Mass in Right lower quadrant

Q) A 55 year old lady presents with vague pain in right lower abdomen. Physical examination reveals a well defined mass there which is non tender and freely mobile. It is non pulsatile as well. What is the most likely possibility?

a) Appendicular mass

b) Mesenteric cyst

c) Perforated tubo ovarian mass

d) Meckel's diverticulum

Answer

b

Mesenteric cysts are uncommon lesions found in this age group. It typically presents as a freely mobile mass  which moves perpendicular to small blwel axis. It is painless as well.

Appendicular mass will have a preceding history of pain abdomen

Similarly perforated  tubo ovarian mass will also have a history of pain 

Meckel's diverticulum does not present as this kind of mass

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  • Gall Bladder Cancer

    Q) Gall bladder cancer arising in the setting of APBDJ , all are true except

    a) It occurs in younger age

    b) Prevalent in Asian countries

    c) More common in males

    d) Less often associated with Gall stones

    Answer (free)
    c) More common in males- It is more common in females

    In APBDJ, pancreatic and biliary duct meet more than 15 mm away from the duodenal wall. APBDJ is seen more in asian countries and is associated as a cause of gall bladder cancer.

    It is seen in younger age group

    Most of the patients are females

    Ref article- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658122/
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    Recurrent Pyogenic Cholangitis

    Q) Not true about  recurrent pyogenic cholangitis :

    a) Mostly there are intrahepatic strictures with involvement of the left side duct

    b) It can present as choledochoduodenal fistula

    c) In it there is complete biliary obstruction which  leads to marked jaundice and pruritis

    d) MRCP and other other cholangiography can be diagnostic

    Answer c

    In recurrent pyogenic cholangitis (RPC)  complete obstruction does not occur and jaundice and pruritis is not marked. RPC is a disease commonly seen in young Asians (also known as oriental cholangiohepatitis) which leads to multiple strictures in extra or intrahepatic ducts.

    Association with Ascaris lumbricoides and Clonorchis sinensis has been noted.

    It can present as choledocholithiasis  with stricture, choledochoduodenal fistula, acute pancreatitis, secondary biliary cirrhosis and can lead to cholangiocarcinoma.

    MRCP can be diagnostic and is preferred because of its non invasive nature.

     

    Flaps in Plastic Surgery

    Q. Z plasty is an example of 

    a) Advancement flap

    b) Delayed flap

    c) Transposition flap

    d) Rotation flap

    Answer for all 

    Flaps in plastic surgery are the cornerstone of management of skin and wound defects. Advancement flaps are used to cover skin defects in face, scalp and neck. Examples of advancement flaps are monopedicled flaps, bipedicled and V Y advancement flap.

    Delay of flap is a surgical preconditioning, in which the blood supply  is partially blocked prior to actual procedure. It increases the length of the flap as well as its uptake rate.

    Transposition flap - used in head and neck surgery, a rectangular flap is rotated.

     

    Beger Procedure for Chronic Pancreatitis

    Q) True about Beger procedure for chronic pancreatitis

    a) Posterior branch of gastro duodenal artery is preserved.

    b) Beger procedure is  a pancreatic head mass resection that can be done for small pancreatic tumors.

    c) Intra pancreatic, choledochal and ampullary structures are removed.

    d) Neck of the pancreas is not  transacted

     

    Answer a) Posterior branch of GDA is preserved

    Beger procedure for chronic pancreatitis is mostly done in Europe. Hans Beger in 1972 in Germany introduced this  for chronic pancreatitis with inflammatory head mass. This is a complex procedure which removes head of the pancreas but leaves duodenum, a thin rim of pancreas around the medial aspect of duodenum and intrapancreatic bile duct intact.

    The difference from  similar Frey's procedure is that in Beger procedure neck of the pancreas is transacted where as in Frey, neck of the pancreas is not cut.

    This procedure is not recommended if there is suspicion of carcinoma  head of pancreas and Whipple is the procedure for that.

    Posterior branch of GDA is preserved in Beger Procedure.

    Reconstruction is at two places: Distal pancreas and rim of the pancreas at medial side of duodenum.

    Free Questions on Pancreas