Q1. Boundaries of gastrinoma triangle are all except
a) Cystic duct & CBD junction
b) Gall Bladder& cystic duct junction
c) Junction of Neck of pancreas & Head of Pancreas
d) 2nd and 3rd part of duodenum
Q2. One of the follwing is not the surgery for duodenal ulcer disease
b) Hill Baker
d) Lewis Tanner
Q3) Duodenal obstruction is caused by all except
a) Duodenal Diverticulum
b) Annular Pancreas
c) SMA syndrome
d) Malrotation of duodenum
Q4) Duodenal atresia is associated with all except
a) Malrotation of gut
b) Tracheo esophageal fistula
c) Imperforate anus
d) Down syndrome
e) All are seen
Q5) Crohn's disease True Statement is
A. Is caused by Mycobacterium paratuberculosis.
B. Is more common in Asians than in Jews.
C. Tends to occur in families.
D. Is less frequent in temperate climates than in tropical ones.
E. Is improved by smoking.
Q6).A 50 year old presents with vague persistent abdominal pain. CT Scan of the abdomen reveals a duodenal diverticulum. Which of the statements is true regarding duodenal diverticulum.
a) The overall incidence of duodenal diverticulum is 7-20% and about 10% of these require surgery.
b) Most of the duodenal diverticula are symtomatic and perforation is the most common complication
c) Surgery should be avoided and carried out only in case of complications like perforation, uncontrooled hemorrahge, persistent biliary or pancreatic symptoms
d) Juxta vaterian diverticulum is the easiest to manage
Q 7. Duodenal injury management false
a) Circumferential skeletonization is required
b) All duodenal repairs require some form of drainage
c) All hematomas near the pancreas requires exploration to check for serosal integrity
d) Most common location is the second portion
The upper part of the triangle is at the porta hepatis ie the junction of cystic duct and CBD. Medially is the junction of head and neck of duodenum and laterally is the junction of 2nd and 3rd part of duodenum
It is the site for 70-80% of gastrinomas with duodenum being the most common site.
Lewis is for radical three field esophagectomy
Taylor procedure is laparoscopic posterior vagotomy with anteriorseromyotomy
Hill Baker procedurer is laproscopic posterior vagotomy and anterior highly selective vagotomy.
Duodenal diverticulum is asymptomatic.
It is a true diverticulum at posteromedial apect of second portion of duodenum
Emergency surgery in duodenal obstruction is required for perforation or haemorrhage.(5-10%)
All other conditions cause duodenal obstruction.
Schakelford page 27
Duodenal atresia can be associated with other GI and biliary tract abnormalities (malrotation, esophageal atresia, ectopic anus, annular pancreas, gallbladder or biliary atresia, vertebral anomalies).
In addition, duodenal atresia can be associated with a duodenal diaphragm as well as congenital abnormalities in other systems. Examples include vertebral defects, anal atresia, tracheoesophageal fistula with esophageal atresia, and radial and renal anomalies (VATER) association and vertebral, anal, cardiac, tracheal, esophageal, renal, and limb (VACTERL) association. Anomalies of the kidneys can occur in VATER association.
These are usually aplasia, dysplasia, hydronephrosis, ectopia, persistent urachus, vesicoureteral reflux, ureteropelvic obstruction, and other conditions.
Down's syndrome is the commonest anomaly.
The cause of Crohn's disease is unknown. No specific microorganism has been identified as a pathogen, and no clear-cut environmental factor, such as smoking, has been implicated, even though many patients with Crohn's disease are heavy smokers. The disease does tend to occur in families. It is more common among Jews than Asians and among people who live in temperate climates than those in tropical ones.
Duodenum Diverticulae are the 2nd most common
diverticulum of small intestine after ileum.Most of these
are asymptomatic and incidentally detected. Only 10%
of the duodenal diverticulae are symptomatic and only 1% require
surgery.Haemorrhage is the most common complication and
perforation is the least common. Surgey is reserved for complicated
disease and where medical therapy has failed. Endoscopic options are
available for bleeding and biliary and pancreatic symptoms.
Juxtavaterian diverticulum ie 2 cm around ampulla are the most difficult to
manage because of proximity to the ampulla
Ref- Yeo: Shackelford's Surgery of the Alimentary Tract, 7th ed.
The steps in duodenal injury
1. exposure to free the duodenum from the retroperitoneal attachments of the entire surface of the duodenum via an extensive Kocher maneuver.
2. the duodenum and head of the pancreas (including the uncinate process)
are elevated medially exposing the inferior vena cava. If associated pancreatic injury is suspected, this maneuver is carried all the way medially to the right lateral border of the aorta. The entire circumference of the duodenum should now be in the operative field, and a thorough examination of the serosal surface should be completed looking for perforations, hematomas, and contusions.
All hematomas, especially those adjacent to the pancreas, should be explored to
confirm serosal integrity. To explore the fourth portion of the duodenum, the small bowel should be rotated into the right lateral abdomen and the ligament of Treitz exposed By incising the ligament and the superior retroperitoneal attachments of the distal duodenum, the circumference of the serosa in this area can be examined.
At operation, it has been shown that 35% of all duodenal injuries will be in the second portion, with the other portions having an equal distribution of 10% to 15%
Ref Shackelford page 685