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Q. A 45 year old male has severe coughing followed by sudden Bilateral pain in lower abdomen. At the same time he develops a swelling in the mid line, lower abdomen which does not change in size on raising the leg muscles. What has really happened?

a) Ruptured aortic aneurysm

b) Obturator hernia

c) Spigelian Hernia

d) Rectus sheath hematoma

Answer

Dumping Syndrome

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Q) Which of the following is true about dumping syndrome

a) Somatostatin analogues are effective in controlling symptoms

b) Symptoms always include flushing and tachycardia 

c) Diarrhea is always part of dumping syndrome

d) Part of treatment includes combining solids with liquids in frequent small meals

Answer Premium only

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

 

 

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Appendicitis in Pregnacy

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Q) Which of the following statement is true about appendicitis in pregnancy?

a) Typical symptoms of appendicitis  are seen in more than 90% of patients.

b) 50% cases of appendicitis occur in 2nd trimester

c) Rate of negative explorations remain low based on clinical presentation alone

d) The sensitivity and specificity of ultrasound diagnosis remain the same in appendicitis in pregnancy

Answer b

Appendicitis  the most common non obstetric emergency in pregnancy. The diagnosis is difficult because the symptoms of pain abdomen, nausea, vomiting, anorexia, raised TLC are common in pregnancy. Appendicitis has a typical presentation in only 50% to 60% cases.

If untreated preterm labor and even fetal loss can occur due to the complications.

Based on clinical presentation alone, the incidence of negative exploration is as high as 25-50%

Ultrasound with graded compression is still a good imaging option but has lower sensitivity and specificity than in normal clinical situation. If ultrasound is equivocal the next best option is MRI which is safe.

Ref Sabiston 20th edition

Complications of duodenal diverticulum

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Q) True statement regarding complications of duodenal diverticulum is

a) Perforation is the commonest complication

b) Obstruction is caused by extra luminal duodenal diverticulum

c) Bleeding is the most common complication of duodenal diverticulum.

d) Diverticulitis is common and easily diagnosed.

Answer

c

Complications of duodenal diverticulum are rare with a reported incidence of 5-10% in those with duodenal  diverticulum. Operative intervention is required in about 1% cases

Perforation is the rarest but the most severe complication of duodenum diverticulum. The most common cause of perforated duodenal diverticulum is diverticulitis. They perforate in the retroperitoneum, adding to diagnostic uncertainty. Ct Scans are most diagnostic to help in this diagnosis.

Read more

GI Bleed

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Q )  A 59 year old male alcoholic male presents with history of upper GI bleed of 1 day duration. During the day he has had three episodes of bleeding each time about 150 ml. Blood is fresh and not associated with retching. He has a history of long standing alcohol intake. What will be the most likely cause of GI bleed?

a) Mallory weiss tear

b) Esophageal varices

c) Gastric ulcer

d) Esophagitis

11 b

Long standing alcohol intake means some stigma of liver disease leading to chronic liver disease and consequently esophageal varices. 

Mallory Weiss tear occurs with retching and after episodes of binge drinking

Gastric and duodenal ulcers are related to alcohol but usually presents at 40 years 

Esophagitis will have associated symptoms of GERD and long standing history

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