Surgery MCQ
Q1. Which one is not an indication of choledocohotomy in laparoscopic CBD exploration
a) CBD diameter 6 mm
b) Multiple large stones in CBD
c) Unsuccessful transcystic exploration
d) Small cystic duct diameter

Q2 True about Dieulafoy's lesion of the stomach
a) It is a very rare cause of GI bleeding (less than 1% incidence)
b) The bleeding artery in Dieulafoy's lesion lies in the submucosa
c) The lesion is seen in the distal stomach near the antrum
d) Surgery is required in all cases to stop the bleeding

Q3. True about enterohepatic circulation of bile?
a) 20% bile salt which reaches liver is lost in the stools per day
b) Bile salt are stored and diluted in Gall bladder
c) 0.2to 0.6g of bile salts are secreted by the liver each day
d) Gall Bladder fills by antegrade mechanism from the liver

Q4.What is true about splenic abscess is:

a) Most of the abscess in spleen occur through local spread such as from kidneys, colon
b) Unilocular splenic abscess has a high mortality rate more than 50%
c) Splenomegaly is typically seen in splenic abscess
d) In one third of adults splenic abscess is multilocular
Q5. What is not true regarding Cholangiocarcinoma?

a) Intrahepatic cholangiocarcinoma is the least common type anatomically
b) Primary resection is the main treatment
c) Liver Transplant is the main treatment
d) A multidisciplinary team should evaluate and manage all patients of cholangiocarcinoma

1) a
In laparoscopic CBD exploration there are two ways. One with less morbidity is the transcystic approach in which cystic duct is dilated and stones are removed through the cystic duct. After the procedure the cystic duct is clipped as in laparoscopic cholecystectomy. This  procedure has the least morbidity as CBD is not opened. Indications of Choledochotmy are

Dieulafoy's lesion of the stomach is not an uncommon cause of upper GI bleeding. Its incidence in all patients with upper GI bleed range from 0.3 to 7%. The cause of such bleeding is a large tortuous vessel in submucosa which leads to ulceration of the over lying mucosa. The lesions occur at 6-10 cm from the cardia near the GE junction. Endoscopy is the diagnostic modality of choice and lesion is controlled by electrocoagulation, heatre probes or photo coagulation

Ref Sabiston 19th edition page 1222

3) c
0.2-0.6 g of bile salts are secreted by liver each day in the form of cholic acid and dexoy cholic acid.
Only 5% of bile salt is excreted per day and 95% is absorbed by the portal vein
Bile is stored and concentrated in the gall bladder
Gall bladder fills by retrograde mechanism by contraction of sphincter of oddi.

4) d
Haematogenous route is the most common route for acquiring splenic abscess (70%). Risk factors inculde polycythemia vera, malignancies, IV drugs etc. Unilocular splenic abscess has mortality rates of 15-20% and multiloculated abscess about 80%. Typical symptoms are fever, pain abdomen, pleuritic chest pain. Splenomegaly is uncommon.
In 1/3rd adults abscess is multilocular.
Read more about questions on spleen here

Perihilar Cholangiocarcinoma also known as Klatskin tumor is the most common type of cholangiocarcinoma followed by lower end cholangiocarcinoma. Intra hepatic cholangiocarcinoma is the least common.

Complete surgical resection to negative margins is the only hope for long-term survival;
highly selected patients with unresectable tumors or underlying liver disease such as primary
sclerosing cholangitis may be considered for liver transplant. Not all patients are considered for liver transplant. To read more about liver transplant see here,
A multidisciplinary team comprising of surgeon, gastroenterologist, oncologists, radian oncologists should evaluate the patient along with support staff

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