Esophagus Length DNB 2018

Q) Length of Esophagus

 A. 20cm
B. 25cm
C. 30-35cm
D. 40cm


Answer

29) b

The esophageal length is anatomically defined as the distance between the cricoid cartilage and the gastric
orifice. It ranges in adults from 22 to 28 cm (24
± 5 SD), 3 to 6 cm of which are located in the abdomen.

The shortest distance between the cricoid cartilage and the celiac axis is the orthotopic route in the posterior mediastinum, being 30 cm. The retrosternal (32 cm) and the subcutaneous route (34 cm) proved to be
longer

Ref Shackelford page 10

GCS

Q. Best predictor in the GCS

A. Eye opening
B. Motor response
C. Verbal response
D. All


23) B, Motor response

Motor score is the best predictor of neurological outcome.

The m component of the GCS,  is not only linearly related to survival, but preserves almost all the predictive power of the GCS 

BAiley

Spinal cord injury

Q) Out of the following which will require Spinal immobilization most?
a. 22 yr Female had a high-speed motor vehicle collision who complains of backpain and no
numbness
b.16 yr male jumped from 6ft landed on both foot denies back pain and weakness
C. Gunshot injury
D. Abdominal injury

Answer is free 

a) 

Spinal cord injuries are a common cause of morbidity and expenditure. Mortality is associated with cervical injuries but not lower spinal cord injuries.

Motor vehicle accidents are the most common cause and gunshot injuries the least common for spinal cord injuries.

Mechanism of injury 

  1. Blunt trauma - Direct impingement, Ischemia, compression or bleeding 
  2. Penetrating - Laceration of spinal cord

Chance fracture - is a type of spinal cord fracture in which there is transverse fracture of all vertebral elements

Management

1 Complete immobilisation

2. Management of associated neurogenic shock ( due to loss of sympathetic tone) with vasopressors  and fluids

Sabiston page 420

 

Tropical Pancreatitis

Q) All are true about tropical pancreatitis except?

a. Associated with Tapioca.
b. Patients have  large stones with fibrosis.
c. Cancerous

d) Onset of disease at 50 years 


Answer d - Free. See here for other questions and this question

Onset 50 years

Tropical pancreatitis is an  idiopathic disease which begins in teens.  It has a high association with diabetes and Pancreatic duct calculi. It is common in South India, Asia, Africa and central America

Etiology 

Malnutrition 

Cassava

Hydrocarbons exposure

These patients have increased risk of cancer

It is associated with SPINK 1 mutation

Ref https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1742869/pdf/v079p00606.pdf

 

Spontaneous fistula closure

Q) Adverse factor for spontaneous fistula closure:

a) Tract <1cm

b)Transferrin > 200

c) Location in esophagus

d) First surgery done in the same institution

Answer free

a) Tract less than 1 cm

Spontaneous fistula closure

Short-turnover  protein (prealbumin,  retinol-binding  protein,  transferrin)  levels should  be  measured  at  least  weekly  to  assess  the  adequacy of  protein  delivery. An  ongoing  catabolic  state  will adversely  affect  short-turnover  protein  levels,  even  with maximal  protein  delivery.

Failure  of  an  enterocutaneous  fistula  to  close  spontaneously  is associated with acronym FRIENDS): 

the  presence  of  a foreign  body  within  the  tract  or  adjacent  to  it,  previous radiation  exposure  of  the  site,  ongoing  inflammation (most  commonly  from  Crohn  disease)  or  infection  that contributes  to  a  catabolic  state,  epithelialization  of  the fistula  tract  (particularly  if  the  fistula  tract  is  less  than 2  cm  long),  neoplasm,  distal  intestinal  obstruction,  and  pharmacologic  doses  of  steroids. 

Fistulas  associated  with  a concurrent  pancreatic  fistula  also  have  a  low  rate  of  spontaneous  closure,  as  do  those  occurring  in  the  presence  of  malnutrition  or  adjacent  infection.

In general,  anatomic  locations  that  are  favorable  for  closure  are  the  oropharynx,  esophagus,  duodenal  stump,  pancreas,  biliary  tree,  and  jejunum.

Investigations in lower GI Bleed

Q Least useful investigation in a pt with recurrent LGI bleed, multiple upper and lower GI endoscopies negative

a) BMFT

b) Double balloon enteroscopy

c) Capsule endoscopy

d) Push endoscopy

Answer

Free for all

A

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.

Sabiston

Chyle leak after esophagectomy

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

Answer free 

c

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.

Treatment of anal incontinence


Q) Newest treatment for anal incontinence?
a. Sacral nerve stimulation
b. Artificial sphincter.
c. Repair of sphincter
d. Gluteus maximus graft

More Questions 

Answer a)

Sacral nerve stimulation is the newest modality in treatment for anal incontinence. In it electrodes are placed via the sacral foramina. The nerve supply of anal sphincter is similar to lower extremity so their stimulation can lead to contraction of various foot muscles.

Others are all older methods

Shackelford page 1779

Modified Nissen’s fundoplication

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

Answer

c

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.

 

Foreign body esophagus

Q) True about foreign body in esophagus

a) Sharp objects should be operated and not retrieved

b) Lead batteries should be removed

c) Most common impacted foreign bodies are dentures

d) Contrast examination of esophagus should be done before endoscopy

 

Answer

b

Sharp objects can be removed over overtubes and not always require surgery. Lead batteries can corrode and decay in the stomach or intestine and should always be removed. Most common impacted foreign bodies are food boluses above a pathological narrowing and require endoscopic break up

Contrast examination is not always required and might complicate things

Bailey page 991

Siewert classification for GE junction tumors

Q) According to Siewert classification tumors at GE junction are

a) Type I

b) Type II

c) Type III

d) Type IV

Answer (free for all)

Answer b

Type I   Lower  (centre located within between 1-5cm above the anatomic OGJ)

Type II Real GE junction  (within 1cm above and 2cm below the OGJ)

Type III  (2-5cm below OGJ)

This classification has only 3 subtypes

According to the Siewert-Stein classification,

Type I tumour 25% approx

Type II - Most common 49%

Type III was present in 25%

This classification helps in deciding the operative management and unified pre op classificationT

Types of Surgery

Type I cancer--depending of the size of the tumour--distal 2/3 oesophagectomy with the resection of the proximal lesser curve of the stomach or total gastrectomy  or THE

In patients with types II and III cancers total gastrectomy

 

Strongest layer of the intestine

Q) Which is the strongest layer of the intestine?

a) Mucosa

b) Submucosa

c) Muscularis propria

d) Muscularis mucosa

Answer:

b) Submucosa is the strongest and most important layer for intestinal anastomosis. It has fibroblasts that will ultimately release collagen and hold the anastomosis together. This layer should be fully incorporated in the anastomosis.

Inverted Vs everted anastomosis of intestine debate has been log going on but now many prefer inverted because mucosa is exposed to mucosa and eventually degrades joining the two submuoca together to cause healing by primary intention.

REF Schakelford: page 923

Duodenal atresia

Question on Duodenal atresia was asked in AIIMS 2017 in April

Q) An infant presents with duodenal atresia. Which of the following is true about this condition?

a) It is the most common GI atresia

b) It presents soon after birth with non bilious vomiting

c) Pre natal detection of duodenal atresia is common

d) Gastro jejunostomy is the procedure of choice to bypass the obstruction

Answer (free) 

C-

Commonly detected in the pre natal ultrasound

Duodenal atresia is seen in 1:5000 live births and most common atresia is jejunoileal (1in 2000). It is associated with lot of other congenital malformations like Down's,  prematurity, biliary atresia etc.

Read More ...