Esophageal hiatus hernia

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

Q) A 38 year lady undergoes USG  abdomen for vague pain abdomen. ON USG she has a large 12 cm lesion in the right lobe of liver, which on CT turns out to be hemangioma.  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 7th  page 1184

Complications of Billroth 2 surgery

Billroth 1 and 2

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 Billroth 1 reconstruction The remnant is anastomosed  to the duodenum

In Billroth 2 duodenum stump is closed and stomach is anastomosed to the jejunum limb

Advantages of Billroth 1 

  1. More Physiological as normal GI continuity is maintained
  2. No problem of afferent and efferent limb
  3. Future procedures like endoscopy and ERCP can be done
  4. Reduced chance of gastric carcinoma in remnant stomach as compared to Billroth 2  ( SKF page 682) 

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 Dumping symptoms have been reported in up to 70% of Billroth II patients and up to 75% of patients after RYGBP
    for obesity.
  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

Shackelford's Surgery of the Alimentary Tract, 2 Volume Set: Expert Consult - Online and Print


Q)  Billroth 1 gastrectomy all are  true except-

a) Normal anatomy of  duodenum is preserved

b) ERCP can still be performed

c) Avoiding efferent and afferent limb problem

d) No risk for gastric cancer because of decreased alkaline reflux



Splenic artery aneurysm

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

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