Q Least useful investigation in a pt with recurrent LGI bleed, multiple upper and lower GI endoscopies negative
b) Double balloon enteroscopy
c) Capsule endoscopy
d) Push endoscopy
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Investigations in lower GI bleed should be specific and less time consuming
Small bowel enteroclysis, which uses a tube to infuse barium, methylcellulose, and air directly into the small bowel, yields better images than simple small bowel follow-through. Because the yield has been reported to be very low and the test is poorly tolerated, it is now rarely used.
Capsule endoscopy uses a small capsule with a video camera. capsule endoscopy is an excellent tool for the patient who is hemodynamically stable but continues to bleed, with reported success rates as high as 90% in identifying a small bowel pathology.
The hemodynamically stable patient should undergo small bowel enteroscopy. Usually performed with a pediatric colonoscope, it is referred to as push endoscopy. It can reach about 50 to 70 cm past the ligament of Treitz in most cases and permits endoscopic management of some lesions. Overall, push enteroscopy is successful in 40% of patients .
Double-balloon endoscopy is another technique gaining in popularity. Although technically difficult, this approach is capable of providing a complete examination of the small bowel. In expert hands, double-balloon enteroscopy can identify a bleeding source in 77% of cases with occult bleeding, with the yield increasing to over 85% if the endoscopy is per-formed within 1 month of an overt bleeding episode.The advantage of this technique is that as well as visualization, biopsies can be performed and therapeutic interventions undertaken.
To conclude investigations in lower GI bleed have to be specific and have high sensitivity also.
Q) Supraduodenal artery of Wilkie is a branch of
b) Rt gastroepiploic
c) Rt gastric
d) Sup Pancreaticoduodenal
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Discuss blood supply of 1st part of duodenum, and course of all arteries mentioned in choices.
Q After esophagectomy ICD draining 800 – 1000ml chyle 5-7 days post operatively. Next management
a) NPO, TPN
b) Enteral feeding with medium chain
c) Re explore and suture the defect
Once the diagnosis is made, one should ensure the pleural space is completely evacuated; if needed, drainage is done by a chest tube or a radiologically directed catheter placement.
Feedings are stopped and total parenteral nutrition (TPN) is started. The amount of chest tube output is then monitored for several days in order to make a decision about the possible need for reoperation. Small leaks can seal with nonoperative therapy. Large initial daily outputs (typically greater than 1 L/day) often fail nonoperative therapy and require reoperation. An absolute amount of drainage for prediction of failure is unknown and one should consider also if there is a gradual reduction in daily output to continue with conservative therapy.
If the drainage is less than 500 mL per day and slowly decreasing, continued conservative therapy is frequently successful. Continued volumes more than 1 L after 2 days of TPN is a good indication of the need for reoperation. In general, it is better to be more rather than less aggressive in returning to the operation theater with a chylothorax. It was more common after THE and was associated with longer intensive care unit (ICU) and hospital stays. There was no difference in mortality between those with and without a chylothorax.
Patients with initial drainage exceeding 2 L within 2 days of starting conservative treatment all required reoperation.
Q) A 45 year old male sustains 30% burns on both legs and anterior abdominal wall. There was mild inhalation injury associated with it. He initially responded well to treatment with IV fluids, Inj Tramadol and enteral feeding.
Three days after the treatment he is having slight tachypnea (30/min) pulse 110/min and BP 98/60. His temp is 97degree F and some areas of partial thickness have converted into full thickness. He is currently on Inj Magnamycin. His platelets are 70ooo, TLC is 17000 and sugar is 200 mg%. What is the next step in management?
a) Continue same management
b) Upgrade the antibiotic and send a fresh culture from skin
c) Treat it as carbon monoxide poisoning
d) Manage in lines of Acute Tubular Necrosis
Answer for premium members
Burns management involves critical care, intensive phase and rehabilitation. Loss of skin and eschar formation predispose individuals to gram positive, gram negative and fungal infections.
Q) Elderly healthy male with impacted denture. Removed endoscopically. Pt developed fever, dyspnoea and respiratory distress over 24 hrs. X-ray revealed Lt hydrothorax and mediastinal emphysema.
a) ICD and NG feeds
b) ICD and TPN
c) Cervical esophagectomy, FJ, debridement, ICD
d) Debridement, primary repair with buttress and ICD
Q. 40 yr old lady with symptoms of GERD. Endoscopy shows hiatus hernia. Symptoms controlled with PPI. Next step
a) Leave alone
b) Manometry with Ph study
c) Ba swallow with Manometry
d) Ba swallow with Ph study
Q) Causes of primary graft non function are A/E
a) Recipient with renal failure
b) Microsteatosis > 60%
c) Cold ischaemia time > 12hrs
d) Non heart beating donor
Discuss the causes of PNF-Primary non function of liver
Q. Hyergastrinemia occurs in all except
c)Brunner gland adenoma
Answer for premium members
Q) Most sensitive investigation for Gastrinoma ?
b) Selective angiography
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Q) Post cholecystectomy injury which is true
a) Bile duct leak occurs in 1%
b) After open cholecystectomy bile duct injury occurs in 0.5 to 1 %
c) Most common cause of bile duct injury is cystic stump blow out and duct of luschka injury
d) Type E injury is clipping of CBD by mistake
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Q) Non hereditary polyp in colon
a) Peutz Jeghers Syndrome
d) Cronkhite Canada
Q. Regarding percutaneous cholecystostomy A/E
a. Technical success in 90 – 98 % of cases
b. Indicated in Grade II cholecystitis with significant pericholecystic inflammation & GOO
c. Indicated in Gr III cholecystitis with significant comorbidity
d. In Grade III cholecystitis with biliary peritonitis, PCC results in significant improvement
Q ) Modified Nissen's Fundoplication
a) 2700 anterior wrap around esophagus
b) 2400 wrap
c) 3600 wrap over > 52 Fr for 1 – 2 cm
d) 600 wrap over 42 Fr for 4 cm
Nissen fundoplication is complete 360 degree but has high incidence of gas bloat. To counter this modification done to wrap over 52 F tube for 1-2 cm
Belsey - Left thoracotomy, mobilization of distal esophagus and stomach, hiatus opened from above, fundus is brought 270 degrees around distal esophagus. Then the whole assembly is brought down and crura is repaired.
Hill procedure - No fundoplication is done
Toupet is anterior fundoplication either 240 degree or 270 degree.