Q1. A 50 year old presents with vague persistent abdominal pain. A 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
d) Juxta vaterian diverticulum is the easiest to manage
Q2. Which of the following is not true for Menetrier's disease
a) It is a premalignant condition of the stomach
b) It is characterized by massive gastric folds in the antrum
c) Hypoproteinemia, Achlorhydria and excessive mucus production are common
d) Associated with CMV infection in children and H Pylori in adults
Q3. Treatment of Type III Carcinoid tumor of the Stomach is
a) Endoscopic Biopsy and excision
b) Gastrectomy with oncological margins
c) Gastrectomy with complete lymph node clearance
d) Endoscopy and fulgration followed by somatostatin
Q4. Which of the following is not true regarding gallbladder cancer following cholecystectomy
a) Subsequent treatment depends on many factors including stage of disease, surgical margins, spillage etc
b) For T1 and T2 lesions cholecystectomy is sufficient
c) The term extended cholecystectomy is preferred to radical cholecystectomy
d) Common Bile Duct (CBD) excision is not required in all cases
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
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.
Menetrier's disease is a rare condition of the stomach characterized
by large hypertrophic mucosal folds in thebody and fundus and
not antrum. Achlorhydria, Hypochlorhydria with Protein loss is
commonly seen in this condition. The exact causeof this disease is
not known but it is associated with CMV infection in children and
H Pylori in adults
Carcinoid stomach is of 4 types. Type I is small and diffuse associated with hypergastrinemia. Type II is also diffuse and it is associated with MEN Syndromes. Type III is the most malignant type. It is not associated with hypergastrinemia. It is large and solitary. Its management is same as that of adenocarcinoma stomach. Endoscopic resection is viable when tumor is less than 2 cm, above muscularis mucosa and less than 6 in number
Ref Yeo: Shackelford's Surgery of the Alimentary Tract, 7th ed.
After cholecystectomy if the histopathology report suggests malignany, many preoperative and intra operative factors have to be considered.
These are duration of symptoms, previous history of jaundice,laparoscopic or open surgery, difficulty and blood loss in surgery, spillage of bile, if an endobag was used or not for gallbladder retrieval. The most important is to define the T stage in the gallbladder .
For T1a and selected T1b lesions (those lesions which do not have neural, lymphatic) simple cholecystectomy suffices, however for T2 lesions, extended cholecystectomy is the procedure of choice
The term extended cholecystectomy is preferred to radical these days because radical can be anything ranging from wedge excision of liver to resection, of duodenum, CBD or even a Whipple's procedure
Extended cholecystectomy entails cholecystectomy + removal of lymph nodes in periportal , hepatoduodenal, right coeliac, posterior pancreaticodudenal and pericholedochal + 2 cm wedge excision of liver.
CBD excision is not always necessary and required only in some select conditions
Sabiston text book of surgery 19 th edition
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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