DMA's SURGERY PG Q & A 16 - 12 - 2017
Published on Dec. 16, 2017, noon

 

1. A large retained stone impacted in the distal com­mon bile duct is noted when T-tube cholangiography is performed after choledochostomy. The best manage­ment of the stone is:

 

(A) Dissolution with sodium cholate

 

(B) Dissolution with heparin

 

(C) Catheter extraction via the tract of the T-tube

 

(D) Transduodenal papillotomy with endoscopic stone extraction

 

2. Which of the following is true about diverticulosis

 

(A). High fiber containing diet is associated with increased incidence of diverticulosis

 

(B). It is premalignant

 

(C). In India> 20% of the population above the above of 40 years is affected by diverticulosis

 

(D). Management is essentially conservative in diverticulosis

 

3. In the most common anomaly of extrahepatic bile duct anatomy, the cystic duct

 

(A) Is absent

 

(B) Inserts into the right hepatic duct

 

(C) Lies parallel to the common duct and enters it close to the' duodenum          

 

(D) Passes anterior to the common duct and enters its left side

 

4. Which of the following is not a location where accessory spleen can be found?

 

(A). Gastrocolic ligament          

 

(B). Gerota’s fascia

 

(C). Large bowel mesentery       

 

(D). Broad ligament

 

5. Caput medusa is obvious in all the following except

 

(A). Budd Chiari syndrome

 

(B). Extra hepatic portal vein thrombosis

 

(C). Non cirrhotic peri portal fibrosis

 

(D). Alcoholic cirrhosis

 

6. Portal hypertension associated with cirrhosis of the liver results from:

 

(A). Thrombosis of the main portal vein

 

(B). Large effluent from enlarged spleen

 

(C). Intrahepatic shunts between hepatic artery and portal vein branches

 

(D). None of the above

 

7. Which of the following is more aggressive rectal carcinoma:

 

(A). Adenocarcinoma                

 

(B). Secondary mucoid carcinoma

 

(C). Signet ring carcinoma

 

(D). Squamous cell carcinoma

 

8. All of the following are recognized features of carcinoid syndrome, except

 

(A). Flushing    

 

(B). Bronchospasm

 

(C). Skin changes of pellagra

 

(D). Increased urinary excretion of vanillyl mandelic acid

 

9. A 70-year-old man presents with dysphagia. For 30 years he has experienced regular episodes of heartburn. An endoscopic biopsy shows, Barrett's oesophagus with high grade dysplasia. Which would you use to treat this patient?

 

(A). Antireflux surgery               

 

(B). Laser ablation

 

(C). Oesophagectomy  

 

(D). PPI treatment with repeat endoscopy in 3-6 months

 

10. Whipple procedure is used in treatment of which of the following condition?

 

(A). Peptic ulcer                       

 

(B). Abdominal perforation

 

(C). Ca pancreas          

 

(D). Intestinal obstruction

 

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1. Ans. (D). Transduodenal papillotomy with endoscopic stone extraction

All the listed techniques have been sug¬gested for dealing with residual common duct stones. Duct flushing techniques have not proved effective for impacted distal common duct stone although removal: via the T-tube tract is feasible, transduodenal papillotomy with endoscopic stone extraction is more effective with a stone impacted in the distal part of the common bile duct. Opera¬tive removal is reserved for situations where other techniques have failed.

2. Ans. (D). Management is essentially conservation in diverticulosis

Surgical management is only recommended in patient presenting with recurrent diverticulitis or with the complication of diverticulitis otherwise the management is conservative.Q
Indication for surgery:
•At least two documented attack of diverticulitis.
•Who don’t improve on medial therapy
•Complicated diverticulitis (i.e. abscess, obstruction, diffuse peritonitis or fistula)
•Recurrent for persistent hemorrhage
•Diverticulitis occurring in younger patients < 40 yrs.

3. Ans. (C). Lies parallel to the common duct and enters it close to the' duodenum

    
There may be a long cystic duct separate from -or fused with the wall of the common duct. All the described abnormalities occur, and the important issue is for the surgeon to define the anatomy correctly before divid¬ing any structures in the biliary area.

4. Ans: (B). Gerota’s fascia

Over 80% of accessory spleens are found in the region of the splenic hilum & vascular pedicle. Other locations in descending order of frequency are:- gastrocolic ligament, the tail of pancreas, the greater curve of the stomach, the splenocolic ligament, small & large bowel mesentery, the left broad ligament in women and the left spermatic cord in men.

5. Ans. (B). Extra hepatic portal vein thrombosis

Caput medusae is not seen in isolated extrahepatic portal vein obstruction because the obstruction is below the origin of the umbilical vein.    .
The presence of caput medusae indicates posthepatic or intrahepatic portal hypertensions because it forms by the recanalization of umbilical vein which connects with the left hepatic branch of portal vein.

6. Ans. (D). None of the above

Alcoholic  cirrhosis- most common cause of portal hypertension (US).
It causes portal blood flow obstruction by    
1. Increased resistance to portal flow at sinusoidal level due to deposition of collagen in Disse' s space
2. Post sinusoidal level secondary to regenerating modules distorting small hepatic vein.

7. Ans. (B). Secondary mucoid carcinoma

8. Ans. (D). Increase urinary excretion of VMA.

Carcinoid syndrome
Caused by - Various vasoactive peptide secreted by the tumour
Most common - 5 hydroxy tryptamine (serotonin)
Other - bradykinin, tachykinin, prostaglandin, substance-P
More common in small bowel carcinoid
Common in patients with hepatic metastases as the vaso-active substances are passes directly into Hepatic vein causing systemic symptoms

Symptoms¬
Most common- Secretary diarrhea Q (75%) and flushing Q (70%)
Other- Reddish blue cyanosis
1    Borborygmi
2    Right sided valvular heart disease Q (pulmonary and tricuspid stenosis)
3    Wheezing bronchial asthma
4    Pellagra like skin lesion, pruritus
5    Lacrimation, facial edema, salivation, retroperitoneal fibrosis
  Symptoms are promoted with- stress, alcohol, exercise and certain food.

Symptoms are controlled by¬ Q
1. Somatostatin analogues (octreotide)
2. Interferon-
3. Tumour debulking
4. Hepatic metastasis enucleation
5. Partial hepatectomy
6. Hepatic dearterialization (short term relief)
7. Hepatic artery embolization.
Chemotherapy- Streptozotocin & 5-FU Q
Diagnosis
1. Urinary and plasma serotonin
2. Urinary 5HIAA (normal 2-Smg/day)
(false positive in serotonin rich food - banana, pine apple, walnuts, pecane, avocades, hickory nuts).
3. Platelet serotonin
          In atypical carcinoid (mostly from foregut)
1    Urinary 5-HIAA normal or mild elevation
2    Urinary 5-HTP or 5HT measurement

9. Ans. (D):  PPI treatment with repeat endoscopy in 3-6 months

There is a significant risk of Barrett's oesophagus and adenocarcinoma arising in such a patient. Peptic strictures may also occur. Severe oesophagitis may lead to dysphagia even without a stricture. Severe dysplasia should be confirmed by repeat endoscopy in the presence of acid blockade. If confirmed, oesophagectomy should be performed.

10. Ans. (C). Ca pancreas

 
Pancreaticoduodenectomy, also known as the Whipple procedure, is the standard operation for cancers of the head or uncinate process of the pancreas. The procedure involves resection of the pancreatic head, duodenum, first 15 cm of the jejunum, common bile duct, and gallbladder, and a partial gastrectomy, with the pancreatic and biliary anastomosis placed 45 to 60 cm proximal to the gastrojejunostomy.