Hirchsprung’s disease

Q) False statement about Hirchsprung's disease is:

a) Male and Female have equal incidence

b) In approximately 8% of the patients entire colon is affected

c) After surgery constipation is the most common problem

d) Down syndrome can be seen in up to 3-5% patients 

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Answer

a

Hirchsprung's  disease is a developmental disorder characterized by absence of ganglion cells in both Auerbach's and Meissner's plexus and males are more frequently affected than females

Absence of these ganglion  cells lead to a very tight anal sphincter with resultant constipation.

This aganglionosis which is similar to Achalasia cardia  begins at anorectal junction and involves rectosigmoid in 80% and entire colon in 8% of cases.

Various surgical options like Duhamel, Swenson and Soave procedures can be done and in all constipation is a common problem

Down's syndrome is associated in 5%

Ref: Sabiston 20th edition page 1876

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HCC Cancer

Q) Which of the following is true about screening in hepatocellular carcinoma (HCC Cancer) 

a) Alpha feto protein should be done 6 monthly

b) Ultrasound abdomen should be done 6 monthly

c) Candidates for liver transplant should be screened every 3 months

d) Nodules more than 2 cm should be followed up  more regularly

Answer b

Cirrhosis is prone for development of HCC. Screening has to be stringent.  Earlier ultrasound of liver and alpha feto protein were both used for screening

In 2009 Marrero et al demonstrated the suboptimal accuracy of AFP and after that it has been removed from the screening protocol and now only ultrasound is being done.

The screening recommendation is not for those patients with severe associated conditions and with advanced liver disease who are already considered for  transplant. So there is no screening for those who are already listed. Nodules more than 1 cm are highly suspicious where as in nodules less than 1 cm only 40% will be malignant.

Ref: blumgart 6th edition

 

 

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

  • gastricbypass.surgery

EUS criteria of malignant lymph node

Q) One of the following is not a criteria of malignancy in lymph node on EUS

a) Size more than 1 cm

b) Prominent intranodal vasculature

c) Sharp well defined  borders

d) Hypoechoic 

Recurrent Pyogenic Cholangitis (RPC)

Q) Which statement is not true about  recurrent pyogenic cholangitis :

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

b) It can present as choledocho duodenal fistula

c) 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.

Men and women are equally affected, and, historically, the disease strikes at an early age (20–40 years) in patients from lower socioeconomic classes. ( Sabiston 21st edition page 1461)

Cause for recurrent pyogenic cholangitis

Association with Ascaris lumbricoides and Clonorchis sinensis has been noted.

Stones and strictures

Clinical Presentation  of Recurrent pyogenic Cholangitis 

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

Radiology for Recurrent Pyogenic Cholangitis 

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

Surgical treatment 

Goal is to clear the biliary tree and to bypass or resect the strictures

Options are 

CBD exploration

Hepaticojejunostomy

Partial liver resections

Relapse in colon cancer

Q) All of the following colon cancers have high rate of relapse except? (# colon 1) 

a) Obstruction/Perforation

b) Venous invasion

c) Mucin production

d) High microsatellite instability

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  transected


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 For Small tumors it can be used

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

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