NEET-SS GI Surgery

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presents

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

2. Which of the following is true regarding shock?

A.Metabolic acidosis, respiratory acidosis


B.Metabolic alkalosis, respiratory acidosis
C.Metabolic acidosis, respiratory alkalosis
D.Metabolic alkalosis, respiratory alkalosis

C. Metabolic acidosis, respiratory alkalosis

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

STAGING - PRESSURE SORES


Stage 1: Non-blanchable erythema without a breach in the epidermis
Stage 2: Partial-thickness skin loss involving the epidermis and dermis
Stage 3: Full-thickness skin loss extending into the subcutaneous tissue but not through underlying
fascia
Stage 4: Full-thickness skin loss through fascia with extensive tissue destruction, maybe involving
muscle, bone, tendon or joint.

Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 3

4. Dr Prakash Natarajan is working on induced pluripotent stem cells(iPSCs) in a lab at Cambridge


University. He is posing some questions for you. Which statement is not true?

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

5. Not true regarding non-surgical management of Mycetoma is

A. Actinomycetoma is treated with Amikacin and Co-Trimoxazole


B. Eumycetoma is managed with Ketoconazole
C. Adequate surgery will eliminate the need for continuing medical treatment
D. Antifungals are not curative of mycetoma but are nonetheless used

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)

● Monofilament polyester polymer


● Tensile strength: 70% at 2 weeks, 50% at 4 weeks and 14% at 8 weeks
● Absorption: Completely absorbed in 180 days
● Ideally used in abdominal closure or where absorbable sutures are needed for a longer time.

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?

A. Post diagnostic tumours are most susceptible to antiproliferative drugs


B. Norton-Simon hypothesis is supported by this patten
C. A period of rapid growth is followed by a quick decline
D. Systemic spread of a cancer begins late, often after diagnosis

B. Norton-Simon hypothesis is supported by this patten

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

9. Rejecting a null hypothesis when it is true is called as:

A. Type 1 error
B. Type 2 error
C. Type 3 error
D. Type 4 error

A. Type 1 error

Null hypothesis - Statement opposite to hypothesis.


Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 11

10. With regards to the WHO surgical safety checklist, sign in is done

A. Before skin incision


B. Before induction of anaesthesia
C. Before patient leaves operating room
D. When patient enters operating room

B. Before induction of anaesthesia

Sign in - Before Induction of anaesthesia


Time out - Before skin incision
Sign out – Before patient leaves operating room
Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 13

11. Narrow band imaging (NBI) is useful in visualising various fine structures during endoscopy.
Which of the following is false?

A. Blue light at 415 nm displays superficial capillary networks


B. Green light at 540 nm displays sub epithelial vessels
C. Indigo carmine is a stain used to enhance diagnostic yield in NBI
D. NBI offers high contrast image of tissue surface

C. Indigo carmine is a stain used to enhance diagnostic yield in NBI

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

Remember World War 2 = WW2. Water appears white in the T2 phase.


The image characteristic and signal intensity from different tissues are governed by the pulse
sequence employed and whether it is T1-weighted or T2-weighted. For instance, fat, methaemoglobin
and mucinous fluid are bright on T1-weighted images, whereas, water and thus most pathological
processes, which tend to increase tissue water content, are bright on T2-weighted images. Cortical
bone, air, hemosiderin and ferromagnetic materials are of very low signal on all pulse sequences. In
general, T1-weighted images are superior in the delineation of anatomy, while T2-weighted images
tend to highlight pathology better.

Ref: Bailey & Love's Short


Practice of Surgery, 27th
Edition, Chapter 14
13. Which of the following special stain and tissue combinations is incorrect?

A. Reticulin: iron
B. Van Gieson: collagen
C. Congo red: amyloid
D. Ziehl-Neelsen: mycobacteria

A. Reticulin: iron

Common special stains


● PAS: glycogen, fungi
● D-PAS: mucin
● Perls’ Prussian blue: iron
● Reticulin: reticulin fibres, fibrosis
● Van Gieson: collagen
● Congo red: amyloid
● Ziehl-Neelsen: mycobacteria

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

15. Which of the following is a non-depolarizing muscle relaxant?

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

C. Loss of adaptive ketogenesis

Metabolic changes in starvation are often similar to changes in trauma and sepsis. Adaptive
ketogenesis doesn’t however occur in trauma and sepsis

Metabolic response to trauma and sepsis


o Increased counter-regulatory hormones: adrenaline, noradrenaline, cortisol, glucagon
and growth hormone
o Increased energy requirements (up to 40 kcal/kg per day)
o Increased nitrogen requirements
o Insulin resistance and glucose intolerance
o Preferential oxidation of lipids
o Increased gluconeogenesis and protein catabolism
o Loss of adaptive ketogenesis
o Fluid retention with associated hypoalbuminemia

Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 19

18. Which of the following is not true about flail chest?

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

C. Best treatment is with mechanical ventilation to splint the ribs

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


19. Which of the following is a principle of Damage Control Resuscitation (DCR) ?

A. Should be initiated after DCS


B. Use of crystalloid with haemostatic resuscitation
C. Permissive hypotension
D. Both A & C

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?

A. Useful only when given within 24 hrs of injury


B. Given in all trauma patients with systolic BP <110 mm Hg
C. Tranexamic acid reduces mortality after trauma
D. Useful in both blunt and penetrating trauma

A. Useful only when given within 24 hrs of injury

It is useful only when given within 3 hours of injury.


Tranexamic acid is an antifibrinolytic drug that reduces the risk of mortality from bleeding in both
blunt and penetrating trauma. One gram is given intravenously over 10 minutes, followed by a further
1g dose over 8 hours. Tranexamic acid should be given to all trauma patients suspected to have
significant haemorrhage, including those with a systolic blood pressure of <110 mmHg or a pulse of
over 110 per minute.

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

A Glasgow outcome score of 4 signifies moderate disability.


Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 24

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

B. Congenital diaphragmatic hernia

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 66

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 66


25. Which of the following statements is not true about Purpura fulminans?

A. Neonatal form is the most common


B. Protein C deficiency is seen
C. Hard eschars are formed
D. Causes hemorrhagic infarctions

A. Neonatal form is the most common

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?

A. 0.5 x TBSA x weight of patient


B. 5.6 x TBSA x weight of patient
C. 3 x {TBSA of 2nd degree burn/2 + TBSA of 3rd degree burn} x weight of patient
D. O.25 x {TBSA of 2nd and 3rd degree burn} x weight of patient
A. 0.5 x TBSA x weight of patient

The most common colloid-based formula is the Muir and Barclay formula:

● 0.5 × percentage body surface area burnt × weight = one portion


● periods of 4/4/4, 6/6 and 12 hours, respectively
● one portion to be given in each period

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

27. Which of the following statements regarding grafts are true?

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

Uric acid (10% of all stones)

● Uric acid is a product of purine metabolism


● May precipitate when urinary pH low
● May be caused by diseases with extensive tissue breakdown e.g. malignancy as in leukemia
● More common in children with inborn errors of metabolism
● Radiolucent stone

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

A. Immediate Nesbitt procedure to correct deformity.


B. Wait for 18-24 months for stabilisation of disease
C. Sildenafil causes pain in acute phase
D. Injection of collagenase can prevent disease from getting into chronic phase

B. Wait for 18-24 months for stabilisation of disease

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

33. Identify the image

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

36. Strawberry gallbladder is seen in

A. Mirizzi syndrome
B. Porcelain gallbladder
C. Cholesterosis
D. Diverticulosis of gallbladder

C. Cholesterosis

Strawberry gallbladder is seen in cholesterosis. It is characterised by submucous aggregations of


cholesterol crystals and cholesterol esters.
Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 54

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.

B. Inadequate ACTH seen

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 ?

A. α-2 vlad glycation protein


B. α-2-Heremans–Schmid glycoprotein
C. Calcicardin associated protein
D. Anti-parafibromin

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

39. Which is true regarding the etiology of proximal gastric cancer?

A. Epstein-Barr virus is associated with proximal gastric cancer


B. Obesity is never associated with proximal gastric tumours
C. Smoking is usually implicated only in distal gastric cancers
D. Diffuse gastric cancers in proximal stomach are seen in thin malnourished men

A. Epstein-Barr virus is associated with proximal gastric cancer

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.

Ref: MD Anderson, Surgical Oncology Handbook, 6th edition, Chapter 9

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

1. As per Alonso-Les/ Todani classification of choledochal cyst, cystic dilatation of intraduodenal


portion of the extrahepatic common bile duct is seen

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

GE junction in portal hypertension classified into four zones :

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 48

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.

MAGIC TRIAL compared perioperative chemotherapy and surgery Vs Surgery alone

● They took into consideration stage II and above cancers


● They subjected the patients to 1-3 cycles of ECF (Epirubicin, cisplatin and 5-FU) pre-
operatively and surgery and 3-cycles post operatively and the other group was subjected to
Direct Surgery.
● Rates of recurrence, survival benefit and distant mets were found to be better on the
chemotherapy side.

Ref: Petrillo A, Pompella L, Tirino G, et al. Perioperative Treatment in Resectable Gastric


Cancer: Current Perspectives and Future Directions. Cancers (Basel). 2019;11(3):399.
Published 2019 Mar 21. doi:10.3390/cancers11030399

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 48

5. Common molecular genetic alterations observed in esophageal & gastric cancers are all except

A. Mismatch repair instability


B. RB
C. E-Cadherin
D. Cyclin DI

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

6. Dr Mayank Bhojwani, a senior gastrointestinal surgeon performed an esophagectomy after a


diagnosis of esophageal cancer was made. The patient started developing a chyle leak which was
noticed in the drain. For the first few days, there was about 1200 ml of chyle in the drain but the
patient was treated conservatively with TPN. It resolved on its own in a few days with the
conservative management. Grade the chyle leak according to the International consensus of
standardization of data collection for complications associated with esophagectomy: Esophagectomy
Complications Consensus Group (ECCG).

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?

A. Absence of esophageal pathology


B. Minimal signs of sepsis
C. Contrast leak out of esophageal lumen
D. Small and contained leak

C. Contrast leak out of esophageal lumen

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.

CHICAGO CLASSIFICATION v3.0

Achalasia and Esophagogastric junction Outflow Obstruction:

● 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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 41


9. What does the following esophageal manometry represent?

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.

Ref: Shackelford Surgery of the Alimentary Tract, 8th edition, Chapter 8

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

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

11. Maximum malabsorption and water loss is seen in

A. Type I SBS
B. Type II SBS
C. Type III SBS
D. Type IV SBS

C. Type III 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

12. Paneth cells of small intestine produce

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 49

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

Changes in acute mesenteric ischemia:


30-60 min: Alteration in intestinal morphology starts
30 min: Subepithelial edema
1 hour: Loss of epithelial cells along villus and increased capillary permeability
2 hours: Total loss of villi

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 87

14. What is the most common complication of jejunal diverticulum?

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.

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 77

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 49

16. Which one of the following deficiencies is produced by carcinoid syndrome?

A. Thiamine
B. Pyridoxine
C. Cobalamin
D. Nicotinic acid

D. Nicotinic acid

The carcinoid syndrome, which is characterized by episodic attacks of cutaneous flushing,


bronchospasm, diarrhoea, and vasomotor collapse, is present mostly in those patients with hepatic
metastases. Primary sites that secrete directly into the venous system, bypassing the portal system (e.g.
ovary, lung) give rise to the carcinoid syndrome without metastasis. A number of humoral factors are
produced by NETS, but those considered to contribute to the carcinoid syndrome include serotonin, 5-
HTP (a precursor of serotonin synthesis), histamine, dopamine, kallikrein, substance P, prostaglandin,
and neuropeptide K. CT scanning was the imaging modality of choice for identifying the site of
disease and the presence of lymphatic or hematogenous metastases. Nicotinic acid (niacin) deficiency
is produced by carcinoid syndrome. This is because of the fact that tryptophan metabolism is diverted
towards serotonin production and endogenous niacin production is depressed.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 49

17. What is the most common primary tumor of the appendix?

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:

A. Fetal gestational age


B. Open appendectomy instead of laparoscopy
C. Delay in antibiotic administration
D. Appendiceal rupture

D. Appendiceal rupture

Pregnancy and appendicitis


It is important to remember that appendiceal perforation is the most important variable in determining
fetal mortality during pregnancy; thus, it is imperative to make the diagnosis early. Conversely, a
general anesthetic increases the risk of premature labor.

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 51

20. Which of the following statements is true regarding ileostomy formation?

A. The abdominal wall aperture should be approximately 1.5 cm in diameter.


B. Sufficient length of well-vascularized ileum is brought through the abdominal wall to create a
spigot.
C. A rod is necessary to maintain the configuration of the stoma in a loop ileostomy.
D. Ileostomy rods are often removed on the 12th post-op day.

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.

A. Preganglionic parasympathetics--superior hypogastric


B. Preganglionic parasympathetics--inferior hypogastric
C. Postganglionic parasympathetics--Inferior hypogastric
D.Postganglionic sympathetics--inferior hypogastric

B. Preganglionic parasympathetics--inferior hypogastric

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

22. What is the preferred management of cecocolic volvulus?

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 51

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

26. What is the normal resting pressure of the anal canal?

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

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 51

27. Which of the following statements is true about solitary rectal ulcers?

A. It is more common in males


B. It is present in anterior aspect of rectum
C. It is present 4 cm above the level of puborectalis sling
D. Local excision is often curative

B. It is present in anterior aspect of rectum

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

28. False statement about Non Occlusive mesenteric ischemia is

A. Papaverine injection into vessel can relieve spasm


B. Vasopressor injection may be associated with NOMI
C. It is commonly seen in atherosclerotic vessels
D. It is often seen in critically ill patients in ICU settings

C. It is commonly seen in atherosclerotic vessels

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.

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 87

29. More than 50 % of mutations in families with HNPCC are due to

A. MSH2 AND PMS1


B. MSH2 AND MLH1
C. MSH1 AND PMS2
D. MSHI AND MLH1

B. MSH2 AND MLH1

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

30. Bilhemia is best detected by

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 53

31. Golf tee appearance of extrahepatic bile duct on ERCP is seen in

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

32. All are techniques of anterior fundoplication except

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 42

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?

A. Biliary tract pain in the presence of normal LFTs


B. Recurrent pancreatitis is seen
C. Altered motility elsewhere in the GIT
D. Sphincter pressure higher than 40 mm Hg correlates to poor response to therapy

D. Sphincter pressure higher than 40 mm Hg correlates to poor response to therapy

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 54

35. Identify the true statement about primary sclerosing cholangitis (PSC) in association with chronic
ulcerative colitis (CUC).

A. Proctocolectomy in CUC modifies disease progression.


B. Severity of colonic disease in CUC correlates with severity of PSC
C. PSC develops in 25% of patients without evidence of IBD
D. TNF inhibitor useful in PSC

C. PSC develops in 25% of patients without evidence of IBD

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

A. Gut bacteria has a protective role in preventing obesity


B. Growth hormone promotes appetite
C. Low calorie diet leads to decreased ghrelin production
D. MC4R gene deficiency is associated with obesity

C. Low calorie diet leads to decreased ghrelin production

● 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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 47


38. Which recently popular surgery consists of creation of a long vertical gastric pouch along lesser
curvature followed by a Billroth II loop gastrojejunostomy?

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.

Ref: Rutledge R, Kular K, Manchanda N. The Mini-Gastric Bypass original technique.


International Journal of Surgery (London, England). 2019 Jan;61:38-41. DOI:
10.1016/j.ijsu.2018.10.042.

39. What is the most common CT finding in Gallbladder cancer ?

A. Wall thickening
B. Mass replacing gallbladder
C. Intraluminal polypoid mass
D. Distended GB with thickening in the neck

B. Mass replacing gallbladder

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

B. Transjugular intrahepatic portosystemic shunt

Nonselective β-blockers, such as propranolol or nadolol, either alone or in combination with


nitrates and esophageal variceal band ligation are recommended, with TIPS as an alternative
option. TIPS is indicated for patients with ascites refractory or intolerant to diuretics, but patients who
undergo TIPS should be closely monitored for hepatic encephalopathy. Patients with moderate to high
MELD scores (>15) are at high risk for 30-day mortality and should not undergo TIPS for refractory
ascites. B-Blockers are contraindicated in cirrhotic patients with refractory ascites, and patients should
avoid abdominal surgery because of high rates of postoperative morbidity and death.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 53


41. “Cotton wool” appearance of hepatic hemangiomas is seen on

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

A. Dorsal edge of left side of caudate lobe & right liver


B. Ventral edge of left side of caudate lobe & right liver
C. Dorsal edge of right side of quadrate lobe & left liver
D. Ventral edge of right side of quadrate lobe & left liver

A. Dorsal edge of left side of caudate lobe & right liver

Inferior vena caval Ligament (Makuuchi / Hepatocaval ligament)


The posterior edge of the left side of the caudate terminates as a fibrous component that
attaches to the crura of the diaphragm and also runs posteriorly, wrapping behind the IVC and
attaching to segment VII of the right liver. In up to 50% of people, this fibrous component is
composed partially or completely of liver parenchyma. Thus, liver tissue may completely
encircle the IVC. This structure is known as the caval ligament and is important to recognize
in mobilizing the right liver or the caudate lobe off the vena cava.

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?

A. There are 12 anatomical zones in the Index


B. Gadolinium-MRI abdomen is more accurate than CT in estimating PCI
C. It does not have a clear correlation with outcomes
D. Patients with low PCI scores are excluded from cytoreductive surgery

B. Gadolinium-MRI abdomen is more accurate than CT in estimating 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.

Ref: MD Anderson, Surgical Oncology Handbook, 6th edition, Chapter 11

44. All are absolute contraindications for liver transplantation except

A. Cholangiocarcinoma
B. Too short survival after transplantation
C. Unacceptable postoperative quality of life
D. Active alcoholism

A. Cholangiocarcinoma

Absolute contraindications to liver transplantation include the following:


● The patient is not fit enough to withstand surgery (e.g., because of advanced cardiac
or pulmonary disease).
● The patient is unlikely to survive the procedure (e.g., active sepsis).
● Survival after transplantation may be too short to justify the risks of transplantation
(e.g., with metastatic disease).
● Active alcoholism or substance misuse is present (noncompliance with medical advice
ascertained on psychiatrist or psychologist evaluation)
● The postoperative quality of life may be unacceptable to the patient (e.g.,, severe intractable
depression).
● Surgery is technically not possible (e.g., patients with extensive venous thrombosis).
● The patient does not choose to undergo the operation.

Relative contraindications to transplantation include the following:


● Age: age limits vary among transplant centers; biologic rather than chronologic age is
more relevant but more difficult to define and quantify.
● Obesity: those with body mass index (BMI) greater than 40 kg/m2 have a poorer
outcome.
● Cholangiocarcinoma: considered only in highly selected patients in agreed protocols with
chemotherapy and irradiation because of early recurrence.
● Chronic or refractory active infections: depending on type of infection and whether
amenable to cure with available therapy.
● Poor social support despite full interventions that will adversely impact on graft or
patient survival, particularly in biologically older patients with anticipated prolonged
recovery after transplant.
● Ongoing tobacco use or illegal drug use.

Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 112

45. Focal fat sparing is seen most commonly in

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

46. Agenesis of pancreas occurs due to mutation in

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

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 90

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

● Size larger than 5 cm


● Disease-free interval less than 1 year
● More than one tumor
● Lymph node positive primary (indicates stage)
● CEA level higher than 200 ng/mL.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 53

48. All are true about autoimmune pancreatitis except

A. Females are affected more than males


B. IgG4 Ab elevated
C. Treatment with Steroids
D. Lymphoplasmacytic pancreas

A. Females are affected more than males

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 55

49. Necrolytic migratory erythema is seen in

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

The abundance of somatostatin receptors on most PNET's makes somatostatin receptor


scintigraphy (SRS) a useful adjunct in localization for tumors not evident on CT or MRI. The
sensitivity for SRS is greater than 80% for all pancreatic endocrine tumors excluding insulinomas.
SRS has an overall sensitivity of 80% to 100% and specificity greater than 90% for gastrinomas
because somatostatin receptors are present in more than 90% of gastrin- secreting PNETs.
Somatostatin receptors are also present in a significant portion of glucagon secreting and non-
functioning PNETs. In contrast, insulin-secreting PNETs and pancreatic adenocarcinomas do not
possess somatostatin receptors. SRS is also useful for detecting hepatic metastases from
noninsulinoma PNETS.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 38

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:

A. 80% distal pancreatectomy with splenectomy


B. Longitudinal pancreaticojejunostomy
C. Distal pancreatectomy with end pancreaticojejunostomy
D. Total pancreatectomy

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.

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 92

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

53. The optimal pH for pancreatic amylase is around

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 55


54. The image given below is the preferred position for laparoscopic splenectomy. What is the benefit
of having an angulated table position as shown above?

A. Better visualisation
B. Less chance of bleeding
C. Easier way to evacuate clots postoperatively
D. Opens up the costophrenic angle.

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.

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 56

55. Which of the following statements is true about HIPEC?

A. Permeability of the peritoneal-plasma barrier influences the efficacy


B. It permeates a depth of 10 mm
C. HIPEC doesn’t increase anastomosis leak rates
D. Temperature of 50 degrees is used

A. Permeability of the peritoneal-plasma barrier influences the efficacy

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.

Ref: MD Anderson, Surgical Oncology Handbook, 6th edition, Chapter 11


56. Which of the following Forrest grades of peptic ulcer carries an intermediate risk of rebleeding?

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)

Ref: Sabiston Textbook of Surgery, 20th edition, Chapter 45

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

Ref: NCCN Guidelines Version 1.2020

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

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 78

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

B. Intervention and trauma

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.

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 88

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