Introducing surgery MCQs in cram sheet format to get the most out of your limited time online. Will be adding more MCQs patterned for NEET SS, DNB CET SS and MRCS Part A exams.

S.NO	Question	Answer and Explanation
1.	Liver abscess ruptures most commonly in a. Pleural cavity b. Peritoneal cavity c. Pericardial cavity d. Bronchus	b. Peritoneal cavity High risk of rupture · size >5 cm · left lobe abscess
2.	True about amoebic liver abscess: a. Male: female >10:1 b. Not predisposed by alcohol c. More common in diabetics d. E. histolytica is isolated in >50% from blood culture	a. Male: female >10:1 Majority of patients are young men (may be due to heavy alcohol consumption)
3.	Not an indication for percutaneous aspiration in amoebic liver abscess) a. Radiographically unresolved lesion afer 6 months b. Suspected diagnosis c. Lef lobe liver abscess d. Compression or outflow obstruction of hepatic or portal vein	a. Radiographically unresolved lesion afer 6 months Radiologic resolution of the abscess cavity is usually delayed. The average time to radiologic resolution is 3 to 9 months and can take as long as years in some patients. Clinical improvement after adequate treatment with antiamoebic agents is a rule.
4.	Liver biopsy is done through 8th ICS midaxillary line to avoid: a. Lung b. Pleural cavity c. Subdiaphragmatic space d. Gall bladder	a. Lung Liver biopsy is done through 8th ICS in midaxillary line to avoid Lung
5.	“Crumbled egg appearance” in liver is seen in a. Hepatic adenoma b. Chronic amoebic liver abscess c. Hydatid liver disease d. Hemangioma	c. Hydatid liver disease Crumbled egg appearance in liver is seen in hydatid disease
6.	Honey-comb liver is seen in a. Micronodular cirrhosis b. Dubin Johnson’s syndrome c. Actinomycosis d. Hydatidosis	c. Actinomycosis Most commonly, Actinomyces reaches liver through portal vein. Liver is gradually replaced by multiple abscesses, typical honey comb liver
7.	Primary sinusoidal dilatation of liver is also known as: a. Hepar lobatum b. Peliosis hepatis c. Von-Meyerburg complex d. Caroli’s disease	b. Peliosis hepatis It is an uncommon disorder characterized by multiple, small, blood-filled sinuses. It occurs in immunocompromised postransplant patients, AIDS patients, and patients taking long term steroids.
8.	Not a contraindication of lap cholecystectomy: a. Acute Cholecystitis b. Ca Gallbladder c. Portal Hypertension d. Bleeding Diathesis	a. Acute Cholecystitis In Acute cholecystitis, Lap cholecystectomy IS NOT CONTRAINDICATED. In other conditions surgery should be done by open method.
9.	A patient presented with RIF pain with dyspepsia. USG showed edematous GB wall. What will be the most sensitive investigation to confirm the suspected diagnosis? a. CECT b. MRI c. HIDA d. ERCP	c. HIDA Hydroxy-iminodiacetic acid (HIDA) is taken by liver and excreted into bile. Failure to fill gallbladder in a time of 2 hours is indicative of Acute cholecystitis
10.	True statement regarding choledochal cyst is all except: a. Type 2 is most common b. Type 1 needs excision and biliary anastomosis c. Surgical excision is the treatment of choice d. Associated with anomalous union of pancreatic and bile duct	a. Type 2 is most common As per Todani classification of Choledocal cysts: · Most common choledochal cyst – Type 1 · APBDJ is seen in 90% of choledochal cyst cases

1/11/2018 09:51:00 PM

Patients with Asymptomatic Cholelithiasis developed symptoms at a rate of approximately 1% to 2% per year.

Complications if surgery is not done were rare (approximately 4% over 25 years) except when preceded by biliary colic.

Complications typically include acute cholecystitis (0.3% per year), obstructive jaundice (0.2% per year), acute pancreatitis (0.04% to 1.5% per year), and gallstone ileus (rare)

Reference

http://www.aafp.org/afp/2014/0315/p468.html

5/04/2016 03:39:00 PM

5/04/2016 01:33:00 PM

• Preparation of the patient 
• Placement of first trocar (midline navel)
• Creation of Pneumoperitinium
• Place patient in Reverse Trendelenburg position slightly rotated to the left
• Apply local anesthetics and 2-3 other trocars under visualization of scope

• Assistant grasps fundus of gallbladder and retract superiorly
• Grasp infundibulum of the gallbladder
• Create tension by pulling slightly superior and laterally on the infundibulum of the gall bladder
• Dissect Calot’s Triangle starting towards the infundibulum of the gall bladder and working your way to the common bile duct 
• Using the gallbladder as point of reference, place 2 distal clips and 1 proximal clip along the cystic duct. 
• Divide making sure both jaws are visible to prevent vascular injur
• Using the gallbladder as point of reference, place 2 distal clips and 1 proximal clip along the cystic artery. 

Source: Dr Cara Lawrence, University of Kentucky

• Divide and cauterize/clip any necessary collateral arteries
• Dissect away the posterior wall of the gall bladder using Hook. 
• Remove gallbladder via bag or trocar
• Irrigate and Suction
• Final visualization check
• Irrigate and suction
• Release of CO2 and suture trocar incisions

Video Link 1: Click here
Video Link 2: Click here

References

• Dr Cara Lawrence, University of Kentucky http://www.mc.uky.edu/mis/ppt/Laparoscopic%20Cholecystectomy_v2.ppt

4/23/2016 02:30:00 AM

Continuing with the MCQ which I posted yesterday, today let's go through the answers and in-depth review of the concepts around obstructive jaundice. Here I would try and cover as many surgery viva questions on Obstructive jaundice as I can.

If you want to go through the question again, here is the link.

Firstly in relation to the the picture which was attached to the last post showing the yellow stained sclera of a jaundice person. The first question was

What is the lowest level of bilirubin to detect jaundice in the sclera? 

Answer: At a total serum bilirubin of 42.8 mmol/l (2.5 mg/dl) and 53.0 mmol/l (3.1 mg/dl), 58% (95% confidence interval [CI] 33-80%) and 68% (95% CI 46-85%) of examiners detected the presence of scleral icterus, respectively [1]

Q.2: What can be the cause of this presentation.
1. Liver cirrhosis with spontaneous bacterial peritonitis
2. Carcinoma of periampullary region with spontaneous bacterial peritonitis
3. Acute Fulminant Viral Hepatitis
4. Carcinoma Stomach with liver metastasis and peritoneal seeding

 Answer: 2. Carcinoma of periampullary region with spontaneous bacterial peritonitis

Points in favour of Periampullary Ca

• Painless progressive jaundice with clay colored stools
• SAP was found to elevated more than 3 times the normal value and mildly elevated ALT/AST
• He does not report any fever at the onset of jaundice. The onset of jaundice was Insidious. History of 2 days of fever can be attributed to SBP. 
• He is a young individual, though he is an alcoholic, but alcoholic liver disease and liver cirrhosis would take quite a long time of exposure to heavy drinking to present.
• Obstructive jaundice due to metastasis will be seen in advanced stages and usually jaundice will not be the first presenting symptom

To confirm our diagnosis we would do a CECT of the abdomen.

Obstructive Jaundice: Points to remember

Differential Diagnosis of Obstructive Jaundice

Intrahepatic cholestasis.

1. PBC.
2. Drugs (for example, phenothiazines).
3. Primary sclerosing cholangitis
4. Dubin-Johnson syndrome: autosomal recessive disorder characterised by conjugated hyperbilirubinaemia and deposition of pigment in hepatocytes.
5. Rotor's syndrome.

Extrahepatic Cholestasis

From within the lumen, in the wall of the duct or from external compression

1. Choledocholithiasis
2. Periampullary Ca
3. Ca Gallbladder
4. Cholangiocarcinoma involving bile duct
5. Lymph node mass in the porta causing biliary obstruction
6. Bile duct stricture
7. Sclerosing Cholangitis
8. Chronic Pancreatitis with duct obstruction

What is Courvoisier's Law?

In cases of jaundice:

• If Gall bladder is palpable, it is not due to choledocholithiasis (Secondary CBD Stone), as it will get fibrosed due to cholecystitis by ongoing disease process and not get distended.

What are exceptions of Courvoisier's Law?

• Double impact action of stone- one at common bile duct and another at cystic duct
• Primary CBD stone
• Distended Gall bladder due to large stone load

---To Be Continued---

References

http://www.ncbi.nlm.nih.gov/pubmed/9271910
http://patient.info/doctor/jaundice-pro

4/19/2016 11:12:00 PM

Icterus

Case Presentation

A 27 year old male came with complaints of Jaundice for a duration of 2 months which was insidious in onset, gradually deepening in color, not intermittent and not associated with pain. He says his stool are lighter in colour than normal. He also had gradually distending abdomen from past 1 month and pedal edema -10 days. He now complaints of fever from past 2 days not associated with chills and rigors. He is a known chronic alcoholic but does not reports of any other medical illnesses.

He is febrile on examination. Gall bladder or any lump is not palpable. Abdomen is moderately distended and mildly tender.

His bilirubin total is 7.5 and direct is 3.8. Bile salts and pigments are postive in urine. SAP was found to elevated more than 3 times the normal value and mildly elevated ALT/AST . Usg Abdomen shows Ascites and chest X ray shows bilateral pleural effusion.

Q.1: What is the lowest level of bilirubin to detect jaundice in the sclera?


Q.2: What can be the cause of this presentation.

1. Liver cirrhosis with spontaneous bacterial peritonitis
2. Carcinoma of periampullary region with spontaneous bacterial peritonitis
3. Acute Fulminant Viral Hepatitis
4. Carcinoma Stomach with liver metastasis and peritoneal seeding

Give your responses in the comments section below. Explanation to be posted tomorrow.

4/18/2016 06:46:00 PM