle contraction. **Why "All of the above" is correct:** Paralytic ileus is rarely a primary disease; it is almost always secondary to systemic or localized insults. * **Peritonitis or Abscess (Option B):** Localized or generalized inflammation of the peritoneum directly inhibits the myenteric plexus. This is the most common clinical cause of ileus. * **Pancreatitis (Option A):** Retroperitoneal inflammation (as seen in pancreatitis or renal colic) triggers a sympathetic reflex that halts bowel motility. * **Pneumonia (Option A & C):** Lower lobe pneumonia can irritate the diaphragm and the parietal peritoneum, leading to a reflex ileus. Furthermore, systemic sepsis and hypoxia associated with severe pneumonia impair intestinal perfusion and motility. **Clinical Pearls for NEET-PG:** 1. **Post-operative Ileus:** This is the most common type. Normal recovery of motility follows a specific sequence: Small Intestine (0–24 hours) → Stomach (24–48 hours) → Colon (48–72 hours). 2. **Electrolytes:** **Hypokalemia** is the most common electrolyte abnormality causing paralytic ileus. 3. **Radiology:** X-rays show uniform gas distribution in both the small and large bowel with "gas down to the rectum," unlike mechanical obstruction where gas is absent distal to the block. 4. **Management:** Usually conservative ("Drip and Suck" – IV fluids and Nasogastric decompression). Opioids should be avoided as they worsen the condition.

Question 757: A 20-year-old man presents with severe right lower quadrant abdominal pain, nausea, and anorexia. The abdominal pain started around his umbilicus and has now migrated to the right lower quadrant. Physical examination reveals exquisite tenderness at McBurney's point. This patient is diagnosed with acute appendicitis. What is the recommended treatment for this condition?

A. Antibiotics only, because the appendix is crucial for survival
B. Surgical resection of the appendix, because appendicitis can lead to appendiceal cancer
C. Surgical resection of the appendix, because appendicitis can lead to perforation or abscess (Correct Answer)
D. A 'watch-and-wait' approach over days to see if inflammation subsides

Explanation: **Explanation:** **1. Why the Correct Answer is Right:** The clinical presentation—migratory pain (Murphy’s sequence), anorexia, and McBurney’s point tenderness—is classic for **Acute Appendicitis**. The standard of care remains **emergency appendectomy** (laparoscopic or open). The primary rationale for surgery is to prevent life-threatening complications. If left untreated, the luminal obstruction (usually by a fecolith) leads to increased intraluminal pressure, ischemia, and eventual **perforation**, which can cause generalized peritonitis or a localized **appendiceal abscess**. **2. Why Incorrect Options are Wrong:** * **Option A:** While "antibiotics-first" is an emerging strategy for uncomplicated cases, the appendix is *not* crucial for survival (it is a vestigial organ). Surgery remains the definitive gold standard to prevent recurrence. * **Option B:** While some appendiceal tumors (like carcinoids) can present as appendicitis, the primary reason for surgery is to prevent acute perforation, not because appendicitis itself "causes" cancer. * **Option D:** A "watch-and-wait" approach is dangerous in acute appendicitis. Delaying surgery beyond 24–48 hours significantly increases the risk of rupture and sepsis. **3. NEET-PG High-Yield Clinical Pearls:** * **Most common cause of Appendicitis:** Fecolith (adults), Lymphoid hyperplasia (children). * **Alvarado Score (MANTRELS):** A score of $\geq 7$ is highly suggestive of appendicitis. * **Most common position of Appendix:** Retrocecal (75%). * **Most common sign:** Right lower quadrant tenderness. * **Investigation of Choice:** Contrast-Enhanced CT (CECT) is the gold standard; Ultrasound is preferred in children and pregnant women.

Question 758: Which of the following is NOT a complication of trichobezoars?

A. Haematemesis
B. Perforation and peritonitis
C. Obstruction
D. Malignancy (Correct Answer)

Explanation: **Explanation:** A **trichobezoar** is a mass of undigested hair trapped in the gastrointestinal tract, typically seen in young females with psychiatric conditions like trichotillomania (hair-pulling) and trichophagia (hair-eating). **Why Malignancy is the Correct Answer:** There is no clinical evidence or pathophysiological mechanism linking trichobezoars to the development of gastrointestinal **malignancy**. Bezoars act as chronic foreign bodies causing mechanical and chemical irritation, but they do not induce neoplastic transformation of the gastric or intestinal mucosa. **Analysis of Incorrect Options:** * **Obstruction (C):** This is the most common complication. The hairball can grow to fill the entire stomach or break off into pieces (Rapunzel syndrome), causing gastric outlet obstruction or small bowel obstruction. * **Perforation and Peritonitis (B):** Constant pressure from the heavy, enlarging mass can lead to pressure necrosis of the gastric wall, resulting in ulceration, perforation, and subsequent peritonitis. * **Haematemesis (A):** The rough texture of the hair mass causes chronic friction against the gastric mucosa, leading to "bezoar-induced" gastric ulcers. These ulcers can erode into mucosal vessels, causing upper GI bleeding and haematemesis. **High-Yield Clinical Pearls for NEET-PG:** * **Rapunzel Syndrome:** A rare form of trichobezoar where the "tail" of the hair mass extends from the stomach into the small intestine (jejunum/ileum). * **Clinical Presentation:** Often presents with a palpable, firm, non-tender epigastric mass, halitosis (due to decaying food trapped in the hair), and patchy alopecia. * **Diagnosis:** **Contrast CT scan** is the investigation of choice (shows a mottled gas pattern/mottled mass). * **Management:** Large trichobezoars usually require **laparotomy and gastrotomy**, as they are often too large and dense for endoscopic removal.

Question 759: What is the investigation of choice for the diagnosis of colon cancer?

A. Colonoscopy (Correct Answer)
B. Double contrast barium enema
C. Triple phase CT
D. Virtual colonoscopy

Explanation: **Explanation:** **Colonoscopy** is the investigation of choice (gold standard) for the diagnosis of colon cancer because it allows for direct visualization of the entire colon and, most importantly, enables **tissue biopsy** for histopathological confirmation. Early detection and definitive diagnosis are only possible through microscopic examination of the lesion. **Analysis of Incorrect Options:** * **Double-contrast barium enema (DCBE):** Once a standard screening tool, it has been largely replaced by colonoscopy. It can show "apple-core" lesions but lacks sensitivity for small polyps and cannot provide a biopsy. * **Triple-phase CT:** While CT is the investigation of choice for **staging** (detecting metastasis and local invasion), it is not the primary diagnostic tool for the intraluminal lesion itself. * **Virtual colonoscopy (CT Colonography):** This is a non-invasive screening alternative for patients who cannot undergo conventional colonoscopy. However, if a lesion is found, a traditional colonoscopy is still required for biopsy. **High-Yield Clinical Pearls for NEET-PG:** * **Screening:** For average-risk individuals, screening starts at age 45. * **Tumor Marker:** **CEA** (Carcinoembryonic Antigen) is used for monitoring recurrence and prognosis, **not** for primary diagnosis. * **Most Common Site:** Historically the rectum, but there is a rising incidence of right-sided (proximal) colon cancers. * **Gold Standard for Staging:** Contrast-Enhanced CT (CECT) of the Chest, Abdomen, and Pelvis. * **Rectal Cancer:** MRI (specifically Pelvic MRI) is the investigation of choice for local staging of rectal cancer.

Question 760: What is the commonest cause of acute mesenteric adenitis?

A. Tuberculosis
B. Brucellosis
C. Pneumococcal infection
D. Idiopathic (Correct Answer)

Explanation: **Explanation:** **Acute Mesenteric Adenitis** is a clinical condition characterized by the inflammation of mesenteric lymph nodes, often mimicking acute appendicitis. **Why "Idiopathic" is the correct answer:** In the majority of clinical cases, no specific causative organism is identified, making **Idiopathic** the most common classification. When a cause is identified, it is most frequently associated with a **viral upper respiratory tract infection** (e.g., Adenovirus, Enterovirus). Among bacterial causes, *Yersinia enterocolitica* is the most common specific pathogen, but overall, non-specific/idiopathic cases predominate in clinical practice. **Analysis of Incorrect Options:** * **A. Tuberculosis:** While abdominal TB is a significant cause of chronic mesenteric lymphadenopathy in developing countries, it typically presents with a chronic course rather than the acute, self-limiting presentation of mesenteric adenitis. * **B. Brucellosis:** This is a zoonotic infection that can cause lymphadenopathy and systemic symptoms, but it is a rare cause of acute abdominal pain compared to viral or idiopathic triggers. * **C. Pneumococcal infection:** *Streptococcus pneumoniae* is a common cause of primary peritonitis (especially in children with nephrotic syndrome or cirrhosis), but it is not a primary cause of mesenteric adenitis. **High-Yield Clinical Pearls for NEET-PG:** * **Clinical Presentation:** Typically affects children and adolescents; presents with RLQ pain, fever, and tenderness. * **Key Diagnostic Feature:** Unlike appendicitis, the pain in mesenteric adenitis is often **shifting** (the point of maximum tenderness moves when the patient is turned from side to side—**Klein’s Sign**). * **Diagnosis:** Ultrasound is the investigation of choice, showing enlarged lymph nodes (>8mm in short axis) with a normal appendix. * **Management:** It is a self-limiting condition; treatment is conservative (analgesics and hydration).

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

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