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Esophageal hiatus hernia

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Q) What is type III esophageal hernia? 

a) Paraesophageal hiatus hernia

b) Sliding hiatus hernia

c) Both sliding and paraesophageal hernia

d) Large part of stomach in the mediastinum with pylorus near the esophageal hiatus

Answer  c

Hiatal hernias are protrusion of stomach through a defect in the esophageal hiatus into the mediastinum.

They are of four  types of hiatus hernia

  1. Sliding - GE junction migrates to the mediastinum and rests superior to the diaphragm.
  2. Paraesophgaeal - Part of stomach migrates through the esophageal hiatus into the mediastinum with GE junction remaining at its normal position.

paraesophgeal hiatus hernia

  1. There are IV types of hiatal hernia

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Hemangioma Liver

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Q) True about management of hemangioma liver

a) All hemangioma more than 10 cm should be resected

b) OCPs and pregnancy should be avoided in young females as there is risk of rupture

c) Arterial embolization should be routinely done in large hemangiomas

d) If surgery is decided  hemangioma located at the periphery should be enucleated

Ans)d

Whatever the size there is no role of resection for asymptomatic hemangioma. Risk of rupture is very small and therefore there is no rationale for stopping OCPS, pregnancy or physical activities.

 Arterial embolization, which may be considered for temporary control of hemorrhage has limited success and is occasionally associated with morbidity

In symptomatic hemangioma liver resection is the treatment of choice, in peripheral tumors enucleation and in centrally placed tumors, formal resection should be done

REf Blumgart Surgery of liver 6th edition

 

Complications of Billroth 2 surgery

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Q) What is true regarding complications of billroth 2 surgery?

a) It has less complications than billroth 1 surgery

b) Recurrent ulceration is more common in the afferent limb as compared to efferent limb.

c) Afferent loop obstruction is more common after billroth 2 surgery

d) Billroth I operation is preferred in scarred duodenum

 

Answer c -

In billroth 2 surgery, afferent limb obstruction is more common

In surgery for benign gastric ulcers, billroth I reconstruction is the preferred choice. Billroth II surgery has problems of

  1. Retained antrum syndrome
  2. Afferent loop obstruction
  3. Duodenal stump leak (1-3%)

Billroth 2 surgery is done when there is

1. Inadequate mobility of the duodenum

2. Scarring of duodenum

Complications of gastric surgery
Complications of gastrectomy

  1. Nutritional and weight loss - Iron deficiency, Copper deficiency, Vit B12 , Anemia
  2. Delayed gastric emptying
  3. Roux statsis- Seen in roux en y loops-  Pain, nausea, vomiting, abdominal bloating
  4. Cholelithiasis-  Higher incidence in roux en y reconstruction as compared to B1 and B 2 gastrectomy
  5. Recurrent ulceration

Complications of Billroth 2 surgery

  1. Dumping syndrome
  2. Afferent loop obstruction - It can be minimized by keeping the length of afferent loop less than 20 cm and using a retrocloic approach.
  3. Bile reflux gastritis - More common with billroth I and billroth 2 surgery, incidence is decreasing after the use roux en y anastomosis

 

Splenic artery aneurysm

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Q) Splenic artery aneurysm is seen in  ( #spleen1)

a) Proximal 1/3rd of splenic artery

b) Proximal 2/3 of splenic artery

c) Middle 1/3 of splenic artery

d) Distal 1/3 of splenic artery

Mass forming lesion Liver

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Q) A 55 year old male presents with obstructive jaundice. Ultrasound evaluation reveals a

hyperechoic 4 cm mass in segment VI of liver with peripheral duct dilatation.

CT abdomen shows a hypodense mass with delayed enhancement in portal pahse.

What is the most likely diagnosis

a) Hepatocellular carcinoma

b) Intrahepatic cholangiocarcinoma

c) Metastatic Adenocarcinoma

d) Carcinoid 

b) Intrahepatic cholangiocarcinoma (IHCC)

IHCC - Mass forming type- have gradual central enhancement and variable delayed enhancement on portal phase

Hepatocellular carcinoma present ....Premium content at Questions on Bile ducts Q16-20

USMLE Trauma

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Q ) A 25 year old male brought to the hospital  after being involved in a road traffic accident that occurred 50 minutes ago. His  initial BP at the scene of accident was  80/40 mm HG with a pulse rate of 120/min.

The paramedics administered 2 litres of normal saline in the ambulance and in the emergency department his BP is 110/70 with a pulse rate of 90/min.

He has tenderness in Left upper quadrant abdomen and USG reveals perisplenic fluid. Next step is to :

a) Take him for exploratory laparotomy

b) Shift him to ICU and observe

c) Do a CT scan of the abdomen

d) Put in a laparoscope and assess

Answer c

This Patient has a splenic injury due to blunt trauma abdomen.The  immediate management  depends on grade of splenic  injury  and response to IV Fluids. This patient is hemodynamically stable after IV fluids  and immediate laparotomy is not needed.

Direct shifting to ICU is also not the right choice because CT is required first and for more severe injuries patient can go to OT

Laparoscopy has no role in splenic injuries