Gastrointestinal Surgery Practice Questions

Q: The following nerves are blocked for repairing inguinal hernia by local anaesthetic except:

Femoral. ***Femoral*** - The **femoral nerve** primarily innervates the anterior thigh muscles and provides sensory supply to the anterior thigh and medial leg; its block is not typically required for **inguinal hernia repair**. - Blocking the femoral nerve would primarily affect **motor function** of the quadriceps and sensation in the distribution of the saphenous nerve, which is not the surgical field for an inguinal hernia. *Ilio-inguinal* - The **ilio-inguinal nerve** provides sensation to the inguinal region, scrotum/labia majora, and the medial aspect of the thigh, making its block essential for anesthesia during **inguinal hernia repair**. - It lies in the **inguinal canal** and is typically targeted with local anesthetic to cover the incision site and surgical area. *Genito femoral* - The **genitofemoral nerve** has both genital and femoral branches, providing sensation to the scrotum/labia majora and a small area of the femoral triangle, respectively, and is therefore often included in an **inguinal block**. - Its blockade helps to cover the sensory innervation of the **spermatic cord** and a portion of the inguinal region, contributing to effective pain control. *Ilio-hypogastric* - The **ilio-hypogastric nerve** provides sensory innervation to the suprapubic and gluteal regions, and its blockade is important for covering the **upper part of the surgical incision** for an inguinal hernia repair. - It runs parallel to the ilio-inguinal nerve and is often blocked concurrently to ensure **comprehensive analgesia** of the abdominal wall.

Q: In a patient of gastric outlet obstruction nutritional support is best delivered by:

Jejunostomy. ***Jejunostomy*** - In **gastric outlet obstruction**, the stomach cannot empty properly, making gastric feeding routes (like Ryles tube or gastrostomy) ineffective. - A **jejunostomy** allows direct delivery of **enteral nutrition** into the jejunum, bypassing the obstructed stomach and duodenum. *Enteral nutrition by Ryles tube* - A **Ryles tube** delivers nutrition into the stomach, which is obstructed in this condition, leading to **stasis** and **vomiting**. - This method would be ineffective and potentially dangerous due to the inability of gastric contents to pass beyond the obstruction. *Gastrostomy* - A **gastrostomy** involves placing a tube directly into the stomach, which is still part of the obstructed system. - Feeding via gastrostomy would lead to accumulation of feed in the stomach, mimicking the issues with oral feeding or a Ryles tube. *Parenteral nutrition* - **Parenteral nutrition** is a viable option for nutritional support but is generally considered a second-line therapy after **enteral routes** fail or are contraindicated. - **Enteral feeding**, when possible (as with jejunostomy), is preferred due to lower cost, reduced risk of infection, and better maintenance of gut integrity.

Q: Which one of the following is the investigation of choice in a patient with haematemesis?

Flexible upper gastrointestinal endoscopy. ***Flexible upper gastrointestinal endoscopy*** - This is the **investigation of choice** for haematemesis as it allows for direct visualization of the upper gastrointestinal tract to identify the source of bleeding [1]. - It also enables **therapeutic intervention**, such as injection sclerotherapy, banding, or clip application, to stop the bleeding [1]. *Contrast enhanced CT scan* - A CT scan is generally **not the primary investigation** for acute haematemesis because it offers less diagnostic accuracy for mucosal lesions and cannot provide therapeutic intervention [1]. - While it can identify large bleeds or structural abnormalities, it is **less sensitive for smaller bleeds** or subtle mucosal abnormalities compared to endoscopy. *Barium meal for stomach and duodenum* - A barium meal is **contraindicated in acute gastrointestinal bleeding** as the barium can obscure endoscopic views and interfere with subsequent attempts at endoscopy or angiography [1]. - It provides **limited diagnostic information** about the active bleeding site and offers no therapeutic capabilities. *Selective left gastric angiography* - Angiography is typically reserved for cases of **severe, persistent bleeding** where endoscopy has failed to locate or control the bleed. - It is an **invasive procedure** with potential complications and is not indicated as the initial diagnostic investigation.

Q: Mousseau-Barbin Tube (M.B.Tube) is used for:

Advanced cancer oesophagus. ***Advanced cancer oesophagus*** - The **Mousseau-Barbin tube** is a type of **endoscopic stent** used for palliative management of **dysphagia** caused by advanced **oesophageal cancer**. - It provides a lumen through obstructed oesophageal segments, allowing patients to swallow food and liquids more easily. *Advanced cancer oropharynx* - While dysphagia can be a symptom of oropharyngeal cancer, the Mousseau-Barbin tube is specifically designed for placement within the **oesophagus**. - Management for advanced oropharyngeal cancer often involves other interventions like **radiotherapy**, **chemotherapy**, or **surgical resection**. *All of these* - This option is incorrect because the Mousseau-Barbin tube has a specific application for the **oesophagus**. - It is not routinely used for cancers of the oropharynx or stomach due to differences in anatomical location and disease progression. *Advanced cancer stomach* - Advanced stomach cancer, particularly in the distal stomach, would not typically benefit from an oesophageal stent. - Gastric outlet obstruction can occur, but specific **gastric stents** or **surgical bypasses** are used for this.

Q: In a case of obstructed hernia, strangulation is suggested by which of the following? 1. Presence of shock 2. Pain is never completely absent 3. Localised tenderness is associated with rebound tenderness 4. Pain persists despite conservative management 5. An external hernia becomes tense, tender, irreducible, with recent increase in size Select the correct answer using the code given below:

1, 2, 3, 4 and 5. ***1, 2, 3, 4 and 5*** - All listed options (presence of **shock**, persistent pain, **localized and rebound tenderness**, failure of conservative management, and a **tense, tender, irreducible hernia** with recent size increase) are classic indicators of **hernia strangulation**. - **Strangulation** is a surgical emergency where the blood supply to the herniated tissue is compromised, leading to **ischemia** and potential **necrosis**, requiring immediate intervention. *1, 2, 4 and 5 only* - This option incorrectly omits **localized tenderness associated with rebound tenderness**, which is a crucial sign of peritoneal irritation and impending or established strangulation. - While other signs are accurate, the absence of this specific finding makes the option incomplete for a comprehensive understanding of strangulation. *1, 2, 3, 4 only* - This option misses the critical clinical sign of an **external hernia becoming tense, tender, irreducible, with a recent increase in size**, which is a direct and often visible sign of strangulation. - The physical examination findings of the hernia itself are paramount in diagnosing strangulation. *1, 3 and 5 only* - This option omits two significant indicators: **pain is never completely absent** (implying continuous, severe pain) and **pain persists despite conservative management**. - Continuous pain and refractoriness to treatment highlight the progressive and severe nature of strangulation.

Q: The most common cause of intestinal obstruction is:

Bands and adhesions. ***Bands and adhesions*** - **Post-surgical adhesions** are the most common cause of small bowel obstruction, often forming after abdominal surgeries due to tissue healing. - These fibrous bands can **constrict or kink** the bowel, leading to a mechanical blockage. *Inflammatory abdominal conditions* - Conditions like **Crohn's disease** or **diverticulitis** can cause obstruction, but they are less frequent than adhesions as a primary cause. - Obstruction due to inflammation often involves **strictures** or inflammation-induced narrowing of the lumen. *Obstructed hernia* - **Hernias** (inguinal, femoral, umbilical, incisional) can become obstructed or strangulated, causing acute obstruction. - While a significant cause, the overall incidence is lower than that of adhesions, especially looking at all cases of intestinal obstruction. *Gastrointestinal malignancy* - **Colorectal cancer** is a common cause of large bowel obstruction, and other GI malignancies can cause small bowel obstruction. - Malignancy-related obstructions typically involve **tumor growth** causing luminal narrowing, but adhesions remain the leading cause overall.

Q: Ventral hernia includes all EXCEPT:

Inguinal hernia. ***Inguinal hernia*** - An **inguinal hernia** is a protrusion of abdominal contents through the **inguinal canal**, located in the groin region. - It is **NOT a ventral hernia** because it occurs through the inguinal canal in the groin, not through the anterior abdominal wall directly. - Inguinal hernias are classified separately as **groin hernias**, distinct from ventral hernias. *Umbilical hernia* - An **umbilical hernia** occurs through a defect in the **umbilical ring** at the umbilicus. - This is a **true ventral hernia** as it protrudes directly through the anterior abdominal wall at the umbilicus. - Common in infants and adults, especially in conditions that increase intra-abdominal pressure. *Epigastric hernia* - An **epigastric hernia** involves protrusion of preperitoneal fat or peritoneum through a defect in the **linea alba** between the xiphoid process and the umbilicus. - This is a **ventral hernia** because it occurs directly in the anterior abdominal wall through the midline. *Para-umbilical hernia* - A **para-umbilical hernia** occurs through a defect in the **linea alba** adjacent to, but not directly through, the umbilical cicatrix. - This is classified as a **ventral hernia** due to its location in the anterior abdominal wall near the umbilicus.

Q: A 48 year old male with the history of chronic duodenal ulcer presented in surgical emergency with the complaints of sudden severe pain in the abdomen. At presentation: Pulse = 120/m, BP = 90/60 mm of Hg Abdomen: Tenderness (+), Rigidity (+), Guarding (+) Respiratory Rate: 20/m X-ray: Gas under right dome of diaphragm The probable diagnosis is:

Perforation Peritonitis. ***Perforation Peritonitis*** - The patient's history of **chronic duodenal ulcer**, sudden severe abdominal pain, signs of **peritonitis** (**tenderness, rigidity, guarding**), and especially the X-ray finding of **gas under the right dome of the diaphragm** (indicating **pneumoperitoneum**) are all classic for a perforated viscus. - The **tachycardia** (Pulse = 120/m) and **hypotension** (BP = 90/60 mm Hg) further suggest a systemic inflammatory response syndrome (SIRS) or even **septic shock** due to peritonitis. *Acute appendicitis* - This typically presents with peri-umbilical pain migrating to the right lower quadrant, with localized tenderness and guarding, not diffuse peritonitis. - **Gas under the diaphragm** is not a feature of uncomplicated appendicitis but occurs with perforation of a hollow viscus. *Acute Pancreatitis* - While it can cause severe abdominal pain and signs of peritonitis, the pain often radiates to the back and is associated with elevated pancreatic enzymes. - **Gas under the diaphragm** is not a typical finding in acute pancreatitis unless there's a complication like colonic perforation. *Acute Myocardial infarction* - Though an MI can present with epigastric pain, it would not typically cause **diffuse abdominal tenderness, rigidity, guarding**, or **pneumoperitoneum**. - The primary symptoms would generally involve chest discomfort, and diagnostic tests would show cardiac enzyme elevation and EKG changes.

Q: What is true about the management of a corrosive injury of oesophagus?

Early skilled endoscopy is a must. ***Early skilled endoscopy is a must*** - **Early endoscopy** within 12-24 hours is crucial to assess the extent and depth of corrosive injury - Helps determine severity (Grade I-III burns) and guide further management - Identifies patients needing aggressive treatment vs. conservative management - **Contraindicated** only in suspected perforation or severe respiratory distress *Broad spectrum antibiotics should be started as soon as possible* - **Prophylactic antibiotics are NOT routinely recommended** for corrosive injuries - Risk of promoting antibiotic resistance without proven benefit - Antibiotics indicated only when signs of infection present: **fever, leukocytosis, or suspected perforation** *Immediate surgery with oesophagectomy is advisable* - **Immediate oesophagectomy is NOT standard management** - Reserved for severe complications: **perforation, extensive necrosis, mediastinitis, or uncontrolled bleeding** - Most patients initially managed conservatively with supportive care - Surgery considered only if conservative measures fail *Immediate NG tube insertion and gastric lavage should be performed* - **Both are CONTRAINDICATED** in corrosive ingestions - **Gastric lavage** can induce vomiting, causing re-exposure of esophagus and risking perforation - **NG tube insertion** can traumatize damaged esophageal mucosa and cause perforation - Management focuses on NBM (nil by mouth), fluid resuscitation, and pain control

Q: Which of the following is NOT a tissue repair surgery for inguinal hernia repair?

Stoppa's repair. ***Stoppa's repair*** - Stoppa's repair is a type of **giant prosthetic reinforcement of the visceral sac (GPRVS)**, which involves placing a large sheet of **synthetic mesh** in the preperitoneal space to buttress the entire myopectineal orifice. - This technique is primarily a **mesh repair** and thus not considered a pure tissue repair method. *Bassini's repair* - This is a classic **tissue repair** method where the conjoint tendon is sutured to the inguinal ligament, reinforcing the posterior wall of the inguinal canal. - It involves using the patient's own tissues without the implantation of synthetic mesh. *Shouldice repair* - Considered a gold standard among **tissue repairs**, it involves a multi-layered reconstruction of the posterior wall of the inguinal canal by approximating the transversalis fascia, conjoint tendon, and iliopubic tract. - The Shouldice repair also avoids the use of mesh. *Desarda repair* - This is a newer **tissue repair** method that utilizes a strip of the external oblique aponeurosis to create a new posterior wall for the inguinal canal. - It is promoted as a tension-free repair that does not use foreign mesh materials.

Question 1

The following nerves are blocked for repairing inguinal hernia by local anaesthetic except:

Accepted Answer

Femoral

Answer

Ilio-inguinal

Answer

Genito-femoral

Answer

Ilio-hypogastric

Question 2

In a patient of gastric outlet obstruction nutritional support is best delivered by:

Accepted Answer

Jejunostomy

Answer

Enteral nutrition by Ryles tube

Answer

Gastrostomy

Answer

Parenteral nutrition

Question 3

Which one of the following is the investigation of choice in a patient with haematemesis?

Accepted Answer

Flexible upper gastrointestinal endoscopy

Answer

Contrast enhanced CT scan

Answer

Barium meal for stomach and duodenum

Answer

Selective left gastric angiography

Question 4

Mousseau-Barbin Tube (M.B.Tube) is used for:

Accepted Answer

Advanced cancer oesophagus

Answer

Advanced cancer oropharynx

Answer

All of these

Answer

Advanced cancer stomach

Question 5

In a case of obstructed hernia, strangulation is suggested by which of the following?

1. Presence of shock
2. Pain is never completely absent
3. Localised tenderness is associated with rebound tenderness
4. Pain persists despite conservative management
5. An external hernia becomes tense, tender, irreducible, with recent increase in size

Select the correct answer using the code given below:

Accepted Answer

1, 2, 3, 4 and 5

Answer

1, 2, 4 and 5 only

Answer

1, 2, 3, 4 only

Answer

1, 3 and 5 only

Question 6

The most common cause of intestinal obstruction is:

Accepted Answer

Bands and adhesions

Answer

Inflammatory abdominal conditions

Answer

Obstructed hernia

Answer

Gastrointestinal malignancy

Question 7

Ventral hernia includes all EXCEPT:

Accepted Answer

Inguinal hernia

Answer

Umbilical hernia

Answer

Epigastric hernia

Answer

Para-umbilical hernia

Question 8

A 48 year old male with the history of chronic duodenal ulcer presented in surgical emergency with the complaints of sudden severe pain in the abdomen. At presentation: Pulse = 120/m, BP = 90/60 mm of Hg Abdomen: Tenderness (+), Rigidity (+), Guarding (+) Respiratory Rate: 20/m X-ray: Gas under right dome of diaphragm The probable diagnosis is:

Accepted Answer

Perforation Peritonitis

Answer

Acute appendicitis

Answer

Acute Pancreatitis

Answer

Acute Myocardial infarction

Question 9

What is true about the management of a corrosive injury of oesophagus?

Accepted Answer

Early skilled endoscopy is a must

Answer

Broad spectrum antibiotics should be started as soon as possible

Answer

Immediate surgery with oesophagectomy is advisable

Answer

Immediate NG tube insertion and gastric lavage should be performed

Question 10

Which of the following is NOT a tissue repair surgery for inguinal hernia repair?

Accepted Answer

Stoppa's repair

Answer

Bassini's repair

Answer

Shouldice repair

Answer

Desarda repair

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

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