Gastrointestinal Surgery — MCQs
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Which of the following are features of umbilical hernia in adults? 1. Patients are commonly overweight with a thinned and attenuated midline raphe. 2. Most patients are asymptomatic or present with a painless swelling. 3. Men are affected more than women. 4. Hernia repair can be done by the technique described by Mayo. Select the correct answer using the code given below.
Which one of the following statements is correct about mesenteric cysts?
Which of the following is the MOST reliable intraoperative feature of viable small bowel? 1. Visible peristalsis 2. Flabby intestinal musculature 3. Shiny appearance of small bowel wall 4. Visible pulsation in the mesenteric artery
Which of the following is NOT included in Grade II acute cholecystitis as per 'Tokyo Consensus Guidelines for Severity'? 1. Elevated white cell count (> 18000/mm3) 2. Renal dysfunction 3. Duration > 72 hours 4. Marked local inflammation
The most common metabolic abnormality associated with gastric outlet obstruction is
A patient presents to the emergency department with pain and distension of abdomen and absolute constipation. What is the investigation of choice ?
A 50 year old diabetic patient with asymptomatic gallstone (> 3 cm) will be best treated by
Consider the following with reference to the management of portal hypertension : 1. Infusion of vasopressin 2. General resuscitation 3. Devascularisation procedure 4. Endoscopic sclerotherapy What is the appropriate sequence in the line of management in the event of massive variceal bleeding in portal hypertension ?
All of the following statements regarding gallstones are true except :
A retained stone in CBD (common bile duct) diagnosed by T-tube cholangiogram is best treated by :
Gastrointestinal Surgery Indian Medical PG Practice Questions and MCQs
Question 971: Which of the following are features of umbilical hernia in adults? 1. Patients are commonly overweight with a thinned and attenuated midline raphe. 2. Most patients are asymptomatic or present with a painless swelling. 3. Men are affected more than women. 4. Hernia repair can be done by the technique described by Mayo. Select the correct answer using the code given below.
- A. 2, 3 and 4
- B. 1, 2 and 3
- C. 1, 3 and 4
- D. 1, 2 and 4 (Correct Answer)
Explanation: ***1, 2 and 4*** - **Overweight patients** often have increased intra-abdominal pressure and weakened abdominal walls, contributing to the development of an umbilical hernia and a **thinned midline raphe**. - **Most adult umbilical hernias are asymptomatic** or present as painless swellings; patients typically notice a bulge that may increase with coughing or straining. Pain usually indicates **complications** such as incarceration or strangulation. - The **Mayo repair** is a classic technique specifically designed for umbilical hernias, involving the overlapping of the rectus sheath for a strong repair. *2, 3 and 4* - While patients are often **asymptomatic** (statement 2 correct) and the **Mayo repair** is standard (statement 4 correct), statement 3 is incorrect; **women are more commonly affected** by umbilical hernias than men. *1, 2 and 3* - Patients are commonly **overweight** (statement 1 correct) and often **asymptomatic** (statement 2 correct), but statement 3 is incorrect as umbilical hernias are seen **more often in women** than men. *1, 3 and 4* - Patients are commonly **overweight** (statement 1 correct) and the **Mayo repair** is a recognized technique (statement 4 correct), but statement 3 is incorrect because **women are more affected** than men. Statement 2 is also correct as most patients are asymptomatic.
Question 972: Which one of the following statements is correct about mesenteric cysts?
- A. It presents most commonly as a painless abdominal swelling. (Correct Answer)
- B. It is more common in males as compared to females.
- C. It occurs most commonly in children less than 18 years of age.
- D. Percutaneous aspiration with injection of sclerosant is the preferred treatment option.
Explanation: ***It presents most commonly as a painless abdominal swelling.*** - **Mesenteric cysts** typically manifest as a **slowly growing**, **asymptomatic abdominal mass**, which is often discovered incidentally or due to mild pressure symptoms. - Their **painless nature** and gradual enlargement contribute to this common presentation. *Percutaneous aspiration with injection of sclerosant is the preferred treatment option.* - **Simple aspiration** or sclerotherapy of mesenteric cysts is generally **contraindicated** due to the high risk of recurrence and potential for complications like infection or rupture. - The **preferred treatment** for mesenteric cysts is surgical excision to prevent recurrence and complications. *It is more common in males as compared to females.* - While rare overall, mesenteric cysts are **more prevalent in females** than males, although the exact reason for this disparity is not fully understood. - Some studies suggest a **female-to-male ratio** of approximately 2:1. *It occurs most commonly in children less than 18 years of age.* - Mesenteric cysts can occur at any age, but they are **more common in adults**, with the highest incidence typically reported in the third to fifth decades of life. - Although they can be found in children, this is **not the most common age group** for presentation.
Question 973: Which of the following is the MOST reliable intraoperative feature of viable small bowel? 1. Visible peristalsis 2. Flabby intestinal musculature 3. Shiny appearance of small bowel wall 4. Visible pulsation in the mesenteric artery
- A. 3. Shiny appearance of small bowel wall
- B. 2. Flabby intestinal musculature
- C. 4. Visible pulsation in the mesenteric artery
- D. 1. Visible peristalsis (Correct Answer)
Explanation: ***Visible peristalsis*** - The presence of **visible peristalsis** is the **MOST reliable indicator** of viable small bowel, demonstrating preserved neuromuscular function and tissue vitality. - Among the classical "3 Ps" of bowel viability (Peristalsis, Pulsation, Pink color), **peristalsis is the most direct indicator** as it confirms functional integrity of the bowel wall itself. - This indicates that the muscle layers of the intestine (longitudinal and circular) are functioning properly with intact innervation. *Shiny appearance of small bowel wall* - A **shiny serosa** is indeed a feature of viable bowel, indicating healthy, well-perfused tissue with an intact mesenteric surface. - However, it is a **less specific indicator** compared to peristalsis, as the appearance can be subjective and may not directly correlate with functional viability. *Visible pulsation in the mesenteric artery* - **Visible pulsation** in the mesenteric artery is one of the classical signs of viability and indicates blood flow to the vessel. - However, arterial pulsation alone **does not guarantee adequate tissue perfusion** or venous drainage, and ischemia can still occur despite pulsatile flow (e.g., venous thrombosis). - Peristalsis is more reliable as it confirms both adequate perfusion AND functional integrity. *Flabby intestinal musculature* - **Flabby intestinal musculature** indicates **non-viable bowel** with loss of tone, suggesting ischemia or necrosis. - Viable bowel typically feels **turgid and elastic** with good tone, not flabby.
Question 974: Which of the following is NOT included in Grade II acute cholecystitis as per 'Tokyo Consensus Guidelines for Severity'? 1. Elevated white cell count (> 18000/mm3) 2. Renal dysfunction 3. Duration > 72 hours 4. Marked local inflammation
- A. 2. Renal dysfunction (Correct Answer)
- B. 4. Marked local inflammation
- C. 3. Duration > 72 hours
- D. 1. Elevated white cell count (> 18000/mm3)
Explanation: ***2. Renal dysfunction*** - **Renal dysfunction** is a criterion for **Grade III (severe)** acute cholecystitis, NOT Grade II, indicating systemic organ failure. - This represents a critical systemic complication requiring intensive care, distinct from the moderate severity markers of Grade II. *1. Elevated white cell count (> 18000/mm3)* - An elevated white blood cell count *greater than 18,000/mm³* **IS** a criterion for **Grade II (moderate)** acute cholecystitis. - This reflects a substantial systemic inflammatory response, categorizing it as a moderate severity finding. *3. Duration > 72 hours* - A duration of symptoms *greater than 72 hours* **IS** a defining criterion for **Grade II (moderate)** acute cholecystitis according to the **Tokyo Guidelines for severity assessment**. - This indicates a more prolonged inflammatory process, often associated with increased local complications. *4. Marked local inflammation* - **Marked local inflammation** **IS** a characteristic of **Grade II (moderate)** acute cholecystitis. - This criterion includes conditions such as pericholecystic abscess, hepatic abscess, gangrenous cholecystitis, or biliary peritonitis, indicating significant local complications.
Question 975: The most common metabolic abnormality associated with gastric outlet obstruction is
- A. hyperchloraemic alkalosis
- B. hypochloraemic acidosis
- C. hyperchloraemic acidosis
- D. hypochloraemic alkalosis (Correct Answer)
Explanation: ***Hypochloraemic alkalosis*** - Gastric outlet obstruction leads to **persistent vomiting of gastric contents**, rich in **hydrochloric acid (HCl)**. - The loss of HCl causes a decrease in plasma chloride (**hypochloraemia**) and an increase in bicarbonate, leading to **metabolic alkalosis**. - This is the **classic metabolic abnormality** seen in pyloric stenosis and other causes of gastric outlet obstruction. *Hyperchloraemic alkalosis* - This is an incorrect combination of electrolyte and acid-base disturbances; hyperchloraemia typically accompanies **acidosis**, not alkalosis. - Hyperchloraemic alkalosis would imply an excess of chloride and base, which does not result from the vomiting of acidic gastric contents. *Hypochloraemic acidosis* - Hypochloraemia can occur with acidosis (e.g., from severe diarrhea with bicarbonate loss), but the primary acid-base disturbance in gastric outlet obstruction is **alkalosis** due to hydrogen ion loss. - Vomiting primarily causes a loss of acid, leading to an increase in blood pH, not a decrease. *Hyperchloraemic acidosis* - This condition is often seen in situations like **renal tubular acidosis** or with the administration of large amounts of **saline solutions**, where chloride intake is high and bicarbonate is lost or diluted. - It specifically does not occur with the loss of highly acidic gastric contents, which would decrease chloride levels and increase pH.
Question 976: A patient presents to the emergency department with pain and distension of abdomen and absolute constipation. What is the investigation of choice ?
- A. Plain X-ray abdomen (Erect) (Correct Answer)
- B. Ultrasonography
- C. Barium meal follow-through
- D. Colonoscopy
Explanation: ***Plain X-ray abdomen (Erect)*** - An erect plain X-ray of the abdomen is the initial and often diagnostic investigation for **bowel obstruction**, revealing **dilated bowel loops** and **air-fluid levels**. - It helps confirm the presence of obstruction and can sometimes indicate its location and severity, though it does not provide information about the cause. *Ultrasonography* - While ultrasound can detect **bowel dilation** and **peristalsis**, it is limited in visualizing the entire bowel and cannot reliably differentiate between various causes of obstruction. - It is more useful for assessing **extraluminal pathology** or **fluid collections** but less effective as a primary diagnostic tool for bowel obstruction. *Barium meal follow-through* - This study involves oral **barium administration** and serial X-rays to visualize the small bowel, but it is **contraindicated** in suspected bowel obstruction due to the risk of exacerbating the obstruction or causing **barium impaction**. - Its primary role is in evaluating chronic or partial obstructions, or malabsorption, not acute presentations with complete obstruction. *Colonoscopy* - **Colonoscopy** is an invasive procedure primarily used for diagnosis and treatment of **colonic pathology**, such as polyps, strictures, or bleeding. - It is **contraindicated** in acute, complete bowel obstruction due to the risk of **perforation** and is not the initial diagnostic choice for acute abdominal pain and absolute constipation.
Question 977: A 50 year old diabetic patient with asymptomatic gallstone (> 3 cm) will be best treated by
- A. Early surgery (Correct Answer)
- B. Bile-salt treatment
- C. Waiting till it becomes symptomatic
- D. ESWL
Explanation: ***Early surgery*** - **Diabetic patients** with gallstones, especially those over 3 cm, have a higher risk of complications like **cholecystitis**, **cholangitis**, and even **gallbladder cancer**, justifying prophylactic cholecystectomy. - The risk of perioperative complications is lower than the risk associated with an acute gallstone event in a diabetic patient. *Bile-salt treatment* - This treatment is primarily used for **small cholesterol gallstones** in patients who are not surgical candidates. - It is ineffective for large gallstones (>3 cm) and calcified stones, and it carries a high recurrence rate. *Waiting till it becomes symptomatic* - In diabetic patients, waiting for symptoms can lead to more severe and **atypical presentations** of complications, which may be harder to manage. - Larger gallstones in diabetic patients pose a significantly increased risk of developing **gallbladder cancer**, making prophylactic removal beneficial. *ESWL (Extracorporeal Shock Wave Lithotripsy)* - **ESWL** is generally reserved for solitary, small (<2 cm), non-calcified gallstones in patients who refuse or are not candidates for surgery. - It is not effective for large gallstones (>3 cm) and carries risks of stone recurrence and fragmentation complications.
Question 978: Consider the following with reference to the management of portal hypertension : 1. Infusion of vasopressin 2. General resuscitation 3. Devascularisation procedure 4. Endoscopic sclerotherapy What is the appropriate sequence in the line of management in the event of massive variceal bleeding in portal hypertension ?
- A. 3, 2, 1, 4
- B. 2, 1, 4, 3 (Correct Answer)
- C. 1, 4, 2, 3
- D. 4, 2, 1, 3
Explanation: ***Correct Option: 2, 1, 4, 3*** - The initial and most critical step in managing massive variceal bleeding is **general resuscitation** to stabilize the patient, including securing the airway, establishing IV access, and restoring blood volume. - After initial resuscitation, **infusion of vasopressin** or other vasoactive drugs (e.g., octreotide or somatostatin) is initiated to reduce portal pressure and control bleeding by causing splanchnic vasoconstriction. - Once the patient is stabilized and pharmacological agents are initiated, **endoscopic sclerotherapy** or band ligation is performed to directly control bleeding from the varices. - If initial measures fail, or in cases of chronic, recurrent bleeding not amenable to endoscopy, a **devascularization procedure** (e.g., portosystemic shunts, or surgical devascularization such as splenorenal shunt) becomes necessary as a definitive, but more invasive, treatment. *Incorrect Option: 3, 2, 1, 4* - **Devascularization procedures** are invasive surgical interventions and are generally considered a last resort for definitive management after less invasive methods have failed or are not suitable. - Starting with a devascularization procedure would bypass critical initial steps of **resuscitation** and immediate control of hemorrhage. *Incorrect Option: 1, 4, 2, 3* - This sequence incorrectly places **vasopressin infusion** and **endoscopic sclerotherapy** before **general resuscitation**. - Without proper resuscitation, the patient may not be stable enough to tolerate these interventions, and vital organ perfusion may be compromised, leading to a worse outcome. *Incorrect Option: 4, 2, 1, 3* - This sequence mistakenly places **endoscopic sclerotherapy** before **general resuscitation**, which is incorrect given the urgency of stabilizing a patient with massive bleeding. - While endoscopy is crucial for diagnosis and treatment, it must follow initial **resuscitation** to ensure patient safety and optimize the chances of success.
Question 979: All of the following statements regarding gallstones are true except :
- A. They can cause intestinal obstruction
- B. They are mostly radio opaque (Correct Answer)
- C. They can lead to acute cholangitis by slipping into the common bile duct
- D. Mixed stones are the commonest type
Explanation: ***They are mostly radio opaque*** - Only about **10-20% of gallstones** are sufficiently calcified to be visible on a plain abdominal radiograph. - The majority of gallstones, especially **cholesterol stones**, are radiolucent and are best visualized by ultrasound. *They can cause intestinal obstruction* - This statement is true. A large gallstone can erode through the gallbladder wall into the small intestine, typically the duodenum, leading to a gallstone ileus. - **Gallstone ileus** is a rare form of mechanical bowel obstruction caused by a gallstone impaction, usually in the terminal ileum. *They can lead to acute cholangitis by slipping into the common bile duct* - This statement is true. Gallstones can migrate from the gallbladder into the **common bile duct (CBD)**, obstructing bile flow and leading to **choledocholithiasis**. - Obstruction of the CBD by gallstones, especially with superimposed bacterial infection, can cause **acute cholangitis**. *Mixed stones are the commonest type* - This statement is true. **Mixed gallstones**, which contain a combination of cholesterol, calcium salts, and bilirubin, are the most prevalent type of gallstones. - Pure cholesterol stones and pure pigment stones (black or brown) are less common than mixed stones.
Question 980: A retained stone in CBD (common bile duct) diagnosed by T-tube cholangiogram is best treated by :
- A. Endoscopic papillotomy (Correct Answer)
- B. Re-exploration of common bile duct
- C. Extra corporeal shock wave lithotripsy
- D. Dissolution therapy
Explanation: ***Endoscopic papillotomy*** - This procedure, typically performed via an **ERCP**, allows for the removal of **retained common bile duct stones** in a less invasive manner than re-exploration. - It involves incising the **sphincter of Oddi** to facilitate stone extraction or spontaneous passage, especially when a **T-tube** is already in place, making access easier. *Re-exploration of common bile duct* - This is a more invasive surgical procedure with higher risks compared to endoscopic approaches. - Re-exploration is generally reserved for cases where **endoscopic techniques fail** or where there are specific contraindications to endoscopy. *Extra corporeal shock wave lithotripsy* - **ESWL** is primarily used for **kidney stones** and sometimes for large pancreatic or gallbladder stones that are difficult to access endoscopically. - Its effectiveness in fragmenting **CBD stones**, especially when a T-tube is present, is limited, and fragments may still obstruct the duct. *Dissolution therapy* - This therapy involves administering **ursodeoxycholic acid** to dissolve cholesterol stones. - It is a **slow process** and is generally ineffective for pigmented stones or for promptly resolving symptomatic or **obstructive retained CBD stones**.
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