Gastrointestinal Surgery Practice Questions

Q: In which of the following conditions is Alvarado score indicated?

Appendicitis. ***Appendicitis*** - The Alvarado score, also known as the MANTRELS score, is a clinical scoring system used to assess the likelihood of **acute appendicitis**. - It considers symptoms (e.g., **migratory right iliac fossa pain**, **anorexia**, **nausea/vomiting**), signs (e.g., **tenderness in the right iliac fossa**, **rebound tenderness**), and laboratory findings (e.g., **leukocytosis**, **shift to the left of neutrophils**). *Pancreatitis* - Pancreatitis is typically diagnosed and managed using criteria such as the **Ranson criteria** or **APACHE II score** for severity assessment, and imaging like CT scans. - The Alvarado score is not applicable for the diagnosis or severity assessment of pancreatitis. *Cholangitis* - Cholangitis is an infection of the bile ducts which is usually diagnosed clinically using the **Charcot's triad** (fever, jaundice, right upper quadrant pain) or **Reynold's pentad** (Charcot's triad plus altered mental status and hypotension). - The Alvarado score has no role in the evaluation of cholangitis. *Cholecystitis* - Cholecystitis, inflammation of the gallbladder, is primarily diagnosed based on clinical symptoms (e.g., **right upper quadrant pain**, **fever**, **leukocytosis**), Murphy's sign, and imaging (ultrasound). - The Alvarado score is specifically designed for appendicitis and is not used for cholecystitis.

Q: Howship-Romberg sign is seen in

Obturator hernia. ***Obturator hernia*** - The **Howship-Romberg sign** is characterized by **medial thigh pain** on hip extension, adduction, and internal rotation, which is indicative of an obturator hernia. - This symptom arises from compression of the **obturator nerve** as it passes through the obturator canal alongside the hernia sac. *Spigelian hernia* - A Spigelian hernia presents as a **ventrolateral abdominal wall defect**, typically between the rectus abdominis muscle and linea semilunaris. - It usually causes localized pain and a palpable lump but does not involve **obturator nerve compression**. *Femoral hernia* - A femoral hernia manifests as a bulge in the **groin region** below the inguinal ligament, often presenting as an emergent strangulated hernia. - While it can cause groin pain, it does not typically involve the **obturator nerve** or present with the **Howship-Romberg sign**. *Inguinal hernia* - Inguinal hernias are common, presenting as a bulge in the groin, either **direct or indirect**, above the inguinal ligament. - Symptoms include a palpable mass and discomfort, but not the specific **medial thigh pain** associated with obturator nerve compression.

Q: A 60-year-old man presents with foul breath and regurgitates food eaten 3 days ago. What is the most likely diagnosis?

Zenker's Diverticulum. ***Zenker's Diverticulum*** - This condition presents with a classic triad of **dysphagia**, **regurgitation of undigested food**, and **foul breath (halitosis)** due to food retention in the diverticulum. - The regurgitation of food eaten several days ago is highly characteristic, indicating significant pooling and decomposition within the **pharyngeal pouch**. *Achalasia cardia* - Characterized by **dysphagia for both solids and liquids** and regurgitation, but the regurgitated food is typically fresh or only recently ingested, not from several days prior. - The primary pathology is the **failure of the lower esophageal sphincter (LES) to relax** and loss of peristalsis in the esophageal body. *Carcinoma esophagus* - Often presents with **progressive dysphagia** (first for solids, then for liquids) and significant **weight loss**. - While regurgitation can occur, it's usually of recently ingested food and rarely associated with the severe halitosis from long-standing food decomposition seen in Zenker's. *Loss of tone of upper esophageal sphincter* - This condition would more likely lead to **regurgitation of stomach contents** into the pharynx, rather than the retention of food in a pouch. - It could contribute to **reflux symptoms** but does not explain the formation of a diverticulum or the prolonged food retention leading to foul breath.

Q: Hamman's sign is seen in which of the following conditions?

Oesophageal perforation. ***Oesophageal perforation*** - **Hamman's sign** is a classic auscultatory finding of a crunching, rasping sound synchronous with the heartbeat, indicative of **mediastinal emphysema** (air in the mediastinum). - Oesophageal perforation allows air to escape into the mediastinum, leading to mediastinal emphysema and thus Hamman's sign. *Acute oesophagitis* - This condition involves inflammation of the oesophagus, often causing symptoms like **dysphagia** and **odynophagia**. - It typically does not involve air leakage into the mediastinum, and therefore, **Hamman's sign is not expected**. *Corrosive burns of oesophagus* - Corrosive injuries cause chemical burns to the oesophageal lining, leading to inflammation, strictures, or in severe cases, perforation. - While perforation is a possibility in severe cases, the primary presentation is typically related to direct tissue damage and inflammation, not consistently with **mediastinal emphysema** unless perforation has occurred. *Benign strictures of oesophagus* - Benign strictures are narrowings of the oesophagus, usually caused by chronic inflammation or reflux. - They primarily cause **dysphagia** due to mechanical obstruction and are not associated with **air leakage into the mediastinum** or Hamman's sign.

Q: Forrest classification is used for evaluating:

Upper GI bleeding. ***Upper GI bleeding*** - The **Forrest classification** is a widely used endoscopic classification system that assesses the status of bleeding from a peptic ulcer. - It helps predict the risk of **rebleeding** and guides treatment decisions, ranging from active bleeding requiring urgent intervention to signs of recent hemorrhage or no visible signs of bleeding. *Familial adenomatous polyposis* - This is a **hereditary syndrome** characterized by the development of hundreds to thousands of adenomatous polyps in the colon and rectum. - Its evaluation primarily involves **genetic testing**, colonoscopy surveillance, and screening for extracolonic manifestations. *Liver transplantation* - The evaluation for liver transplantation involves complex scoring systems like the **MELD (Model for End-Stage Liver Disease) score** or Child-Pugh score. - These scores assess the severity of liver disease and predict short-term mortality to prioritize patients for transplantation. *Lower GI bleeding* - Lower GI bleeding typically originates distal to the ligament of Treitz and is evaluated using different techniques like **colonoscopy**, angiography, or capsule endoscopy. - Specific classification systems for lower GI bleeding are not commonly referred to as the Forrest classification.

Q: In a female with appendicitis in pregnancy the treatment of choice is:

Surgery at earliest. ***Surgery at earliest*** - **Prompt surgical intervention** is crucial for appendicitis in pregnancy to prevent complications such as perforation, peritonitis, and maternal or fetal morbidity and mortality. - Delaying surgery increases the risk of rupture, which can be devastating for both the mother and the fetus. *Continue pregnancy with medical Rx* - **Medical management (antibiotics alone)** is generally ineffective for acute appendicitis in pregnant women and carries a high risk of progression to perforation. - This approach would expose the mother and fetus to serious complications, including sepsis and preterm labor, without addressing the underlying surgical pathology. *Surgery after delivery* - Delaying surgery until after delivery is unsafe and potentially fatal, as **appendiceal rupture could occur at any time** during pregnancy. - The risk of **perforation, peritonitis, and subsequent complications** is too high to justify waiting. *Abortion with appendectomy* - **Therapeutic abortion** is not indicated for uncomplicated appendicitis in pregnancy and does not improve the maternal prognosis for the appendicitis itself. - The focus is on treating the underlying medical condition (appendicitis) while preserving the pregnancy, if possible.

Q: Most common cause of esophageal perforation at the site of cricopharynx -

Iatrogenic. ***Iatrogenic*** - Most esophageal perforations, especially at the cricopharyngeal level, are **iatrogenic**, typically occurring during **endoscopic procedures** such as esophagogastroduodenoscopy (EGD), transesophageal echocardiography (TEE), or esophageal dilation. - The cricopharynx (or upper esophageal sphincter) is a narrow, relatively weak area of the esophagus, making it susceptible to injury during instrument passage. - Accounts for approximately **50-70%** of all esophageal perforations at this site. *Spontaneous* - Spontaneous esophageal perforation (Boerhaave syndrome) usually occurs in the **distal esophagus** following episodes of severe retching and vomiting. - It is far less common in the cervical esophagus or cricopharyngeal region compared to iatrogenic causes. *Foreign body* - Foreign body impaction can cause esophageal perforation, particularly at anatomical narrowing points. - However, at the cricopharynx level, **iatrogenic injury during endoscopic removal** of foreign bodies is more common than direct perforation from the foreign body itself. *Traumatic* - **External blunt or penetrating trauma** to the neck can cause esophageal perforation, but this is less common than iatrogenic causes at the cricopharynx. - While trauma can certainly cause perforation, instrument-related perforations during medical procedures are statistically more frequent in this area.

Q: Alvarado score is used for

Acute appendicitis. ***Acute appendicitis*** - The **Alvarado score**, also known as the MANTRELS score, is a clinical prediction rule used to assist in the diagnosis of **acute appendicitis**. - It assigns points based on symptoms (migratory pain, anorexia, nausea/vomiting), signs (tenderness in the right iliac fossa, rebound tenderness), and laboratory findings (elevated temperature, leukocytosis, left shift of neutrophils). *Acute epididymitis* - Diagnosis typically relies on clinical findings like **unilateral testicular pain and swelling**, often associated with dysuria or urethral discharge. - While it has scoring systems (like the Epididymitis Severity Score), the **Alvarado score** is not used for its diagnosis. *Acute pancreatitis* - Diagnosed based on characteristic **epigastric pain**, elevated serum amylase or lipase levels, and imaging findings. - Severity is often assessed using scoring systems like **Ranson's criteria** or APACHE II, not the Alvarado score. *Acute cholecystitis* - Diagnosed by symptoms such as **right upper quadrant pain**, fever, and leukocytosis, often with **positive Murphy's sign** and imaging evidence (e.g., gallbladder wall thickening on ultrasound). - The **Alvarado score** is not relevant to the diagnosis or severity assessment of acute cholecystitis.

Q: A 40 years old male was brought emergency with severe abdominal pain. On examination, pulse rate was 112/minute and systolic BP was 80 mmHg. Chest x-ray is given below. What is the most appropriate management?

Exploratory laparotomy. ***Exploratory laparotomy*** - The chest x-ray shows **pneumoperitoneum (air under the diaphragm)**, which, combined with severe abdominal pain, tachycardia, and hypotension (signs of **septic shock**), is highly indicative of a **perforated viscus**. - **Emergency exploratory laparotomy** is the definitive treatment to identify and repair the perforation, control contamination, and prevent further deterioration. *Saline wash of stomach* - This procedure is typically used for gastric lavage in cases of **poisoning or drug overdose**, or to clear the stomach in preparation for endoscopy. - It does not address a viscus perforation or the widespread abdominal contamination and systemic septic response seen in this patient. *Intercostal tube drainage* - **Intercostal tube drainage** (chest tube placement) is used to drain air (pneumothorax) or fluid (pleural effusion, hemothorax, empyema) from the pleural space, not the abdominal cavity. - While there is air visible on the x-ray, it is **subdiaphragmatic (pneumoperitoneum)**, not within the pleural space, and thus a chest tube would be ineffective and inappropriate. *IV antibiotics* - **Intravenous antibiotics** are crucial for managing sepsis associated with a perforated viscus and should be administered promptly. - However, antibiotics alone are **not sufficient** to treat the underlying mechanical problem of a perforation, which requires surgical repair to prevent ongoing bacterial contamination and sepsis.

Q: Cushing ulcers are:-

Stress ulcers in head injury. ***Stress ulcers in head injury*** - **Cushing ulcers** are acute **gastric or duodenal ulcers** that develop after a severe **head injury** or other central nervous system trauma. - The pathophysiology involves **vagal overstimulation** due to increased intracranial pressure, leading to hypersecretion of **gastric acid** and reduced mucosal blood flow. *Stress ulcers in hiatus hernia* - A **hiatus hernia** is a condition where part of the stomach protrudes through the diaphragm into the chest cavity, which can predispose to reflux and esophagitis. - While patients with hiatus hernia might develop ulcers, these are not specifically termed Cushing ulcers, and the primary cause is mechanical or reflux-related, not neurological. *Stress ulcers in burns* - **Stress ulcers** that occur in burn patients are known as **Curling ulcers**, not Cushing ulcers. - These are typically caused by **hypovolemia, vasoconstriction**, and **ischemia** of the gastrointestinal mucosa due to significant fluid loss and systemic inflammatory response. *Stress ulcers in depression* - **Depression** is a mood disorder that can influence gastrointestinal function through the **gut-brain axis**, potentially affecting motility and visceral hypersensitivity. - However, depression is not directly associated with the formation of acute stress ulcers like Cushing ulcers, which are primarily linked to severe CNS injury.

Question 1

In which of the following conditions is Alvarado score indicated?

Accepted Answer

Appendicitis

Answer

Pancreatitis

Answer

Cholangitis

Answer

Cholecystitis

Question 2

Howship-Romberg sign is seen in

Accepted Answer

Obturator hernia

Answer

Spigelian hernia

Answer

Femoral hernia

Answer

Inguinal hernia

Question 3

A 60-year-old man presents with foul breath and regurgitates food eaten 3 days ago. What is the most likely diagnosis?

Accepted Answer

Zenker's Diverticulum

Answer

Achalasia cardia

Answer

Carcinoma esophagus

Answer

Loss of tone of upper esophageal sphincter

Question 4

Hamman's sign is seen in which of the following conditions?

Accepted Answer

Oesophageal perforation

Answer

Acute oesophagitis

Answer

Corrosive burns of oesophagus

Answer

Benign strictures of oesophagus

Question 5

Forrest classification is used for evaluating:

Accepted Answer

Upper GI bleeding

Answer

Familial adenomatous polyposis

Answer

Liver transplantation

Answer

Lower GI bleeding

Question 6

In a female with appendicitis in pregnancy the treatment of choice is:

Accepted Answer

Surgery at earliest

Answer

Continue pregnancy with medical Rx

Answer

Surgery after delivery

Answer

Abortion with appendectomy

Question 7

Most common cause of esophageal perforation at the site of cricopharynx -

Accepted Answer

Iatrogenic

Answer

Spontaneous

Answer

Foreign body

Answer

Traumatic

Question 8

Alvarado score is used for

Accepted Answer

Acute appendicitis

Answer

Acute epididymitis

Answer

Acute pancreatitis

Answer

Acute cholecystitis

Question 9

A 40 years old male was brought emergency with severe abdominal pain. On examination, pulse rate was 112/minute and systolic BP was 80 mmHg. Chest x-ray is given below. What is the most appropriate management?

Accepted Answer

Exploratory laparotomy

Answer

Saline wash of stomach

Answer

Intercostal tube drainage

Answer

IV antibiotics

Question 10

Cushing ulcers are:-

Accepted Answer

Stress ulcers in head injury

Answer

Stress ulcers in hiatus hernia

Answer

Stress ulcers in burns

Answer

Stress ulcers in depression

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

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