Small Bowel Transplantation — MCQs
Match the following 1. Hirschsprung's disease 2. Posterior urethral valve 3. Choledochal cyst 4. Intussusception A. Jaundice B. Currant jelly stools C. Distended abdomen D. Oligohydramnios
Post transplant lymphoma most commonly associated with:
Liver transplant for which of the following conditions will require a duct-to-jejunal anastomosis rather than a duct-to-duct anastomosis?
What is the most common immunosuppressant regimen used in renal transplant for maintenance?
Most common complication after intestinal transplantation is
After a renal transplant, what is the most common opportunistic infection?
"String of beads" appearance on horizontal abdominal view X-ray is suggestive of:
Moschcowitz repair is done for:
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
The following statements regarding small bowel tuberculosis are correct except
Small Bowel Transplantation Indian Medical PG Practice Questions and MCQs
Question 1: Match the following 1. Hirschsprung's disease 2. Posterior urethral valve 3. Choledochal cyst 4. Intussusception A. Jaundice B. Currant jelly stools C. Distended abdomen D. Oligohydramnios
- A. 1-C, 2-D, 3-B, 4-A
- B. 1-A, 2-D, 3-B, 4-C
- C. 1-C, 2-D, 3-A, 4-B (Correct Answer)
- D. 1-D, 2-C, 3-A, 4-B
Explanation: ***Correct Answer: 1-C, 2-D, 3-A, 4-B*** **Correct Associations:** - **Hirschsprung's disease (1) → Distended abdomen (C)**: Congenital absence of ganglion cells in the distal bowel leads to functional obstruction and subsequent abdominal distension. This is a hallmark presentation in neonates and infants. - **Posterior urethral valve (2) → Oligohydramnios (D)**: Urethral obstruction in utero prevents normal fetal urine output, resulting in decreased amniotic fluid (oligohydramnios). This can be detected on prenatal ultrasound. - **Choledochal cyst (3) → Jaundice (A)**: Congenital dilatation of the bile ducts causes biliary obstruction, presenting with jaundice as part of the classic triad (jaundice, abdominal mass, and pain). - **Intussusception (4) → Currant jelly stools (B)**: Telescoping of bowel causes mucosal ischemia and venous congestion, leading to bloody mucoid stools with characteristic "currant jelly" appearance. This is a pathognomonic feature. *Incorrect: 1-C, 2-D, 3-B, 4-A* - Incorrectly associates choledochal cyst with currant jelly stools (which is specific to intussusception) and intussusception with jaundice (which indicates biliary pathology). *Incorrect: 1-A, 2-D, 3-B, 4-C* - Wrongly links Hirschsprung's disease with jaundice instead of its characteristic abdominal distension, and misidentifies intussusception's primary feature. *Incorrect: 1-D, 2-C, 3-A, 4-B* - Swaps the associations between Hirschsprung's disease and PUV. Oligohydramnios is specific to urinary tract obstruction (PUV), not intestinal pathology (Hirschsprung's).
Question 2: Post transplant lymphoma most commonly associated with:
- A. Epstein-Barr virus (Correct Answer)
- B. HHV-6
- C. Herpes simplex
- D. Cytomegalo virus
Explanation: ***Epstein-Barr virus*** - **EBV** is strongly implicated in the pathogenesis of **post-transplant lymphoproliferative disorder (PTLD)**, especially in patients receiving immunosuppressive therapy [1]. - The immune suppression post-transplant allows for uncontrolled B-cell proliferation driven by latent EBV infection, leading to lymphoma [2]. *HHV-6* - While HHV-6 can cause reactivation and complications in transplant recipients, it is **not commonly associated** with lymphoma development. - Its clinical manifestations usually include **fever, rash, encephalitis**, and bone marrow suppression. *Herpes simplex* - **HSV** infections are common in transplant patients due to immunosuppression, presenting as mucocutaneous lesions [3]. - However, HSV is **not a known oncogenic virus** that directly contributes to the development of post-transplant lymphoma. *Cytomegalo virus* - **CMV** is a significant pathogen in transplant recipients, causing various syndromes like pneumonitis, colitis, and retinitis [3]. - Although CMV can cause **indirect immunomodulatory effects**, it is not a primary cause of post-transplant lymphoma, unlike EBV.
Question 3: Liver transplant for which of the following conditions will require a duct-to-jejunal anastomosis rather than a duct-to-duct anastomosis?
- A. Alagille syndrome
- B. Liver cirrhosis
- C. Primary biliary cholangitis
- D. Primary sclerosing cholangitis (Correct Answer)
Explanation: ***Primary sclerosing cholangitis*** - **Primary sclerosing cholangitis (PSC)** is characterized by **inflammation and scarring of the bile ducts**, leading to strictures and impaired bile flow. - Due to the widespread nature of the disease and the potential for residual diseased ducts in the recipient, a **duct-to-jejunal anastomosis (Roux-en-Y hepaticojejunostomy)** is preferred to ensure optimal drainage and avoid complications like cholangitis and anastomotic strictures at the native duct. *Alagille syndrome* - **Alagille syndrome** is a genetic disorder causing **bile duct paucity and cholestasis**. - While it affects the bile ducts, the native large bile duct in the recipient is often suitable for a **duct-to-duct anastomosis** without significant risk of recurrent disease-related strictures. *Liver cirrhosis* - **Cirrhosis** from most causes (e.g., viral hepatitis, alcohol) primarily affects the **liver parenchyma**, not the bile ducts directly. - In such cases, the native bile duct is usually healthy, allowing for a straightforward **duct-to-duct anastomosis**. *Primary biliary cholangitis* - **Primary biliary cholangitis (PBC)** is an autoimmune disease primarily affecting the **small intrahepatic bile ducts**. - The larger extrahepatic bile ducts are typically spared and healthy, making a **duct-to-duct anastomosis** the standard and preferred method for bile drainage after transplant.
Question 4: What is the most common immunosuppressant regimen used in renal transplant for maintenance?
- A. Calcineurin inhibitors + Purine antagonists + Basliximab
- B. Glucocorticoids + Cyclophosphamide
- C. Cyclophosphamide + Purine antagonists + Glucocorticoids
- D. Calcineurin inhibitors + Purine antagonists + Glucocorticoids (Correct Answer)
Explanation: ***Calcineurin inhibitors + Purine antagonists + Glucocorticoids*** - This triple therapy regimen is the **most common and effective** approach for long-term maintenance immunosuppression in renal transplant recipients [1]. - **Calcineurin inhibitors** (e.g., tacrolimus, cyclosporine) are the cornerstone for preventing T-cell activation, **purine antagonists** (e.g., mycophenolate mofetil, azathioprine) inhibit lymphocyte proliferation, and **glucocorticoids** provide broad anti-inflammatory effects [1]. *Calcineurin inhibitors + Purine antagonists + Basliximab* - **Basiliximab** is typically used for **induction therapy** (immediately post-transplant) to prevent acute rejection by blocking the IL-2 receptor, not as a long-term maintenance component. - The standard maintenance regimen *replaces* induction agents like basiliximab with a long-term steroid or calcineurin inhibitor alongside a purine antagonist. *Glucocorticoids + Cyclophosphamide* - **Cyclophosphamide** is a potent alkylating agent primarily used in specific autoimmune diseases or certain cancers, and its use in transplant is generally limited to cases of organ rejection resistant to standard therapy due to its significant toxicity. - This combination is **not a standard maintenance regimen** for renal transplant due to the high toxicity and side effects of cyclophosphamide. *Cyclophosphamide + Purine antagonists + Glucocorticoids* - As mentioned, **cyclophosphamide** is not a first-line agent for maintenance immunosuppression in renal transplant due to its severe side effect profile, including myelosuppression and hemorrhagic cystitis. - While purine antagonists and glucocorticoids are components of maintenance therapy, the inclusion of cyclophosphamide makes this an **uncommon and usually unfavorable regimen** for long-term use.
Question 5: Most common complication after intestinal transplantation is
- A. Intestinal obstruction
- B. Graft vs host disease
- C. Intestinal necrosis
- D. Sepsis (Correct Answer)
Explanation: ***Sepsis*** - **Infection** is the leading cause of morbidity and mortality after intestinal transplantation, making **sepsis** the most common complication. - The immunocompromised state due to immunosuppressive therapy and the inherent bacterial load of the gastrointestinal tract contribute significantly to the high risk of severe infections. *Intestinal obstruction* - While intestinal obstruction can occur post-transplant due to adhesions or strictures, it is **less common** than infectious complications. - It typically manifests later and may require surgical intervention but doesn't have the same high frequency as sepsis. *Graft versus host disease* - **Graft-versus-host disease (GVHD)** is a significant complication in intestinal transplantation, but it is **not the most common**. - Its incidence varies, and while serious, it does not surpass the overall frequency of infectious complications and sepsis. *Intestinal necrosis* - **Intestinal necrosis** (e.g., due to infarction or severe rejection) is a severe complication but is **less frequent** than sepsis. - It is often a consequence of vascular compromise or overwhelming rejection, leading to graft failure or perforation.
Question 6: After a renal transplant, what is the most common opportunistic infection?
- A. Varicella Zoster Virus (VZV)
- B. Coxsackie Virus
- C. Epstein-Barr Virus (EBV)
- D. Cytomegalovirus (CMV) (Correct Answer)
Explanation: ***Cytomegalovirus (CMV)*** - **CMV** is the most common opportunistic infection after renal transplantation, particularly in the first 6 months due to immunosuppression [1]. - It can cause a range of clinical syndromes, including **fever**, **leukopenia**, **gastroenteritis**, **pneumonitis**, and **hepatitis**, and can also have indirect effects that increase the risk of graft rejection. *Varicella Zoster Virus (VZV)* - While VZV can cause opportunistic infections in transplant recipients (e.g., **shingles**), it is less common than CMV [1]. - VZV typically occurs later post-transplant and is characterized by a **vesicular rash** in a dermatomal distribution. *Coxsackie Virus* - **Coxsackie virus** infections are less frequently reported as significant opportunistic infections in renal transplant recipients compared to other viral pathogens. - They are generally associated with hand-foot-and-mouth disease, herpangina, or myocarditis, which are not the most common post-transplant complications. *Epstein-Barr Virus (EBV)* - **EBV** can cause post-transplant lymphoproliferative disorder (PTLD), which is a serious complication, but EBV infection itself is not the most common opportunistic infection overall [1]. - PTLD is more common in the first year after transplant and often presents with **lymphadenopathy**, **fever**, or **graft dysfunction**.
Question 7: "String of beads" appearance on horizontal abdominal view X-ray is suggestive of:
- A. Intussusception
- B. Sigmoid volvulus
- C. Small bowel obstruction (Correct Answer)
- D. Large bowel obstruction
Explanation: ***Small bowel obstruction*** - A "string of beads" appearance on a horizontal abdominal view X-ray refers to small gas bubbles trapped between the valvulae conniventes in a dilated small bowel loop. - This finding is highly suggestive of **complete small bowel obstruction**, particularly when accompanied by multiple air-fluid levels and dilated bowel loops. *Intussusception* - While it causes obstruction, intussusception usually appears as a **target sign** (doughnut sign) on ultrasound or a **meniscus sign** on barium enema, not a string of beads on plain X-ray. - Plain X-rays may show signs of **bowel obstruction**, but the string of beads is not characteristic. *Sigmoid volvulus* - Sigmoid volvulus is characterized by a **dilated loop of colon** forming an inverted U-shape, often described as a **coffee bean sign** or **omega sign**, on plain X-ray. - This involves the large bowel, and the "string of beads" specifically relates to gas in the small bowel. *Large bowel obstruction* - Large bowel obstruction typically presents with a **dilated colon** proximal to the obstruction and a collapsed distal colon, often with absent or minimal gas in the rectum and sigmoid. - While air-fluid levels can be present, the "string of beads" is a specific sign of gas within dilated small bowel loops, distinguishing it from most large bowel obstructions.
Question 8: Moschcowitz repair is done for:
- A. Vault prolapse
- B. Adenomyosis
- C. Enterocele (Correct Answer)
- D. Chronic inversion of uterus
Explanation: ***Enterocele*** - The **Moschcowitz repair** is a historical procedure designed to repair an **enterocele** by obliterating the cul-de-sac. - It involves placing a series of high **purse-string sutures** in the posterior cul-de-sac peritoneum to elevate it and prevent bowel herniation. *Vault prolapse* - Vault prolapse involves the **prolapse of the vaginal apex** after hysterectomy. - While it can coexist with an enterocele, the Moschcowitz repair specifically targets the **enterocele defect**, not the overall vault support. *Adenomyosis* - **Adenomyosis** is a condition where endometrial tissue grows into the muscular wall of the uterus. - It is managed medically or surgically via **hysterectomy**, and is unrelated to surgical repairs for pelvic organ prolapse. *Chronic inversion of uterus* - **Chronic uterine inversion** is a rare condition where the uterus turns inside out, typically following childbirth. - Management involves **manual or surgical repositioning of the uterus** and is unrelated to the Moschcowitz repair for enterocele.
Question 9: 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 10: The following statements regarding small bowel tuberculosis are correct except
- A. There are two types : ulcerative and hyperplastic
- B. In the ulcerative type, the bowel serosa is studded with tubercles
- C. The ulcerative type occurs when the virulence of the organism is greater than the host defence
- D. The strictures are common in the ulcerative type (Correct Answer)
Explanation: ***The strictures are common in the ulcerative type*** - While both ulcerative and hyperplastic types of small bowel tuberculosis can lead to complications, **strictures are more characteristic of the hyperplastic type**. - In the **hyperplastic form**, chronic inflammation, fibrosis, and granuloma formation cause wall thickening and luminal narrowing, resulting in strictures. *There are two types : ulcerative and hyperplastic* - This statement is correct. Small bowel tuberculosis is broadly classified into **ulcerative** and **hyperplastic** forms, with mixed types also occurring. - The type is often determined by the interplay between the virulence of the organism and the host's immune response. *In the ulcerative type, the bowel serosa is studded with tubercles* - This statement is correct. The **ulcerative type** is often associated with the **spread of infection to the serosa**, leading to the formation of visible **tubercles**. - This indicates more extensive disease and possible peritoneal involvement. *The ulcerative type occurs when the virulence of the organism is greater than the host defence* - This statement is correct. The **ulcerative form** is often observed when the **organism's virulence is high** and/or the host's **immune response is weak**, leading to destructive lesions. - This imbalance results in caseating necrosis and ulceration of the bowel wall.
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