Questions in digestive System surgery from exams
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Q 1) .Not true about CEA (Carcino Embryonic antigen) in Carcinoma Colon

a)  It is a useful screening test in Carcinoma colon
b) Slight elevation of CEA  can occur in certain beningn diseases.
c) CEA is useful as a prognostic marker in Cancer of Colon
d) Preoperative CEA value is a predictor of survival in Carcinoma Colon
...................................................................................................................................................

Q2) . Which of the following statement is not true for ideal hepaticojejunostomy





a) The anastomosis should be tension free
b) All the suture knoys should  be on the  outside of bile duct
c) Mucosal contact must exist between  the mucosa of the bowel and bile duct
d) Anastomosis done with single layer  absorbable sutures
...................................................................................................................................................

Q3) . Barrett's esophagus is a premalignant condition. Which of  the following statement is false regarding
Barrett's esophagus


a) Barrett's mucosa predisposes to Squamous cell carcinoma of esophagus
b) Risk of Cancer is 0.5% per year
c) Prevalence of Barrett's esophagus in general  population is  2-7%
d) Intestinal type of mucosa  with goblet cells is the most  common histopathological finding

.................................................................................................................................................................................................

Q 4). A 45 year old lady presents to the HepatoBiliary  Clinic with a  large 3 cm stone in the neck of gall bladder
eroding into the Common Bile duct (CBD) effacing about  50% of its diameter. Patient  has been counselled  about  surgery and is willing for the same.What would be the most  appropriate  surgery for this patient?

a) Cholecystectomy, removal of stone and primary repair of CBD over a T tube
b) Radical Cholecystectomy
c) Cholecystectomy and use of a flap of Gall Bladder to repair the defect in CBD
d) Cholecystectomy and Roux en Y Hepaticojejunostomy
...................................................................................................................................................


Q 5) . A 50 year old presents with vague persistent abdominal pain. CT Scan of the abdomen reveals a duodenal diverticulum. Which of the
statements is true regarding duodenal diverticulum.

a) The overall incidence of duodenal diverticulum is 7-20% and about 10%  of these require surgery.
b) Most of the duodenal diverticula are symtomatic and perforation is the most common complication
c) Surgery should be avoided and carried out only in case of complications  like perforation, uncontrooled hemorrahge, persistent biliary or pancreatic symptoms
d) Juxta vaterian diverticulum is the easiest to manage








  1) a
   CEA  is an oncofetal protein that is normally present during fetal life but can be present in low concentrations in healthy adults. Structurally, it is a           glycoprotein with a molecular weight of 200 kDa. It is  not useful as a screening test because of its low sensitivity in early-stage disease.
   It can be increased in several beningn diseases such as rheumatoid arthritis, cystic diseases of kidneys, COPD, cirrhosis.
  It is useful as a follow up investigation after colonic resection because increasing levels correlate with the stage of the disease and similarly preop values correlate with the severity of the disease
............................................................................................................................................................................................................................................................
2) b
Ideal Hepaticojejunostomy should be tension free with mucosal approximation and done using single layer absorbale suture
All though it is desired that the suture knot should be outside but absorbale suture are bein used , in the posterior layer knots may be place on the inside of the lumen

.......................................................................................................................................................................................................................................................

3) a
Barrett's esophagus is associated with adenocarcinoma and not squmaous cell carcinoma. Metaplasia occurs most commonly because of GERD and the normal esopheal lining is replaced by columnar cells
These columnar cells can be (i) Junctional cells (ii) Gastric cells and (iii) Intestinal Type of cells
Prsence of intestinal type of cells with prsence of goblet cells is the sine quo non of Barrett's esophagus
All other options are true.
......................................................................................................................................................................................................................................................

4d
This patient has typical feature of Mirizzi's syndrome named after the Pablo Mirizzi.
It is a rare condition in which stone gets impacted in the neck of Gall Bladder. The stone compresses the CBD externally or can lead to fistula formation with the CBD.
Patients generally present with pain abdomen, jaundice and fever.

The Csendes classification of Mirizzi syndrome  is

Type 1: external compression of the common bile duct
Type 2: a cholecystobiliary fistula is present involving less than one third the circumference of the bile duct
Type 3: a fistula is present involving up to two thirds the circumference of the bile duct
Type 4: a fistula is present with complete destruction of the wall of the bile duct


Mirizzi Syndrome Treatment
Type 1 - Mirizzi syndrome  treatment is fundus first cholecytectomy or partial cholecystectomy
  For Type 2 to 4 the best treatment would be cholecystectomy and Roux en Y hepaticojejunostomy. A flap of gall bladder may sometimes be used if it appears healthy.

Ref: Complications of Gallstones: The Mirizzi Syndrome, Gallstone Ileus, Gallstone Pancreatitis, Complications of “Lost” Gallstones
Surgical Clinics of North America -  Volume 88, Issue 6
............................................................................................................................................................................................................................................................
5.c
Duodenum Diverticulae are the 2nd most common
diverticulum of small intestine after ileum.Most of these
are asymptomatic and incidentally detected. Only 10%
of the duodenal diverticulae are symptomatic and only 1% require
surgery.Haemorrhage is the most common complication and
perforation is the least common. Surgey is reserved for complicated
disease and where medical therapy has failed. Endoscopic options are
available for bleeding and biliary and pancreatic symptoms.
Juxtavaterian diverticulum ie 2 cm around ampulla are the most difficult to
manage because  of proximity to the ampulla

Ref- Yeo: Shackelford's Surgery of the Alimentary Tract, 7th ed.







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