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

 

 

Gall Bladder Cancer in setting of APBDJ

Q) Gall bladder cancer arising in the setting of  Abnormal Pancreatico Biliary duct Junction (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


c)  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/

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 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.

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.

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

Roux en Y gastric bypass Surgery

Q) Which  of the following statement about Roux en Y gastric bypass Surgery is not true?

a) After weight loss it resolves symptoms of venous ulcers due to stasis

b) Symptoms of pseudo tumor cerebri are resolved

c) Heartburn is alleviated immediately

d) Protein malnutrition is a very common problem


d ) Protein malnutrition is common in Biliopancreatic division and duodenal switch not in gastric bypass

Essential components of successful Roux en Y gastric bypass are 

  1. Small Gastric pouch (15-20ml). In Roux en Y gastric bypass surgery, gastric pouch is constructed from cardia of the stomach to prevent gastric dilatation and minimize acid production
  2. roux limb length 65-75 cm

After RYGB 90% of patients immediately start to have relief from heartburn and other symptoms mentioned in the question

Saby ref 

Hormonal Response (Very Imp from MCQ point of view) 

  1. Increase Glucagon like peptide (GLP)
  2. Increase Peptide YY
  3. Low Ghrelin

Early complications, within 30 days after surgery 4 % of patients and include bleeding, perforation or leakage,

Late complications such as significant abdominal pain, small bowel obstruction, anastomotic stenosis or marginal ulceration can occur in 15–20 % of patients after 30 days from surgery to over 10 years 

Results

20–30 % long term, over 2 years of weight loss and maintenance 

remission of hypertension, type 2 diabetes mellitus, obstructive sleep apnoea and musculoskeletal pain.

Approximately 40 % of obese patients with type 2 diabetes go into remission within days or weeks after RYGB

REf 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709370/

For In depth bariatric surgery knowledge, try this book Bariatric Surgery Complications and Emergencies

 

Also important points  from bailey, weight loss and diabetic control is highest after BPD and DS, Table 64.5 bailey