NEET-SS GI Surgery
NEET-SS GI Surgery
NEET-SS GI Surgery
National-level Free
MOCK EXAM on
NEET-SS:
GI Surgery
DISCLAIMER: The questions here
have been created by experts in
line with exam patterns and the
syllabus. Questions from previous
NEET-SS exams have not been
reproduced here.
NEET-SS GI Surgery
Part A
1. Metabolic response to injury consists of Ebb and Flow phases. Ebb phase lasts for about?
A. 0-6 hrs
B. 6-12 hrs
C. 12-24 hrs
D. 24-48 hrs
D. 24 - 48 hrs
The Ebb phase lasts for 24-48 hours. The catabolic part flow phase lasts for 3 to 10 days. The
anabolic phase or recovery phase lasts for weeks.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 1
The metabolic acidosis and increased sympathetic response in shock result in an increased respiratory
rate and minute ventilation to increase the excretion of carbon dioxide (and so produce a
compensatory respiratory alkalosis).
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 2
3. Mr Rajamannar had a pressure sore with loss of epidermis and a part of dermis. What stage is the
bedsore?
A.1
B.2
C.3
D.4
B.2
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 3
A.Re-programming factors such as NANOG and LIN28 are required to induce differentiation
B.They are inherently safe as there is no risk of oncogenic activation
C.iPSCs proliferate in vitro as efficiently as ESCs and are pluripotent
D.They were developed in 2006 by Dr Shinya Yamanaka
B. They are inherently safe as there is no risk of oncogenic activation
Induced PSCs were developed in 2006 by Dr Shinya Yamanaka based on earlier work by Dr John
Gordon. Retroviral or lentiviral transfection is used to introduce a combination of transcription factors
(OCT3/4, SOX2, and either Kruppel-like factor and C-MYC (together designated the OSKM
reprogramming factors) or NANOG and LIN28), it was shown that specialised somatic cells can be
reprogrammed to become stem cells.
Moreover, iPSCs proliferate in vitro as efficiently as ESCs and are pluripotent, thereby circumventing
concerns about the use of human embryos. Reprogramming somatic cells to become iPSCs using
retroviruses is that genomic integration of the virus may lead to activation of oncogenic genes,
causing tumorigenesis. To reduce this risk, non-retroviral vectors have been used (such as
adenovirus and Sandai virus vectors, that do not insert their own genes into the host cell genome), or
plasmids, episomal vectors and synthetic RNA.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 4
C. Adequate surgery will eliminate the need for continuing medical treatment
In actinomycetoma, cyclical, combined drug therapy with amikacin sulphate and co-trimoxazole is the
treatment of choice. In eumycetoma, ketoconazole, itraconazole and voriconazole are the drugs of
choice. They may need to be used for up to a year. Use of these drugs should be closely monitored for
side effects. While not curative, these drugs help to localise the disease by forming thickly
encapsulated lesions which are then amenable to surgical excision.
Postoperative medical treatment should continue for an adequate period to prevent recurrence.
This can be local or distant to regional lymph nodes. Recurrence is usually due to inadequate surgical
excision, use of local anaesthesia, lack of surgical experience, non-compliance with drugs.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 6
6. Polydioxanone (PDS) is a suture that is commonly used for abdominal closure. It is completely
absorbed in
A. 90 days
B. 180 days
C. Never completely absorbed
D. Non-absorbable
B. 180 days
Polydioxanone (PDS)
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 7
7. Which one of these is true about cancer growth with respect to the Gompertzian growth pattern?
Gompertzian growth: In its early stages, growth is exponential but, as the tumour grows, the growth
rate slows.
● The majority of the growth of a tumour occurs before it is clinically detectable
● By the time they are detected, tumours have passed the period of most rapid growth, that period
when they might be most sensitive to antiproliferative drugs
● There has been plenty of time, before diagnosis, for individual cells to detach, invade, implant, and
form distant metastases. In many patients cancer may, at the time of presentation, be a systemic
disease
● ‘Early tumours’ are genetically old, yielding many opportunities for mutations to occur, mutations
that might confer spontaneous drug resistance (a probability greatly increased by the existence of cell
loss)
● The rate of regression of a tumour will depend upon its age (the Norton–Simon hypothesis extends
this: chemotherapy results in a rate of regression in tumour volume that is proportional to the rate of
growth for an unperturbed tumour of that size)
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 10
8. A bacterium can divide every 20 minutes. Beginning with a single individual, how many bacteria
will be there in the population if there is exponential growth for 3 hours?
A. 18
B. 440
C. 512
D. 1024
C. 512.
A bacterium can divide every 20 minutes. In 3 hours there will be 9 divisions. Thus we will have 29
bacteria in 3 hours, which is equal to 512.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 11
A. Type 1 error
B. Type 2 error
C. Type 3 error
D. Type 4 error
A. Type 1 error
10. With regards to the WHO surgical safety checklist, sign in is done
11. Narrow band imaging (NBI) is useful in visualising various fine structures during endoscopy.
Which of the following is false?
NBI uses two discrete bands of light: blue at 415 nm and green at 540 nm. Narrow band blue light
displays superficial capillary networks, whereas green light displays subepithelial vessels; when
combined, they offer an extremely high contrast image of the tissue surface. Indigo carmine is not
used in NBI. It is used in chromo-endoscopy.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 15
12. MRI abdomen was performed in a patient with ascites. In T2 phase ascitic fluid appears
A. White
B. Black
C. None
D. Both, depending on the case
A. White
A. Reticulin: iron
B. Van Gieson: collagen
C. Congo red: amyloid
D. Ziehl-Neelsen: mycobacteria
A. Reticulin: iron
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 16
14. Airway assessment is done with modified Mallampati testing. On assessment of the patient
planned for elective Modified radical mastectomy, only hard palate was seen. What is the modified
Mallampati grade?
A. Grade 1
B. Grade 2
C. Grade 3
D. Grade 4
D. Grade 4
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 17
A. Suxamethonium
B. Rocuronium
C. Decamethonium
D. Di-acetylcholine
B. Rocuronium
Muscle relaxants are categorized into depolarizing and nondepolarizing agents. Suxamethonium (prev
called Di-acetylcholine) is the most common depolarizing agent despite its adverse effects (eg.
Hyperkalemia, myalgia, anaphylaxis, malignant hyperthermia) because of quick onset and short
duration of action. Non-depolarizing agents provide longer, predictable activity but require careful
monitoring, appropriate timing and action reversal. Eg. Rocuronium, Pancuronium, Atracurium.
Decamethonium is an obsolete agent (depolarizing blocker).
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 18
16. Malnutrition universal screening tool (MUST). What score do you treat?
A. >3
B. 2 or >2
C. 1 or >1
D. >4
B. 2 or >2
Risk of undernutrition is high when the score is 2 or above. It certainly requires treatment.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 19
17. Which of the following is a classical feature of metabolic response seen in trauma and sepsis
which differentiates it from starvation by?
A. Hepatic glycogenolysis
B. High plasma glucagon levels
C. Loss of adaptive ketogenesis
D. Lipid oxidation
Metabolic changes in starvation are often similar to changes in trauma and sepsis. Adaptive
ketogenesis doesn’t however occur in trauma and sepsis
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 19
A. It is a clinical diagnosis
B. CT with contrast and 3D reconstruction of chest wall is the gold standard for diagnosis
C. Best treatment is with mechanical ventilation to splint the ribs
D. Surgery is useful in case of underlying pulmonary contusion
The diagnosis is made clinically in patients who are not ventilated, not by radiography. To confirm
the diagnosis the chest wall can be observed for paradoxical motion of a chest wall segment. The CT
scan, with contrast to display the vascular structures and a 3-D reconstruction of the chest wall, is the
gold standard for diagnosis of this condition. Traditionally, mechanical ventilation was used to
‘internally splint’ the chest, but had a price in terms of intensive care unit resources and ventilation-
dependent morbidity.
Currently, treatment consists of oxygen administration, adequate analgesia (including opiates) and
physiotherapy. If a chest tube is in situ, topical intrapleural local analgesia introduced via the tube, can
also be used. Ventilation is reserved for cases developing respiratory failure despite adequate
analgesia and oxygen. Surgery to stabilise the flail segment using internal fixation of the ribs may be
useful in a selected group of patients with isolated or severe chest injury and pulmonary contusion.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 27
C. Permissive hypotension
Damage control resuscitation (DCR) should be concurrent with DCS. The principles of DCR include
permissive hypotension, avoidance of crystalloid with haemostatic resuscitation, and recognition and
management of acute traumatic coagulopathy.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 30
20. Which of the following treatment strategies in the treatment of trench foot is not correct?
A. TPA
B. NSAIDS
C. Rapid rewarming
D. Nerve blocks
C. Rapid rewarming
In Immersion injuries, treatment should focus on:
● Gentle warming (Rapid rewarming can lead to burns)
● NSAIDs
● Rehydration with warm fluids
● Surgery only after demarcation occurs naturally
● Protect against further trauma and infection
● Recent developments, such as the use of tissue plasminogen activator (TPA) and nerve blocks,
show promising results in reducing amputations, but have to be started within 24 hours.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 29
21. Which of the following statements is not true about the use of tranexamic acid in trauma?
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 23
22. 70 yr old Mr Varadarajan suffered an head injury 6 months ago. His neuro-rehabilitation specialist
termed his Glasgow outcome score as 4. He has:
A. Good recovery
B. Moderate disability
C. Severe disability
D. Persistent vegetative state
B. Moderate disability
23. A TOTAL trial was started in leading European Pediatric surgery centres as a means to managing
which Pediatric surgical condition?
A. Duodenal atresia
B. Congenital diaphragmatic hernia
C. Undescended testis
D. Bronchopulmonary malformations
The Tracheal Occlusion To Accelerate Lung growth (TOTAL) trial is led by several European centers
as a means to treat CDH. It has not yet been approved by the FDA. Occlusion of trachea leads to
accumulation of lung fluid which stimulates lung growth.
24. A paediatric tertiary care hospital in Cochin is planning to purchase a Extracorporeal membrane
oxygenator. Which among the following is the most common indication for ECMO?
A. Meconium aspiration
B. Congenital diaphragmatic hernia
C. Respiratory distress syndrome
D. Sepsis
A. Meconium aspiration
Meconium aspiration is the most common application for neonatal ECMO with the highest survival
rate (>90%) among all conditions. Other indications include respiratory distress syndrome, PPHN,
sepsis, and congenital diaphragmatic hernia.
Purpura fulminans is a rare condition in which intravascular thrombosis produces rapid skin necrosis
and hemorrhagic infarction, which progresses rapidly to septic shock and disseminated intravascular
coagulation. It may be subdivided into three types based on etiology - acute infectious, neonatal and
idiopathic purpura fulminans.
Acute infectious is the commonest form. It is most common in children under 7 years of age,
following an upper respiratory tract, infection, or in asplenia. Endotoxins produce an imbalance in
procoagulant and anticoagulant endothelial activity, producing protein C deficiency. This gives the
clinical picture of an initial petechial rash developing into confluent ecchymoses and hemorrhagic
bullae, which necrose to form well demarcated lesions that form hard eschars. Extensive tissue loss is
common.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 40
26. Muir and Barclay formula is often used to calculate the colloid requirement in patients with burns.
Which of the following is accurate regarding the volume of one portion of colloid to be given in a
specific time period?
The most common colloid-based formula is the Muir and Barclay formula:
Plasma proteins are responsible for the inward oncotic pressure that counteracts the outward capillary
hydrostatic pressure. Without proteins, plasma volumes would not be maintained as there would be
oedema. Proteins should be given after the first 12 hours of burn because, before this time, the
massive fluid shifts cause proteins to leak out of the cells
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 41
A. Imbibition is not a process associated with survival of split-skin grafts in the first 48 hours.
B. Gentle handling and the best postoperative care play only a minor role to ensure the successful
take of a full-thickness graft.
C. Grafts will take on exposed tendons and cortical bone.
D. Contraction occurs in all grafts used in tissue repair but is dependent on the amount of dermis
taken with the graft.
D. Contraction occurs in all grafts used in tissue repair but is dependent on the amount of
dermis taken with the graft
Imbibition is the means whereby a split-skin graft is nourished during the first 48 hours of life in its
recipient site. Gentle handling is important to create the best conditions for taking a full-thickness
graft. Grafts do not take on bare tendon or cortical bone, because these do not produce granulations or
vascular support. Graft contraction depends on the amount of dermis in the graft and is thus greatest
in split-skin grafts and least in full-thickness grafts. More the dermis, lesser the contraction.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 42
28. Which among the following is an indication of combined liver & lung transplant?
A. Cystic fibrosis
B. Amyloidosis
C. Hyperoxalosis
D. None
A. Cystic fibrosis
Sequential bilateral single lung-liver transplantation (SBSL-LTx) is a therapeutic option for patients
with end stage lung and liver disease (ESLLD) due to cystic fibrosis (CF).
Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 25
29. A 49 year old woman, Raveena Bhat, with end stage renal failure undergoes a cadaveric renal
transplant. However, after reviewing the patient after 4 months she presented with oliguria and right
lower leg edema. What is the probable etiology?
A. Lymphocele
B. Acute rejection
C. Renal vein thrombosis
D. CNI toxicity
A. Lymphocele
Lymphocele is a fluid collection between the renal graft and the urinary bladder. It is an uncommon
complication (0.6% to 18%) following renal transplantation. The development of lymphocele has
been ascribed to inadequate ligation of the afferent lymphatics coursing over the recipient iliac vessels
or located within the allograft hilum. Many collections remain subclinical. In fact, up to 50% of
patients may show a small collection on ultrasound scanning after renal transplantation and most of
them resolve spontaneously. Large collections may present clinically by deterioration of renal graft
function or as a painless ipsilateral lower limb edema, at 2 weeks to 6 months after transplantation.
Ultrasound is the key to diagnosis, but other radiological procedures such as the isotope renal
scanning, computed tomography, intravenous urography and magnetic resonance imaging might be
necessary in complicated cases. Prevention by careful ligation of lymphatics during the dissection of
iliac vessels is better than intervention later for cure.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 82
30. The transplant team at Pittsburgh was discussing NODAT in a few patients after a series of Liver
transplants. NODAT is a complication of
A. Ciclosporin
B. Tacrolimus
C. Azathioprine
D. Rituximab
B. Tacrolimus
New Onset Diabetes After Transplant (NODAT a common and serious complication after solid organ
transplantation. NODAT is more common with Tacrolimus. It decreases the insulin release and
increases beta cell toxicity. Kidney transplant recipients who develop NODAT have variably been
reported to be at increased risk of fatal and nonfatal cardiovascular events and other adverse outcomes
including infection, reduced patient survival, graft rejection, and accelerated graft loss compared with
those who do not develop diabetes.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 82
31. Ravi Rajkumar, a famous film director was diagnosed with leukaemia. He was treated at a
renowned hemato oncology centre in Chennai. He was diagnosed with renal stones within a few
weeks of his treatment. What is the most probable stone?
A. Cysteine
B. Uric acid
C. Calcium phosphate
D. Calcium oxalate
B. Uric acid
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 76
32. A 40 year old male Raghavan Gunda presented with complaints of penile deformity and pain on
erection causing difficulty in intercourse. True regarding the management is
The man suffers from Peyronie’s disease. The cause is not clearly known - probably involves minor
injury to the erect penis with secondary microhemorrhage beneath the tunica albuginea and secondary
fibrosis resulting in classic dorsal deformity.
During the active phase (18-24 months) medical treatment has little efficacy. After the disease
stabilises, surgery is indicated to correct deformity only when it interferes with sexual intercourse.
Nesbitt procedure is the name of the surgical procedure to treat Peyronie’s disease. Injection of
collagenase is a newer modality of treatment also to be used only in chronic phase.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 79
A. Urinary catheter
B. Varicel catheter
C. Epistaxis catheter
D. None
C. Epistaxis catheter
Anterior bleeding from Kiesselbach’s plexus may be controlled by silver nitrate cautery under local
anaesthesia. Even in more posterior epistaxis, the bleeding point can often be Vaseline-impregnated
ribbon gauze or a non-absorbable sponge. There are also many haemostatic, absorbable materials that
can be used to pack the nose to help control bleeding. An alternative to anterior packing is the use of
an inflatable epistaxis balloon catheter. The catheter is passed into the nose and the distal balloon is
inflated in the nasopharynx to secure it. The proximal balloon, which is sausage shaped, is then
inflated within the nasal fossa to compress the bleeding point. Although usually effective, they can be
uncomfortable.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 46
34. 12 years after undergoing left modified radical mastectomy, a 70-year-old woman develops raised
red subcutaneous nodules over the left arm. What is the most likely diagnosis?
A. Lymphangitis
B. Lymphedema tarda
C. Lymphangiosarcoma
D. Metastatic breast cancer
C. Lymphangiosarcoma
It is a rare tumor that develops as a complication of long-standing (usually more than 10 years)
lymphedema, most frequently described in a patient who has previously undergone radical
mastectomy (Stewart-Treves syndrome). Clinically, patients present with acute worsening of the
edema and appearance of subcutaneous nodules that have a propensity toward hemorrhage and
ulceration. The tumor can be treated, as other sarcomas, with preoperative chemotherapy and radiation
followed by surgical excision, which usually takes the form of radical amputation. Overall, the tumor
has a poor prognosis.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 58
35. Superficial vein reflux is effectively demonstrated by Doppler scans. Superficial or crural vein
reflux is defined as retrograde flow in the reverse direction to physiological flow which lasts for ___
seconds or more.
A. 2
B. 1
C. 0.5
D. 0.25
C. 0.5
Superficial or crural vein reflux is defined as retrograde flow in the reverse direction to physiological
flow lasting for 0.5 seconds or more. The proximal deep veins require a duration of 1 second or more
to be classified as incompetent.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 57
A. Mirizzi syndrome
B. Porcelain gallbladder
C. Cholesterosis
D. Diverticulosis of gallbladder
C. Cholesterosis
37. An ill male infant presents with vomiting and diarrhoea. Na is 128mmol/L, K is 5.5 mmol/L,
blood glucose is 126mg/dL and cortisol is 50 nmol/L. Which of the following is false about this
condition?
A. Autosomal Recessive
B. Inadequate ACTH seen
C. Can present with short stature and hypertension.
D. 21 Hydroxylase deficiency is a common cause.
The child has congenital adrenal hyperplasia which presents with virilization and adrenal
insufficiency in children. Most commonly, it is due to a defect in 21-hydroxylase. Low cortisol leads
to excessive ACTH secretion and an increase in androgen precursors. Hypertension and short stature
are common signs. Affected patients are treated by cortisol and fludrocortisone.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 52
38. Calcification uraemic arteriolopathy (Calciphylaxis) is associated with reduction in levels of
which is named calcification inhibitory protein ?
B. α-2-Heremans–Schmid glycoprotein
The underlying aetiology of calcific uraemic arteriolopathy (Calciphylaxis) remains unclear but a
number of potential factors have been postulated. A reduction in the serum levels of a calcification
inhibitory protein, α-2-Heremans–Schmid glycoprotein, and abnormalities in smooth muscle cell
biology in uraemic patients may play a role in the development of the syndrome.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 51
Epstein–Barr virus infection is associated with a specific form of gastric adenocarcinoma, one that is
more prevalent in Hispanics and non-Hispanic whites compared to Asians, more often in the cardia
and body, and more often diffuse type. Obesity is associated with proximal gastric cancers. Cigarette
smokers have a two to three times increased risk of proximal gastric cancer. Diffuse-type tumors are
more common in younger patients with no history of gastritis and spread transmurally and by
lymphatic invasion. Diffuse-type tumors appear to be associated with obesity.
40. Dr Rajan Sivakumar, consultant paediatric surgeon has a few questions for you. He was planning
a Nuss procedure on a young boy Nuss procedure is used for the correction of
A. Cervical rib
B. Depressed sternum
C. Scapular deformity
D. Spine deformity
B. Depressed sternum
Pectus excavatum
The sternum is depressed, with a dish-shaped deformity of the anterior portions of the ribs on one or
both sides. It is never a cause of respiratory problems. It can be repaired to improve its cosmetic
appearance either as an open procedure (the Ravitch procedure) which involves resecting the affected
costal cartilages and mobilising the sternum, or as a minimally invasive technique, the Nuss
procedure. A metal bar is placed behind the sternum to hold this central panel in its new position and
has to be removed after a period of time.
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 55
Part B
A. Туре I cyst
B. Type II cyst
C. Туре III cyst
D. Type IV cyst
C. Туре III
Type III cyst is essentially a cystic dilation of the intraduodenal portion of the extrahepatic common
bile duct.
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 46
2. Which one of the following provides the high resistance watershed area between the portal and
azygos system?
A. Truncal zone
B. Palisade zone
C. Perforating zone
D. Gastric zone
B. Palisade zone
1. The gastric zone extends 2 to 3 cm below the gastroesophageal junction. These veins run
longitudinally in the submucosa and lamina propria to the short gastric and left gastric veins.
2. The palisade zone extends 2 to 3 cm superiorly from the gastric zone in the lower esophagus.
These parallel palisades run longitudinally and correspond to the esophageal mucosal folds. There are
multiple communications between these veins in the lamina propria, but there are no perforating veins
in the palisade zone linking the intrinsic and extrinsic venous plexuses.Condensing all the findings
together, it seems likely that the palisade zone acts as a watershed between the portal and the azygos
systems and the venous arrangement in this zone appears to be capable of supporting bidirectional
flow produced by physiologic changes in pressure during the respiration.
3. The perforating zone extends approximately 2 cm higher up the esophagus, just superior to
the palisade zone. In this zone the vessels perforate through the esophageal wall linking the internal
and external veins.
4. The truncal zone extends 8 to 10 cm up the esophagus and is characterized by four or five
longitudinal veins in the lamina propria. In this zone, there are irregular perforating veins from the
submucosa to the external esophageal venous plexuses.
Ref: Shackelford Surgery of the Alimentary Tract, 8th edition, Chapter 135
3. What is a known complication of papain therapy for phytobezoars?
A. Hyponatremia
B. Hypernatremia
C. Hypokalemia
D. Hyperkalemia
B. Hypernatremia
In 1959, Dan and coworkers were the first to suggest enzymatic therapy to attempt dissolution of the
bezoar. Papain, found in Adolph’s Meat Tenderizer, is given in a dose of 1 tsp in 150 to 300 mL water
several times daily. The sodium concentration in Adolph’s Meat Tenderizer is high, so hypernatremia
may result if large quantities are administered.
4. Gastric cancer patients receive 3 cycles of new-adjuvant chemotherapy and another 3 cycles of
adjuvant chemotherapy after surgery. This was based on the findings of which famous trial?
A. CLASSIC
B. CRITICS
C. ARTIST
D. MAGIC
D. MAGIC
Results of the UK Medical Research Council Adjuvant Gastric Infusional Chemotherapy (MAGIC)
trial were reported in 2006. Test group patients receive perioperative chemotherapy (preoperative
chemotherapy followed by surgery followed by additional postoperative chemotherapy). The control
group undergoes surgery alone. Both progression-free survival and overall survival were improved in
the treatment arm; 5-year survival was 36% in the treatment plus surgery group and 23% in the
surgery-only group.
5. Common molecular genetic alterations observed in esophageal & gastric cancers are all except
B. RB
RB gene mutations are not seen commonly in gastric and esophageal cancers.
Ref: DeVita, Hellman, and Rosenberg's Cancer: Principles & Practice of Oncology, 11th edition,
Chapter 51
A. Type III A
B. Type II A
C. Type II B
D. Type III B
C. Type II B
A chyle leak of more than 1 litre which resolves with TPN is type II B
Ref: Shackelford Surgery of the Alimentary Tract, 8th edition, Chapter 43
7. Which of the following situations is not a criteria for non-operative management of esophageal
perforation?
Contrast leak out of esophageal lumen is an indication for surgery. The contrast should drain into the
esophagus ideally for us to proceed with non-operative management.
Ref: Shackelford Surgery of the Alimentary Tract, 8th edition, Chapter 48
8. Based on manometric classification of achalasia cardia best results with surgery are seen in type
A. I
B. II
C. III
D. IV
B. II
Heller’s myotomy is the standard of care in achalasia cardia. There are three types of achalasia cardia
according to Chicago classification. Type II achalasia had the best response, those with type III have
the poorest response but tend to do better with myotomy as compared to pneumatic dilation, and type
I patients present with an intermediate response that worsens with increasing dilatation of the
esophagus.
● Type I achatasia (classic): Median IRP 15mm Hg: 100% failed peristalsis with DCI <100 Hg.
Premature contractions with DCI<450 Hg cm satisfy criteria for failed peristalsis
● Type II achalasia (with esophageal compression): Median IRP> 15mm Hg: 100 failed
peristalsis, panesophageal pressurization with ≥20% of swallows
● Type III achalasia (spastic achalasia): Median IROP > 15 mm Hg, no normal peristalsis,
spastic contractions with DCI > 450 mm Hg s cm with ≥20%of swallow
● Esophagogastric junction outflow obstruction (achalasia in evolution) - Median IRP > 15 mm
Hg: Sufficient evidence of peristalsis criteria for type I-III are not met.
Integrated relaxation pressure (IRP) is the mean of the 4 seconds of maximal deglutitive relaxation in
the 10-second window beginning at the upper esophageal sphincter relaxation referenced to gastric
pressure: distal contractile integral (DCI) is the amplitude X duration x length (mm Hg s cm) of the
distal esophageal contraction exceeding 20 mm Hg from the transition zone to the proximal margin of
the lower esophageal sphincter.
A. Type I Achalasia
B. Type II Achalasia
C. Type III Achalasia
D. Normal
C. Type III Achalasia
All three subtypes of achalasia are characterized by impaired esophagogastric junction (EGJ)
relaxation (integrated relaxation pressure [IRP] >15 mm Hg) and absent peristalsis. In type 1 (A),
there is negligible pressurization in the esophageal body, evident by the absence of any area
circumscribed by the 30-mm Hg isobaric contour (black line). In type 2 (B), panesophageal
pressurization occurs evident by the banding pattern of the 30-mm Hg isobaric contour spanning from
the upper esophageal sphincter to the EGJ. This represents elevated intrabolus pressure and is
associated with contraction of the longitudinal muscle on the muscularis propria. Type 3 achalasia (C)
is characterized by spastic contractions (short distal latency [DL]) in the esophageal body.
10. Which operation for duodenal ulcer is least likely to produce undesirable postoperative symptoms?
A. Subtotal gastrectomy
B. Truncal vagotomy and pyloroplasty
C. Truncal vagotomy and antrectomy
D. Highly selective vagotomy
The highly selective vagotomy has an extremely low percentage of side effects.
Ref: Shackelford Surgery of the Alimentary Tract, 8th edition, Chapter 59
A. Type I SBS
B. Type II SBS
C. Type III SBS
D. Type IV SBS
Type III patients with an end jejunostomy are the most challenging to manage because they have high
fluid output losses. Without both the ileum and the colon, they will have the greatest malabsorptive
issues as compared with the other patients. End jejunostomy patients no longer have the water
reservoir and absorptive potential of the colon but also lose ileal site-specific nutritional deficiencies.
When end jejunostomy patients have less than 100 cm of jejunum remaining, there is the added issue
of loss of gastric acid and intestinal secretions, resulting in a chronic net-secretory state of high fluid
output. The type III patients with less than 100 cm of jejunum typically will need permanent PN/IV
support.
Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 79
A. Lysozyme
B. Mucus
C. Neurotensin
D. Enteroglucagon
A. Lysozyme
Paneth cells remain in the crypt bases, where they protect intestinal stem cells from damage by
releasing signaling molecules that affect the host tissues and influence the microbial populations to
maintain homeostasis in the intestine. Paneth cells secrete lysozyme, tumor necrosis factor (TNF), and
the cryptdins, which are homologues of leukocyte defensins thought to be related to the host mucosal
defense system; and enteroendocrine cells, of which there are more than 15 distinct populations that
produce the gastrointestinal hormones.
13. In acute mesenteric ischemia, total loss of villi in the small intestine occurs in which time frame?
A. 2 hours
B. 1 hour
C. 4 hours
D. 6 hour
A. 2 hours
A. Bleeding
B. Obstruction
C. Perforation
D. Diverticulitis
D. Diverticulitis
Although jejunoileal diverticula are the least common small bowel diverticula, they are the most
likely to be symptomatic as a result of complications that include diverticulitis with or without
perforation, hemorrhage, and obstruction.
Diverticulitis is the most common presentation, accounting for up to 55% of complications. Clinically,
patients have localized or diffuse abdominal pain, fever, and leukocytosis. Imaging may reveal an
inflammatory mass, abscess, fat stranding, or air within the mesentery. Most perforations will
be walled off by the surrounding mesentery or small bowel. The presentation and imaging may be
suspicious for perforated colonic diverticulitis or appendicitis depending on the location of the abscess.
The mortality rate for perforated diverticulitis can reach 50% due to the difficulty, and
subsequent delay, in diagnosis.
15. Which of the following genes involved in Crohn’s disease is associated with progression to
malignancy?
A. FHIT
B. NLAG
C. ATG16L1
D. CARD15/NOD2
A. FHIT
The FHIT gene located on 3p14.2 has been identified as a tumor suppressor gene and is suggested to
play a role in the pathogenesis of Crohn’s disease as well as in the development and progression of
Crohn’s disease–related cancers.
Long-standing Crohn’s disease predisposes to cancer of the small intestine and colon. These
carcinomas typically arise at sites of chronic disease and more commonly occur in the ileum.
Most are not detected until the advanced stages, and prognosis is poor. Although this relative risk for
small bowel cancer in Crohn’s disease is approximately 100-fold, the absolute risk is still small. Of
greater concern is the development of colorectal cancer in patients with colonic involvement and a
long duration of disease.
Dysplasia is the putative precursor lesion for Crohn’s disease–associated cancer. Patients with long-
standing Crohn’s disease should have an equally aggressive colonoscopic surveillance regimen as
patients with extensive ulcerative colitis. Small bowel adenocarcinoma associated with Crohn’s
disease has an aggressive behavior and a strong predominance of extracellular mucin. In surgical
specimens from patients with Crohn’s disease, mucinous-appearing anal fistulas and ileal areas of
adhesion/retraction should always be closely examined by a pathologist to evaluate for dysplasia or
malignancy.
A. Thiamine
B. Pyridoxine
C. Cobalamin
D. Nicotinic acid
D. Nicotinic acid
A. Carcinoid
B. Adenocarcinoma
C. Mucinous tumours
D. Secondary Metastases
A. Carcinoid
Carcinoid tumors are the most common tumor primary identified in the appendix. Adenocarcinoma of
the appendix is rare and occurs at a frequency of 0.08% to 0.1% of all appendectomies. Mucinous
tumors of the appendix are appendiceal tumors that are not frankly malignant but, if ruptured, can
result in intraperitoneal spread and the development of pseudomyxoma peritonei (PMP).
Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 50.
18. With appendicitis during pregnancy, the factor most strongly associated with fetal mortality is:
D. Appendiceal rupture
A recent large study was conducted comparing appendicitis in more than 3000 pregnant women with
more than 94,000 nonpregnant women. The study found that the rate of negative appendectomy was
higher in pregnant women compared with nonpregnant women (23% vs 18%). Rates of fetal loss and
early delivery were considerably higher in women with complex appendicitis (6% and 11%,
respectively) compared with negative (4% and 10%, respectively) and simple (2% and 4%,
respectively) appendicitis.
Complex appendicitis and a negative appendectomy remained risks for fetal loss on multivariate
analysis. Interestingly, laparoscopy was associated with a higher rate of fetal loss compared with open
appendectomy (odds ratio of 2.31). Ultrasonography has been extremely useful in helping diagnose
appendicitis. If findings are equivocal, magnetic resonance imaging (MRI) should be performed. One
must strive to avoid unnecessary appendectomies that place the fetus at risk; however, delays in
operative care for appendicitis likewise place the fetus at risk.
Ref: Aras, Abbas, Karaman, Erbil, Pekşen, Çağhan, Kızıltan, Remzi, & Kotan, Mehmet Çetin.
(2016). The diagnosis of acute appendicitis in pregnant versus non-pregnant women: A
comparative study. Revista da Associação Médica Brasileira, 62(7), 622-627.
https://doi.org/10.1590/1806-9282.62.07.622
Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 50.
19. What is the emergency surgical procedure that can be adopted in a case of malnourished patient
with fulminant ulcerative colitis who is on steroids
A. End ileostomy
B. Subtotal colectomy and end ileostomy
C. Proctocolectomy and end ileostomy
D. Subtotal colectomy and ileoanal anastomosis
B. Subtotal colectomy and end ileostomy
Although a restorative proctocolectomy with IPAA as a single stage procedure has been reported
for toxic megacolon, proctectomy and anastomosis are generally ill-advised in the acutely ill patient
within an unprepared bowel. Total proctocolectomy in the urgent setting carries a prohibitively high
mortality rate and the leak rate of primary anastomosis is unacceptably high. Total abdominal
colectomy with ileostomy and preservation of the rectum is therefore the preferred operation for this
condition. This procedure can be expeditiously performed with relatively low morbidity and mortality,
and it serves the main purpose of removing the diseased colon and avoiding a difficult and morbid
pelvic dissection.
B. Sufficient length of well-vascularized ileum is brought through the abdominal wall to create a
spigot.
In forming an ileostomy, the ileum is brought through the abdominal wall at a site selected before the
operation to ensure that the location is ideal for maintaining the seal of an appliance. A disc of skin is
excised, the dissection is carried longitudinally through the center of the rectus muscle, and the
posterior fascia is divided. The abdominal wall aperture should be approximately 2.5 cm in diameter.
Sufficient length of well-vascularized ileum is brought through the abdominal wall to permit creation
of a spigot that will protrude well above skin level (Brooke configuration), allowing the ileal contents
to pour into an appliance sealed to the adjacent skin.
The ileostomy is completed by approximating the full thickness of the divided wall of the ileum to the
subcuticular tissue of the abdominal skin of the stoma site, placing sutures in so as to maintain the
everted configuration of the stoma. By use of these same principles, a loop ileostomy may be
fashioned. The loop ileostomy can be fashioned over an ileostomy rod, but a rod is not necessary to
maintain the configuration of the stoma. If an ileostomy rod is used, it can be removed on the fifth
postoperative day.
Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 51
21. Pelvic splanchnic nerves primarily carry ____________ to the _____________ plexus.
Splanchnic nerves carry sympathetic fibers, the pelvic splanchnic nerves transmit preganglionic
parasympathetic fibers from S2, 3, and 4. These fibers are carried to the inferior hypogastric plexus.
The parasympathetic fibers from the inferior hypogastric plexus supply the smooth muscle of the
pelvic viscera, while the sympathetic fibers from the inferior hypogastric plexus supply vascular
smooth muscle of vessels supplying the pelvic viscera. The superior hypogastric plexus is a
continuation of the intermesenteric plexus, it contributes sympathetic fibers to the inferior hypogastric
plexus through hypogastric nerves.
Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 143
A. Decompression
B. Endoscopic detorsion
C. Right colectomy
D. Hartmann procedure
C. Right colectomy
Although there have been reports of endoscopic detorsion of cecal volvulus, the success rate is
significantly lower than in sigmoid volvulus, and the procedure is associated with the risks of
increasing distention because of insufflation of air during the procedure. Surgical intervention is
therefore warranted in almost all cases of cecocolic volvulus. Right colectomy is the procedure of
choice. Primary anastomosis is usually preferred unless the volvulus has resulted in frankly
gangrenous bowel, in which case resection of the gangrenous bowel with ileostomy is a safer
approach.
23. Which of the following pouches used for surgery in ulcerative colitis has the maximum capacity?
A. J pouch
B. W pouch
C. U pouch
D. S pouch
B. W pouch
The four-limbed W pouch was introduced in 1985 by Nicholls and Pezim in an effort to address the
outflow complications seen in the S pouch and improve the functional result of the J pouch. The W
pouch is created from four 12-cm lengths of ileum in a W configuration. The apex of the pouch is the
site of the IPAA so there is no efferent limb with this pouch configuration. The four-limbed
construction makes this a capacious and bulky pouch that offers increased reservoir akin to the native
rectal ampulla. However, the size and bulk can be problematic within the confines of a narrow pelvis.
In a narrow pelvis, design of the reservoir may be modified such that the distal two limbs are each 11
to 12 cm in length and the more proximal two limbs are 9 to 10 cm long, effectively making the
reservoir out of two J pouches that are offset from one another.
Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 162
24. Which genetic mutation of the adenoma-carcinoma sequence leads to development of carcinoma
from late adenoma?
A. APC
B. KRAS
C. DCC
D. p53
D. p53
Loss of 17p chromosome coding for p53 leads to malignant transformation of a late adenoma to
carcinoma.
Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 51
25. While investigating rectal bleeding in 67 year old Ali Samad, multiple adenomatous polyps were
found and hence polypectomy done. On histological analysis, carcinoma was found to invade into the
submucosa but was limited to the head of the polyp. What is Haggitt’s classification for this?
A. Level 0
B. Level 1
C. Level 2
D. Level 3
B. Level 1
Haggitt and colleagues have proposed a classification for polyps containing cancer according to the
depth of invasion, as follows:
● Level 0: Carcinoma does not invade the muscularis mucosae (carcinoma in situ or
intramucosal carcinoma)
● Level 1: Carcinoma invades through the muscularis mucosae into the submucosa but is
limited to the head of the polyp
● Level 2: Carcinoma invades the level of the neck of the polyp (junction between the head and
stalk)
● Level 3: Carcinoma invades any part of the stalk
● Level 4: Carcinoma invades into the submucosa of the bowel wall below the stalk of the
polyp but above the muscularis propria
Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 51
A. 40 – 80 mmHg
B. 80 – 160 mmHg
C. 20 – 40 mmHg
D. <20 mmHg
A. 40 – 80 mmHg
Normal resting pressure is 40 – 80 mmHg contributed 85% by Internal sphincter and 15% by External
sphincter. Normal squeeze pressure is 80 – 160 mmHg contributed 100% by External sphincter. Anal
manometry is measure with water filled balloons which measure strength, tone and function
27. Which of the following statements is true about solitary rectal ulcers?
Solitary rectal ulcers are most commonly found in the anterior aspect of rectum. They are seen in
young women with a mean age of 25 years. The ulcer often forms a lead point for intussusception. It
is located 4 – 12 cm from the anal verge at the level of puborectalis sling. Local excision is never
done. Avoiding constipation, local mesalamine and pelvic floor biofeedback are the mainstay of
treatment. Rectopexy is done when there is a full thickness prolapse. Delorme’s procedure is done
when there is an internal/mucosal prolapse.
Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 51
Non Occlusive mesenteric Ischemia (NOMI) is due to contraction of otherwise normal vessel lumen.
There is usually no disease process present. It is commonly seen in vasopressor administration
especially in critically ill patients in ICU. Impairment of flow can result in ischemia and thrombosis.
It is also seen in marathon runners. Papaverine given into SMA via a catheter is often given till
symptoms improve.
Lynch syndrome (also called hereditary nonpolyposis colon cancer or HNPCC) is the most
frequently occurring hereditary colorectal cancer syndrome in the United States and western Europe.
HNPCC families fulfilling Amsterdam Criteria I led to the discovery of the first two human MMR
genes— hMSH2 and hMLH1. These genes accounted for 45–86% of all classic HNPCC
families.There also was a higher risk for hMSH2 mutation carriers to develop extracolonic cancers, in
particular endometrial cancer, as compared with hMLH1 mutation carriers.
The lifetime risk of developing colorectal cancer in Lynch syndrome is 80 percent, and the mean
age of diagnosis is 45 years. Most cancers develop in the proximal colon. Autosomal dominant
inheritance. Specific genes that have been shown to be responsible for syndrome include HMSH2
(located on chromosome 2p21), hMLHI (3p21), hMSH6 (2p16-21), and HPMS2 (7p21). Mutations in
MSH2 or MLHI account for more than 90% of identifiable mutations in patients with Lynch
syndrome.
Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 51
A. USG
B. ERCP
C. CECT
D. Cholangiography
B. ERCP
Bilhemia is an extremely rare condition in which bile flows into the bloodstream through the hepatic
veins or portal vein branches. This flow occurs in the context of a high intrabiliary pressure exceeding
that of the venous system. The cause can be gallstones eroding into the portal vein or accidental or
iatrogenic trauma. The condition can be fatal secondary to embolization of large amounts of bile into
the lungs. Usually, however, bile flow is low, and the fistulas close spontaneously. The clinical
presentation is that of rapidly increasing jaundice, marked direct hyperbilirubinemia without elevation
of hepatocellular enzyme levels (e.g., AST, ALT), and septicemia. This diagnosis is best determined
by ERCP. Treatment is directed at lowering intrabiliary pressures through stents or sphincterotomy.
A. Secondary cholangitis
B. Papillary bile duct cancer
C. Parasitic infection
D. PSC
B. Papillary bile duct cancer
Papillary tumors make up only 10% of cholangiocarcinoma and are more common in the
distal bile duct. These fleshy polypoid tumors expand the lumen of the duct and have less risk
of an invasive component.
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter
20
A. Watson
B. Dor
C. Toupet
D. Belsey Mark IV
C. Toupet
Nissen and Toupet are posterior fundoplication techniques. Dor, Watson and Belsey Mark 1V are
anterior fundoplication techniques.
In the field of antireflux surgery, there has been a long-standing debate about which fundoplication
provides superior control of GERD symptoms while mitigating postoperative side effects (e.g:
dysphagia and gas-bloat). The Nissen fundoplication, first described in the 1950s, has become a
standard in antireflux surgery. The fat pad is then mobilized from the anterior stomach or esophagus
to visualize the true EGI and to be able to exclude both vagus nerves from the wrap. Toupet
fundoplication involves posterior partial wrap of 180 to 270 degrees, with additional tacking sutures
to fix the stomach to the crura in the abdomen. Dor fundoplication is most commonly used in the
setting of esophageal myotomy but consists of an anterior 180-degree wrap.
33. Which of the following mutations foretells poor prognosis in cases of cholangiocarcinoma?
A. K-RAS
B. N-RAS
C. p53
D. Wnt
A. K-RAS
Poor overall survival and early recurrence in cholangiocarcinoma were characterized by the presence
of K-ras mutations and multiple aberrations in cellularregulation, including activated human
epidermal growth factor receptor 2 (HER2) and epidermal growth factor receptor (EGFR) signaling.
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 51A
34. Which of the following statements is false regarding Sphincter of Oddi dysfunction?
Sphincter of Oddi dysfunction manifests as biliary tract pain, with normal liver function test results
and recurrent pancreatitis, may be caused by a structurally abnormal sphincter or a histologically
normal but functionally abnormal one. The theoretical pathophysiologic event occurs with injury to
the sphincter from trauma from various etiological causes. Alternatively, patients may have elevated
sphincter pressure in the absence of fibrosis, suggesting a spasm of the muscular component. This
subset of patients may have evidence of altered motility elsewhere in the gastrointestinal tract.
Manometry has also been used to make the diagnosis, with sphincter pressure higher than 40 mm Hg
predicting good response to therapy.
35. Identify the true statement about primary sclerosing cholangitis (PSC) in association with chronic
ulcerative colitis (CUC).
PSC develops in approximately 25% of patients without evidence of IBD. Invasive screening
of asymptomatic patients with PSC reveals that many have no endoscopic or histologic
evidence of IBD.
Lack of association between the severity of colonic disease and the likelihood of development
and severity of PSC strengthens the skepticism that CUC may not directly cause PSC. Failure
of proctocolectomy to modify the natural history of PSC argues against a direct causative role
of CUC in PSC. Clinical trial of PSC patients with pentoxifylline, a TNF inhibitor, no
beneficial effect on symptoms or liver tests was seen.
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 41
36. A Patient with IBD was diagnosed with PSC. Liver biopsy done shows bridging necrosis.
According to Ludwig staging he falls under
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
C. Stage III
Septal fibrosis and bridging necrosis are characteristic of Ludwig stage III PSC.
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 41
37. Dr Rajan Palaniappan is taking a class for you on obesity. False statement about obesity is
● MC4R deficiency gene (melanocortin 4 receptor), is associated with obesity, increased fat
mass, and insulin resistance.
● Bacteria within the gut, known as the microbiome, play an essential role in the metabolism
and immune system. Simply giving low-dose penicillin (LDP) to newborn mice for 4 weeks
increases obesity when the mice are later fed a high-fat diet.
● Ghrelin, the only known orexigenic gut hormone, is also known as the hunger hormone and is
secreted by P/D1 cells of the gastric fundus.
● Ghrelin stimulates release of various neuropeptides, such as neuropeptide Y and growth
hormone, from the hypothalamus, which creates an orexigenic or increased appetite state
● Increased levels of ghrelin produce increased food intake, and increased levels develop in
individuals after low-calorie diets, thus suggesting that one possible mechanism for the failure
of most diets after 6 months is the increase in the appetite hormone ghrelin.
A. SADI
B. MGB
C. EndoCinch
D. Roux-en-Y gastric bypass
B. MGB
Mini gastric bypass (MGB) consists of creation of a long vertical gastric pouch along lesser curvature
followed by a Billroth II loop. It was first described by Dr Robert Rutledge and is a modification of
RYGB with a single anastomosis. It is a technically less remanding operation that can be reversed
easily. The highly effective weight loss and good co-morbidity resolution has made MGB an
attractive option for many surgeons. There is however a higher incidence of anaemia and diarrhoea
due to a longer biliopancreatic limb.
A. Wall thickening
B. Mass replacing gallbladder
C. Intraluminal polypoid mass
D. Distended GB with thickening in the neck
CT findings in CA Gallbladder
● Mass replacing the gallbladder (seen in 40% to 65% of patients),
● Focal or diffuse gallbladder wall thickening (seen in 20% to 30%) and
● An intraluminal polypoid mass (seen in 15% to 25%)
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 18
40. Of the following therapeutic options, which one would be more effective for a patient with
cirrhosis with refractory ascites not responding to dietary restrictions and high dose diuretics?
A. Somatostatin infusion
B. Transjugular intrahepatic portosystemic shunt
C. Large volume paracentesis
D. Peritoneovenous shunt
A. CECT
B. MRI
C. EUS
D. Angiography
D. Angiography
Hepatic angiography is also rarely used for diagnosis of hemangioma; yet it can be helpful in selected
cases in which definitive diagnosis cannot be established by noninvasive imaging modalities. Classic
angiographic features include the characteristic “cotton wool” appearance that circumscribes a large
feeding vessel with displacement and diffuse pooling of intravenous contrast material.
Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 131
42. Understanding the anatomy of the Makuuchi ligament is crucial to the consummate liver surgeon
who wishes to excel in liver transplant. Makuuchi ligament courses between
Ref: Morjane A, Dahmane R, Ravnik D, Hribernik M. Anatomy and surgical relevance of the
hepatocaval ligament. A study on cadaveric livers. Cells Tissues Organs. 2008;187(3):243-246.
doi:10.1159/000110083
43. The Peritoneal Cancer index was invented by Prof Sugarbaker in the United states. What is true
regarding PCI?
Preoperative PCI scores established through gadolinium-enhanced MRI correlate better with PCI
scores established through surgery than do preoperative PCI scores established through CT and that
gadolinium-enhanced MRI offers notable improvements in the detection of small bowel nodules.
However CT is most commonly used all over the world.
The PCI, a scoring system created by Sugarbaker, documents the volume and distribution of
mucinous implants throughout the abdomen as determined at the time of operative exploration. After
lysis of adhesions and inspection of the entire parietal and visceral peritoneum, the abdomen is
divided into 13 regions (0-12). PCI score has a clear correlation with outcomes and mortality. Patients
with high PCI scores are excluded from cytoreductive surgery due to poor outcomes.
A. Cholangiocarcinoma
B. Too short survival after transplantation
C. Unacceptable postoperative quality of life
D. Active alcoholism
A. Cholangiocarcinoma
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 112
A. Segment 2
B. Segment 8
C. Segment 5
D. Segment 4
D. Segment 4
An awareness of the common locations of focal fat deposition and focal sparing from
steatosis is important, so as not to mistake these for tumors. Common locations for focal fat
deposition include segment IV adjacent to the falciform ligament (Ohashi et al, 1995; Paulson
et al, 1993) and around the gallbladder (Yoshimitsu et al, 1997). A common location for focal
fatty sparing is in the posterior aspect of segment IV (Matsui et al, 1995; White et al, 1987)
or along the gallbladder fossa. It has been suggested that areas of focal fatty sparing are due
to aberrant venous drainage to the liver because these areas do not receive portal venous flow
from the main portal trunk.
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 18
A. PDX 1
B. Notch signaling pathway
C. Hedgehog pathway
D. Wnt signaling pathway
A. PDX1
The initiation of pancreas bud formation and differentiation of the ventral bud from the
hepatic-biliary fates is dependent on the expression of pancreatic duodenal homeobox 1 (PDX1)
protein and pancreas-specific transcription factor 1 (PTF1). In the absence of PDX1 expression
in mice, pancreatic agenesis occurs, indicating its importance in the early phases of
organogenesis.
Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 55
47. All are prognostic factors in patients undergoing resection of colorectal liver metastasis except
A. Stage of primary
B. Time from primary resection
C. Location of metastasis
D. Number of metastasis
C. Location of metastasis
Memorial Sloan-Kettering Cancer Centre (MSKCC) has developed a criteria which encompasses five
pre-operative factors to assess prognosis after liver resection for colorectal metastasis. Location of
metastasis doesn’t play a role. The five factors are
Male are more commonly affected by autoimmune pancreatitis. Autoimmune pancreatitis is a chronic
inflammatory disorder that involves the pancreas. At least two different histologic variants have been
defined. Type 1 is the most common; it is characterized by dense, periductal lymphoplasmacytic
infiltrates, storiform fibrosis, and obliterative venulitis. Plasmatic cells typically stain positive for
immunoglobulin G4. In type 2, the pancreas is infiltrated by neutrophils, lymphocytes, and plasma
cells that destroy and obliterate the epithelium in the pancreatic duct.
Autoimmune pancreatitis is more common in men than in women. Up to 80% of patients are older
than 50 years. Patients with autoimmune pancreatitis can develop acute symptoms such as jaundice or
AP, closely mimicking patients with pancreatic adenocarcinoma. However, most patients with chronic
pancreatitis develop chronic abdominal discomfort associated with abnormal elevation of amylase and
lipase levels.
A. Insulinoma
B. VIPoma
C. Glucagonoma
D. Somatostatinoma
C. Glucagonoma
Classic presentation of the “4 D’s”: diabetes, dermatitis, deep vein thrombosis, and depression is
characteristic of glucagonoma. It is also characterized by a severe catabolic state with weight
loss, depletion of fat and protein stores, and associated vitamin deficiencies.
The characteristic skin lesion, a necrolytic migrating erythema, is noted in approximately two thirds
of patients and often appears before other symptoms of the syndrome. The cause is believed to be
severe amino acid deficiency, although trace element deficiency and general malnutrition probably
contribute. Parenteral administration of amino acids was found to result in the disappearance of skin
lesions.
Diabetes develops in 76 % to 94% of patients with glucagonoma at some point during their illness but
it is usually mild.
Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 38
50.Somatostatin receptor scintigraphy is a useful localizing tool in all of the following except
A. Gastrinoma
B. Somatostatinoma
C. Insulinoma
D. Glucagonoma
C. Insulinoma
51. A 52-year-old male Subramanian Nathan, known to be alcoholic, is evaluated because of chronic
abdominal pain. The clinical diagnosis of chronic pancreatitis is supported by ERCP findings of
pancreatic ductal ectasia with alternating areas of stricture and dilatation. Several pancreatic ductal
stones are also noted. With chronic pain as the operative indication, the most appropriate procedure
would be:
B. Longitudinal pancreaticojejunostomy
Some patients present with not only large-duct disease but also significant inflammatory disease
within the head of the pancreas, and Puestow-type lateral pancreaticojejunostomy may be insufficient
to address potential sources of pain within the pancreatic head. Frey introduced a procedure that
combines duodenum-sparing resection of the pancreatic head, without formal division of the neck
of the pancreas, combined with longitudinal pancreaticojejunostomy of the dorsal duct. The Frey
procedure appears to be an acceptable surgical alternative to achieve durable long-term pain relief and
decrease opiate dependence in selected patients. In several series, relief of pain and weight gain were
achieved in more than 75% of cases after the Frey procedure.
52. In a patient with a mucinous cystic neoplasm of pancreas with ovarian stroma, which of the
following markers would not be positive?
A. ER
B. PR
C. Alpha inhibin
D. Her2 Neu
D. Her 2 Neu
MCNs contain mucin-producing epithelium and are identified histologically by the presence of
mucin-rich cells and ovarian-like stroma. Staining for estrogen and progesterone is positive in most
cases. Most cases are positive for alpha inhibin as well. Ovarian stroma is usually seen only in
females.
Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 98
A. 4
B. 5
C. 7
D. 11
C. 7
Pancreatic enzymes are inactivated at a low pH; therefore, pancreatic bicarbonate provides an optimal
pH for acinar cell enzyme function.
A. Better visualisation
B. Less chance of bleeding
C. Easier way to evacuate clots postoperatively
D. Opens up the costophrenic angle.
Right lateral decubitus position of the patient for laparoscopic splenectomy. The table is angulated,
giving forced lateral flexion of the patient to open the costophrenic space.
Efficacy of HIPEC is influenced by molecular size, affinity to lipids, first-pass clearance from the
plasma by the liver and the permeability of the peritoneal-plasma barrier. The estimated penetration
depth of intraperitoneal chemotherapy is only 3 to 5 mm maximum. HIPEC at the time of surgical
resection may double the rate of anastomotic leakage and increases the risk of bone marrow
suppression, intra-abdominal abscess, and fever. Hyperthermia (41° to 42°C) has direct cytotoxic
effects and a synergistic effect with chemotherapy.
A. Ib
B. IIa
C. IIb
D. IIc
C. IIb
The risk of bleeding is high in Grade I and IIa. It is intermediate in grade IIb. It is low in grade IIc and
III.
Ref: Sabiston textbook of Surgery, 20th edition, Chapter 46
57. After a fall, 57 year old Jaya Rajagopalan presents to the OPD with localised mid abdominal pain.
On examination a right palpable mass is seen not crossing the midline. It is palpable even on
contraction of the rectus muscle. What is this sign called?
A. Kehr sign
B. Mannkopf sign
C. Ransohoff sign
D. Fothergill sign
D. Fothergill sign
An abdominal wall mass that does not cross midline and remains palpable when the rectus is
contracted is indicative of rectus sheath hematoma and is called Fothergill sign.
● Kehr sign - Left shoulder pain when supine and pressure placed on the left upper abdomen
(seen in hemoperitoneum).
● Mannkopf sign - Increased pulse when painful abdomen is palpated
● Ransohoff sign- Yellow discoloration of umbilical region (seen in ruptured CBD)
58. Diagnostic dilemmas never cease in surgery. What would be the best option of treatment in a 85
year old male Rajeev Sitaram Sharma who has been diagnosed with stage III resectable squamous cell
carcinoma esophagus of proximal esophagus. He was sent for new-adjuvant chemoradiotherapy. The
response was complete. How would you proceed?
A. Definitive chemoradiotherapy
B. Surgery
C. Surgery followed by neoadjuvant chemoradiation
D. Local resection
A. Definitive chemoradiotherapy
There is little debate that locally advanced adenocarcinoma, stage IIb and III diseases, should be
treated with concurrent neoadjuvant chemoradiation followed by restaging and consideration for
surgical resection. Squamous cancers are increasingly being treated with definitive chemotherapy and
radiation, especially those located in the cervical and very proximal esophagus.
Treatment for SCCA tumors located in the mid- distal esophagus is often individualized. Two
European trials (Bedenne, 2007; Stahl, 2005) have shown statistical survival equipoise in groups
treated with definitive chemoradiation versus chemoradiation plus surgery if they responded to
therapy. However, both of these trials suffered from excessive mortality in the surgical arm, and DFS
was significantly favored in the surgical arm of one trial. Nonetheless, in patients with SCCA of the
esophagus who have had a clinical complete response to therapy there are advocates for observation
rather than surgical resection; a decision our group bases on individual cases. Nonresponding patients
and those with tumours behind the airway should be considered for resection, based on presence of
disease and high-risk recurrence areas.
In this patient, considering the proximal location of the tumour, complete response to chemoradiation
and the advanced age of the patient - definitive chemoradiotherapy seems to be a better option than
surgery. Adenocarcinomas are poor responders to radiotherapy and surgery is preferred in EAC.
Ref: Shackelford Surgery of the Alimentary Tract, 8th edition, Chapter 38
59.Which of the following do you think is a clinically useful biomarker in diagnosing radiation
enteritis?
A. Plasma arginine
B. Plasma citrulline
C. Plasma succinate
D. Plasma oxalate
B. Plasma citrulline
Plasma citrulline, an end product of enterocyte glutamine metabolism, is a marker that has been
studied in a variety of conditions affecting the small bowel, rejection following small bowel transplant,
celiac disease, and viral enteritis. Plasma citrulline in patients receiving myeloablative therapy for
hematologic malignancies demonstrated that the marker correlated with mucosal damage and
recovery
60. In the modern era, what is the most common cause of hepatic artery aneurysms?
A. Drug abuse
B. Intervention and trauma
C. Transplantation
D. Idiopathic
Historically, infection was the most common etiology for hepatic artery aneurysms, classically after
intravenous drug abuse or intraabdominal infection. Now, this represents a much less common cause,
between 4% and 10% hepatic arteries. The majority are now either degenerative or associated with
trauma or interventional biliary and hepatic procedures. Some reports now estimate pseudoaneurysms
to approach nearly 50% of all hepatic artery aneurysms. Aneurysms associated with liver
transplantation now make up an increasing proportion of hepatic artery aneurysms, 17% in some
reports.