Gastrointestinal Surgery Practice Questions

Q: A 25 year old man presents with a 3-day history of pain in the right lower abdomen and vomiting. The patient's general condition is satisfactory, and clinical examination reveals a tender lump in the right iliac fossa. What is the most appropriate management in this case?

Ochsner-Sherren regimen. ***Ochsner-Sherren regimen*** - The presence of a **tender lump** in the right iliac fossa combined with a 3-day history strongly suggests a contained appendix mass or abscess. The **Ochsner-Sherren regimen** is appropriate here. - This conservative management includes **IV fluids**, **antibiotics**, **nil by mouth (NBM)**, **nasogastric aspiration**, and pain control, aiming to resolve the inflammation before interval appendectomy (typically after 6-8 weeks). *Immediate appendicectomy* - This is indicated for **uncomplicated acute appendicitis**, where there is no evidence of a contained mass or abscess. - Performing surgery on a mature appendix mass can be technically difficult, increasing the risk of **perforation** and **complications**. *Exploratory laparotomy* - This is a more extensive surgical procedure, typically reserved for cases with **diffuse peritonitis**, **haemodynamic instability**, or suspicion of other serious intra-abdominal pathology that requires immediate wide exploration. - Given the stable condition and localized findings, it is not the initial appropriate approach. *External drainage* - **External drainage** is specifically used for a well-formed **appendix abscess** that is amenable to percutaneous (image-guided) drainage. - While it's an option for some abscesses, the Ochsner-Sherren regimen is the initial conservative step for an appendix mass, with drainage considered if the mass progresses to a drainable abscess.

Q: Multiple air fluid levels in X-ray of abdomen are seen in

Intestinal obstruction. ***Intestinal obstruction*** - **Air fluid levels** are a classic radiographic sign of bowel obstruction, resulting from the accumulation of gas and fluid proximal to the obstructed segment. - The obstructed bowel segments fill with ingested air and digestive fluids, forming distinct horizontal fluid levels layered below gas bubbles, particularly evident on **erect or decubitus abdominal X-rays**. *Hollow viscera perforation* - This condition is characterized by the presence of **free air under the diaphragm** (pneumoperitoneum), not typically by multiple air-fluid levels within the bowel loops. - While fluid might extravasate, the primary radiographic finding is *free intraperitoneal gas*, indicating a breach in the luminal wall. *Pyoperitoneum* - Refers to the presence of **pus within the peritoneal cavity**, which would manifest as diffuse fluid accumulation rather than discrete air-fluid levels within bowel segments. - While gas might be present if associated with a gas-forming infection, it's not the primary or defining characteristic like the ordered air-fluid levels of obstruction. *None of the options* - This option is incorrect because **intestinal obstruction** is a well-established cause of multiple air-fluid levels on abdominal X-rays. - The other conditions listed do not typically present with this specific radiographic pattern as their primary or defining feature.

Q: Most common cause of acute abdomen in a young girl?

Acute appendicitis. ***Acute appendicitis*** - **Acute appendicitis** is the most common cause of acute abdomen in children and young adults, including young girls. - Its high incidence across this age group makes it the leading diagnosis for acute abdominal pain requiring surgical intervention. *Ovarian torsion* - While it can cause severe acute abdominal pain in young girls, **ovarian torsion** is less common than appendicitis. - It often presents with sudden onset, severe, unilateral lower abdominal pain, sometimes with a palpable mass. *Mittelschmerz* - "**Mittelschmerz**" refers to pelvic pain experienced by some women during ovulation, typically mid-cycle. - This is a physiological event, not an acute surgical emergency, and the pain is usually mild and self-limiting. *Renal colic* - **Renal colic** is caused by kidney stones and is characterized by severe, colicky pain radiating from the flank to the groin. - While possible, it is less common in young girls compared to appendicitis and often associated with urinary symptoms.

Q: A patient after a heavy meal and episode of forceful vomiting presents with severe epigastric pain. On examination, there is tenderness and rigidity in the upper abdomen. X-ray shows pneumomediastinum. What is the most likely cause?

Spontaneous rupture of the esophagus. ***Spontaneous rupture of the esophagus*** - The combination of **post-emetic epigastric pain**, upper abdominal tenderness/rigidity, and **pneumomediastinum** is characteristic of Boerhaave syndrome, which is a **spontaneous transmural esophageal rupture**. - This rupture often occurs after a heavy meal or forceful vomiting, leading to a sudden increase in **intra-esophageal pressure**. *Penetrating injury to the esophagus* - While a penetrating injury could cause esophageal rupture and pneumomediastinum, the clinical scenario describes a **spontaneous event** following a meal, not trauma. - Absence of an external wound, trauma history, or foreign body ingestion makes this less likely. *Perforation of a peptic ulcer* - A perforated peptic ulcer would typically cause **severe, sudden onset epigastric pain** and **peritonitis**, but it would lead to **pneumoperitoneum** (free air in the abdomen) rather than pneumomediastinum. - While it could cause referred pain to the chest, the direct finding of air in the mediastinum points away from an isolated abdominal perforation. *Rupture of an emphysematous bulla* - Rupture of an emphysematous bulla would cause a **pneumothorax** or **pneumomediastinum**, but it would not typically present with severe epigastric pain and abdominal signs. - There would usually be a history of **lung disease** or smoking, and respiratory symptoms would be more prominent.

Q: A patient presents with abdominal pain. On physical examination there was abdominal guarding and tenderness. A plain erect chest X-ray reveals air under diaphragm. Probable diagnosis is

Perforated abdominal viscus. ***Perforated abdominal viscus*** - The presence of **abdominal guarding** and **tenderness** indicates peritoneal irritation, while **air under the diaphragm** on an erect chest X-ray (**pneumoperitoneum**) is a classic sign of a perforated hollow abdominal organ. - This combination strongly suggests a **perforated abdominal viscus**, such as a **perforated peptic ulcer** or perforated diverticulitis, leading to the leakage of air and intestinal contents into the peritoneal cavity. *Acute myocardial infarction* - Acute myocardial infarction primarily presents with **chest pain**, radiation to the arm/jaw, and shortness of breath, not typically severe abdominal pain with guarding. - While it can cause some epigastric discomfort, it would not explain the **pneumoperitoneum** seen on the chest X-ray. *Aortic dissection* - Aortic dissection typically causes **sudden, severe tearing chest or back pain**, often radiating to the back. - There is no direct link between aortic dissection and **air under the diaphragm** unless there's a co-existing, unrelated issue, which is not suggested by the primary symptoms. *None of the options* - Given the clear clinical and radiological findings of **pneumoperitoneum** and **peritoneal signs**, a perforated abdominal viscus is the most fitting diagnosis among the choices provided. - This option is incorrect as there is a highly probable diagnosis among the given choices.

Q: A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -

Proceed to laparotomy and appendicectomy. ***Proceed to laparotomy and appendicectomy*** - A **rising pulse rate, tachycardia, and fever** indicate **worsening sepsis** or **perforation** of the appendicular mass, necessitating urgent surgical intervention. - Continuing conservative management in the face of these signs carries a high risk of **morbidity and mortality** from peritonitis or widespread sepsis. *Continue Ochsner Sherren regimen with close monitoring* - The Ochsner Sherren regimen is a **conservative approach** for a stable appendicular mass, which is no longer the case with signs of deterioration. - **Clinical worsening** (tachycardia, rising fever, increased pulse) signifies failure of conservative management and requires a shift to surgical intervention. *Continue conservative management* - Continuing conservative management despite **signs of deterioration** (rising pulse, tachycardia, fever) would lead to further progression of the disease and potential life-threatening complications. - These symptoms suggest that the infection is **not contained** and is likely spreading, indicating the need for immediate surgical treatment. *Intravenous antibiotics* - While intravenous antibiotics are part of the initial conservative management, they are **insufficient** alone for an appendicular mass showing signs of deterioration. - The worsening clinical picture suggests a **failed antibiotic response** or a more severe underlying issue (e.g., abscess rupture) that requires surgical drainage or removal.

Q: All of the following are true about Nissen Fundoplication except which of the following?

Reinforcement is done only in the posterior half. ***Reinforcement is done only in the posterior half*** - This statement is incorrect because the **Nissen fundoplication** typically involves a **360-degree wrap** of the gastric fundus around the lower esophagus. - A 360-degree wrap provides complete reinforcement to prevent reflux, unlike a partial wrap which might be used in other procedures but not a standard Nissen. *It is done for GERD* - **Nissen fundoplication** is a common surgical procedure performed to treat severe **Gastroesophageal Reflux Disease (GERD)** that is refractory to medical management. - The procedure aims to strengthen the **lower esophageal sphincter (LES)** and prevent the reflux of stomach contents into the esophagus. *Upper part of stomach is plicated around the lower esophagus* - Specifically, the **fundus** (upper part) of the stomach is wrapped around the distal esophagus to create a functional valve. - This wrap helps to reinforce the LES and prevent stomach acid from flowing back up into the esophagus. *It is done for paraesophageal hiatus hernia* - **Nissen fundoplication** is often performed concurrently with the repair of a **hiatal hernia**, especially a **paraesophageal hernia**, to anchor the stomach in its correct anatomical position and prevent recurrence. - Repair of the hernia alone may not be sufficient to prevent reflux, making the fundoplication an important additional step.

Q: What is the appropriate management for a patient with a carcinoid tumor of the appendix larger than 2 cm?

Right hemicolectomy. ***Right hemicolectomy*** - Carcinoid tumors of the appendix larger than **2 cm** are considered at high risk for **lymph node metastasis** and recurrence. - A **right hemicolectomy** provides adequate margins and allows for lymph node dissection, which is essential for staging and definitive treatment in such cases. *Appendicectomy* - An **appendicectomy** alone is typically sufficient for carcinoid tumors of the appendix that are **less than 1 cm** and localized to the tip. - For larger tumors, appendicectomy carries an unacceptably high risk of **incomplete resection** and metastatic disease. *Appendicectomy + abdominal CT scan* - While an **abdominal CT scan** is useful for assessing local spread and distant metastases, it does not address the need for a more extensive surgical resection for a **large primary tumor**. - A simple **appendicectomy** in this scenario would be inadequate as definitive treatment. *Appendicectomy + 24 hrs urinary HIAA* - **24-hour urinary 5-hydroxyindoleacetic acid (5-HIAA)** is a biomarker used to detect and monitor **carcinoid syndrome**, which occurs in a minority of patients with carcinoid tumors. - Measuring 5-HIAA is primarily for assessing systemic symptoms rather than determining the primary surgical management of the **tumor size**.

Question 1

A 25 year old man presents with a 3-day history of pain in the right lower abdomen and vomiting. The patient's general condition is satisfactory, and clinical examination reveals a tender lump in the right iliac fossa. What is the most appropriate management in this case?

Accepted Answer

Ochsner-Sherren regimen

Answer

Immediate appendicectomy

Answer

External drainage

Answer

Exploratory laparotomy

Question 2

Multiple air fluid levels in X-ray of abdomen are seen in

Accepted Answer

Intestinal obstruction

Answer

Hollow viscera perforation

Answer

Pyoperitoneum

Answer

None of the options

Question 3

Most common cause of acute abdomen in a young girl?

Accepted Answer

Acute appendicitis

Answer

Ovarian torsion

Answer

Renal colic

Answer

Mittelschmerz

Question 4

A patient after a heavy meal and episode of forceful vomiting presents with severe epigastric pain. On examination, there is tenderness and rigidity in the upper abdomen. X-ray shows pneumomediastinum. What is the most likely cause?

Accepted Answer

Spontaneous rupture of the esophagus

Answer

Penetrating injury to the esophagus

Answer

Perforation of a peptic ulcer

Answer

Rupture of an emphysematous bulla

Question 5

A 6-year-old boy experienced life-threatening shock. His CT scan showed a large amount of ascites, bowel wall thickening, and poor or absent enhancement of the strangulated bowel segment, showing gangrenous bowel on surgical exploration. Which of the following statements about anastomosis is true?

Accepted Answer

should be done by single layer taking submucosa

Answer

should be done with catgut

Answer

should be done by continuous layers as it takes less time

Answer

should be done by single layer seromuscular Lembert sutures

Question 6

A patient presents with abdominal pain. On physical examination there was abdominal guarding and tenderness. A plain erect chest X-ray reveals air under diaphragm. Probable diagnosis is

Accepted Answer

Perforated abdominal viscus

Answer

Acute myocardial infarction

Answer

Aortic dissection

Answer

None of the options

Question 7

Which of the following characteristics is most accurate about Boerhaave syndrome?

Accepted Answer

Most common site is left posterolateral aspect 3 - 5 cms above the gastroesophageal junction

Answer

Most cases follow a bout of heavy eating or drinking

Answer

Perforation of the esophagus due to barotrauma

Answer

Sudden severe chest pain is an early manifestation

Question 8

A 25 year old male is receiving conservative management for an appendicular mass since 3 days now presents with a rising pulse rate, tachycardia and fever. The mode of management must be -

Accepted Answer

Proceed to laparotomy and appendicectomy

Answer

Intravenous antibiotics

Answer

Continue Ochsner Sherren regimen with close monitoring

Answer

Continue conservative management

Question 9

All of the following are true about Nissen Fundoplication except which of the following?

Accepted Answer

Reinforcement is done only in the posterior half

Answer

It is done for GERD

Answer

Upper part of stomach is plicated around the lower esophagus

Answer

It is done for paraesophageal hiatus hernia

Question 10

What is the appropriate management for a patient with a carcinoid tumor of the appendix larger than 2 cm?

Accepted Answer

Right hemicolectomy

Answer

Appendicectomy

Answer

Appendicectomy + abdominal CT scan

Answer

Appendicectomy + 24 hrs urinary HIAA

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

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