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
1) b
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.
The gastrinoma triangle, also known as the gastrinoma triad, is a region in the abdomen defined by three anatomical boundaries:
Duodenum: The first part of the small intestine, where gastrin-secreting tumors (gastrinomas) are commonly found.
Pancreas: Particularly the head and tail of the pancreas, which can also harbor gastrinomas.
Biliary tree: This includes structures like the gallbladder and bile ducts, where tumors may also occur.
Importance of the Gastrinoma Triangle
Diagnosis: Identifying the gastrinoma triangle is crucial in diagnosing gastrinomas, which can cause Zollinger-Ellison syndrome—a condition characterized by excessive gastric acid secretion, leading to recurrent ulcers.
Surgical Planning: Understanding the boundaries helps surgeons locate and resect tumors effectively, especially when they are difficult to detect due to their small size or location.
Treatment: It aids in planning appropriate treatment strategies, including medical management and surgical options.
Q2. One of the following is not the surgery for duodenal ulcer disease
a) Taylor
b) Hill Baker
c) HSV
d) Lewis Tanner
2) d
Lewis is for radical three field esophagectomy
Taylor procedure is laparoscopic posterior vagotomy with anteriorseromyotomy
Hill Baker procedure is laparoscopic posterior vagotomy and anterior highly selective vagotomy.
Q3) Duodenal obstruction is caused by all except
a) Duodenal Diverticulum
b) Annular Pancreas
c) SMA syndrome
d) Malrotation of duodenum
3) a
Duodenal diverticulum is asymptomatic.
It is a true diverticulum at posteromedial aspect of second portion of duodenum
Emergency surgery in duodenal obstruction is required for perforation or hemorrhage. (5-10%)
All other conditions cause duodenal obstruction.
Many individuals with a duodenal diverticulum may be asymptomatic. However, symptoms can arise, including:
Abdominal pain
Nausea or vomiting
Bloating
Potential complications like diverticulitis (inflammation), obstruction, or bleeding.
Further reading Shackleford page 27
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
4) e
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).
Trisomy 21 (Down Syndrome)
Duodenal atresia is significantly associated with Down syndrome, with an increased incidence in affected infants.
2. Congenital Heart Defects
Common heart defects, such as atrioventricular septal defects and ventricular septal defects, are frequently seen alongside duodenal atresia.
3. Malrotation
Many infants with duodenal atresia may also have intestinal malrotation, which can complicate surgical management.
4. VACTERL Association
This refers to a group of congenital defects that may include:
Vertebral defects
Anal atresia
Cardiac defects
Tracheoesophageal fistula
Esophageal atresia
Renal anomalies
Limb defects
5. Other Gastrointestinal Anomalies
Conditions like jejunal atresia or intestinal duplications may also be present.
6. Oligohydramnios
This condition, characterized by low amniotic fluid levels, is often seen in cases of duodenal atresia, as it can lead to fetal gastrointestinal obstruction.
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.
5) c
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.
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 symptomatic and perforation is the most common complication
c) Surgery should be avoided and carried out only in case of complications
d) Juxta vaterian diverticulum is the easiest to manage
6) c
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 diverticula are symptomatic and only 1% require surgery.
Hemorrhage is the most common complication and perforation is the least common.
Indications for Surgery
Diverticulitis: Inflammation of the diverticulum can lead to severe pain and complications.
Obstruction: If the diverticulum causes a blockage in the duodenum.
Bleeding: Significant gastrointestinal bleeding may necessitate surgical intervention.
Symptoms: Persistent symptoms that do not respond to conservative management may warrant surgery.
Surgical Options
Diverticulectomy: The surgical removal of the diverticulum itself, often performed if the diverticulum is symptomatic.
Resection: In some cases, a portion of the duodenum may be resected if the diverticulum is associated with significant pathology or if there is a concern about malignancy.
Bypass Surgery: If the diverticulum is causing obstruction and cannot be safely removed, a bypass may be created around the affected area.
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
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
7) b
The steps in duodenal injury surgery are as follows
1. Extensive Kocher maneuver.
2. Expose the inferior vena cava.
3. If more exposure of duodenum and pancreas is required go upto the right lateral border of the aorta.
Look for contusions hematoma and serosal tears
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.
35 % injuries are in 2nd part of duodenum
Rest are evenly distributed
Ref Shackelford
Q8) Not true about duodenal diverticula?
a) Extraluminal are more common than intraluminal
b) Most commonly seen with in 2cm of ampulla
c) Most of them are symptomatic with epigastric pain
d) Surgical treatment is diverticulectomy
Q9) Which of the following is not true about duodenal adenocarcinoma
a) Adenocarcinoma is the most common malignancy affecting duodenum
b) Most of the patients with duodenal adenoacarcinoma have a palpable mass
