Gastrointestinal Surgery Practice Questions

Q: A 34-year-old male patient complains of sudden severe epigastric pain along with vomiting, tenderness, guarding. On examination there is abdominal rigidity and tachycardia. He admits to taking NSAIDs for pain. The radiological examination of the patient is given below. All statements given below are true except?

Pain often radiates to groin. ***Pain often radiates to groin*** - The clinical presentation (sudden severe epigastric pain, vomiting, tenderness, guarding, rigidity, tachycardia, NSAID use) and the radiological imaging showing **free air under the diaphragm** are highly suggestive of **perforated viscus**, likely a perforated peptic ulcer. - Pain from a perforated ulcer typically **radiates to the shoulder** (due to diaphragmatic irritation) or generalizes throughout the abdomen, but **not typically to the groin**. *Tenderness on per-rectal examination* - **Tenderness on per-rectal examination** can be present in cases of generalized peritonitis, as the inflammation can extend to the pelvic peritoneum. - This finding is consistent with the diffuse inflammation caused by a perforated viscus. *Blumberg sign is positive* - **Blumberg sign**, also known as **rebound tenderness**, is a classic sign of **peritoneal irritation** or peritonitis. - Given the severe abdominal pain, guarding, and rigidity, peritonitis is highly likely in this patient, making a positive Blumberg sign expected. *Dullness over flanks is observed* - **Dullness on percussion over the flanks** indicates the presence of **fluid** in the peritoneal cavity (ascites). - In a perforated viscus, gastric or intestinal contents, along with inflammatory exudates, can accumulate in the dependent areas of the abdomen, leading to dullness in the flanks.

Q: Identify the tube shown in the image:

Sengstaken-Blakemore catheter. ***Sengstaken-Blakemore catheter*** - This catheter is identifiable by its **triple lumen** and **two inflatable balloons** (one esophageal, one gastric), designed to compress bleeding esophageal varices. - The image clearly displays these characteristic balloons and multiple ports, distinguishing it from other tubes. *Minnesota tube* - A Minnesota tube is similar to the Sengstaken-Blakemore catheter but has **four lumens** instead of three, with an additional **esophageal aspiration port** above the esophageal balloon. - While structurally similar, the specific lumen configuration visible in the image is consistent with the Sengstaken-Blakemore design. *Ryle's tube* - A Ryle's tube is a simple **nasogastric tube** with a single lumen, primarily used for feeding or gastric decompression. - It does not feature the complex balloon system seen in the image. *Malecot's catheter* - A Malecot's catheter is a **self-retaining catheter** with a mushroom-shaped tip, typically used for drainage (e.g., nephrostomy). - Its design is simple and lacks the inflatable balloons and multiple lumens characteristic of the depicted device. *Foley's catheter* - A Foley's catheter is a **urinary catheter** with a single inflatable balloon for retention in the bladder and two lumens (one for drainage, one for balloon inflation). - While it has an inflatable balloon, its overall structure and intended use are distinct from the esophageal-gastric balloon system shown.

Q: Identify the structure held with artery forceps:

Appendix. ***Appendix*** - The image shows a **vermiform appendix** — a small, finger-shaped organ projecting from the **large intestine** near the ileocecal junction. It is being held by artery forceps. - The characteristic blind-ended tubular structure attached to the cecum is clearly visible, consistent with the anatomical location and appearance of the appendix. *Meckel's diverticulum* - A Meckel's diverticulum is an **outpouching of the small intestine** (ileum), which would appear as an extension of the ileal wall, often with its own mesentery. - While it can be confused with the appendix, its origin from the small bowel and often broader base or different internal lining (gastric or pancreatic tissue) usually distinguishes it. *Zenker's diverticulum* - Zenker's diverticulum is an **outpouching of the pharyngeal mucosa** (a false diverticulum) located in the upper esophagus. - This structure is found in the **neck/mediastinum**, completely unrelated to the intra-abdominal organs shown in the image. *Colostomy stoma* - A colostomy stoma is a **surgically created opening** of the colon onto the surface of the abdomen, designed to divert fecal matter. - This image clearly depicts an **intra-abdominal organ** being manipulated during surgery, not an externalized stoma. *Fallopian tube* - The fallopian tube is a **paired tubular structure** in the female reproductive system extending from the uterus to the ovary. - While tubular, it has a different anatomical location (adnexa/pelvis) and arises from the uterus, not the cecum, with a more delicate, fimbriated distal end.

Q: Which of the following is Lanz incision?

B. ***B*** - The image labeled **B** represents the **Lanz incision**. This is a **transverse incision** made in the right iliac fossa, usually 2 cm below the umbilical level, centered at the midpoint between the anterior superior iliac spine (ASIS) and the umbilicus. - The Lanz incision is a popular choice for **appendectomy** as it offers good cosmetic results and adequate exposure for most cases of appendicitis due to its location within a natural skin crease (Langer's lines). *A* - The image labeled **A** points to a **vertical incision** in the right lower quadrant, parallel to the rectus abdominis muscle. This is typically a **gridiron incision** if it's placed obliquely, but as depicted, it could represent a variation or a different type of incision altogether, such as a muscle-splitting incision. - This incision is often associated with the **McBurney's point**, which is located one-third of the way from the ASIS to the umbilicus, and is a classical approach for appendectomy. *C* - The image labeled **C** depicts an incision in the **right upper quadrant**, below the costal margin. This location is characteristic of a **Kocher's subcostal incision**. - A Kocher's incision is primarily used for procedures involving the **gallbladder** and **biliary tree**, such as cholecystectomy, or other upper abdominal surgeries. *D* - The image labeled **D** represents a different surgical incision that is not the Lanz incision. - The Lanz incision is specifically the transverse incision in the right iliac fossa as shown in option B. *None of the above* - This option is incorrect because **B** clearly indicates the **Lanz incision**, a recognized surgical incision. - The Lanz incision is a specific type of transverse incision used for appendectomy, distinct from other regional incisions.

Q: The following is appearance of bowel intraoperatively. Which is correct about the condition?

Obliteration of liver dullness. ***Obliteration of liver dullness*** - The image shows a **perforation** of the bowel (indicated by the arrow), which leads to the escape of **free air into the peritoneal cavity**. - **Free air under the diaphragm** displaces the liver, causing the percussion note over the liver to change from dullness to tympany, thus "obliterating" liver dullness. *Increased bowel sounds* - **Peritonitis** resulting from bowel perforation often leads to a **paralytic ileus**, characterized by **decreased or absent bowel sounds**. - Increased bowel sounds are more common in **early bowel obstruction** or gastroenteritis. *Blood on per rectal examination* - While bowel pathologies can cause rectal bleeding, a simple **perforation** without significant mucosal injury or a vascular lesion is **not typically associated with blood on per rectal examination**. - This finding is more indicative of conditions like **colitis, hemorrhoids, or rectal tumors**. *Increased air fluid levels* - **Increased air fluid levels** are typically seen on **X-rays in cases of bowel obstruction**, where fluid and gas accumulate proximal to the obstruction. - In bowel perforation, **free air is outside the bowel lumen** in the peritoneal cavity, and while some ileus might be present, increased air-fluid levels inside the bowel are not the primary or most characteristic finding. *Shifting dullness* - **Shifting dullness** is a percussion finding used to detect **free fluid (ascites)** in the peritoneal cavity, not free air. - In bowel perforation, there is **pneumoperitoneum (free air)**, which causes **tympany**, not dullness. - Shifting dullness would be found in conditions like **cirrhosis with ascites, peritoneal carcinomatosis, or tuberculous peritonitis**.

Question 1

A 55-year-old man presents to the emergency department with sudden-onset tearing chest pain radiating to the interscapular region. He has a history of poorly controlled hypertension. BP is 178/96 mmHg in the right arm and 142/80 mmHg in the left arm. He is diaphoretic and in moderate distress. A CT angiogram of the chest is obtained. The image demonstrates an intimal flap originating 3 cm distal to the left subclavian artery with the false lumen extending through the descending thoracic aorta to the level of the renal arteries; the ascending aorta and aortic root appear normal. Which of the following is the most appropriate management?

Accepted Answer

Initiate IV labetalol to achieve a target heart rate below 60 bpm and systolic BP below 120 mmHg, and admit to the ICU

Answer

Arrange emergent cardiopulmonary bypass and open surgical repair of the aorta

Answer

Perform urgent thoracic endovascular aortic repair (TEVAR) in the interventional suite

Answer

Administer IV thrombolytics and obtain repeat CT angiography in 24 hours to assess progression

Answer

Perform emergent bedside transesophageal echocardiography and prepare for pericardiocentesis

Question 2

A 67-year-old woman with a history of atrial fibrillation on warfarin presents with sudden-onset severe periumbilical pain out of proportion to physical examination findings. She has a heart rate of 110 bpm, blood pressure of 88/60 mmHg, and temperature of 37.2°C. Her abdomen is rigid with diffuse tenderness, guarding, and rebound on palpation. Serum lactate is 4.8 mmol/L. CT angiography of the abdomen with contrast demonstrates a filling defect at the origin of the superior mesenteric artery consistent with embolus, pneumatosis intestinalis of the small bowel, and portal venous gas. Which of the following is the most appropriate next step in management?

Accepted Answer

Emergent surgical exploration with bowel resection of non-viable segments

Answer

Systemic anticoagulation with unfractionated heparin and repeat CT in 6 hours

Answer

Urgent endoscopy to evaluate for ischemic colitis

Answer

Interventional radiology consultation for catheter-directed thrombolysis

Answer

Admission for IV antibiotics and serial abdominal examinations

Question 3

The following image shows \qquad and the test being performed is \qquad ?

Accepted Answer

Meckel's Diverticulum, Technetium scan

Answer

Carcinoid Tumor, Octreo-scan

Answer

Extra-adrenal Pheochromocytoma, PET DOPA scan

Answer

Adrenal Pheochromocytoma, MIBG scan

Answer

Intestinal Lymphoma, PET-CT scan

Question 4

All the following statements regarding this condition are true except:

Accepted Answer

Broad-base of this defect should be amputated at its base

Answer

It is remnant of vitello intestinal duct

Answer

This condition can be a lead point for ileoileal or ileocolic intussusception

Answer

This condition is mostly asymptomatic

Answer

It is the most common congenital anomaly of the gastrointestinal tract

Question 5

A 34-year-old male patient complains of sudden severe epigastric pain along with vomiting, tenderness, guarding. On examination there is abdominal rigidity and tachycardia. He admits to taking NSAIDs for pain. The radiological examination of the patient is given below. All statements given below are true except?

Accepted Answer

Pain often radiates to groin

Answer

Tenderness on per-rectal examination

Answer

Blumberg sign is positive

Answer

Dullness over flanks is observed

Answer

Obliteration of liver dullness on percussion

Question 6

Identify the tube shown in the image:

Accepted Answer

Sengstaken-Blakemore catheter

Answer

Ryle's tube

Answer

Malecot's catheter

Answer

Foley's catheter

Answer

Minnesota tube

Question 7

Identify the structure held with artery forceps:

Accepted Answer

Appendix

Answer

Meckel's diverticulum

Answer

Zenker's diverticulum

Answer

Colostomy stoma

Answer

Fallopian tube

Question 8

Which of the following is Lanz incision?

Accepted Answer

B

Answer

A

Answer

C

Answer

None of the above

Answer

D

Question 9

The following is appearance of bowel intraoperatively. Which is correct about the condition?

Accepted Answer

Obliteration of liver dullness

Answer

Increased bowel sounds

Answer

Blood on per rectal examination

Answer

Increased air fluid levels

Answer

Shifting dullness

Question 10

A 30-year-old man presents with abdominal pain and fever for one day. He has history of diarrhea for last several months which contains blood. What is the diagnosis?

Accepted Answer

Toxic megacolon

Answer

Pneumatosis intestinalis

Answer

Cecal volvulus

Answer

Intestinal perforation

Answer

Fulminant colitis

Gastrointestinal Surgery — MCQs

Gastrointestinal Surgery — MCQs

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