Free Questions

Free MCQs in Surgery

Ameloblastoma

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Q) Which of the following is true about ameloblastoma 

a) It is seen in children below 5 years

b) It is the most common odontogenic tumor

c) Mandible is the most common site 

d) It is highly malignant

Ans 

c Mandible is the most common site

It is the 2nd  most common odontogenic tumor. It is locally invasive and can cause severe deformity. It is seen in middle age group and not children.

Mandible is the most common site of origin seen in 80% cases. It is slow growing  but it remains locally aggressive with high rates of recurrence.

Given the choices above, c  is the most probable one.

Ameloblastoma is a benign, slow growing, locally invasive odontogenic tumor. It is the second most common odontogenic neoplasm. It accounts for 11% of all odontogenic tumors.

Ref:  http://atlasgeneticsoncology.org/Tumors/AmeloblastomID5945.html

Understanding Duodenal Atresia: Causes, Symptoms, and Treatment

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Q) An infant presents with duodenal atresia. Which of the following is true about this condition?

a) It is the most common GI atresia

b) It presents soon after birth with non bilious vomiting

c) Pre natal detection of duodenal atresia is common

d) Gastro jejunostomy is the procedure of choice to bypass the obstruction

Answer 

C-

Commonly detected in the pre natal ultrasound

Duodenal atresia is seen in 1:5000 live births .Most common atresia is jejunoileal (1 in 2000). It is associated with lot of other congenital malformations like Down's,  prematurity, biliary atresia etc.

Duodenal atresia can have many stages like duodenal webs, complete stenosis and complete separation.

Mostly (80%) stenosis is distal to the ampulla of vater so the bile coming out from the ampulla goes in the stomach and infant presents with bilious emesis.

Typical radiographic sign is double bubble. One bubble in stomach and one in duodenum. Ante natal sonography is able to pick up most cases.

Duodenal atresia Double bubble sign
Double Bubble

 

Surgical options include- Duodenoduodenostomy and Duodenojejunostomy.

Another related MCQ to this question is that Double bubble sign is seen in which other conditions

  1. Duodenal stenosis
  2. Annular Pancreas
  3. Atresia of duodenum

 

 

 

 

Understanding Duodenal Atresia in Infants: Key Facts and Diagnostic Insights

Duodenal atresia is a congenital condition that affects newborns, impacting their gastrointestinal (GI) system. While not the most common form of GI atresia, it is a significant condition that requires early detection and treatment. This article delves into the critical aspects of duodenal atresia, including its symptoms, diagnosis, and treatment options.

What is Duodenal Atresia?

Duodenal atresia is a congenital obstruction of the duodenum, the first part of the small intestine. This condition occurs in approximately 1 in 5,000 live births and is associated with other congenital malformations, such as Down syndrome, prematurity, and biliary atresia.

Prenatal Detection of Duodenal Atresia

Early Diagnosis through Ultrasound

One of the most notable aspects of duodenal atresia is that it is commonly detected during prenatal ultrasounds. Advances in antenatal sonography allow doctors to identify most cases before birth, providing an opportunity for early planning and intervention. The typical sign on ultrasound is a "double bubble" appearance, which indicates the presence of fluid-filled areas in both the stomach and duodenum.

Symptoms and Presentation

Bilious Vomiting After Birth

Duodenal atresia typically presents soon after birth, with one of the hallmark symptoms being bilious vomiting. In around 80% of cases, the obstruction is located distal to the ampulla of Vater, allowing bile from the liver to mix with stomach contents, leading to greenish, bilious emesis.

Associated Congenital Conditions

Infants with duodenal atresia may also present with other congenital anomalies, such as Down syndrome, heart defects, or other gastrointestinal malformations like jejunoileal atresia, which is actually the most common type of GI atresia (occurring in 1 in 2,000 live births).

Types of Duodenal Obstructions

Stages of Duodenal Atresia

Duodenal atresia can occur in various forms, ranging from partial obstruction, such as duodenal webs, to complete separation of the duodenum. These different forms dictate the severity of symptoms and the urgency of intervention.

  1. Duodenal Webs – Thin membranes that partially block the duodenum.
  2. Stenosis – A narrowing of the duodenum that restricts food passage.
  3. Complete Atresia – A total obstruction where the duodenum is completely separated.

Diagnostic Features

Double Bubble Sign on Imaging

Postnatally, duodenal atresia is diagnosed through abdominal imaging, with the "double bubble" sign being a classic radiographic finding. This sign appears as two distinct gas-filled bubbles—one in the stomach and one in the duodenum—indicating the obstruction.

Treatment of Duodenal Atresia

Surgical Intervention

The treatment for duodenal atresia is surgical, with the goal of bypassing or removing the obstruction. Contrary to some misconceptions, gastrojejunostomy is not the preferred procedure. Instead, a duodenoduodenostomy is often performed to connect the two ends of the duodenum, allowing normal passage of food from the stomach to the intestines.

Post-Surgical Outlook

With early surgical intervention, the prognosis for infants with duodenal atresia is generally positive. Post-operative care is crucial to ensure proper digestion and prevent complications such as infection or malabsorption.

Bleeding Peptic ulcer

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Q) In a 55 year old male  with a bleeding peptic ulcer, endoscopy is done. Which of the following findings on endoscopy predicts the highest rate of re bleed?

a) Non bleeding vessel

b) Adherent clot

c) Flat pigmented spot

d) Clean base ulcer

Click here for more stomach MCQs

Free Answer 

Answer a

a) Non bleeding vessel IIA - Out of the choices given

Bleeding peptic ulcer is mostly from the posterior surface of the lesion and can be sometimes lethal

Forrest classification is used to grade the risk of re bleeding in peptic ulcers.

According to the stigmata of recent bleed, the chances of re bleed increase.

Endoscopic appearance of bleeding peptic ulcer classification

 Forrest Classification

Ia - Active Spurting                   Highest 90% chance of acute bleeding peptic ulcer ICD 10

Ib-  Active oozing

IIa Non bleeding vessel             50% chance of re bleed

IIB Adherent clot

IIC Flat Pigmented spot

III Clean based ulcer

Sabiston 1154 21th edition

Q) How to treat a bleeding peptic ulcer? Bleeding gastric ulcer management?

Steps to manage a bleeding peptic ulcer

  1. Secure two large bore IV lines for fluid and blood products. Evaluate for coagulopathy
  2. Simultaneous evaluation for source of bleeding and history. Important causes to rule out are chronic liver disease, NSAID use etc
  3.  Simultaneous IV PPI infusion
  4. Endoscopic control  of bleeding peptic ulcer- Thermal coagulation, hemoclips, Adrenaline injections etc
  5. Operative procedure For  Duodenum bleed - Longitudanally opening the anterior wall of duodenum and 3 point suture ligation
  6. For Gatric ulcer bleeding - depends on the site of ulcer and might require Antrectomy/Partial gastrectomy

Our Recommendations

BEST TEXTBOOKS FOR GENERAL SURGERY

Bailey & Love’s Short Practice of Surgery, 27th Edition

Sabiston’s Textbook of Surgery

Schwartz’s Principles Of Surgery

SRB’S Manual Of Surgery

 

Contraindication of liver transplantation

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Q)Contraindications of liver transplantation have changed over the years. Which is an absolute contraindication of  liver transplantation

a) Previous breast cancer

b) Portal vein thrombosis

c) Active tuberculosis

d) Active substance abuse

d

Previous history of breast cancer if completely treated is not an contraindication of liver transplant. Portal vein thrombosis was earlier considered a relative contraindication but almost all series have shown similar results in patients with PVT than patients without PVT.

IN portal vein thrombosis, inflow to the new liver can me taken in many ways

a) thrombectomy

b) Jump grafts from Superior mesenteric vein 

c) Anastomosis have been done from big collaterals

Active tuberculosis can be managed after transplant.

Modified ATT regimens without INH and Rifampicin are being  used.  Any kind of active substance abuse alcohol,  drugs etc are absolute contraindications for liver transplant because the disease will recur.

Nutrient Absorption

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Q) What is true regarding absorption of nutrients from small intestine?

a) Bile salt is required for absorption of Vitamin B12

b) Parathyroid hormone increases calcium absorption

c) Triglycerides are synthesized by intestinal epithelial cells before being released in portal circulation

d)  Iron deficient individual can absorb 80% of dietary iron

Answer

b

Calcium absorption is due to Vitamin D and Parathyroid hormone.

Bile salt is required for absorption of fat soluble vitamins like Vitamin A, D, E& K

Vitamin B12 requires intrinsic factor. Triglyceride absorption occurs in the form of Free fatty acids and monoglycerides.

Only 20% iron is absorbed by iron deficient individuals

 

 

Causes of Acalculus Cholecystitis

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Q) Which of the following is not a cause of acalculus cholecystitis? Questions on bile duct

a) Kinking of the neck of gall bladder

b) Acalculus cholecystitis Sphincter spasm

c) Thrombosis of cystic artery

d) Over eating

Ans d

Acalculus cholecystitis can be both acute and chronic in the absence of stones. Although it can present acutely, acalculous cholecystitis typically presents more insidiously.

Mostly the acute form is recognized and chronic form is called biliary dyskinesia.

The cause of acalculus cholecystitis are

  1. Kinking or fibrosis of neck of gall bladder.
  2. Thrombosis of cystic artery
  3. Sphincter of Oddi spasm
  4. Prolonged fasting
  5. Dehydration
  6. Sepsis
  7. Systemic diseases MODS

Ref: By Jarrell - NMS Surgery (National Medical Series for Independent) (Sixth Edition) (2015-07-30) [Paperback]

Jaundice in acalculus cholecystitis  is known to occur because of ischemia and inflammation cystic duct gets obstructed due to edema

Diagnosis

Chronic acalculus cholecystitis is a cholescintigraphy nuclear scan (HIDA) with the administration of cholecystokinin (CCK). After the . A calculated ejection fraction of 35% or less may be indicative of hypokinetic functioning of the gallbladder. An ultrasound of the gallbladder may also be useful. If this shows a thickened gallbladder wall of over 3.5 mm, this may be due to cholecystitis.

Acute acalculus cholecystitis - USG CT or HIDA

 

BEST BOOKSMCQ practise 

MRCS Part A: Essential Revision Notes: Book 1

MRCS Part A: Essential Revision Notes: Book 2

 

Omental cyst

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Q) True statement about omental cyst is ?

a) It is always unilocular

b) Commonly seen in old age group

c) Arise from acquired or congenital obstruction of the lymphtaic channels

d) Complications are more common in old age.

Answer c

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Lymph node stations in Carcinoma stomach

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Q) In gastric cancer, lymph node station 12 corresponds to 

a) Common hepatic

b) Hepatoduodenal

c) Retropancreatic

d) Superior Mesenteric

Ans b

In gastric cancer, lymph node station 12 corresponds to the hepatoduodenal ligament lymph nodes.  These nodes are specifically located along the hepatoduodenal ligament and are further subdivided into groups based on their anatomical relationship: along the hepatic artery (12a), along the bile duct (12b), and behind the portal vein (12p)

Altemeier procedure

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Q) True about altemeier procedure?

a) It is proctosigmoidectomy with posterior levataroplasty

b) Done in left lateral position

c) Recurrence rate can be as high as 50%

d) Altemeier was the 1st person to do it

Ans a

The Altemeier procedure, also known as perineal rectosigmoidectomy, is a surgical technique used to treat rectal prolapse.

Altemeier procedure is a perineal surgical procedure in moribund and old patients.

It combines proctosigmoidectomy with posterior  levatorplasty.

A disadvantage of the perineal proctosigmoidectomy is the increased recurrence rates of
12% to 24% compared with the abdominal approach.

It is done in prone jack- knife position It was initiated by Mikulicz in 1899 and popularized by Altemeier in 1920s

Esophageal hiatus hernia

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Q) What is type III esophageal hernia? 

a) Paraesophageal hiatus hernia

b) Sliding hiatus hernia

c) Both sliding and paraesophageal hernia

d) Large part of stomach in the mediastinum with pylorus near the esophageal hiatus

Answer  c

Hiatal hernias are protrusion of stomach through a defect in the esophageal hiatus into the mediastinum.

They are of four  types of hiatus hernia

  1. Sliding - GE junction migrates to the mediastinum and rests superior to the diaphragm.
  2. Paraesophgaeal - Part of stomach migrates through the esophageal hiatus into the mediastinum with GE junction remaining at its normal position.

paraesophgeal hiatus hernia

  1. There are IV types of hiatal hernia

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