Free Questions

Free MCQs in Surgery

Ulcerogenic cause of hypergastrinemia

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Q) A 42-year-old male presents with multiple recurrent duodenal ulcers, abdominal pain, and chronic diarrhea. Fasting serum gastrin levels are >1000 pg/mL. Which of the following is the most likely ulcerogenic cause of hypergastrinemia?

A. Atrophic gastritis
B. Zollinger–Ellison syndrome
C. Chronic proton pump inhibitor use
D. Helicobacter pylori infection

Ans b

B. Zollinger–Ellison syndrome

Explanation:

  • Zollinger–Ellison syndrome (ZES) is caused by a gastrinoma (a gastrin-secreting tumor), typically located in the pancreas or duodenum.

  • It leads to massive hypergastrinemia, increased gastric acid secretion, and multiple, recurrent, or atypical peptic ulcers.

  • Diarrhea and steatorrhea are common due to acid inactivation of pancreatic enzymes.

🔍 Other Options:

  • A. Atrophic gastritis:

    • Leads to hypochlorhydria/achlorhydria with secondary hypergastrinemia, but non-ulcerogenic (low acid state).

  • C. Chronic PPI use:

    • Causes compensatory hypergastrinemia due to acid suppression, but again non-ulcerogenic unless stopped abruptly in predisposed individuals.

  • D. Helicobacter pylori infection:

    • May increase gastrin levels mildly, but ulcers are primarily due to mucosal damage and inflammation, not from gastrin hypersecretion.

🧠 Key Point:

Zollinger–Ellison syndrome is the only ulcerogenic cause of hypergastrinemia.
Fasting gastrin >1000 pg/mL with low gastric pH is diagnostic.

Sucking chest wound

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Q) A 30-year-old male presents to the emergency department after a stab wound to the right chest.

On examination, there is a 4 cm open wound in the 5th intercostal space anteriorly, with a sucking sound during inspiration, decreased breath sounds on the right, and respiratory distress.

What is the next best step in management? # Theme neet ss mocktest 1

A. Immediately close the wound with an airtight dressing
B. Insert a chest tube on the same side and then close the wound
C. Intubate and initiate positive pressure ventilation
D. Apply a three-sided occlusive dressing to the wound

Answer D. Apply a three-sided occlusive dressing to the wound

This is a classic presentation of an open pneumothorax, also known as a sucking chest wound. When the chest wound is ≥2–3 cm (or ≥2/3 the diameter of the trachea), air preferentially enters through the chest wall defect instead of the trachea, impairing ventilation.

Management steps:

  1. Initial step: Apply a three-sided occlusive dressing — this allows air to escape during exhalation but prevents air from entering during inhalation, avoiding tension pneumothorax.

  2. Definitive step: Place a chest tube (thoracostomy) on the same side before fully sealing the wound.

A is incorrect because a fully sealed dressing without a chest tube can cause tension pneumothorax.
B is correct only after the initial temporary occlusive dressing is applied.
C may be needed later but not before securing the wound.

Suturing Techniques

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Q) During a surgical skills assessment, you are asked to perform a hand-sewn intestinal anastomosis using a continuous, inverting suture that enters the bowel lumen.

Which of the following suture techniques best fits this description?

#Theme from INI CET GI Mock test

A. Lembert suture
B. Cushing suture
C. Gambee suture
D. Connell suture

Correct Answer: D. Connell suture

The Connell suture is a continuous, inverting, full-thickness suture technique. It is unique because:

  • The needle enters the bowel lumen, passing through the mucosa.

  • It is run parallel to the incision line.

  • It achieves inversion of the bowel edge, which promotes serosal healing but intraluminal suture exposure is a drawback.

  • Historically used for the inner layer of two-layer bowel anastomoses.

Comparison with Other Options:

A. Lembert suture

  • Seromuscular only, avoids the mucosa

  • Interrupted or continuous

  • Inverting, but does not enter lumen

B. Cushing suture

  • Continuous, inverting

  • Parallel to incision

  • Penetrates submucosa but not mucosa (no lumen entry)

C. Gambee suture

  • Interrupted, inverting

  • Passes through a small portion of mucosa

  • Designed to minimize mucosal eversion and reduce luminal exposure

Gall bladder stone with obstruction

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A 65-year-old male presents with abdominal pain, vomiting, and a history of multiple episodes of cholecystitis. X ray image is given below.

What is the most likely diagnosis?

Gall stone and intesinal obstruction

A. Acute cholecystitis
B. Gallstone ileus
C. Small bowel volvulus
D. Duodenal perforation

 

 

Answer: B. Gallstone ileus

Explanation:
Rigler's Triad consists of pneumobilia, small bowel obstruction, and an ectopic gallstone, which is diagnostic of gallstone ileus. This condition occurs when a gallstone enters the bowel through a biliary-enteric fistula, leading to mechanical obstruction.

A large gallstone (>2.5 cm) erodes through the gallbladder wall, creating a cholecysto-enteric fistula (most commonly into the duodenum).

The stone enters the bowel and may cause obstruction, most often at the ileocecal valve due to its narrow lumen.

The presence of air in the biliary tree (pneumobilia) results from communication between the biliary and intestinal tracts.

Surgery Instrument

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Q) Identify the instrument

 

 

 

 

 

 

 

a) Craniotome

b) Hudson Brace

c) Humby's knife

d) CUSA

Ans b

The Hudson brace is a manually operated surgical drill used in neurosurgery and orthopedic procedures. It consists of a hand-cranked mechanism with interchangeable drill bits for trephination or skull perforation.

Puzzle people by Thomas Starzl

Axillary lymoh node dissection in ca breast

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Q) Which of the following statements is most accurate regarding axillary lymph node dissection (ALND) in breast cancer staging?

a) Level I and level II ALND requires the removal of at least 10 lymph nodes for accurate staging, and level III nodes should always be included in the dissection, regardless of the presence of gross disease in levels I and II.

b) The axillary dissection should include tissue from levels I and II, with a focus on the area inferior to the axillary vein, extending laterally to the latissimus dorsi muscle and medially to the pectoralis minor muscle, when there is no gross disease in level II nodes.

c) Level III nodes should be dissected in all cases of breast cancer for accurate staging, as they are always involved in metastatic spread.

d) Level I and level II ALND can be skipped in cases of clinically negative axilla, as there is no need for lymph node evaluation in the absence of suspicion of metastasis

Ans b) The axillary dissection should include tissue from levels I and II, with a focus on the area inferior to the axillary vein, extending laterally to the latissimus dorsi muscle and medially to the pectoralis minor muscle, when there is no gross disease in level II nodes.

In breast cancer surgery, axillary lymph node dissection (ALND) is used to evaluate the extent of cancer spread to the lymph nodes and to help stage the disease. The following key points should be noted:

Why Option b is correct:

  • Level I and II ALND are typically performed when there is a need to stage the axilla, and it is crucial to remove lymph nodes from these levels to accurately assess the presence of metastatic cancer. The dissection should focus on the tissue inferior to the axillary vein, from the latissimus dorsi muscle laterally to the medial border of the pectoralis minor muscle. This area corresponds to the levels I and II nodes.
  • If there is no gross disease detected in the level II nodes, further dissection into level III nodes is generally not needed. This ensures a more selective approach, avoiding unnecessary complications associated with dissection of more extensive lymph node regions.

Why the other options are incorrect:

  • Option a): While 10 lymph nodes are often considered the minimum number for accurate staging, level III nodes should not always be included in ALND unless there is gross disease detected in levels I and II. Dissecting level III nodes in the absence of disease is not routine practice due to the increased risk of complications.
  • Option c): Level III nodes are not routinely dissected in all cases. They are only considered when there is gross disease in level I and II nodes. This step is generally reserved for cases where there is clinically evident disease, as level III nodes are more challenging to access and carry a higher risk of complications.
  • Option d): In cases of clinically negative axilla, ALND may not be necessary, but for accurate staging and treatment decisions, lymph node evaluation (such as with sentinel lymph node biopsy or ALND) is still important. Skipping the dissection entirely without any evaluation is not appropriate, as there may be microscopic disease in the axillary nodes that could influence prognosis and treatment planning.

Constipation in childhood

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Q) A 4-year-old child presents with a history of infrequent, hard stools associated with painful defecation.

There is no history of vomiting, fever, or blood in the stool. On examination, there is a palpable fecal mass in the left lower abdomen, and the anal tone is normal.

What is the most likely diagnosis? # Theme from Mock test 32

A) Hirschsprung disease
B) Functional constipation
C) Intussusception
D) Anal fissure

Ans b

Functional constipation is the most common cause of constipation in children. It is characterized by hard stools, infrequent bowel movements, and often associated with painful defecation leading to stool withholding.

It is diagnosed clinically based on the Rome IV criteria, with no evidence of an organic cause.

Why the other options are incorrect:

A) Hirschsprung disease:

  • Typically presents in infancy with failure to pass meconium within 48 hours, abdominal distension, and bilious vomiting. The anal tone may be increased, and rectal examination may reveal an explosive release of stool.

C) Intussusception:

  • Presents with intermittent, severe abdominal pain, vomiting, and "currant jelly stools." A palpable "sausage-shaped" mass is found in the abdomen, not a fecal mass.

D) Anal fissure:

  • Can cause painful defecation, but it is usually associated with streaks of bright red blood on the stool and pain during defecation, without palpable fecal masses.

Breast cancer TNBC

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Q) Which of the following patients with operable breast cancer is the most appropriate candidate for preoperative systemic therapy?

A) A patient with ER-positive, HER2-negative breast cancer with a 1 cm tumor and clinically node-negative disease who desires breast conservation

B) A patient with HER2-positive breast cancer with a 3 cm primary tumor and clinically node-positive disease

C) A patient with triple-negative breast cancer with a 1 cm tumor and clinically node-negative disease who prefers mastectomy

D) A patient with ER-positive, HER2-positive breast cancer with a 1.5 cm tumor and no lymph node involvement

Correct Answer: B) A patient with HER2-positive breast cancer with a 3 cm primary tumor and clinically node-positive disease

Preoperative systemic therapy is generally recommended for:

  1. HER2-positive or triple-negative breast cancer when the tumor is ≥cT2 (≥2 cm) or clinically node-positive (cN1).
  2. Patients with a large tumor relative to breast size who desire breast-conserving surgery.
  3. Patients with clinically node-positive disease (cN+) who may achieve node-negative (cN0) status with systemic therapy.

Option B meets these criteria with both HER2-positive disease and clinically node-positive status, making the patient an ideal candidate for preoperative systemic therapy.

Choice A: A patient with ER-positive, HER2-negative breast cancer with a 1 cm tumor and clinically node-negative disease who desires breast conservation
  • Explanation: This patient has an ER-positive, HER2-negative tumor that is small (1 cm) and clinically node-negative. These characteristics indicate a low risk of aggressive disease, and preoperative systemic therapy is typically not necessary for small, low-risk tumors. In this case, surgery would likely be the primary treatment option, followed by adjuvant therapy if needed.

Choice C: A patient with triple-negative breast cancer with a 1 cm tumor and clinically node-negative disease who prefers mastectomy

  • Explanation: Although this patient has triple-negative breast cancer (TNBC), the tumor size is only 1 cm and clinically node-negative. Preoperative systemic therapy is generally reserved for larger tumors (≥cT2) or node-positive disease in TNBC cases to improve outcomes or allow breast conservation. In this scenario, with a small, node-negative tumor, the preferred approach might be surgery first, as systemic therapy may not offer substantial additional benefits.

Choice D: A patient with ER-positive, HER2-positive breast cancer with a 1.5 cm tumor and no lymph node involvement

  • Explanation: This patient has HER2-positive breast cancer, but the tumor size is only 1.5 cm, which is below the ≥cT2 threshold for recommending preoperative systemic therapy. Additionally, the absence of lymph node involvement (cN0) indicates a lower burden of disease. While HER2-positive patients often benefit from systemic therapy, a neoadjuvant (preoperative) approach may not be necessary unless the tumor or nodal status meets certain thresholds (≥cT2 or ≥cN1).

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