a) Duodenum
b) Jejunum
c) Ileum
d) Appendix
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Q4. True about ileostomy output is
a) Sodium excretion is two to three times that of normal stool
b) Contents of ileostomy are alkaline
c) Usually it starts functioning in 24 hours
d) Uric Acid renal calculus formation is more common than cholelithiasis
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Q5. Most common cause of nausea and vomiting in patients with carcinoma head of pancreas is
a) Tumor infiltration of coeliac nerve plexus
b) Direct tumor infiltration of duodenum
c) Tumor infiltration around Superior Mesentary artery
d) External Compression of duodenum
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Answers
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1. b
There are no trials which determine that use of right colon is better than the left. In the absence of clinical trial choice of conduit depends on vascularity and surgeon's preference. Although the risk of developing malinancy is 1000 times high but in most large series involving 500-1000 patients only 1 or 2 patients developed cancer over a period of 20-30 years.
The risk of resecting the esophagus in badly adherent mediastinum is high so most of the surgeons opt for retro sternal bypass and not esophageal resection. The disadvantage of this approach is that it sometime converts the esophagus into a mucocele which can cause pain and mediastinal compression later on.
Ref Book- Shackelford's Surgery of Alimentary canal
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2) a
CT is least sensitive in distinguishing T1-T3 lesions. It has better ability to define T4 lesions when there is involvemnt of trachea, pericardium or aorta.
In a known case of carcinoma esophagus a lymph node greater than 1 cm is mostly malignant. Contrast Enhanced Computed Tomography (CECT) has its best role in predicting distant metastasis by picking up secondaries in liver, omental or even adrenal involvement
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3. d
Carcinoid tumors are those which are derived from enterochromaffin cells which belong to APUD system.Gastrointestinal carcinoids are distributed via embryologic origins: foregut, midgut, and hindgut. Foregut carcinoids account for approximately 7% of all carcinoids, whereas midgut and hindgut carcinoids represent 62% and 30% of all carcinoids, respectively. Because of the preponderance of APUD cells within the ileum and appendix, the most common sites are the appendix (35%) and small intestine (23%), followed by the rectosigmoid (12%) and colon (6%).
Carcinoid tumors have five histologic patterns: insular, trabecular, glandular, undifferentiated, and mixed
Clinical features of Carcinoid tumor in foregut
Gastric carcinoids arise from enterochromaffin-like cells and are classified into three groups. Type I consists of gastric carcinoids associated with chronic atrophic gastritis type A. This group represents 75% of all gastric carcinoids and is marked by a lack of parietal cells, achlorhydria, and hypergastrinemia. The tumors are often less than 1 cm in diameter, diffusely involve the stomach, and metastasize in 10% of all cases, with an overall 5-year survival rate approaching 100%
Patients with type I gastric carcinoid are often 70 to 80 years of age and female with symptoms of abdominal pain. Carcinoid syndrome is not seen, and these tumors usually follow an indolent course.
Type II gastric carcinoid tumors are associated with Zollinger-Ellison syndrome and familial multiple endocrine neoplasia type I syndrome. Patients in this group, 5% of those with gastric carcinoids, are younger (in their sixth decade of life), exhibit no evidence of carcinoid syndrome, and have a tumor size less than 1.5 cm with an equal gender distribution. Although metastases develop in up to 25%, the clinical course is usually indolent.
(type III) consists of sporadic carcinoid tumors. Patients in this group have larger tumors, and hepatic metastases develop in more than 65%. This group of patients (15% to 25% of those with gastric carcinoids) is associated with the development of an atypical carcinoid syndrome and have a 5-year survival rate near 50%. Indicators of tumor aggressiveness include angiolymphatic invasion, clinicopathologic type, mitotic index, Ki-67 grade, and tumor size.
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4. a
An ileostomy starts to function 48 to 72 hours after construction. A mature ileostomy produces between 400 and 700 mL of effluent per day. This volume remains relatively constant for an individual. The contents are weakly acidic (pH 6.1 to 6.5). Sodium excretion is 60 to 120 mEq/day, which is two to three times higher than in normal feces.
Cholelithiasis occurs in 30% and Renal stones in 10%
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5.a
Nausea and vomiting occurs in upto 50% of patients in carcinoma head of pancreas. Obstructive jaundice in 90%. The most common cause of nausea and vomiting is motility disturbance of stomach and duodenum due to infiltration of coeliac nerve plexus. Rest of the choices are other causes. Small intestine motility disturbcance can occur due to tumor infiltrating the SMA ( Superior Mesentary Artery)
Blumgart: Surgery of the Liver, Biliary Tract and Pancreas, 4th ed.
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