MEN 1

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Q) A 32-year-old woman presents with fatigue and kidney stones. Labs show:
- Serum calcium: 11.6 mg/dL (elevated)
- PTH: inappropriately elevated
- Serum prolactin: normal
- Fasting glucose: elevated, HbA1c: 7.2%
Her brother had a gastrinoma and hyperparathyroidism in his 30s.
A MEN1 mutation is detected on genetic testing.

Which of the following is the most appropriate next step in her evaluation?
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Cystic neoplasm of pancreas

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Q) A 60-year-old woman is found to have a 3.2 cm pancreatic cystic lesion on MRI. EUS shows internal echogenic material within the cyst cavity. To accurately determine whether this represents mural nodules rather than intraluminal debris, which of the following is the most definitive diagnostic approach?
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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?
✅ Answer: 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.

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Flaps in Plastic Surgery

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Q: A 48-year-old male undergoes excision of a chronic pilonidal sinus with a rhomboid-shaped defect over the sacrococcygeal region. The reconstructive plan involves a local flap designed adjacent to the defect, where the flap is transposed into the primary defect and the donor site is closed primarily. The flap follows the lines of minimal skin tension and relies on subdermal vascular supply without a named artery. What is the correct classification of this flap?

A. Rotation flap
B. Axial pattern transposition flap
C. Random pattern transposition flap
D. Advancement fasciocutaneous flap

Pericardial Injury

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Q: A 25-year-old male presents after a stab wound to the left 5th intercostal space at the midclavicular line.

He is hypotensive, tachycardic, and confused. eFAST reveals pericardial fluid. What is the next best step in management?

A. Pericardiocentesis
B. Emergency thoracotomy
C. CT angiography of the chest
D. Chest tube insertion