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Surgery answers

  2. 2. ANSWERS1. Regarding to gallstone is/are true except: A. TRUE. Risk factor of gallstone 5F( fat, fair, fertile, forty, female) Other risk factor are patient with hereditary spherocytosis/sickle cell anemia(haemylosis increase bilirubin formation) and rapid weight loss (Bailey and love, B. TRUE. Bile constituents which are cholesterol, calcium salts, bile acids, bile pigment and phospholipid can be found in every type of gallstone. Only the percentage is difference between the types of gallstone. C. TRUE. There are 2 types of pigment stone which is black and brown. Usually,the one which form in biliary duct is the brown type. It is usually cause by bile stasis and infected bile. For black stone, it is caused by haemolysis. D. FALSE. Increase in pH value(decrease bile acid) will cause formation of crystal is true. But for gastric emptying, it is a false statement. Abnormal emptying of gallbladder is a true answer. (Bailey n love) E. FALSE. For cholesterol stone, the size is usually small and multiple (OverviewC. Wolpers and A. F. Hofmann. Solitary versus multiple cholesterol gallbladder stones Journal of Molecular Medicine.Volume 71, Number 6, 423-434)2. These statement is true about gallstones: A. TRUE. Only for small and functioning bile duct with patient that can’t undergone operation or do not want to be operated. Chenodeoxycholic acid is one of the drugs that can dissolve the stone. (Journal: Surgery: basic science and clinical evidence) B. FALSE. Causes of pigment stone formation are from excessive hemolysis of the blood not excessive packed red blood cell transfusion. (Baley and love pg 120) C. FALSE. It’s true that gallstone can cause intestinal ileus but it cause by obstruction of the intestinal not by parasympathetic stimulation. The narrowest part of the small intestine is the ileo-cecal valve. If the gallstone is too large to pass through the valve, it can obstruct the small intestine and cause an ileus. ( D. TRUE. Cholecystitis is often caused by cholelithiasis (the presence of choleliths, or gallstones, in the gallbladder), with choleliths most commonly blocking the cystic duct directly. This leads to inspissation (thickening) of bile, bile stasis, and secondary infection by gut organisms, predominantly E. coli and Bacteroides species. ( E. FALSE. It is because E. Coli doesn’t produce urease. The one which produce urease is proteus ( Following these statements is/are true about Acute Pancreatitis except: A. TRUE. 10% of cases with acute pancreatitis is presented with haemodynamic instability and hematemesis or melena sometimes develops (5%). ( B. FALSE. Characteristic of Acute Pancreatitis pain is it develop quickly and reaching maximum intensity within minutes. C. TRUE. Based on sign and symptom of acute pancreatitis, liver abscess and ascending cholangitis, all 3 of them are having fever, abdominal pain and jaundice especially on ascending cholangitis. ( in comparison between this 3 disease) D. TRUE. Cullen’s sign is discolored skin is which is usually blue-black and becomes greenish brown or yellow. Cullens sign may appear 1 to 2 days after the onset of anorexia and the severe,
  3. 3. poorly localized abdominal pains that are characteristic of acute hemorrhagic pancreatitis. ( E. TRUE. If there’s biliary obstruction, it can cause acute pancreatitis for example in periampullary carcinoma or gallstone obstructing the lumen of biliary. (Baley n Love pg 1120)4. All these statements are true about Acute Pancreatitis: A. TRUE. One of complication of is pancreatic ascites(Baley and Love pg 1144). Basicly, if there is fluid in the abdomen, it will predispose us to get Spontaneous Bacterial Peritonitis. Other condition are such as CHF, Budd-Chiari syndrome, liver cirrhosis and other disease that cause ascites ( B. TRUE. Pancreatic duct obstruction resulting from gallstone, structure formation from trauma or pancreatic cancer can cause chronic pancreatitis. However, most common cause is high alcohol consumption. (Baley and love, Pg 1146) C. TRUE. Acute methanol poisoning appears to produce pancreatic injury. In a series of 22 consecutive patients admitted with a diagnosis of acute methanol poisoning, we found evidence of pancreatic damage in 11 patients. ( ( J Hantson P, Mahieu. Pancreatic injury following acute methanol poisoning. Toxicol Clin Toxicol. 2000;38(3):297-303.) D. FALSE. Alcohol abuse is second most common causes of acute pancreatitis which account for 25% of cases. Most common cause is biliary calculi which account for 50-70% of patients (Baley and Love, Pg 1139) E. FALSE. It is because MRCP is not invasive procedure like ERCP. In ERCP, 1-3% develops pancreatitis ( and Baley and love, pg 1139)5. Patho-clinical changes in Acute Pancreatitis: A. TRUE. Pancreatic necrosis refers to a diffuse or local area of non-viable parenchyma that is typically associated with pancreatic fat necrosis and it is also possible to find calcium precipitates in it. (hematoxylinophilic) (Baley and love pg 1142 and B. TRUE. Non of biochemical test having a diagnostic value to diagnose Acute Pancreatitis. Typically, the diagnosis is made on the basis of clinical presentation and an elevated serum amylase level. But a normal serum amylase doesn’t exclude acute pancreatitis. We can also do serum lipase level because it provides more sensitive and specific test than amylase. If there is doubt, use contrast -enhanced CT. ) (Baley and love pg 1140) C. TRUE. Sentinel loop dilatation is an ilues of intestine which is cause by acute pancreatitis and caused the intestine to dilate. Although it was confirmed that dilatation of the first part of the duodenum and the first loop of the jejunum was a common sign, isolated dilatation of the transverse colon was demonstrated to be the most frequent accompaniment of acute pancreatitis, being present in one-third of the cases. (I.M. Miller MB, BS, DCH and M.H. Irving MD,The value of the plain abdominal roentgenogram in the diagnosis of acute pancreatitis, The American Journal of Surgery Volume 123, Issue 6, June 1972, Pages 671-673) D. FALSE. In acute pancreatitis, elevated amylase levels usually parallel lipase concentrations, although lipase levels may take a bit longer to rise than blood amylase levels and will remain elevated longer. ( E. TRUE. If the diagnosis of the acute pancreatitis is in doubt, we can use CT abdomen to rule out other acute abdomen condition. (Bailey and Love pg 1140)
  4. 4. 6. Acute Pancreatitis can be diagnosed through: A. FALSE. Diagnosis of acute pancreatitis is made on the basis of clinical presentation (i.e epigastric pain radiated to the back a/w nausea, vomiting etc) and ↑amylase level. (Bailey & Love pg 1140) B. TRUE. Ranson Criteria, Glasgow scale & Apache II score used to assess the severity of acute pancreatitis whereby appropriate management approach will be done according to the severity. Ranson criteria Glasgow criteria On admission On admission age > 55years Age > 55years WBC >16000/mL WBC > 15000/mL LDH > 350 IU/L Glucose > 10mmol/L (no hx of DM) Glucose >200mg/Dl Urea > 16mmo/L (no response to IV fluid) AST > 250 IU/L PaO2 < 8kPa/60mmHg Within 48 hours Within 48hours hct ↓ > 10% Ca < 2mmol/L BUN ↑ > 5mg/dL Albumin <32g/L Ca < 8mg/dL LDH > 600 IU/L paO2 < 60 mmHg/8 kPa AST/ALT > 600 IU/L Base deficit > 4mg/dL Fluid sequestration > 6L Score > 3 indicates severe attack Score > 3 indicates severe attack (73% sensitivity, 77% specificity) APACHE II score has the advantage of being able to assess the patient at any point of time during the ilnness, however, it is very cumbersome. Score >8 indicates severe attack Apache II score : Other scores – BISAP score, Atlanta criteria C. FALSE. ALT > 150 unit/L indicates gallstone pancreatitis and more fulminant disease. AST > 250 unit/L is the right answer, not ALT. D. FALSE. Ranson criteria is valid only after 48 hours after onset and not at any time other time during the disease ( E. FALSE. The parameters are shown as above.7. Regarding gallstones; A. TRUE. Gallstone/biliary colic occur in 10-25% of patients  Due to gallbladder contraction when gallstones is accidentally impacted in cystic duct  Severe upper quadrant pain a/w nausea, vomiting radiated to right scapular tip  Resolves over 30-90 minutes  Constant, not relieved by emesis, antacids, defecation/positional changes. B. TRUE. Especially the brown type of pigmented stone. 3 types of stones:  Cholesterol – a/w obesity, high calorie diet and OCP
  5. 5.  Pigment - < 30% cholesterol, 2 types : black (bilirubin pigment, a/w hemolysis i.e spherocytosis, sickle cell dss) & brown (rare; a/w infected bile, foreign bodies in bile ducts i.e parasites/stent ; contain Ca bilirubinate, Ca palmitate and Ca stearate  Mixed – most common type (Bailey&Love pg 1120) C. FALSE. Courvisier’s law = in the presence of jaundice, an enlarged gallbladder is unlikely to be due to gallstones; or signs of malignancy. As in gallstones, the wall is fibrosed and incapable of enlargement. D. TRUE. Explaination as above (B). Other drugs causing gallstones:  Hypolipidemic drugs – clofibrate etc --- increase hepatic elimination of cholesterol via biliary secretion  Somatostatin analogue (i.e octreotide) ---decreasing gallbladder emptying causing stasis. E. TRUE. Formation of cholecystoenteric fistula predisposed to migration of stome into intestine causing gallstone ileus, presents with IO.8. Concerning pancreatitis; A. FALSE. Causes of pancreatitis – GET SMASHED B. FALSE. Cullen’s sign = bluish discoloration around umbilicus – hemorrhagic pancreatitis migrating thru round ligament. Grey Turner’s sign = bluish discoloration of the flanks C. FALSE. (refer above question) D. TRUE. (refer above question) E. TRUE. (refer above question)9. The statement below describes about pancreatic tumour A. FALSE. 85% of pancreatic tumors are ductal adenocarcinoma of the pancreas which is malignant types. Other benign types are:  Cystadenoma  Insulinoma B. TRUE. FYI, jaundice in periampullary tumor is intermittently wax and wane – central necrosis and sloughing/pressure opening of minimally obstructed duct. Surgery is primary modality of treatment whereby pancreaticoduodenectomy (Whipple) is the standard procedures. ( C. TRUE. Glucagonoma – secrete glucagon -> glycogenolysis -> hyperglycemia ( D. TRUE. ZES = gastrin secreting tumor -> hypertrophy of gastric mucosa -> increased #parietal cells -> increase acid production -> gastric ulceration ( E. TRUE. Thrombophlebitis migrans/migratory = thrombophlebitis of small segment of vein that resolves in one area and begins in another area 50% patients with pancreatic Ca have it. http:// Concerning cholelithiasis A. FALSE. Calcified gallstone is radioopaque which account for 90% of gallstone B. TRUE. Hemolytic disorders – sickle cells, spherocytosis, B thalassemia predisposed to black stones.
  6. 6. C. FALSE. Charcoat triad is features of cholangitis = fever + abdominal pain (RUQ) + jaundice Reynaulds pentad = Charcoat triad + hypotension + mental status changes. Other Charcoat triad is for multiple sclerosis = nystagmus, intention tremor, scanning/staccato speech D. FALSE. No direct relationship. E. FALSE. Lead to adenocarcinoma of the gallbladder, usually preceeded with chronic cholecystitis. ( Sorry for the inconvenience12. Sorry for the inconvenience13. Sorry for the inconvenience14. Sorry for the inconvenience15. Sorry for the inconvenience16. Portal hypertension A. FALSE. Budd-chiari syndrome is the cause of intrahepatic, predominantly sinusoidal and/or postsinusoidal. B. TRUE. In portal hypertension, patient can have exudate or transudate ascites and to determine it, we need to do aspiration of peritoneal fluid. Bailey n love’s page 1091 C. TRUE. It is one of the sign of portal hypertension. TRUE. Esophageal varices and PUD usually present with upper GI bleed. Bailey n love’s page 1063. D. True. In portal hypertension, the spleen ws enlarged lead to sequestration of blood cells leading to pancytopenia. ( (http:// Causes of acute pancreatitis A. TRUE. B. TRUE. C. TRUE. D. TRUE. E. FALSE. NSAIDS is the cause of peptic ulcer disease. Causes Biliary tract disease (approximately 40%), Alcohol (approximately 35%), Post-ERCP (approximately 4%), Trauma (approximately 1.5%), Drugs (approximately 2%), Infection (<1%), Hereditary pancreatitis (<1%), Hypercalcemia (<1%), Developmental abnormalities of the pancreas (<1%), Hypertriglyceridemia (<1%), Tumor (<1%), Toxins (<1%), Postoperative (<1%), Vascular abnormalities (<1%), Autoimmune pancreatitis (<1%) and idiopathic. ( Liver cirrhosis A. FALSE. It is irreversible liver damage. (Oxford handbook of clinical medicine page 252) B. TRUE. Cirrhosis is characterized by regenerating nodules and fibrosis. Incompletely formed liver nodules, nodules without fibrosis (nodular regenerative hyperplasia), and congenital hepatic fibrosis (ie, widespread fibrosis without regenerating nodules) are not true cirrhosis. Cirrhosis can be micronodular or macronodular. Typically, nodules lack lobular organization; terminal
  7. 7. (central) hepatic venules and portal triads are distorted. ( C. TRUE. Liver transplant is the only definitive treatment of liver cirrhosis. Oxford handbook of clinical medicine page252. D. TRUE. Patient will have sign of stigmata of liver diseases such as spider naevi, ascites, palmar erythema, clubbing, gynecomastia Oxford handbook of clinical medicine page252. E. TRUE. HCC is a complication of liver cirrhosis. The sphincter of Oddi (SOD) A. FALSE. CCK relax the SOD. B. TRUE. It regulates the flow of bile and pancreatic juice into the duodenum and prevents reflux of duodenal contents into the ducts. C. FALSE. Gastrin contract the SOD. D. These contractions are present throughout the interdigestive period. Bile A. TRUE. Bile contains mostly cholesterol, bile acids (also called bile salts), and bilirubin (a breakdown product of red blood cells). It also contains water and body salts (potassium and sodium), as well as very small amounts of copper and other metals. B. FALSE. Bile contains conjugated bile acids. Lippincott biochem page223 C. TRUE. Bile contains conjugated bilirubin. Lippincott biochem page 280 D. FALSE. Bile is required for the uptake of cholesterol in small intestine. Lippincott biochem page222 E. FALSE. It is excreted into the duodenum, helping to break down fats. Cullen’s sign may be seen in : A. Cushing’s syndrome – FALSE ** it has nothing to do with any bleeding in the peritoneum B. Acute pancreatitis - TRUE ** Especially acute HEMORRHAGIC pancreatitis ** Grey Turner’s sign also is present (discolouration of the flank) C. Hirchsprung’s disease – FALSE ** Normally, muscles in the intestine push stool to the anus, where stool leaves the body. Special nerve cells in the intestine, called ganglion cells, make the muscles push. A person with Hirschsprungs disease does not have these nerve cells in the last part of the large intestine  Children with Hirschsprungs disease might also have anemia, a shortage of red blood cells, because blood is lost in the stool, but NOT in the peritoneum D. Carcinoma of the pancreas – FALSE
  8. 8. ** Usually in pancreatic CA – pt is presented with weight loss, abdominal mass (d/t tumour itself), palpable gallbladder (Courvoisier’s sign : a palpable gb in jaundiced pt is usually d/t biliary obstruction by a pancreatic CA) or hepatic metastasis (Davidson’s Essential of Medicine, pg.461) E. Peritonitis – TRUE ** Peritonitis is usually following intra-abdominal pathology. Risk factors of peritonitis including bacterial invasion results in infection and inflammation and perforation of the GI tract. Usually, this is a complication of appendicitis, diverticulitis, peptic ulcer, ulcerative colitis, strangulated obstruction, abdominal neoplasm, or a stab wound. Peritonitis may also result from chemical inflammation, as in rupture of fallopian tubes or the bladder, perforation of a gastric ulcer, or released pancreatic enzymes  so any rupture can lead to haemoperitoneum. Cullens sign : the appearance of faint, irregularly formed hemorrhagic patches on the skin around the umbilicus. The discolored skin is usually blue-black and becomes greenish brown or yellow. Cullens sign may appear 1 to 2 days after the onset of anorexia and the severe, poorly localized abdominal pains that are characteristic of acute hemorrhagic pancreatitis. It is also present in massive upper GI hemorrhage and ruptured ectopic pregnancy. Pathophysiology : usually results from hemoperitoneum, and the diffusion of blood along periumbilical tissues produces the discoloration around the navel. Diffusion of blood via the falciform ligament may also produce periumbilical blood staining. This discoloration is typically blue or purple but may occur in various shades of green or yellow depending on the stage of erythrocyte breakdown Conditions Associated with Cullen’s Sign Pancreatitis Ruptured ectopic pregnancy Ruptured aortic aneurysm Ruptured spleen Ruptured common bile duct Perforated duodenal ulcer Hepatocellular carcinoma Hepatic lymphoma Metastatic thyroid cancer Percutaneous liver biopsy Haemochromatosis is characterized by A. yellow discoloration of the skin – TRUE ** Discolouration or bronzing of the skin is due to high serum ferritin levels (1000 to 10,000) in the body. There must be elevated ferritin levels in the blood for symptoms to occur. If not, no symptoms will appear. ** Skin bronzing or hyperpigmentation (70%): This reflects a combination of iron deposition and melanin. The classic triad of cirrhosis, diabetes mellitus, and skin pigmentation occurs late in the disease, when total iron body content is 20 grams (ie, >5-times normal). B. Diabetes Mellitus resulting from insufficient insulin production - FALSE
  9. 9. ** As well as liver disease, other serious conditions can be caused by excess iron: Diabetes, arthritis, heart disease and psychological problems C. Liver enlargement – TRUE ** It is the abnormal and excessive absorption of iron from food in which the excess iron is retained and deposited in various joints and organs throughout the body, in particular, the liver. Normally, the liver stores iron for the essential purpose of providing new red blood cells with iron. This is necessary for life and good health, however, when excess quantities are stored in the liver, it becomes enlarged and causes serious damage to the tissue such as cirrhosis D. A genetic defect on chromosome 6 – TRUE ** The gene responsible for the disease is called HFE and is located on chromosome 6 E. Saturation of the iron binding lactoferrin – FALSE ** It has nothing to do with iron binding because in haemochromatosis is HFE is mutated in most individuals with hereditary hemochromatosis. HFE interacts with the transferrin receptor and causes a clear decrease in the affinity with which the receptor binds transferrin. This interaction also may modulate cellular iron uptake and decrease ferritin levels. When a mutant or nonfunctional variant of the HFE gene is present, ferritin levels are not under influence of a normal and functional HFE gene, which leads to enhanced accumulation of iron in peripheral tissues, so it is related with transferring, NOT lactoferrin. The causes of acute pancreatitis include : A. Post-ERCP – TRUE ** People who undergo therapeutic ERCP are at slight risk for complications, including severe pancreatitis, infection, bowel perforation, or bleeding. Complications of ERCP are more common in people with acute or recurrent pancreatitis. B. Azathioprine – TRUE (rare) ** The incidence of acute pancreatitis in our IBD patients (1.6%) is similar to that previously described. Drugs, mainly AZA/MP, are the leading cause. AZA-induced acute pancreatitis is always mild. Patients with CD are at a higher risk for AZA/MP-associated acute pancreatitis. C. Alcohol – TRUE (common – 35% of cases) ** The condition is most often caused by alcoholism and alcohol abuse (70% of cases in the United States) ** Large amounts of alcohol consumption can cause damage to the pancreas. Alcohol harms the pancreas by lessening the amount of digestive enzymes that are released by the pancreas, which therefore causes inflammation and leaking of the digestive enzymes. The digestive enzymes then attack the pancreas. Significant alcohol ingestion can also cause a condition of the pancreas called acute pancreatitis. D. NSAIDS – FALSE ** Trial shows that rectal indomethacin given immediately before ERCP can reduce the incidence and severity of post-ERCP pancreatitis. (Am J Gastroenterol. 2007 May;102(5):978-83. Epub 2007 Mar 13.)
  10. 10. E. Gallstones – TRUE (common – 45% of cases) ** The most common cause of acute pancreatitis is the presence of gallstones—small, pebble- like substances made of hardened bile—that cause inflammation in the pancreas as they pass through the common bile duct. Regarding the pancreas; A. Ectopic pancreatic tissue may be found in the distal end of the oesophagus – TRUE ** Also called pancreatic heterotopias, usually at gastroesophageal junction in 16% of pediatric/ young adult patients. It may be congenital and independent of Barrett’s esophagus. Usually no clinical significance, but may exhibit pathologic changes of pancreatic tissue including ductal carcinoma, other malignancy, or pancreatitis. Micro: benign appearing pancreatic ducts and acini Cytology: clusters of benign appearing ducts and small acini mixed with inflammatory cells Micro images: esophageal squamous mucosa overlying pancreatic type parenchyma, immunostaining for trypsin, lipase and amylase Positive stains: trypsin, chymotrypsin, amylase, lipase B. Ranson’s criteria are used to stage chronic pancreatitis – FALSE ** Indication - Predicts prognosis in ACUTE Pancreatitis C. Speckled calcification of pancreas may occur in chronic pancreatitis – TRUE ** A plain film of the abdomen is usually the first diagnostic test used to establish a diagnosis of chronic pancreatitis. Diffuse, speckled calcification of the gland may suffice as a positive finding A3C1-49E5-B6A0-C19DE1F94871&GDL_Disease_ID=0ADCFD83-7DE7-4D53-82F5-6F0C9BFB7F14 D. Pseudocysts are usually multiple – TRUE ** The pseudocyst can be single or multiple, with multiple cysts found more often in patients with alcoholism. As it is usually associated with pancreatitis, as pancreatitis is commonly d/t alcoholism, so it is TRUE multiple pseudocyst is more common. E. Diabetic smokers have an increased risk of develop carcinoma head of pancreas – TRUE ** The disease is associated with smoking and chronic pancreatitis, and DM occurs in advanced cases because the Islet of Langerhans is involved. (Davidson’s Essential of Medicine, pg.457, 459)25. The following are potential complications of gallstones A. TRUE. Acute pancreatitis B. FALSE. Pancreatic cancer C. TRUE. Ascending cholangitis D. FALSE. Primary biliary cirrhosis – autoimmune : anti-smooth muscle antibodies (OHCM : 258) E. TRUE. Empyema of gallbladder Complications of gallstones (OHCM: 591) In the gallbladder • biliary colic • acute cholecystitis
  11. 11. • chronic cholecystitis • empyema of the gall bladder • mucocele • perforation In the bile duct • biliary obstruction • acute cholangitis • acute pancreatitis In the intestine • intestinal obstruction (gallstone ileus)26. The followings is/are true of tumours of the liver A. TRUE. Metastases are the commonest tumours seen in the liver (Bailey & Love’s: 1097 – 1100) Primary Benign • Haemangiomas : most common • Hepatic adenoma : rare • Focal nodular hyperplasia : unusual Malignant • Hepatocellular carcinoma: one of the most common cancer • Cholangiocarcinoma Secondary Commonest tumours of the liver : metastatic from pancreas, colon, stomach, oesophagus and breast B. TRUE. Cirrhosis is a risk for hepatocellular carcinoma (HCC) whatever the cause (Clinical surgery handbook: 312) Common in Africa and asia, commoner in men than women Risk factors • cirrhosis : especially due to chronic viral hepatitis (HBV/HCV) or alcohol • aflatoxin exposure • contraceptives • androgens C. TRUE. HCC are particularly sensitive to chemotherapy  Treatment for HCC (Bailey & Love’s: 1099) (1) Surgical: remove the known cancer with a 1 – 2 cm margin of unaffected liver tissue. In chronic liver disease, the volume of liver resects should be minimized to reduce the incidence of postoperative liver failure. In major resections, local or segmental resections are preferred (2) Non-surgical: majority diagnosed with HCC will not be amenable to surgical resection because of the advanced stage of the cancer or the severity of the underlying liver disease. These patient can be offered local ablative treatment such as transarterial embolisation, transarterial chemoembolisation, percutaneous ethanol ablation or radiofrequency ablation (3) Adjuvant: chemotherapy will improve the prognosis of patient following resection of HCC and it may damage the function of the liver in those with underlying chronic liver disease D. TRUE. Liver ultrasound will detect the majority of liver tumours  In secondary liver tumours : ultrasound is the primary investigation, with Ct and MRI to define metastases and look for a primary
  12. 12.  In HCC: ultrasound scans show filling defects in 90% of cases (Kumar & clark’s: 363) E. TRUE. Hemangiomas are the commonest benign liver tumours27. The following statements is/are true; A. TRUE. Serum amylase is rarely normal in acute pancreatitis. Diagnosis is made on the basis of the clinical presentation and an elevated serum amylase level. Investigation:  Serum amylase level three to four times above normal within 24 hours of the onset of pain is indicative of the disease.  Serum amylase is normal in patient has presented a few days later as amylase levels gradually fall back towards normal over the next 3 – 5 days. (false negative result)  If serum lipase can be checked, it provides a slightly more sensitive and specific test than amylase. It remains elevated for a longer period of time than amylase. However it is not significantly greater than amylase and technically difficult to measure (Bailey & love’s : 1140), (kumar & clark’s: 377 – 378) B. FALSE. ERCP may be useful in the diagnosis of acute pancreatitis  Identification and removal of stones in the common bile duct in gallstones pancreatitis (bailey & love’s: 1141) C. FALSE. Pseudocyst is an uncommon complication of acute pancreatitis. Complications of acute pancreatitis (Bailey & love’s : 1143) Systemic Local (more common in the first week) (usually develop after the first week)  Cardiovascular: Shock, arrhythmias  Acute fluid collection  Pulmonary : ARDS  Sterile pancreatic necrosis  Renal failure  Infected pancreatic necrosis  Haematological: DIC  Pancreatic abscess  Metabolic: Hypoglycemia, Hyperglycemia,  Pseudocyst Hyperlipidemia  Pancreatic ascites  GIT: ileus  Pleural effusion  Neurological: Visual disturbances,  Portal/splenic vein thrombosis Confusion Irritability, Encephalopathy  Pseudoaneurysm  Miscellaneous:Subcutaneous fat necrosis  Arthralgia Pseudocyst: Typically following an attack of acute pancreatitis requires 4 weeks or more, but can develop in chronic pancreatitis or after pancreatic trauma D. Thromboplebitis migrans is associated with pancreatic cancer Clinical features. (Clinical surgery handbook: 310) Carcinoma of the head of pancreas 65% Carcinoma of the body 25% and tail 10% • Obstructive jaundice 90%: due to • Usually asymptomatic in the early stages compression or invasion of the common • Weight loss and back pain 60% bile duct. Gallbladder is typically • Epigastric mass palpable • Jaundice suggests spread to hepatic hilar • Pain 70%: epigastric or left upper LN or metastases quadrant, often vague and radiates to • Thrombophlebitis migrans 7% the back • Diabetes mellitus 15%
  13. 13. • Hepatomegaly due to metastases • Anorexia, nausea, vomiting, fatigue, malaise, dyspepsia and pruritus • Acute pancreatitis is occasionally the first presenting feature • Thrombophlebitis migrans 10%: present as emboli. Splenic vein thrombosis may lead to splenomegaly in 10% patient E. Ascites occurs early in the course of pancreatic cancer. On examination, pancreatic cancer’s findings. (Bailey & love’s: 1149)  Jaundice  Weight loss  Palpable liver  Palpable gall bladder (Courvoisier’s law : when the common duct is obstructed by a stone, distension of the gall bladder is rare, when the duct is obstructed in some other way, such as neoplasm, distension of the gall bladder is common)  Palpable mass  Ascites  Supraclavicular nodes  Tumor deposits in the pelvis.28. The followings is/are true of infection involving the biliary tract A. TRUE. Bile within the biliary tree is usually sterile. Bile is usually sterile. Anatomical barriers protect bile from being invaded by bacteria both via the haematogenous route by hepatocellular and cholangiocellular gap junctions and via the enteric route by a well-functioning sphincter of oddi, constant bile flow and the bacteriostatic/bacteriocidal action of bile acids and immunoglobulins, particularly IgA in bile. B. TRUE. Septicemic shock with gram negative organisms can occur. The most commonly detected bacteria are:  Gram negative: E.coli (44 – 58%), klebsiella spp (14 – 34%), Enterococcus spp (0 – 53%), Enterobacter spp (5 – 13%), Citrobacter spp (0 - 6%), proteus spp (3-10%)  Anaerobes: Bacteroides spp (1 – 18%), Clostridium spp (4 – 16%) C. TRUE. A cholestatic picture may be seen biochemically D. FALSE. Blood cultures are rarely positive. In the early phase of acute cholangitis, bacteria are detected in at least 75% of bile culture and often in blood cultures taken during rise in temperature. Mixed infections of bile are found in 30 – 80% of bacterial cholangitis and in > 80% of cases with severe acute suppurative cholangitis E. TRUE. ERCP is a risk factor for cholangitis. Risk factors:  Common bile duct stones  Benign and to a markedly lesser degree malignant biliary strictures  Endoscopic sphincterotomy  Biliary endoprosthesis  Obstructive jaundice  Recent clinical infection  Age > 70 years  Diabetes
  14. 14.  Previous biliary interventions id=taE276KCyecC&pg=PA1541&lpg=PA1541&dq=bile+within+the+biliary+tree+is+usually+st erile&source=bl&ots=2EayeaCl7C&sig=1sQlWTxpe813GDqh0bI9-7MydKg&hl=en&ei=TZWZT dCyKYL3rQfgyZXxCw&sa=X29. Acute Pancreatitis A. FALSE. Mild acute pancreatitis mortality rate = 1%, Severe acute pancreatitis mortality rate = 20% to 50%, no overall mortality been stated (Bailey & Love’s p1139) B. TRUE. Bendrofluazide is a thiazide diuretic = one of the possible causes for acute pancreatitis. Other causes for acute pancreatitis:  Gallstone  Ampullary tumour  Viral infection ( mumps, coxsackie)  Alcoholism  Autoimmune  Malnutrition  Post ERCP  Hypercalcaem  Scorpion bite (Bailey & Love’s p1139, C. TRUE. Trauma to the pancreas frequently due to blunt trauma e.g. MVA (Bailey & Love’s p1137, D. FALSE. Bacterial infection in pancreas occur as one of the complication which is infected pancreatic necrosis, not in acute phase. (Bailey & Love’s p1142) E. FALSE. Assessment of severity is based on Ranson or Glasgow scoring system. APACHE II also can be used, but usually in ICU. Ranson score >3 indicate severe pancreatitis, if 8 or more indicate organ failure + necrosis (Bailey & Love’s p1140)30. Raised plasma amylase A. TRUE. Hyperamylasaemia can be asymptomatic (without symptoms of pancreatitis) encountered in other acute disorders such as acidosis, infarcted small bowel and inflammatory bowel disease. However the levels are much lower compared to acute pancreatitis which is 3 to 4 times higher than normal. (Clinical Surgery 2nd Edition p363, B. TRUE. Medline, PubMed, Cochrane Library have been researched, the following study presents the first case of ruptured ectopic pregnancy accompanied by markedly elevated amylase and lipase levels mimicking acute pancreatitis ever reported. ( C. TRUE. Renal failure results in increased isoamylases. Serum amylase clearance done by the kidney. Patient with renal failure will have high level of amylase as the kidney cannot metabolize it. (, overview) D. TRUE. Diagnosis of acute pancreatitis is confirmed by level of serum amylase exceeding 5 times than normal. Hyperamylasaemia can be encountered in other acute disorder, however the levels are much lower. (Clinical Surgery 2nd Edition p363) E. TRUE. Hepatic Portal Venous Gas (HPVG) is associated with necrotic bowel (72%), ulcerative colitis (8%), intra-abdominal abscess (6%), small bowel obstruction (3%), and gastric ulcer (3%).
  15. 15. HPVG appears as a branching radiolucency extending to within 2 cm of the liver capsule. (http:// Carcinoma of pancreas A. TRUE. At the time of presentation, >85% with ductal adenocarcinoma are unsuitable for resection because too advance. Ductal adenocarcinoma is the commonest among other tumour of the pancreas such as cystic tumour and tumour of the ampulla. Surgical resection known as pancreatoduodenectomy or Whipple’s procedure. (Bailey & Love’s p1150) B. FALSE. 5 year survival rates of 1-2% (Clinical Surgery 2nd Edition p366) C. FALSE. Pancreatic tumour not related to OCP usage. Risk factor for pancreatic cancer;  Age 65 to 75 YO  Family history  Male  Chronic pancreatitis  Black ethnicity  Diabetes Mellitus  Smoking  Familial adenomatous polyposis (Bailey & Love’s p1149) D. FALSE. Tumour marker CA19-19 is not highly specific or sensitive, but baseline level should be established to identifying recurrence in the future. Ultrasound and CT scan is the best way to demonstrate the tumour, but if CT scan fails, endoscopic ultrasound can be used. Histological confirmation is desirable but not essential if the imaging clearly shows a tumour. (Bailey & Love’s p1150) E. TRUE. One of the risk factor for pancreatic tumour is DM. It may present with peripheral neuropathy as DM complication if the patient has DM with pancreatic tumour.32. Acalculous cholecystitis A. FALSE. Acalculous cholecystitis has a slight male predominance, this condition can occur in persons of any age and also occur in all races ( overview) B. TRUE. Ischemia in the splanchnic is one mechanism implicated in the pathogenesis of acute acalculous cholecystitis. Other causes of acalculous cholecystitis:  Bile stasis  prolonged distention of gallbladder (, Bailey & Love’s p 1122) C. FALSE. Percutaneous cholecystostomy (not cholecystectomy) is done in critically ill patients in the absence of significant gangrene. (Clinical Surgery 2nd Edition p351) D. FALSE. Commonest organism are E.Coli, Klebsiella sp. and Streptococcus sp. same as in acute cholecystitis. 15 to 30 percent culture are positive with these micro-organisms. (Clinical Surgery 2nd Edition p 350) E. TRUE. Gallbladder carcinoma can cause obstruction and stasis of the bile and predispose it infection. (Clinical Surgery 2nd Edition p350)33. Gallbladder stone A. TRUE.  From Bailey 3 type of stone- cholesterol, mixed and pigment  80% stone are cholesterol or mixed.
  16. 16. B. FALSE  From Bailey m/s 1119 there are 2 type of pigment stone –black and brown  Black composed of insoluble/unpolymerized bilirubin mixed with calcium phosphate and calcium bicarb- in condition sickle-cell disease/ spherocytosis  Brown contain calcium bilirubinate, calcium palmitate and calcium stearate C. FALSE  It’s a rare disease, aetiology is unclear but there maybe an association with existing gallstone disease. – from Bailey 1129 D. TRUE  Bailey m/s 1112 a plain x-ray will show radio opaque gallstone in 10% patient. E. TRUE  Emedicine website- The gallbladder mucocele distension, which is usually noninflammatory, results from an outlet obstruction of the gallbladder and is commonly caused by an impacted stone in the neck of the gallbladder or in the cystic duct (Hartmann’s pouch a bulbous region of the neck of the gallbladder)34. Acute pancreatitis A. FALSE  Bailey m/s 1140 diagnose acute pancreatitis is made on basis of the clinical presentation and elevated serum amylase level. 3-4 times greater than normal. B. FALSE  Bailey m/s 1140 disease is calcified as severe when three or more factors are presents. C. FALSE  Bailey m/s 1139 occasionally tumors at ampulla of vater may cause acute pancreatitis. D. TRUE  Bailey m/s 1143 refer table 64.5 ARDS is one of the complication. E. TRUE  Bailey m/s 1140 grey turner sign is bluish discolouration of the flanks. Cause by bleeding into the fascial planes.35. Pancreatic carcinoma A. TRUE  Bailey m/s 1149 jaundice secondary to obstruction is commonest – pruritus, dark urine, pale stool with steatorhea. Assoc with nausea n vomiting. B. TRUE  Bailey m/s 1148 more than 85% of pancreatic cancer is ductal adenocarcinoma. Ductal adenocarcinomas arise most commonly in the head of pancreas. C. TRUE  Bailey m/s 1148 more than 85% of pancreatic cancer is ductal adenocarcinoma ( x sure la) D. FALSE  Bailey m/s 1150 u/s will determine wether or not the bile duct is dilated. It is highly suspicion of tumor in head of pancreas, the preferred test is a contrast-enhanced CT scan. E. TRUE  Bailey m/s 1150 at the time of presentation more than 85% patient with ductal adenocarcinoma are unsuitable for curative resection because the disease is too advanced.36. Non- surgical treatment of gallstone A. TRUE. Suitable for radioluscent stone less than 1cm
  17. 17. B. TRUE. Usually achieved by 3 month ursodeoxycholic acid C. TRUE. May be undertaken by MTBE D. TRUE. Recommended by young patient awaiting for renal transplant E. FALSE. Has low incident of recurrent stone after medical dissolution37. Cholangiocarcinoma A. TRUE. Represent 1% of all GIT cancer – bailey n love (p:1128) B. TRUE. Related to clonorchiasis sinensis infection (bailey n love (p: 1127-1128)  clonorchiasis is fluke infections which inhabit the bile ducts and intrahepatic ducts  related also to UC, hepatolithiasis, choledochal cyst, sclerosing cholangitis C. FALSE. Rarely associated with choledocholithiasis –can affect the intrahepatic duct lead to bile duct tumour D. FALSE. Metastases early – slow growing tumours E. TRUE. Present with obstructive jaundice in 90 % of cases (bailey n love (p:1128)  most common, followed by abdominal pain, early satiety and weight loss38. Gallstone ileus A. FALSE. Usually follows iatrogenic fistulation of the gallbladder in to the GIT tract  Gallstones ileus is a condition which affects elderly due to intraluminal intestinal obstruction by large gallstone  2% occur in pt with gallstones, 20% in elderly secondary to mechanical obstruction which in vast majority occur in small intestine B. FALSE. Calculi usually impact in the proximal ileus  the level of obstruction is changing until the stone becomes firmly impacted usually in the terminal ileum (cusheiri clinical surgery; p:356) C. FALSE. Usually produces complete obstruction  Tend to occur in elderly secondary to erosion of the large stone  Pt may have recurrent attacks as the obstruction is frequently incomplete or relapsing as a result of a ball-valve effect (bailey n love p: 1190) D. TRUE. May produce air in the biliary tree, air seen in the biliary tree on plain abdominal x-ray (davidson p:992) E. FALSE. Is most common in the < 60 years old  Mostly affect the elderly due to intraluminal intestinal obstruction by a large gallstones that enter the intestinal tract through a fistula, usually btw GB and duodenum (cusheiri clinical surgery; p:356)39. Regarding fistula A. FALSE. Is an extending from blind ending abscess cavity (Wikipedia)  It is generally a disease condition, but a fistula may be surgically created for therapeutic reasons  Various types of fistulas include; • Blind: with only one open end • Complete: with both external and internal openings • Incomplete: a fistula with an external skin opening, which does not connect to any internal organ • Although most fistulas are in forms of a tube, some can also have multiple branches. B. TRUE. Healing is facilitated by recurrent infection C. TRUE. Communication between 2 surfaces of epithelium
  18. 18.  abnormal communication between 2 epithelially lined surface  tract by granulation tissues but may epithelialised in chronic case  can be congenital o acquired D. FALSE. Posterior type have multiple external opening  according to Goodsall’s rule used indicate the likely position of the internal opening according to the external opening position.  anal fistula with an external opening that is anterior will hv internal opening that is anterior  fistula with posterior opening or >3cm from anal verge will open internally in the posterior midline  so, anterior hv multiple external opening (c picture of goodsall’s rule) (surgery blueprint clinical case p:100-101) E. TRUE. High output bowel fistula a/w severe electrolyte imbalance  long fistula tract hv increased resistance and decreased likelihood of epithelialization eg: in crohn disease ( inflammation area of intestine  narrow n fibrosis  progression the disease  fistula tract  greater fluid and electrolyte loss, nutritional handicap)  mnemonic FRIEND for features which tend to keep fistula open (high output fistula) : foreign body, radiation, infection, epithelialization, neoplasm, distal obstruction  Low (<200cc/24 hours), moderate (200-500cc/24 hours), vs. high (>500cc/24 hours) (surgery blueprint clinical case p:376)40. Familial Adenomatous polyposis A. TRUE. Autosomal dominant.  autosomal dominant inherited disease due to mutation of APC gene  >100 colonic adenomas are diagnostic  Surgery is the only means of preventing colonic cancer (bailey n love p:1178) B. TRUE. Pre-malignant  risk of colorectal cancer 100% in pt with FAP  m=f  large bowel mainly affected but can occur in stomach, duodenum and small intestine  carcinoma occurs after 10-20 years after the onset of polyposis.  1 or more cancers will already be present in 2/3 of those pt presenting with symptoms (bailey n love p:1178) C. FALSE. Associated with Crohn disease  +ve family hx with colorectal adenoma  New mutation in APC gene  assoc. with benign mesodermal tumours such as desmoids tumour and osteomas (bailey n love p:1178) D. FALSE. Cause electrolytes imbalance  Most patients with FAP are asymptomatic until they develop cancer. As a result, diagnosing presymptomatic patients is essential.  Of patients with FAP, 75-80% have a family history of polyps and/or colorectal cancer at age 40 years or younger.  Nonspecific symptoms, such as unexplained rectal bleeding (hematochezia), diarrhea, or abdominal pain, in young patients may be suggestive of FAP. ( E. TRUE. Majority treated with colectomy  colectomy with ileorectalanastomosis to avoid an ileostomy in a young patient and the risk of pelvic dissection to nerve function (bailey n love p:1178)
  19. 19. 41. Constipation is a/w : A. TRUE. From MIMS, the side effects of morphine includes respiratory depression, lightheadedness, dizziness, sedation, nausea, vomiting, constipation, sweating. But most important side effect is respiratory depression especially in acute poisoning. (MIMS and Pharmacology lippincotts 3rd edition page 161) B. No answer C. TRUE. Deficiency in thyroid hormone can cause constipation (ref:essential human physiology amar chatterjee) D. FALSE. Diabetes insipidus (DI) is a condition in which the kidneys are unable to conserve water. Cause by lack of ADH hormone (central DI) or inability of the kidney to respond to ADH (nephrogenic DI). Symptoms include excessive thirst or excessive urine volume. ( ) E. FALSE. Lactulose is one of the laxatives agents which included in bulking agents group.42. Carcinoma of cecum : A. FALSE. Patient with ca caecum commonly presented with anemia, presence of mass in right iliac fossa and symptoms of intermittent obstruction. Those who has left sided ca colon most likely to present with alternating bowel habit. bailey and love 25th edition page 1181 B. TRUE. Ca caecum when resectable can be surgically removed by hemicolectomy. C. FALSE. Anemia of chronic disease is usually normocytic anemia. Microcytic hypochromic anemia usually caused by iron deficiency anemia and thalassemia. oxford handbook of clinical medicine page 310-311 D. TRUE. Flexible sigmoidoscopy is increasingly used for diagnosing ca of colon. bailey and love 25th edition page 1181 E. TRUE. Inflammatory bowel disease is one of the risk factor medscape43. Volvolus: A. TRUE. A volvulus occur when a part of colon twisting over its mesentery resulting in acute, subacute or chronic obstruction. A complete obstruction will lead to compromise vascular supply of the bowel, eventually leading to ischemic gangrene and bowel wall perforation. medscape and & bailey and love 25th edition B. TRUE. I cannot find sources directly relate peritonitis and volvulus. But, there is a statement if there is a hole in the gastrointestinal tract, such as perforated colon, bacteria may enter into the peritoneum. So, if the volvulus already severely twisted and perforated, it may cause peritonitis. C. FALSE. Barium enema is not the treatment. Treatment include untwisting of the volvulus by the help of sigmoidoscopy or during laparotomy/laparoscopy. If the affected area already infarcted, hemicolectomy may be indicated. lecture notes on general surgery 10th edition & medscape D. TRUE. Other common place include caecum and small intestine. lecture notes on general surgery 10th edition E. FALSE. From medscape, “The presentation of symptomatic malrotation is much more common in younger children” and from lecture notes on general surgery 10th edition , the sigmoid type of volvulus more common in elderly and caecal type is more common in neonates with congenital malrotation.44. Colorectal carcinoma : A. TRUE. bailey and love 25th edition page 1179
  20. 20. B. FALSE. A sunburst appearance is a type of periosteal reaction giving the appearance of a sunburst secondary to an aggresive periosteitis. It is frequently associated with osteosarcoma but can also occur with other aggressive bony lesions such as an Ewing sarcoma. C Helms, Fundametals of skeletal radiology. Saunders C. TRUE. Rectal bleed and altered bowel habit more commonly caused by left sided colorectal cancer. Other symptoms include tenesmus and obstruction. bailey and love 25th edition page 1181 D. TRUE. bailey and love 25th edition page 1180 E. TRUE. robbins pathology 8th edition page 61945. Ureteric obstruction due to calculus, IVU showed: A. True. medscape B. True. medscape C. No answer D. True. medscape E. True. IVU is useful for confirming the exact location of a stone within the urinary tract. medscape & lecture notes on general surgery 10th edition page 32746. Foley’s catheter A. TRUE. It state that in urethral catheterization it must follow a through hand wash & sterile glove. (From Bailey & love page 1316) and (from B. FALSE. It should be 400mm in length.referred from nurse at urology ward & at the foley catheter packaged itself. C. FALSE. The French scale (Fr.) is used to denote the size of catheters. Each unit is roughly equivalent to 0.33 mm in diameter. meaning 1F=0.33mm in diameter (for example: 18 Fr. indicates a diameter of 6 mm). The smaller the number, the smaller the catheter. A larger sized catheter is used for a male because it is stiffer, thus easier to push the distance of the male urethra. Catheters come in several sizes:  Number 8 Fr. and 10 Fr. are used for children.  Number 14 Fr. and 16 Fr. are used for female adults.  Number 20 Fr. and 22 Fr. are usually used for male adults. ( Products/Nursing_Fundamentals_II/lesson_3_Section_1.htm From Bailey & love page 1316 state that the usual size for adult is 14F (from id=urinary_catheters) state that usual size for adults is 14 or 16F D. FALSE. French gauge(F) is defined as the circumference in milimetre-maksudnyer 1F= 1 mm in the usual size use is 14F=14 mm in circumference (From Bailey & love page 1316) E. TRUE. Widely considered to be a unisex catheter, the indwelling urethral catheter is used by both women and men with urinary incontinence caused by obstruction (blockage in the urethra) or urinary retention (incomplete bladder emptying) from ( Renal Cell Carcinoma A. FALSE from Bailey & love page 1273, and from state : If there is a malignant cause for the hematuria there is usually no pain
  21. 21. B. TRUE. From Bailey page 1310 said that can be metastasise via bloodstream to the bone,liver &lung C. TRUE. From Bailey page 1311 said that it can also invade the IVC D. TRUE. From bailey &love page 1309 said that tumour cell are swept away into the circulation & end up in lung where there grow to form cannonball secondary deposit E. FALSE. Renal cell carcinoma is the most common type of kidney cancer in adults. It occurs most often in men ages 50 - 70.(from In adult is knwn as Grawitz tumour from Bailey & love page 1309.wilms tumor is also knwm as nephroblastoma common in chidren48. Ca Prostate A. TRUE. from Baliey & love page 1354 B. FALSE. In bailey & love page 1359 said that the treatment for ca prostate is to reduce the testosterone production not use testosterone therapy either by orchidectomy orLHRH agonist C. TRUE. from bailey & love page 1355 said that in T4 staging it can invade the adjacent structure such as rectum or pelvic side wall. D. TRUE. from bailey & love page 1357 in radiological examination state that osteolytic metastasis are very common & may coexist with the sclerotic one E. TRUE. from Bailey & love page 1355 state that ca prostate can spread via lymphatic vessel passing the obturator fossa or along the side of the rectum to the LN beside the internal iliac vein & in hollow of the sacrum or it can pass over the seminal vesical drain into the external iliac LN.49. Causes of acute testicular swelling A. TRUE. from curriculum/acute-scrotum.pdf state that it can be ischemic that are Torsion of the testis (synonymous with torsion of the spermatic cord),Intravaginal; extravaginal (prenatal or neonatal), Appendiceal torsion, testis or epididymis,T esticular infarction due to other vascular insult (cord injury, thrombosis) or Trauma that are Testicular rupture,Intratesticular hematoma, testicular contusion, or Infectious conditions:Acute epididymitis,Acute epididym oorchitis,Acute orchitis,Abscess (intratesticular, intravaginal, scrotal cutaneous cysts),Gangrenous infections (Fournier’s gangrene) or Inflammatory conditions:Henoch-Schonlein purpura (HSP) vasculitis of scrotal wall,Fat necrosis, scrotal wall or Hernia:Incarcerated,strangulated inguinal hernia, with or without associated testicular ischemia or Acute on chronic events:Spermatocele, rupture or hemorrhage,Hydrocele, rupture, hemorrhage or infection,Testicular tumor with rupture, hemorrhage, infarction or infection ,varicocele B. TRUE. C. TRUE. D. FALSE. E. TRUE50. Ureteric stone A. TRUE. Give to a more consistent dull pain when the stone become impacted  As the stone progress to the lower ureter, the waves of loin pain are typically more to the groin, external genitalia, and the anterior surface of thigh  Testis may be retracted by cresmastric spasm  Stone in intramural ureter, pain can be referred to the tip of penis  Pain increased by exercise and relieved by rest
  22. 22.  5 sites of narrowing • Ureteropelvic junction • Crossing the iliac artery • Juxtaposition of vas deferens or broad ligament • Entering the bladder wall • Ureteric orifice from Bailey & love page 1300 B. FALSE. from bailey page 1301 state that if it small stone it can pass naturally although it can take many months as long as the patient is no disabled but if there is recurrent attack of colic ,stone enlarging,urine is infected or complete obstruction of the kidney surgery is indicated. C. FALSE. triple phosphate = calcium, ammonium, magnesium phosphate aka staghorn calculi  usually fill the renal pelvis and collecting system –bcoz it large  women > men affected  formed by action of bacteria foung between the stone crystals  other stones are smaller than staghorn, ranging size few mm to 1-2cm, usually obstructing the urinary tract- ureter. (cusheiri p: 596 - 597) D. TRUE. from Bailey page 1302 or from states that Extracorporeal shock-wave lithotripsy is used to remove stones slightly smaller than a half an inch that are located near the kidney. This method uses ultrasonic waves or shock waves to break up stones. Then, the stones leave the body in the urine. E. FALSE. TCC = transitional cell carcinoma of ureter  Urothelial tumors of the renal pelvis and ureters (upper urinary tract) are relatively rare. Tumors of the renal pelvis account for approximately 10% of all renal tumors and approximately 5% of all urothelial tumors  The mean age in persons who develop upper urinary tract urothelial tumors is 65 years.  The incidence of TCC increases with age. Moreover, TCC tumors are rarely found at autopsy.  TCCs are strongly associated with smoking.  Squamous cell carcinoma comprises 1-7% of upper tract urothelial tumors associated with longstanding infected staghorn calculi. overview51. Hypercalcemia can result A. TRUE. Super saturation of urine due to high calcium B. TRUE. Due to increase calcium deposition in renal tubule lead to high calcium concentration in the urine, impaired sodium and water reabsorption causing polyuria. C. TRUE. Mnemonic for hypercalcemia : groans (constipation), moans (psychic moans (e.g., fatigue, lethargy, depression)), bones (bone pain, especially if PTH is elevated), stones (kidney stones), and psychiatric overtones (including depression and confusion)." Increase water resorption by intestine D. TRUE. pigment stones are divided into 2-  Black stone; insoluble bilirubin pigment polymer mixed with calcium phosphate and calcium bicarbonate, usually due to hereditary spherocytosis  Brown stone; calcium bilirubinate, calcium palmitate and cacium steaterate.  Both formed when failure of deconjugation of bilirubin deglucoronide by B- deglucoronidase thus caused insoluble unconjugated bilirubin precipitate. E. FALSE. Hypocalcaemia can cause tetany. In the neuromuscular system, ionized calcium levels facilitate nerve conduction, muscle contraction, and muscle relaxation. when the concentration
  23. 23. of calcium ions (Ca++) in extracellular fluids such as plasma falls below normal. The nervous system becomes increasingly excitable, and nerves discharge spontaneously, sending impulses to skeletal muscles and causing spasmodic contractions ( remember that skeletal muscle contraction does not depend on extracelluar Ca but depends on Ca derived from sarcoplasmic reticulum released as a result of action potential generated by a stimulus to nervous system--- hypocalcemia in this case)  If tetanus: spores contain toxin called tetanospasmin that enters the CNS and blocks the release of GABA/Glycine which regulate the excitatory neurons ( Ach releasers )...this regulatory control is lost and the excitatory neurons release Ach unopposed at the neuromuscular junctions generating action potentials...thus muscle spasm52. Predisposing factor for renal calculi A. FALSE. liver cirrhosis can cause hepatorenal syndrome. Risk factors for stone disease  Diet  Drugs: corticosteroid  UTI: urease producing bacteria predispose to struvite stones  Mobility: low activity cause bone dimeneralization  Systemic disease:gout  Family history: cystinuria  Renal anatomy: PUJO  Previoys bowel resection (taken from oxford handbook and urology) B. TRUE. extrinsic factors which is geographical location, climate and season: more common in hot climates C. FALSE. it is not related to thyroid hormone. It is related to parathyroid hormone (hyperparathyroidism) which caused increase resorption of calcium from bone. D. FALSE. inability of kidney to concentrate the urine due to impaired water resorption. OHCM: high calcium caused nephrogenic diabetes insipidus. E. FALSE. it is caused due to low water intake. High animal protein and high salt intake can caused hypercalciuria thus increase risk to get renal stone.53. Hematuria in abdominal injury A. FALSE. normally conservative tx; surgical exploration is indicated when:  The patient develops shock which does not respond to resuscitation with fluids and blood transfusion  The HB decreases  There is urinary extravasation and associated bowel or pancreatic injury  Expanding peri renal hematoma  Pulsatile peri renal hematoma B. FALSE. one of investigation of hematuria is by IVU: shows obstructed ureter or occasionally contrast leak from the site of injury. (oxford handbook of urology) C. No answer D. TRUE. one of treatment that can used to treat ureteric avulsion is by using stenting. Other surgical treatment that can be done based on the anatomical position: e-medicine emergency urology: • Upper ureteral injuries (a) Ureteroureterostomy. involves an end-to-end repair of ureteral defects smaller than 3 cm.
  24. 24. (b) Ureteropyelostomy: In the event of a ureteral avulsion from the renal pelvis or a very proximal ureteral injury, the ureter may be anastomosed directly into the renal pelvis. (c) Ureterocalicostomy: If the renal pelvis or ureteropelvic junction is damaged beyond repair, ureterocalicostomy may be performed. In this procedure, the ureteral stump is sewn end-to-side into an exposed renal calyx. • Midureteral injuries (a) Transureteroureterostomy. Transureteroureterostomy can be performed to manage an extensive defect that involves the mid or upper ureter if the length for anastomosis to the bladder is insufficient. A feeding tube or double-J stent should be placed from the donor kidney, across the anastomosis, and down to the bladder. This procedure yields a high success rate (97%). • Lower ureteral injuries (a) Ureteroneocystostomy. Injuries to the lower ureter are usually associated with disruption of its blood supply from the iliac vessels. Therefore, these injuries are best repaired with ureteroneocystostomy (b) Vesicopsoas hitch. This is the treatment of choice for lower ureteral injuries that cannot be successfully repaired with ureteroneocystostomy alone.  Other surgical options • Urinary diversion (a) Urinary diversion in the form of a stent and/or nephrostomy tube should be considered, when indicated. A stent aligns the area of anastomosis, prevents extravasation, prevents obstruction from edema, and provides a scaffolding around which the ureter may heal. Studies of ureteral healing have demonstrated that the mucosa has healed by 3 weeks and muscular continuity is established by 7 weeks. Thus, many recommend that a stent remain in place for 6-8 weeks after a repair. Stents come in various diameters (4-8F) and lengths. The size of stent chosen depends on the diameter and length of the ureter. E. FALSE. refer the answer in question A54. Renal transplantation A. FALSE. older patient >65y/o less likely to be considered because of major comorbidities. (baily and love) B. FALSE. the transplant kidney is placed in the iliac fossa in the retroperitoneal position leaving the native kidneys in situ. C. TRUE. no urine output in post transplant patient may indicate rejection D. TRUE. immunosuppressive therapy is given in organ transplantation- in order to suppress rejection, E. TRUE. Contraindications for Kidney Transplantation  There are certain absolute contraindications to renal transplantation: • Disseminated or untreated cancer • Severe psychiatric disease • Unresolvable psychosocial problems • Persistent substance abuse • Severe mental retardation • Un-reconstructable coronary artery disease or refractory congestive heart failure  Relative contraindications:
  25. 25. • Treated malignancy. The cancer-free interval required will vary depending on the stage and type of cancer. Consultation with a board-certified oncologist is required in most cases. • Substance abuse history. Patients must present evidence of involvement in at least 12 months of drug-free rehabilitation. This includes written documentation of participation in rehabilitation including negative random toxicologic screens. • Chronic liver disease. Candidates with chronic hepatitis B or C or persistently abnormal liver function testing must have hepatology consultation prior to transplantation. • Cardiac disease. All patients over the age of 55 or those with a history of diabetes, hypertension, or tobacco abuse must have dobutamine stress echocardiography, or exercise or pharmacologic stress cardiac scintigraphy. Any patient with a history of a positive stress test or history of congestive heart failure must have cardiology evaluation prior to transplantation. • Structural genitourinary abnormality or recurrent urinary tract infection. Urologic consultation is required prior to transplantation. • Past psychosocial abnormality. Master of Social Work (MSW) or psychiatry evaluation, as appropriate. • Aortoiliac disease. Patients with abnormal femoral pulses or disabling claudication, rest pain or gangrene will require evaluation by a board certified vascular surgeon prior to consideration. Patients with significant aortoiliac occlusive disease may require angioplasty or aortoiliac grafting prior to transplantation. In acute pancreatitis A. FALSE. antibiotic treatment is not indicated unless for prophylaxis in severe attack acute pancreatitis for the prevention of local and other septic complications. (Bailey and love) B. FALSE. occur in chronic pancreatitis (Bailey and love) C. TRUE. conservative approach is indicated with IV fluid administration (Bailey and love) D. TRUE. minimally invasive procedure- pancreatic necrosectomy, midline laparatomy can be done (Bailey and love) E. FALSE. a normal serum amylase does not exclude acute pancreatitis particularly patient presented a few days later (Bailey and love)56. ERCP A. FALSE. Given medication to help numb the back of your throat and a sedative to help you relax during the exam. Usually local anaesthetic will be sprayed in the throat. ( , disorders/endoscopic-retrograde-cholangiopancreatogram-ercp?page=3) B. FALSE. It can be used to check for jaundice. ( retrograde-cholangiopancreatogram-ercp) C. FALSE. ERCP and PTC are both non invasive procedure, but ERCP is the first choice. ( ) D. FALSE. It is one of the complication of doing ERCP (inflammation to the pancreas ( E. TRUE. It can be used to diagnose stricture of the pancreatic duct (
  26. 26. 57. Ascending cholangitis a/w: A. TRUE. charcot’s triad B. TRUE. charcot’s triad C. TRUE. See below for more info  D. FALSE. E. TRUE. • Charcots triad consists of fever, RUQ pain, and jaundice. It is reported in up to 50-70% of patients with cholangitis. However, recent studies believe it is more likely to be present in 15-20% of patients. • Fever is present in approximately 90% of cases. • Abdominal pain and jaundice is thought to occur in 70% and 60% of patients, respectively. • Patients present with altered mental status 10-20% of the time and hypotension approximately 30% of the time. These signs, combined with Charcots triad, constitute Reynolds pentad. • Consequently, many patients with ascending cholangitis do not present with the classic signs and symptoms.[4] • Most patients complain of RUQ pain; however, some patients (ie, elderly persons) are too ill to localize the source of infection. • Other symptoms include the following: 1. Jaundice 2. Fever, chills, and rigors 3. Abdominal pain 4. Pruritus 5. Acholic or hypocholic stools 6. Malaise Acute choleycytitis A. TRUE. In 90% of cases, acute cholecystitis is caused by gallstones in the gallbladder. Severe illness and, rarely, tumors of the gallbladder may also cause cholecystitis. ( B. FALSE. Antibiotic given when coming to the A&E department in order to fight any infection ( C. TRUE. As acute cholecystitis usually can clear up by itself ( D. TRUE. If the inflammation continues and recurs. • In the emergency room, patients with acute cholecystitis are given fluids through a vein and antibiotics to fight infection. • Although cholecystitis may clear up on its own, surgery to remove the gallbladder (cholecystectomy) is usually needed when inflammation continues or recurs. Surgery is usually done as soon as possible, however some patients will not need surgery right away. • Nonsurgical treatment includes pain medicines, antibiotics to fight infection, and a low-fat diet (when food can be tolerated). • Emergency surgery may be necessary if gangrene (tissue death), perforation, pancreatitis, or inflammation of the common bile duct occurs.
  27. 27. • Occasionally, in very ill patients, a tube may be placed through the skin to drain the gallbladder until the patient gets better and can have surgery.( E. TRUE.Complications • Empyema (pus in the gallbladder) • Gangrene (tissue death) of the gallbladder • Injury to the bile ducts draining the liver (a rare complication of cholecystectomy) • Pancreatitis • Peritonitis (inflammation of the lining of the abdomen) ( Regarding the imaging of gallbladder A. FALSE. If possible, the patient should not eat for 6 or more hours before the test ( 010_6.htm) B. FALSE. It is NOT radio opaque ( ACCORDING TO DR. GHASSAN; 90% of gall bladder stone is radiolucent and only 10% is radio opaque C. FALSE. As both will appear almost the same in the imaging procedure. Need to do extra investigation such as blood works and tumor marker to confirm. D. FALSE. It usually detect acute cholecystits, and for chronic cholecystitis, bliid investigation will be more helpful ( 010_6.htm) E. TRUE. According to the: • Courvoisier Laws: Courvoisier Law states that an enlarged gallbladder which is painless is more likely to be due obstruction by carcinoma than by gall stones. Courvoisier-Terrier sign on the other hand states that a dilated gall bladder in a jaundiced patient is likely to be due to tumor as opposed to non-dilated bladder which is usually due to stone obstruction. ( jaundice-combination.html)60. Regarding hydrocele A. FALSE. It is benign scrotal mass and it will disappear after few months of life ( B. TRUE. Post-surgical complications are also common and include hernia recurrence, infected and noninfected fluid collections(hydrocele) C. TRUE. ( D. TRUE. Hydrocele can adversely affect fertility. ( overview) E. FALSE. Will disappear in the first month of life and no need to reduce. (
  28. 28. 61. Regarding Hydrocephalus A. TRUE. Symptom depend on causes of blockage, person age how much brain tissue has been damaged by swelling  some of symptom in infant include bulging anterior fontanelle, dilated scalp vein, sun- setting eyes(gaze downward) , Macewens sign (a more than normal resonant note on percussion of the skull behind the junction of the frontal, temporal, and parietal bones), large head, irritability, seizure,vomiting, high-pitch cry, difficulty in feeding, slow growth,headache(older children), restricted movement -symptom in adult- increase ICP symptom such as headache, seizure, vomiting. Pubmed B. TRUE. Ventriculoperitoneal shunt is one of the method to treat hydrocephalus. insertion of cathether into lateral ventricle which is connected to shunt valve under scalp and finally to distal catheter which is tunneled subcutaneously down to abdomen and inserted into perironeal cavity. When CSF pressure > shunt valve pressure- CSF will flow and absorb by peritoneal lining. Bailey & love C. TRUE. Non-communicating a.k.a obstructive occur when there is a lesion blocking CSF pathway from lateral ventricle to fourth ventricle. Common site include foramen of munro and aqueduct( congenital aqueduct stenosis/ tectal plate glioma). communicating types occur when intracerebral CSF pathway are patent but there is accumulation of CSF might be due to impaired CSF absorption eg in meningitis / SAH Bailey and love D. FALSE. No evidence saying that hydrocephalus is premalignant E. TRUE. If left untreated, hydrocephalus can lead to brain damage, a loss in mental and physical abilities, and even death. With early diagnosis and timely treatment, however, most children recover successfully.- kidshealth. Untreated hydrocephalus has a 50 - 60% death rate, with the survivors having varying degrees of intellectual, physical, and neurological disabilities Pubmed62. Hypertrophic Pyeloric Stenosis A. FALSE. it is the developmental disorder of enteric nervous system, characterized by absence of ganglion cell in distal colon- medscape. disease characterized by congenital absence of intramural ganglion(aganglionosis) and presence of hyperthrophic nerves in distal large bowel. Bailey’s and love(pg 87) B. FALSE. definite diagnosis of HPS depend on histological examination of an adequate rectal biopsy by an experienced pathologist. contrast enema may show extent of aganglionic segment( transition zone between dilated proximal normally innervated bowel and contacted aganglionic part). Bailey’s and love(pg 87) C. FALSE. ramsted operation is treatment for pyloric stenosis. surgery aim to remove aganglionic segment and bring down healthy ganglionic bowel to the anus ( pull-through operation….basically kita buang non-functioning part and sambung remaining normal part dgn anus. Eg: Swenson, Duhamel, Soave and transanal procedure. Bailey’s and love pg 87 D. TRUE. vomiting and refusing to eat is some of the symptom of HPS and these can lead to electrolyte imbalance. Management of complications of recognized aganglionosis is directed toward reestablishing normal fluid and electrolyte balance, preventing bowel overdistension (with possible perforation), and managing complications, such as sepsis. Medscape E. TRUE. may be familial or a/w down syndrome or other genetic disorder. genes mutation have been identified on chromosome 10(involving the RET proto-oncogene) and on chromosome 13 in some patient. Bailey and love’s
  29. 29. 63. Intussusceptions A. FALSE. Surgery only be done if intestine is torn / barium enema is fail/ contraindicated for non- operative reduction/ pathological lead point is suspected. intussusceptions is milked back by gentle compression from its apex. resection only done if it is irreducible/ complicated by infarction/ pathological lead point. Bailey’s and love pg 80 B. TRUE. Patient presented with sign of intestinal obstruction such as vomiting(billous), abdominal distension and colicky abdominal pain. plain radiograph usually show sign of small intestine obstruction and soft tissue opacity. Bailey’s and love pg 81 C. TRUE. Stool mixed with blood and mucus (sometimes referred to as "currant jelly" stool because of its appearance). Mayo clinic D. FALSE. Twisting of bowel called volvulus not intussusceptions . it is invagination of one portion of intestine into an adjacent segment. Bailey and love E. TRUE. Non-operative reduction can be attempt by using an air or barium enema. Bailey and love64. Umbilical Hernia in a 1 years old baby A. FALSE. If hernia persist at 2 years of age or older it is unlikely to resolve. Bailey and love’s B. FALSE. Umbilical hernia is common and typically harmless condition, most resolve spontaneously. Mayo clinic C. TRUE. It is resulted partly from failure of the round ligament to cross the umbilical ring and partly from absence of the richet fasia. Bailey and love pg 981 D. TRUE. Complications can occur when the protruding abdominal tissue becomes trapped (incarcerated) and can no longer be pushed back into the abdominal cavity but it is rare in children. Mayo clinic E. FALSE. Conservative treatment is indicated under age of 2 years as it usually resolve spontaneously. Bailey and love pg 98165. Obstructive jaundice in neonates A. TRUE. In biliary atresia, the extrahepatic bile ducts are occluded causing obstructive jaundice and progressive liver fibrosis in early infancy. (Ref: Bailey & Love’s Short Practice of Surgery 25th Edition, page 86)  The causes of neonatal jaundice (Ref: Paediatric Protocols For Malaysian Hospitals 2 nd Edition, page 62): • Haemolysis due to ABO or Rh isoimmunisation, G6PD deficiency, microspherocytosis, drugs • Physiological jaundice • Cephalhaematoma, subaponeurotic haemorrhage • Polycythaemia • Sepsis e.g. septicaemia, meningitis, UTI, intra uterine infection • Breastfeeding and breastmilk jaundice • GIT obstruction: increase in enterohepatic circulation B. TRUE. C. TRUE. Biliary atresia as one of the causes of obstructive jaundice in neonates can be treated successfully by the Kasai procedure. (Ref: Paediatric Protocols For Malaysian Hospitals 2nd Edition, page 69) D. TRUE. Liver transplantation is indicated later if there is failure to achieve or maintain bile drainage. (Ref: Paediatric Protocols For Malaysian Hospitals 2nd Edition, page 69) E. FALSE.
  30. 30. 66. Inguinal hernias A. FALSE. Inguinal hernias in children are almost always indirect and due to a patent processus vaginalis (Ref: Bailey & Love’s Short Practice of Surgery 25th Edition, page 75) B. FALSE. Inguinal hernias in children are much more frequent in boys, especially in born prematurely. It develops in at least one in 50 boys and about 15% are bilateral. (Ref: Bailey & Love’s Short Practice of Surgery 25th Edition, page 75) Incidence: boys:girls=6:1 (Ref: Paediatric Protocols For Malaysian Hospitals 2nd Edition, page 313) C. TRUE. The infant may be vomiting and irritable.  The inguinal hernia typically causes an intermittent swelling in the groin or scrotum on crying or straining.  Unless an inguinal swelling is observed, diagnosis relies on the history and presence of palpable thickening of the spermatic cord (or round ligaments in girls)  Some may present as firm, tender, irreducible lump in the groin/scrotum as a result of obstruction by the external ring (Ref: Bailey & Love’s Short Practice of Surgery 25th Edition, page 75) D. TRUE. Incarcerated hernia:  Often used loosely as an alternative to obstruction or strangulation but is correctly employed only when it is considered that the lumen of that portion of the colon occupying a hernia sac is blocked with faeces (Ref: Bailey & Love’s Short Practice of Surgery 25th Edition, page 969)  Its content literally imprisoned in hernial sac but alive and functioning normally (Browse’s Introduction to the Symptoms & Signs of Surgical Disease 4th Edition, page 366)  Most incarcerated hernias in children can be successfully reduced by sustained gentle compression (‘taxis’) aided by cautious analgesia. (Ref: Bailey & Love’s Short Practice of Surgery 25th Edition, page 75)  Attempt manual reduction as soon as possible to relieve compression on the testicular vessels. The child is rehydrated and given IV analgesic with sedation. Constant gentle manual pressure is applied in the direction of the inguinal canal to reduce the hernia. 1 (Ref: Paediatric Protocols For Malaysian Hospitals 2nd Edition, page 313) E. TRUE. The explanation is same as in (B). Inguinal hernias in children are much more frequent in boys, especially in born prematurely. (Ref: Bailey & Love’s Short Practice of Surgery 25th Edition, page 75).67. Hirschsprung’s disease A. FALSE. Occurs more often in males than in females, with a male-to-female ratio of approximately 4:1. However, with long-segment disease, the incidence increases in females. ( B. TRUE. Characterised by the congenital absence of intramural ganglion cells (aganglionosis) and the presence of hypertrophic nerves in the distal large bowel. (Ref: Bailey & Love’s Short Practice of Surgery 25th Edition, page 86) Congenital aganglionosis of the distal bowel defines Hirschsprung disease. Both the myenteric (Auerbach) plexus and the submucosal (Meissner) plexus are absent, resulting in reduced bowel peristalsis and function. ( C. TRUE. Surgery aims to remove aganglionic segment and bring down healthy ganglionic bowel to the anus; these ‘pull-through’ operations (e.g. Swenson, Duhamel, Soave and transanal procedures) can be done in a single stage or in several stages after first establishing a proximal
  31. 31. stoma in normally innervate bowel. (Ref: Bailey & Love’s Short Practice of Surgery 25th Edition, page 87) D. TRUE. The aganglionosis is restricted to the rectum and sigmoid colon in 75% of patients (short segment), involves the proximal colon in 15% (long segment) and affects the colon and a portion of the terminal ileum in 10% (total colonic aganglionosis) (Ref: Bailey & Love’s Short Practice of Surgery 25th Edition, page 86-87) E. FALSE. Definitive diagnosis depends on histological examination of an adequate rectal biopsy. A contrast enema may show the extent of the aganglionic segment. (Ref: Bailey & Love’s Short Practice of Surgery 25th Edition, page 87).68. Transportation of neonates from district to referral hospital A. FALSE. The principles of initial stabilization are as follows  Airway  Breathing  Circulation/Communication  Drugs/Documentation  Environment/ Equipment  Fluids-Electrolytes/Glucose  Gastric decompression • ABG is important in order to assess the need for intra transport ventilation (Ref: Paediatric Protocols For Malaysian Hospitals 2nd Edition, page 26) B. TRUE. Both are the more common abdominal wall defects. Fluid loss and hypothermia are important considerations in these babies.  Gastroschisis: defect in the anterior abdominal wall about 2-3cm diameter to the right of the umbilicus with loops of small intestine and large intestine prolapsing freely without a covering membrane.  Exomphalos: defect of anterior anbominal wall of variable size which has a membranous covering and the umbilical cord usually attached to the apex of the defect. C. FALSE. Transport incubator would be ideal as a prevention of heat loss which involves maintaining an optimal ambient temperature and covering the exposed surfaces. (Ref: Paediatric Protocols For Malaysian Hospitals 2nd Edition, page 28) D. FALSE. E. FALSE. Ventilation only if absolutely necessary if there is trachea-oesophageal fistula as it may lead to intubation of the fistula, insufflations of the GI tract, and possible perforation if there is distal atresia of the bowel. (Ref: Paediatric Protocols For Malaysian Hospitals 2nd Edition, page 29)