Surgery 1

Question 1

A 59yr old underwent partial gastrectomy 3wks ago. He received an extended course of abx. He currently complains of intermittent abdominal cramps n diarrhea. Sxs begin 25-30 minutes after eating n r associated with nausea, weakness, palpitation, lightheadedness and diaphoresis
Dx?
The most appropriate step in the mx?

Answer 1

Dumping syndrome
Dietary modification ( small, frequent meals, slowly, avoid simple sugars n increase fiber n protein)
- is due to loss of normal action of the pyloric sphincter—> rapid emptying of the hypertonic gastric content

Question 2

A 27 yr old female presented with severe epigastric pain radiating to the back, nausea, vomiting. She was recently diagnosed with functional biliary sphincter of oddi dysfunction for which she underwent ERCP with sphincterotomy 24hrs ago. The most appropriate next step is?

Answer 2

Serum amylase n lipase.

The most common complication of ERCP is acute pancreatitis

Question 3

An incidental finding of a well circumscribed liver lesion with a central scar in a 20-50 yr old woman likely represents?

Answer 3

Focal nodular hyperplasia. Rx is rarely required

Question 4

A 37 yr old male comes with acute onset of intense peri umbilical abdominal pain associated with nausea n vomiting. He was diagnosed with acute bacterial endocarditis 4 days ago n echo showed vegetations on mitral valve and he’s being treated with vancomycin. Mild diffuse abdominal tenderness is present. No signs of obstruction or perforation on abdominal X-ray. The most likely dx is?

Answer 4

Acute mesenteric ischemia- acute, pain out of proportion to physical findings; embolic source

Question 5

SBO can initially b managed conservatively. But if there r signs of complication, immediate surgical intervention is indicated. What r this signs?

Answer 5

pain characteristic, Fever, hemodynamic instability, guarding, leukocytosis, significant metabolic acidosis

Question 10

A pt comes with painless jaundice, anorexia, wt loss, a palpable gb. He most likely has?
What happens to the intra and extra hepatic biliary ducts?

Answer 10

Pancreatic head tumor( cancer)

- dilation of the biliary ducts is expected

Question 13

A 70yr old lady with a known CLL is brought to the ED with acute, sudden onset LUQ pain and syncope. She’s lethargic, pale, in distress due to abdominal pain. BP is 80/50, PR 120, T- 37.3
Diffusely tender abdomen, decreased bowel sounds. Hgb is 8.4
Dx?

Answer 13

Atraumatic splenic rupture

her hematologic malignancy is a risk factor

Question 15

Pancreatic cyst mx

• benign ( most cases)
• risk for malignant transformation ( features n mx)

Answer 15

Benign cysts r managed conservatively ( surveillance imaging)
-large size, solid component or calcification, main pancreatic duct involvement, thickened or irregular cyst wall - are associated with increased risk of malignant transformation. ENDOSCOPIC U/S GUIDED BIOPSY SHOULD B DONE. Or SURGICAL RESECTION

Question 17

A 69 yr old man comes with left lower abdominal pain which was intermittent but has been constant over the past day. Has had nausea, fever. Has hx of chronic constipation. T- 38.6, BP- 120/70, PR- 98. Tender left lower quadrant otherwise normal abdominal examination. Has leukocytosis.
Dx?
Most appropriate diagnostic test?

Answer 17

Acute diverticulitis

Abdominal CT with contrast

Question 18

63 yr old man comes with weight loss of 2months. Mucosal pallor, mild hepatomegaly, positive fecal occult blood, IDA, u/s- solitary liver lesion2x3cm
Most likely Dx?

Answer 18

Metastatic liver cancer - the most common cause of liver mass ( undiagnosed colorectal ca is the likely primary in this case)
- primary HCC usually has raised alpha feto protein level

Question 19

Episodic RUQ pain in the absence of GB (previous cholecystectomy) dilated CBD in the absence of stones , opioids May cause precipitation of pain
Most likely Dx?

Answer 19

Sphincter of oddi dysfunction

Question 20

Persistent vomiting, epigastric discomfort and tenderness following blunt abdominal trauma, no fever distention or diarrhea is suggestive of? Dx is made by?

Answer 20

Duodenal hematoma

Abdominal CT

Question 21

A pt with wt loss n fatigue,multiple liver lesions on CT scan suggesting metastasis. Rectal examination reveals normal sphincter tone but a slightly enlarged, non tender prostate
The most likely test to establish the dx is?

Answer 21

Colonoscopy

Colorectal ca is the most common source of liver metastasis

Question 22

A 65yr old comes with 2wks of dysuria, turbid foul smelling urine. He has noticed bubbles while urinating. He is being treated for BPH. He was diagnosed with acute diverticulitis 4 wks ago n treated. Urine culture grows Ecoli, klebsiella, proteus. The most likely cause of the pt’s condition is?

Answer 22

Colovesical fistula.

• fecaluria, pneumaturia, UTI with mixed flora
• can b a complication of acute diverticulitis, Chron disease, malignancy

Question 23

70yr old came with nausea, early satiety, abdominal distention n vomiting 🤮 . He has significant wt loss. But no dysphagia, hematemesis, melena. Epigastrum is tender to palpation. A succussion splash is elicited. K- 2.7, cl- 89, bicarbonate- 32 glucose- 220
Dx?

Answer 23

GOO secondary to pancreatic adenocarcinoma( common cause of GOO)

Question 24

Intermittent solid food dysphagia mostly in young men, associated with atopic conditions like asthma
Dx?

Answer 24

Eosinophilic esophagitis

Question 25

A patient having amylase rich exudative pleural effusion; hx of alcohol use n recurrent epigastric pain,, most likely Dx?

Answer 25

Pancreaticopleural fistula- commonly due to acute or chronic pancreatitis

Question 26

A 45 yr old is having nausea n vomiting on her 3rd pod. She hadn’t passed flatus or had a bowel movement since the surgery. Abdomen is mildly distended n bowel sounds r decreased abdominal X-ray shows dilated loops of bowel with no transition point, air in the colon/rectum
most likely Dx?
The best next step in the mx is?

Answer 26

prolonged postop ileus(>72hrs after surgery)

Bowel rest n serial examination

Question 27

Surgical Management of (timing)

1) Emphysematous gallbladder
2) Low risk pts with acute nonemphysematous cholelithiasis
3) high risk pts( eg systemic illness) with cholelithiasis

Answer 27

1) Emphysematous gallbladder- urgent cholecystectomy
2) Low risk pts with acute nonemphysematous cholelithiasis- delayed cholecystectomy prior to hospital discharge,ideally within 72hrs.
3) high risk pts( eg systemic illness) with cholelithiasis- delayed until after recovery.

Question 28

A chest tube draining a turbid, green fluid in a patient who had chest trauma is most consistent with?

Answer 28

Esophageal perforation

Question 29

An elderly woman with progressive abdominal pain, nausea/vomiting, abdominal distention, high pitched bowel sounds, X-ray showing distended bowel loops with air fluid levels, fullness n tenderness within the rt groin
Most likely Dx?

Answer 29

SBO secondary to incarcerated hernia

Question 30

A pt came with UGIB, he is receiving NS through a peripheral iv catheter
The best next step in the mx?

Answer 30

Obtain a second IV axis. The first step in the mx of UGIB is to establish vascular axis with two large bore IV catheters

Question 31

Pancreatic pseudocyst Mx?

Answer 31

Minimal or no sxs- expectant mx

Severe sxs, complications- endoscopic drainage

Question 32

A pt with stuttering episodes of nausea, vomiting; pneumobilia; hyperactive bowel sounds, dilated loops of bowel most likely has

Answer 32

Gallstone ileus ( a mechanical obstruction following passage of gallstones through a biliary enteric fistula into the small bowel

Question 33

A painful fluctuant mass 4-5 cm cephalad to the anus( around the tip of coccyx) in the intergluteal region with associated mucous, purulent or bloody drainage in a 25 yr old obese man with sedentary occupation Is most likely consistent with?

Answer 33

Pilonidal disease ( an edematous, infected hair follicle becomes occluded, infection spreads subcutaneously and forms an abscess)

Question 34

5 weeks of constant, progressive epigastric pain that is worse with eating, wt loss in a 55yr old smoker; u/s shows gallstones with no gallbladder inflammation or ductal dilation, endoscopy is non revealing The best next step in the mx is?

Answer 34

Abdominal CT - highly sensitive in detecting pancreatic ca

Question 35

A 76 yr old woman was diagnosed with acute diverticulitis n given oral abx 5 days ago. Now she came with abdominal pain, nausea and fever. CT scan shows 5 cm rim enhancing perisigmoid fluid collection. Has leukocytosis. The most appropriate next step in the mx is?

Answer 35

Percutaneous abscess drainage under CT guidance. | -<3 cm abscess- iv abx without drainage can b tried

Question 36

A 57 yr old smoker comes with constant, progressive back pain that is worse at night n when supine; wt loss. Back/neurologic examinations, imaging r all normal. Which of the following Ix is most appropriate? A) BM biopsy. B)CT of abdomen. C) UGI endoscopy

Answer 36

Abdominal CT! Because it looks like the pt is having pancreatic ca( body or tail)

Question 37

Difference between SBO and paralytic ileus presentations.

Answer 37

- Paralytic ileus- constant pain, decreased bowel sounds - SBO- colicky pain, increased bowel sounds - X-ray

Question 38

Advanced pancreatic ca (eg. Liver Mets), causing Obstructive jaundice with pruritus- treatments?

Answer 38

Endoscopic CBD stent is the first line therapy. Surgical bypass is sometimes considered as a second line treatment where stent placement would be technically challenging - No difference in survival between the two options

Question 39

Which of the following is strongly associated with increased progression n severity of crohn disease ? A) smoking. B obesity. C)DM

Answer 39

Smoking

Question 40

A pt with blunt abdominal trauma has signs of hypovolemic shock, has concomitant rt lower ribs fracture The pt most likely has which intraabdominal organ injury?

Answer 40

Liver laceration. | Liver is the most commonly injured organ in blunt abdominal trauma

Question 41

A patient has developed a postoperative ileus. He received metoclopramide and morphine. Which one of these drugs is a contributor to his ileus?

Answer 41

Morphine. Metoclopramide has promotility effects

Question 42

A 43 yr old man comes due to worsening anal pain for the past two days. He initially had it during defecation but now it’s constant n severe. Has hx of constipation and anoreceptive intercourse. Erythematous, tender 1 cm fluctuant mass near the anal orifice with induration of the overlying skin Dx? Cause?

Answer 42

Perianal abscess | Occlusion of an anal crypt gland

Question 43

A patient who has melena, RUQpain, jaundice, anemia following a recent liver biopsy likely has?

Answer 43

Hemobilia ( bleeding into the biliary tract)- a rare cause of UGI bleeding

Question 44

A 70 yr old man comes with RUQ pain worsening, fever anorexia for the past 2 days. He was treated for acute diverticulitis 4 weeks ago. He has DM n htn. CT scan of the abdomen shows hypoattenuating lesion in the liver( see image) Dx? Mx?

Answer 44

Pyogenic liver abscess. Pt is diabetic, had diverticulitis ( spread of bacteria from inflamed intestines thru the portal circulation) hematogenous spread, direct extension from biliary tract infection are other routes. Mx- blood culture, abx - percutaneus aspiration n drainage

Question 45

The most common malignancy to present with bloody ascites is?

Answer 45

HCC | Suspect in the case of persistently bloody traumatic ascites

Question 46

A 19yr old came with persistent abdominal discomfort. He came to the ED 3days back after he fell while mountain biking 🚵‍♀️ . He recalls hitting the handlebars before flipping n landing on his back. Investigations were normal at that time. Now he had an episode of non bilious vomiting; he has echymosis on the upper abdomen, tender to palpation. U/s shows free fluid in the upper abdomen The most likely cause is?

Answer 46

``` Pancreatic injury ( fluid collection from pancreatic duct injury) Increasing amylase over serial measurements can occur ```