Gastrointestinal Surgery — MCQs

A 60-year-old male with a history of peptic ulcer disease presents with sudden-onset severe epigastric pain radiating to the back, vomiting, and shock. Examination reveals a rigid, board-like abdomen. Upright chest X-ray shows air under both hemidiaphragms. What is the most appropriate initial surgical management?

Q967

A 25-year-old male presents with pain starting from the umbilicus moving to the right iliac fossa, associated with fever, nausea, and tenderness in the right iliac fossa. His WBC count is 14,000/cmm. What is the Alvarado score?

Q968

Resection of which part of intestine does not significantly affect fluid and electrolyte balance?

Q969

A Sengstaken-Blakemore tube is used for the management of :

Q970

While managing oesophageal perforations, which of the following factors favour non-operative management? 1. Perforation by a flexible endoscope 2. Contained perforation without free communication 3. Perforation with a small septic load 4. Perforation of the abdominal oesophagus Select the correct answer using the code given below:

Gastrointestinal Surgery Indian Medical PG Practice Questions and MCQs

Question 961: Splenunculi are commonly seen in which location?

A. Hilum of spleen (Correct Answer)
B. Tail of spleen
C. Mesocolon
D. Splenic ligaments

Explanation: **Explanation:** **Splenunculi**, also known as **accessory spleens**, are small nodules of healthy splenic tissue found apart from the main body of the spleen. They result from the failure of fusion of separate splenic primordia within the dorsal mesogastrium during the fifth week of embryonic development. **1. Why Option A is Correct:** The **splenic hilum** is the most common site for splenunculi, accounting for approximately **75-80%** of cases. This is because the hilum is the primary site where the splenic buds aggregate during organogenesis. **2. Analysis of Incorrect Options:** * **Option B (Tail of Spleen):** While splenunculi are found near the spleen, the "tail of the spleen" is not a standard anatomical term; however, the **tail of the pancreas** is the second most common site (approx. 20%) due to its proximity to the hilum. * **Option C & D (Mesocolon & Splenic Ligaments):** These are recognized but much less frequent ectopic sites. Other rare locations include the greater omentum, the pouch of Douglas, and even the left scrotum (splenogonadal fusion). **Clinical Pearls for NEET-PG:** * **Prevalence:** Found in roughly 10-15% of the general population. * **Surgical Significance:** In patients undergoing splenectomy for hematological disorders (e.g., **Immune Thrombocytopenic Purpura (ITP)** or Hereditary Spherocytosis), failure to identify and remove a splenunculus can lead to **recurrence of the disease** (hypertrophy of the accessory tissue). * **Radiology:** On CT scans, they appear as well-defined ovoid masses that enhance identically to the parent spleen. * **Most common sites (in order):** Hilum > Tail of Pancreas > Gastrosplenic ligament > Greater omentum.

Question 962: Which of the following is not an indication for splenectomy?

A. Hairy cell leukemia
B. Thrombocytopenia
C. Iatrogenic splenic trauma
D. Bone marrow failure (Correct Answer)

Explanation: ***Bone marrow failure*** - In bone marrow failure (e.g., aplastic anemia), the spleen serves as an important site of **extramedullary hematopoiesis** (compensatory blood cell production outside the bone marrow) - Splenectomy would **remove this compensatory mechanism** and worsen the patient's condition - Therefore, bone marrow failure is a **contraindication**, not an indication for splenectomy *Hairy cell leukemia* - This is a chronic B-cell lymphoproliferative disorder with massive splenomegaly - Splenectomy is indicated when medical treatment fails or for symptomatic relief *Thrombocytopenia* - Immune thrombocytopenic purpura (ITP) is a classic indication for splenectomy - Performed when medical management (steroids, IVIG) fails - Spleen is the primary site of platelet destruction in ITP *Iatrogenic splenic trauma* - Intraoperative injury to the spleen during abdominal surgery - Splenectomy is indicated when hemostasis cannot be achieved or injury is severe (Grade IV-V)

Question 963: What is the most appropriate treatment for an 8cm chylolymphatic mesenteric cyst?

A. Aspiration
B. Enucleation (Correct Answer)
C. Conservative
D. Resection of the cyst along with the adjacent bowel

Explanation: ***Enucleation*** - This is the standard surgical treatment for most **mesenteric cysts**, as it allows for complete removal of the cyst while preserving the adjacent bowel and its vital blood supply. - Successful **enucleation** has a very low recurrence rate and provides a definitive tissue diagnosis to rule out rare cases of malignancy. *Aspiration* - Aspiration is associated with a very high **recurrence rate** (50-100%) because the cyst-secreting lining is left behind. - It also carries risks of **infection**, **hemorrhage**, and leakage of cystic fluid causing chemical peritonitis, and it fails to provide a histological diagnosis. *Resection of the cyst along with the adjacent bowel* - This is an overly aggressive approach for a typically benign condition and should be avoided unless necessary to preserve **bowel viability**. - **Bowel resection** is reserved for cases where the cyst cannot be separated from the bowel wall or when the mesenteric blood supply is irrevocably compromised. *Conservative* - Conservative management is generally not recommended for symptomatic or large cysts (like this 8cm one) due to the risk of complications. - Potential complications include **intestinal obstruction**, **volvulus**, **torsion** of the cyst, **hemorrhage** into the cyst, or infection.

Question 964: A patient presents with lower right abdominal pain and rebound tenderness. Intraoperatively, an inflamed Meckel's diverticulum is found. This clinical presentation most closely mimics which condition?

A. Cholecystitis
B. Perforation
C. Appendicitis (Correct Answer)
D. Intestinal obstruction

Explanation: ***Appendicitis*** (Meckel's Diverticulitis Mimicking Appendicitis) - Inflammation of a Meckel's diverticulum (**Meckel's diverticulitis**) occurs in the right lower quadrant and is clinically indistinguishable from **acute appendicitis**. - Lower right abdominal pain and **rebound tenderness** are classic signs of localized **peritonitis** associated with inflammation of a structure near the ileocecal region. *Perforation* - Perforation causes signs of diffuse peritonitis, marked by generalized abdominal rigidity and severe systemic illness, rather than localized pain and rebound tenderness in the right lower quadrant. - It is generally a subsequent complication of severe diverticulitis, not the primary cause of this initial localized presentation. *Intestinal obstruction* - Obstruction due to Meckel's (e.g., intussusception or volvulus) presents with symptoms like **colicky pain**, abdominal distension, and **bilious vomiting**. - **Rebound tenderness** is not a primary feature unless the obstruction progresses to severe strangulation and localized ischemia. *Cholecystitis* - **Cholecystitis** is inflammation of the gallbladder, causing pain predominantly in the **right upper quadrant** or epigastrium, often linked to fatty meals. - This location is inconsistent with pain and rebound tenderness strictly localized to the **lower right abdomen**.

Question 965: Which of the following procedures has the highest risk of causing the recurrence of duodenal ulcers?

A. Highly selective vagotomy (Correct Answer)
B. Gastro-jejunostomy
C. Gastrectomy
D. Truncal vagotomy

Explanation: ***Highly selective vagotomy***- ***Highly selective vagotomy*** (or parietal cell vagotomy) denervates only the acid-producing parietal cell mass, reducing basal and maximal acid output less intensely than other procedures. This procedure preserves the innervation of the **gastric antrum** and **pylorus**, maintaining physiological motility but resulting in the highest reported **ulcer recurrence rate** (historically 10-20%).*Gastrectomy*- A subtotal **gastrectomy** involves physically removing the portion of the stomach (body and/or antrum) responsible for acid or gastrin production, leading to a drastic reduction in acid load and a very low recurrence rate. This procedure is generally associated with the highest rates of **post-gastrectomy syndromes** (e.g., afferent loop syndrome, dumping syndrome) compared to vagotomy alone.*Truncal vagotomy*- **Truncal vagotomy** divides the main vagus trunks, causing near-maximal reduction of cephalic-phase acid secretion but requires mandatory **drainage procedures** (**pyloroplasty** or gastrojejunostomy) due to resulting gastric atony. The profound reduction in acid output achieved by this method gives it a significantly lower recurrence rate than highly selective vagotomy.*Gastro-jejunostomy*- **Gastro-jejunostomy** (often referring to the creation of a stoma between the stomach and jejunum) is typically performed as the **drainage procedure** necessary after truncal vagotomy, allowing food egress when the pylorus is dysfunctional. While effective in preventing stasis, a gastro-jejunostomy carries a specific risk of **marginal ulceration** (anastomotic ulceration) but the overall rate of recurrence for the combined operation is low.

Question 966: A 60-year-old male with a history of peptic ulcer disease presents with sudden-onset severe epigastric pain radiating to the back, vomiting, and shock. Examination reveals a rigid, board-like abdomen. Upright chest X-ray shows air under both hemidiaphragms. What is the most appropriate initial surgical management?

A. Conservative management with nasogastric decompression and antibiotics
B. Graham's patch (omental patch repair) with peritoneal lavage (Correct Answer)
C. Partial gastrectomy with gastrojejunostomy
D. Truncal vagotomy with pyloroplasty

Explanation: ***Graham's patch (omental patch repair) with peritoneal lavage*** - The clinical presentation (sudden severe abdominal pain, **rigid board-like abdomen**, shock) and radiological finding (**pneumoperitoneum** - air under both hemidiaphragms) are pathognomonic for **perforated peptic ulcer**, a life-threatening surgical emergency. - **Graham's omental patch repair** is the **gold standard** initial surgical management for acute peptic ulcer perforation. - The procedure involves **simple closure** of the perforation site with **omental plug** (omentum used to reinforce the repair), followed by **thorough peritoneal lavage** to remove contaminated gastric/duodenal contents and reduce septic complications. - This provides rapid source control with minimal operative time, crucial in hemodynamically unstable patients. - Post-operatively, patients receive **H. pylori eradication therapy** and **proton pump inhibitors** to prevent recurrence. *Conservative management with nasogastric decompression and antibiotics* - Non-operative management may be considered only in **highly selected cases**: small sealed perforations (Hinchey stage I), minimal free air, hemodynamically stable patients without generalized peritonitis. - This patient has **clinical peritonitis** (rigid abdomen), **shock**, and **free air under both hemidiaphragms**, indicating large perforation with significant contamination - absolute indications for **emergency surgery**. - Conservative management would result in **overwhelming sepsis**, **multiorgan failure**, and death in this scenario. *Partial gastrectomy with gastrojejunostomy* - **Gastrectomy** is a **definitive ulcer surgery** reserved for: refractory ulcers despite medical therapy, recurrent perforations, suspected malignancy, or when primary repair is technically impossible (e.g., large chronic ulcers with friable edges). - It is **NOT** the initial procedure for acute simple perforation due to significantly **higher morbidity and mortality** (requires anastomosis in contaminated field, longer operative time). - In an emergency setting with shock and peritoneal contamination, the priority is **rapid damage control** (Graham's patch), not definitive ulcer surgery. *Truncal vagotomy with pyloroplasty* - **Vagotomy with drainage procedure** (pyloroplasty or gastrojejunostomy) was historically performed as **definitive anti-ulcer surgery** in the pre-PPI era to reduce acid secretion. - With modern **H. pylori eradication** and **effective PPIs**, definitive ulcer surgery is rarely needed. - In acute perforation with shock, performing vagotomy adds unnecessary operative time and complexity, increasing mortality risk. - Current practice: **simple repair first** (Graham's patch), then medical management; definitive surgery only if medical therapy fails.

Question 967: A 25-year-old male presents with pain starting from the umbilicus moving to the right iliac fossa, associated with fever, nausea, and tenderness in the right iliac fossa. His WBC count is 14,000/cmm. What is the Alvarado score?

A. 6
B. 4
C. 5
D. 7 (Correct Answer)

Explanation: ***7*** - The Alvarado score (MANTRELS) is a clinical scoring system used to diagnose **acute appendicitis** based on symptoms, signs, and laboratory findings. - **Components present in this patient:** - **M**igration of pain (umbilicus → RIF): **1 point** - **A**norexia/Nausea (nausea present): **1 point** - **T**enderness in right iliac fossa: **2 points** - **R**ebound tenderness: **0 points** (not mentioned) - **E**levated temperature (fever): **1 point** - **L**eukocytosis (WBC 14,000 > 10,000/cmm): **2 points** - **S**hift to left (neutrophilia): **0 points** (not provided) - **Total score: 1 + 1 + 2 + 1 + 2 = 7 points** - A score of **7-8 indicates probable appendicitis** and typically warrants surgical intervention or further imaging based on clinical judgment. *4* - A score of 4 suggests **low probability of appendicitis**. - This score indicates that appendicitis is unlikely, warranting observation or alternative diagnosis consideration. *5* - A score of 5 indicates **intermediate/equivocal probability** of appendicitis. - Patients typically require **active observation, serial examinations**, or imaging (ultrasound/CT) for confirmation. *6* - A score of 6 also falls into the **intermediate risk category** with higher suspicion than score 5. - Usually warrants **imaging or close observation** but is lower than the calculated score for this patient.

Question 968: Resection of which part of intestine does not significantly affect fluid and electrolyte balance?

A. Ileum
B. Proximal jejunum
C. Distal jejunum (Correct Answer)
D. Colon

Explanation: ***Distal jejunum*** - The distal jejunum has significant **adaptive capacity** to take over the absorptive functions of other parts of the small intestine if they are resected. - Its resection typically has the **least impact** on fluid and electrolyte balance compared to other segments of the intestine, as critical absorption of most nutrients, water, and electrolytes occurs more proximally or distally. *Ileum* - The ileum is crucial for the absorption of **vitamin B12** and **bile salts**; its resection can lead to **malabsorption** and severe diarrhea. - Loss of bile salt absorption can result in **fat malabsorption** and lead to fluid and electrolyte disturbances. *Proximal jejunum* - The proximal jejunum is the primary site for the absorption of most **nutrients** (carbohydrates, proteins, fats), **water**, and **electrolytes**. - Its resection can lead to significant **malnutrition** and severe fluid and electrolyte imbalances due to widespread malabsorption. *Colon* - The colon is responsible for the final absorption of **water** and **electrolytes**, compacting stool for elimination. - Its resection can severely impair the body's ability to conserve water and electrolytes, leading to **dehydration** and electrolyte disturbances.

Question 969: A Sengstaken-Blakemore tube is used for the management of :

A. Corrosive poisoning
B. Variceal bleeding (Correct Answer)
C. Tension pneumothorax
D. Asphyxia

Explanation: ***Variceal bleeding*** - A **Sengstaken-Blakemore tube** is specifically designed with gastric and esophageal balloons to apply direct pressure and tamponade **bleeding esophageal varices**, a common complication of portal hypertension. - It is utilized as a temporary measure to control severe hemorrhage when endoscopic interventions fail or are unavailable. *Corrosive poisoning* - Management of corrosive poisoning focuses on **supportive care**, pain management, and preventing further injury; a Sengstaken-Blakemore tube is not indicated. - Using such a tube could potentially worsen esophageal damage or perforation in corrosive injuries. *Tension pneumothorax* - A tension pneumothorax is a **thoracic emergency** requiring immediate **needle decompression** or chest tube insertion. - A Sengstaken-Blakemore tube is an upper gastrointestinal device and has no role in managing pulmonary conditions. *Asphyxia* - Asphyxia involves a lack of oxygen and is managed by establishing an **open airway**, providing ventilation, and addressing the underlying cause. - A Sengstaken-Blakemore tube is irrelevant to the treatment of asphyxia.

Question 970: While managing oesophageal perforations, which of the following factors favour non-operative management? 1. Perforation by a flexible endoscope 2. Contained perforation without free communication 3. Perforation with a small septic load 4. Perforation of the abdominal oesophagus Select the correct answer using the code given below:

A. 1, 3 and 4
B. 2, 3 and 4
C. 1, 2 and 3 (Correct Answer)
D. 1, 2 and 4

Explanation: ***1, 2 and 3*** - **Perforation by a flexible endoscope** often results in smaller, less destructive perforations due to the instrument's flexibility, making non-operative management feasible if other favorable conditions are met. - **Contained perforation without free communication** implies that the leak is localized and not actively spreading into surrounding tissues, reducing the risk of widespread mediastinitis or peritonitis. - **Perforation with a small septic load** indicates minimal contamination, which simplifies management and improves the chances of successful non-operative treatment through antibiotics and supportive care. *1, 3 and 4* - This option correctly identifies factors 1 and 3, but **perforation of the abdominal esophagus** is generally treated surgically due to the high risk of widespread peritonitis and severe sepsis. - While smaller perforations are more manageable, the anatomical location in the abdominal cavity predisposes to rapid and severe contamination. *2, 3 and 4* - This option correctly includes factors 2 and 3 that favor non-operative management but incorrectly suggests that **perforation of the abdominal esophagus** is managed non-operatively. - The high risk of peritonitis from an abdominal oesophageal perforation often necessitates surgical intervention to prevent severe complications. *1, 2 and 4* - This option correctly identifies factors 1 and 2 but mistakenly includes **perforation of the abdominal esophagus** as a factor favoring non-operative management. - Abdominal oesophageal perforations are high-risk situations generally requiring early surgical repair to prevent life-threatening complications.

Practice by Chapter

Esophageal Disorders

Practice Questions

Gastric Disorders

Practice Questions

Small Intestine Pathology

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Appendicitis

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Inflammatory Bowel Disease

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Intestinal Obstruction

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Gastrointestinal Bleeding

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Diverticular Disease

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Anorectal Disorders

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Colorectal Neoplasms

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Gastrointestinal Stomas

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Bariatric Surgery Principles

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