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
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
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
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.
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
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
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
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.
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.