India’s most trusted platform for NEET SS

NEET SS January 2022

MCh GI Surgery Recall

Disclaimer: These are not exact questions from the NEET SS

exams. These are merely questions based on similar concepts
1. What will be the T staging for growth in the fundus of the gallbladder infiltrating the serosa without
involvement of liver parenchyma?

A. T1
B. T2a
C. T2b
D. T3

D. T3

Invasion of serosa of GB is a T3 lesion

Ref: AJCC 8th edition, Chapter 24.

2. A 46 year old patient underwent resection of 30cm of terminal ileum for mesenteric vascular
accident. Which of the following drugs can be used in him as treatment of bile acid malabsorption
diarrhoea?

A. Urso deoxycholic acid

B. Cheno deoxycholic acid
C. Cholestyramine
D. Medium chain fatty acids

C. Cholestyramine

BILE SALT-BINDING RESINS:

Conjugated bile salts are normally absorbed in the terminal ileum. Disease of the terminal ileum (eg,
Crohn’s disease) or surgical resection leads to malabsorption of bile salts, which may cause colonic
secretory diarrhea. The bile salt-binding resins cholestyramine, colestipol, or colesevelam,
may decrease diarrhea caused by excess fecal bile acids. These products come in a variety of powder
and pill formulations that may be taken one to three times daily before meals. Adverse effects include
bloating, flatulence, constipation, and fecal impaction. In patients with diminished circulating bile
acid pools, further removal of bile acids may lead to an exacerbation of fat malabsorption.
Cholestyramine and colestipol bind a number of drugs and reduce their absorption; hence, they should
not be given within 2 hours of other drugs. Colesevelam does not appear to have significant effects on
absorption of other drugs.

Ref: Katzung Basic & Clinical Pharmacology 12th edition, Chapter 62

3. A guy having colorectal cancer with liver metastasis, underwent anterior chemotherapy. While he
was taken up for subsequent surgery, he was found to have blue liver syndrome. Which of the
following drugs would be the culprit?

A. Irinotecan
B. Oxaliplatin
C. Ifosfamide
D. Vincristine

B. Oxaliplatin

Steatohepatitis is seen with irinotecan and sinusoidal damage occurs with oxaliplatin.

Veno-occlusive disease or blue liver syndrome, is characterised by the discontinuity of the sinusoidal
membrane, collagenization of the perisinusoidal space and sinusoidal dilatations with erythrocyte
congestion in centrilobular zones due to damage to the sinusoidal endothelial cells. Oxaliplatin may
cause liver injury, including sinusoidal obstruction syndrome (SOS).
Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 52

Ref: Choi JH, Won YW, Kim HS, Oh YH, Lim S, Kim HJ. Oxaliplatin-induced sinusoidal
obstruction syndrome mimicking metastatic colon cancer in the liver. Oncol Lett. 2016
Apr;11(4):2861-2864. doi: 10.3892/ol.2016.4286. Epub 2016 Feb 29. PMID: 27073565; PMCID:
PMC4812530.

4. A 32 year old female who was taking oral contraceptive pills was found to have a 4x4 cm mass in
the right lobe of liver. Choose the appropriate line of management

A. Stop the OCPs

B. Continue to have close follow up
C. Resection
D. Angioembolization

B. Continue to have close follow up

In the given question, size is mentioned as 4 *4cm. Hence followup is the answer.
Risk of malignancy and rupture warrants resection. Quantifying the risk of rupture is difficult, but it
has been estimated to be as high as 30% to 50%, with all instances of spontaneous rupture occurring
in lesions 5 cm and larger.

Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 52

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 132

5. Which of the following statements regarding gallbladder malignancy is true?

A. Porcelain gallbladder has 50% risk of malignancy

 B. Gallbladder polyps pose a definitive risk
C. Pigmented stones have high risk then cholesterol stones
D. Abnormal biliopancreatic junction has high risk of causing GB cancer

D. Abnormal biliopancreatic junction has high risk of causing GB cancer

Porcelain gallbladder has 10% risk of malignancy.

There is no evidence that patients with gallbladder polyposis carry an increased risk of gallbladder
malignancy. Conversely, several studies have demonstrated that the presence of a single gallbladder
polyp larger than 10 mm carries an increased malignancy risk and cholecystectomy is generally
recommended.

Type of stone is not associated with incidence of gallbladder cancer.

Risk factors include entities that may also cause inflammation in the gallbladder wall, such as APBJ,
choledochal cysts, and PSC.

APBDJ is well known as a risk factor for developing carcinoma of the gallbladder Nuzzo et al.
Approximately 80% of APBDJ patients have congenital choledochal cysts. The occurrence rate of
biliary tract carcinoma of the gallbladder is between 3% and 18%, while the rate of biliary tract
carcinoma of the extrahepatic bile duct is at least 33% to 54%.

Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 55

Ref: Kang CM, Kim KS, Choi JS, Lee WJ, Kim BR. Gallbladder carcinoma associated with
anomalous pancreaticobiliary duct junction. Can J Gastroenterol. 2007 Jun;21(6):383-7. doi:
10.1155/2007/383949. PMID: 17571173; PMCID: PMC2658122.

6. Choose the correct sequence among these surgeries for chronic pancreatitis in the order of
increasing radicality

A. Frey<Berne<Beger<Whipple
B. Berne<Frey<Beger<Whipple
C. Beger<Whipple<Berne<Frey
D. Beger<Berne< Frey<Whipple

B. Berne<Frey<Beger<Whipple
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 58.

7. A patient with a hydatid cyst is taken up for laparoscopic deroofing of the cyst. Post-operatively
100ml of bile is found in the drain. What should be the appropriate line of management at this stage?
A. ERCP sphicterotomy
B. Redo Laparoscopy and omental packing of cavity
C. Wait and watch
D. Exploratory laparotomy

A. ERCP sphicterotomy

Biliary Fistula
The incidence of biliary fistula after hydatid liver surgery varies from 1% to 10% (Abu Zeid
et al, 1998; Barros, 1978). Endoscopic treatment is the main approach, and the aim of
endoscopic drainage for biliary fistulas is to reduce the bilio duodenal pressure difference
to zero. The optimal endoscopic approach for managing external biliary fistula resulting from
hydatid liver disease has not been established. Sphincterotomy alone, stent, or nasobiliary drain
placement alone, and the combination of sphincterotomy and stenting or nasobiliary drainage
have been used successfully for fistula healing. The overall success rate is 83.3% to 100%.
Although closure time has been reported to be as short as 2 to 6 days, the average duration
of bile drainage after stent placement is generally 2 to 4 weeks (Ozaslan & Bayraktar, 2002;
Şimşek et al, 2003).

Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 74

8. Which of these nodal groups are not dissected in Whipple’s pancreaticoduodenectomy?

A. Suprapyloric
B. Superior mesenteric
C. Coeliac
D. Infrapyloric

C. Coeliac

Standard lymphadenectomy.
No. 5 Supra pyloric lymph nodes; No. 6 infra pyloric lymph nodes; No. 8a lymph nodes in the
anterosuperior group along the common hepatic artery No. 12b lymph nodes along the bile duct; No.
12c (located next to 12b), lymph nodes around the cystic duct; No. 13a lymph nodes on the posterior
aspect of the superior portion of the head of the pancreas; No. 13b lymph nodes on the posterior
aspect of the inferior portion of the head of the pancreas; No. 14a-b lymph nodes along right side of
superior mesenteric artery No. 17a lymph nodes on the anterior surface of the superior portion of the
head of the pancreas; No. 17b lymph nodes on the anterior surface of the inferior portion of the head
of the pancreas.
Extended lymphadenectomy. No. 8p lymph nodes in the posterior group along the common hepatic
artery; No. 12a lymph nodes along the hepatic artery; No. 12p lymph nodes along the portal vein; No.
14c-d lymph nodes along the left side of superior mesenteric artery; No. 16 lymph nodes around the
abdominal aorta besides standard range of lymph node dissection.

Ref: Qian, Lihan; Xie, Junjie; Xu, Zhiwei; Deng, Xiaxing; Chen, Hao; Peng, Chenghong; Li,
Hongwei; Chai, Weimin; Xie, Jing; Wang, Weishen; Shen, Baiyong (2020). The Necessity of
Dissection of No. 14 Lymph Nodes to Patients With Pancreatic Ductal Adenocarcinoma Based
on the Embryonic Development of the Head of the Pancreas. Frontiers in Oncology, 10(), 1343–.
doi:10.3389/fonc.2020.01343

9. After Whipple’s procedure, drain fluid on postoperative day 3 showed very high levels of amylase.
Patient also had an amylase rich collection in the lesser sac that was percutaneously drained
(300ml).How would you grade this postoperative pancreatic fistula?

A. Biochemical leak
B. Grade B
C. Grade C
D. Grade A

B. Grade B

Here the patient has undergone a specific treatment procedure i.e., percutaneous drainage to drain the
pancreatic leak. So it falls under grade 2 POPF.
Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 105

10. A lady who had previously undergone a jejunocolic anastomosis after resection for mesenteric
ischemia, was now found to have short bowel syndrome. What is the type of SBS that she is suffering
from?

A. Type 1
B. Type 2
C. Type 3
D. Type 4

B. Type 2

A jejuno-colic anastomosis is a type 2 SBS

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 79

11 .A Patient diagnosed to have ITP has a platelet count of 45000/mm3.. When do you start
transfusing platelets, during splenectomy for him?

A. On the day of surgery before induction of anaesthesia

B. Previous night
C. After ligation of splenic artery
D. Just after incision is made

C. After ligation of splenic artery

Hematologic conditions are the most common indication for splenectomy, close communication with
a hematologist in the perioperative period is important. For autoimmune thrombocytopenia (ITP),
when the platelet count is below a certain threshold (generally <20 × 109/L), preoperative steroids,
immunoglobulins, and possibly intraoperative platelet transfusion are beneficial. Prednisone (1 mg/kg
per day beginning 5 to 7 days before surgery) can be used to increase preoperative platelet counts. In
addition, in certain cases, immunoglobulins (2 g/kg divided into two doses) may be given 48
hours prior to surgery. With thrombocytopenia (platelets <50,000), it is important to have platelets
on standby for the operating room because it is most beneficial to transfuse platelets after
ligation of the splenic artery.

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 137.

12. What will be the Child’s score for a patient with cirrhosis, who is conscious, oriented with
moderate ascites, bilirubin(2 mg/dl), INR-1.1, and albumin - 2.2 mg/dl?

A. 8
B. 9
C. 10
D. 11
C. 10

2 points for bilirubin;

1 point for INR;
3 points for albumin;
1 point for absent encephalopathy;
3 points for moderate ascites.

So Child’s score for this case is 10.

Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 54

13. A 28 year old gentleman came to you with a history of genetically proven familial adenomatous
polyposis in his 23years old brother. He is otherwise asymptomatic. What would you advise him to
undergo?

A. Screening colonoscopy alone

B. Screening colonoscopy and genetic analysis
C. Upfront prophylactic colectomy
D. Reassurance and follow up

A. Screening colonoscopy alone

Colorectal screening in individuals of affected families begins at age 12 and can be initiated with
flexible proctosigmoidoscopy. If polyps are seen, a full colonoscopy is warranted. If no polyps are
identified on the initial flexible proctosigmoidoscopy, the exam should be repeated every 1 to 2 years
until the age of 35 and every 3 to 5 years thereafter for at-risk first degree relatives who have not
undergone predictive testing or for those who have undergone DNA analysis that provides no
information about whether they are affected. Patients at risk for AFAP should receive endoscopic
screening with colonoscopy at ages 12, 15, 18, and 21 years, and then every 2 years. About one-third
of patients with AFAP can be managed long term endoscopically by polypectomy. For the upper GI
tract, screening begins at 20 to 25 years of age. Screening intervals are based on the Spigelman
staging system.

Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 52

14. Screening colonoscopy in a high risk patient identified a polyp in the descending colon that was
excised with a snare. Histopathological examination showed the presence of muscular elements in the
polyp. What are we dealing with?

A. Hyperplastic polyp
B. Adenomatous polyp
C. Puetz Jegher polyp
D. Inflammatory polyp

C. Puetz Jegher polyp

The polyps of Peutz-Jeghers syndrome are most common in the small intestine, although they may
occur in the stomach and colon and, with much lower frequency, in the bladder and lungs. Grossly,
the polyps are large and pedunculated with a lobulated contour. Histologic examination demonstrates
a characteristic arborizing network of connective tissue, smooth muscle, lamina propria, and glands
lined by normal-appearing intestinal epithelium.

The arborization and presence of smooth muscle intermixed with lamina propria are helpful in
distinguishing polyps of PeutzJeghers syndrome from juvenile polyps.
Ref: Robbins & Cotran Pathologic Basis of Disease, 10th edition, Chapter 17

15. As per Bismuth Corlette classification , how will you classify this perihilar growth?

A. Type 1
B. Type 2
C. Type 3
D. Type 4

D. Type 4
The image shows a hilar growth extending into both the hepatic ducts. So, it belongs to Bismuth type
4.

Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 55

16. What is the treatment of choice for gastric varicosities due to left sided portal hypertension?

A. Endoscopic banding
B. Endoscopic variceal ligation
C. Splenectomy
D. TIPS

A. Splenectomy
Isolated splenic vein thrombosis (left-sided portal hypertension) is usually secondary to
pancreatic inflammation or neoplasm. The result is gastrosplenic venous hypertension, with superior
mesenteric and portal venous pressures remained normal. The left gastroepiploic vein becomes a
major collateral vessel, and gastric rather than esophageal varices develop. This variant of portal
hypertension is important to recognize because it is easily reversed by splenectomy alone.

Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 54

17. How will you stage a carcinoma stomach that has involved the subserosa with five positive
regional nodes? (As per UICC staging)

A. Stage II
B. Stage IIIA
C. Stage IIIB
D. Stage IV

B. Stage IIIA

Subserosal involvement is T3 disease. Presence of five positive regional nodes amounts to N2

So, T3N2 disease will come under Stage IIIA.

Ref: Sabiston Textbook of Surgery, 21st edition , Chapter 49

18. A lap cholecystectomy specimen in a physiologically well preserved female shows T1b lesion.
What will be the preferred treatment?

A. Adjuvant chemotherapy
B. Extended cholecystectomy with segment IVb and V with nodal dissection
C. Reassurance and follow up
 D. Adjuvant radiotherapy

B. Extended cholecystectomy with segment IVb and V with nodal dissection

Gallbladder cancer after cholecystectomy.

With the finding of carcinoma after cholecystectomy, subsequent treatment depends on depth of
penetration of the gallbladder wall and surgical margins. With T1a lesions, in which the carcinoma
penetrates the lamina propria but does not invade the muscle layer, cholecystectomy suffices for
therapy. The likelihood of nodal disease in this setting is less than 3% and cholecystectomy cures 85%
to 100% of patients. The cystic duct margin should be reviewed to ensure a negative margin, and
sometimes, it is necessary to resect the CBD to obtain a negative margin.
For those penetrating the muscularis but not the deeper connective tissue or serosa, classified as T1b
lesions, cholecystectomy may be sufficient as long as the margins are negative, although this remains
controversial. With T1b lesions and perineural, lymphatic, or vascular invasion, the likelihood of
nodal disease increases significantly. Therefore, extended cholecystectomy is generally
recommended for all patients who are medically fit with T1b or greater level of invasion.

The extended cholecystectomy is directed at obtaining an R0 resection of the disease, including the
draining lymph node basins. Therefore, removal of the hepatoduodenal, gastrohepatic, and
retroduodenal lymph nodes should be included. Resection of the cystic duct margin to uninvolved
mucosa may require resection of the CBD with Roux-en-Y reconstruction. Because local extension
into the hepatic parenchyma is common, 2 cm of apparently normal hepatic parenchyma from the
gallbladder fossa is resected.
Ref: Sabiston Textbook of Surgery, 21st edition, chapter 55.
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 49.

19. Post operative biopsy of a lap cholecystectomy specimen showed the presence of malignancy. The
specimen was extracted through the umbilical port. What will you do along with extended
cholecystectomy in this patient?

A. Excision of all four ports

B. Excision of umbilical port
C. No role for port excision
D. Excision of epigastric port

C. No role for port excision

Port site disease is associated with disseminated peritoneal metastases, and prophylactic port site
resection is not associated with improved survival or disease recurrence in patients with incidental
findings of gallbladder cancer and, thus, should not be considered during definitive resection.

Ref: NCCN Guidelines 2022

Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 49.

20. A patient with carcinoma gallbladder showed involvement of muscularis propria , with free cystic
duct margins. What should be the ideal surgical procedure?

A. Excision of segment IVb, V without lymph nodal dissection

B. Excision of segments IVb,V with lymph nodal dissection without bile duct excision ( as cystic
duct margins are free)
C. Excision of segments IVb,V with bile duct excision
D. Surgery is not needed

B. Excision of segments IVb,V with lymph nodal dissection without bile duct excision ( as cystic
duct margins are free)

In general, we recommend the following principles based on the literature and our own data.
T1a tumors can be treated with a simple cholecystectomy. T1b tumors, although associated
with good long-term survival after simple cholecystectomy, are associated with a higher
locoregional recurrence rate, and in most patients, liver resection and lymph node dissection
should be performed (see later). A negative cystic duct margin must be ensured, and a bile
duct resection, if required to obtain a negative margin for a T1 tumor, is recommended.
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 49.

21. Which of these does not fit into the category of borderline resectable pancreatic malignancy?

A. Tumour abutting the inferior vena cava

B. Coeliac axis contact >180
C. Superior mesenteric vein encasement >180
D. Hepatic artery involvement

B. Coeliac axis contact >180

Solid tumour in the head of pancreas with >180 degrees contact with coeliac artery, is classified under
locally advanced disease as per NCCN resectability criteria.
Ref: NCCN Guidelines Version 2.2021

22. What is the best method to localise an insulinoma?

A. SRS
B. Ultrasound
C. Selective venous sampling
D. CT scan

C. Selective venous sampling

Although most insulinomas are identified with computed tomography (CT) or ultrasound (US), when
they are very small these methods may not localize the tumor, and arterial stimulation venous
sampling may then be helpful. To perform this test, the right and left hepatic veins are
catheterized via a femoral puncture. Calcium is injected successively into the gastroduodenal,
proximal splenic, superior mesenteric, and proper hepatic arteries. After each injection, venous
blood is sampled from the hepatic veins at 30, 60, and 120 seconds, and a positive
localization corresponds to a twofold increase in hepatic vein insulin levels. The accuracy of
this method to localize the tumor to a region of the pancreas (i.e., head, body, tail) is 94%
to 100%.
USG is the first investigation of choice. Insulinoma rarely express somatostatin receptors, SRS
scintigraphy is not useful.
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 65

23. Select the correct electrolyte abnormality seen in congenital hypertrophic pyloric stenosis.

A. Hyponatremic metabolic acidosis

B. Hypernatremic hypochloremic metabolic acidosis
C. Hyponatremic hyperchloremic metabolic alkalosis
D. Hyponatremic hypochloremic metabolic alkalosis

D. Hyponatremic hypochloremic metabolic alkalosis

Hypertrophic pyloric stenosis (HPS) is a disease of newborns, with an incidence of 1 in 300 to 900
live births. It is most common between the ages of 2 and 8 weeks. Boys are affected four times
more often than girls, with first-born male infants being at highest risk. Hypertrophy of the circular
muscle of the pylorus results in constriction and obstruction of the gastric outlet, leading to
nonbilious, projectile emesis.
Loss of hydrochloric acid secondary to persistent emesis leads to hypokalemic, hyponatremic,
hypochloremic, metabolic alkalosis, with paradoxical aciduria and dehydration. Although the
exact cause of HPS remains unknown, a lack of nitric oxide synthase in pyloric tissue has been
implicated.

Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 67.

24. Contrast CT done for a patient with acute pancreatitis 48 hours after the onset of abdominal pain
shows the presence of minimal peri pancreatic fluid, with <30% necrosis without any extra pancreatic
complications. Calculate the modified CT severity index

A. 6
B. 7
C. 8
D. 9

A. 6

4 points for the peripancreatic fluid and 2 points for the necrosis. Modified CT severity index for this
case will be 6.
Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 55

25. On evaluating a liver mass, triple phase contrast shows a cystic mass in the left lobe of liver with
internal septations showing minimal enhancement. Identify the lesion?

A. Biliary cystadenoma
B. Hydatid cyst
C. Hemangioma
D. Simple hepatic cyst

A. Biliary cystadenoma

Cystic mass with thin enhancing septations indicate a biliary cystadenoma.

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 121.

26. On evaluating a cystic lesion in the body of the pancreas, cyst fluid showed elevated CEA levels
with moral amylase and Calcification on imaging. What should be the next line of management?

A. Distal pancreatectomy
B. Watchful waiting
C. Percutaneous drainage
D. Endoscopic cystogastrostomy

A. Distal pancreatectomy

It is a mucinous cystic neoplasm of the pancreas.

Possibility of body cystic lesion with high CEA level --MCN

Mucinous Cystic Neoplasms

Due to the malignant potential of MCNs, it is generally recommended that these lesions be
resected. MCNs are more often located in the distal pancreas and therefore may be amenable
to splenic preservation and laparoscopic resection, which has been demonstrated to be safe and
feasible. The remnant pancreas is not known to be at risk following resection of MCNs and
therefore patients do not require long-term follow-up. Patients with features that are concerning
for malignancy should have formal pancreatectomy, and if a patient has a mucinous
cystadenocarcinoma, he or she should undergo postoperative surveillance, as for patients with
pancreatic cancer.

Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 60.
Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 56.

27. Which of these is the most common variant anatomy of hepatic artery?

A. Replaced right hepatic artery arising from superior mesenteric artery

B. Replaced left hepatic artery arising from left gastric artery
C. Right hepatic artery arising from coeliac trunk
D. Accessory right hepatic artery arising from abdominal aorta

A. Replaced right hepatic artery arising from superior mesenteric artery

Replaced right hepatic artery arising from the superior mesenteric artery is the most common
anatomical variant.
Ref: Schwartz's Principles of Surgery, 11th Edition, Chapter 31.

28. Which of these segments is not removed in a right hepatectomy?

A. Segment 6
B. Segment 4
C. Segment 5
D. Segment 8

C. Segment 4

Right hepatectomy will involve removal of segments 5, 6, 7 and 8.

Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 54.

29. An elderly male presented with biliary colic showed focal thickening of gallbladder fundal wall
with gallstones. What is the ideal procedure for this patient?
 A. Cholecystectomy with Wedge resection of liver for 1 cm
B. Extended cholecystectomy with removal of segments IVa and V
C. Extended cholecystectomy with removal of segments IVb and V
D. Extended cholecystectomy with removal of segments of V and VI

A. Cholecystectomy with Wedge resection of liver for 1 cm

Focal gallbladder wall thickening may be incidentally encountered on abdominal CT performed for
other reasons. The differential diagnosis for focal gallbladder wall thickening includes benign
etiologies such as focal adenomyomatosis, benign polyps and localized chronic cholecystitis, as well
as malignant etiologies such as gallbladder cancer, lymphoma and metastases.

In particular, the fundus is the most common location for focal adenomyomatosis, a benign condition
that is typically asymptomatic and usually requires no treatment or follow up. Adenomyomatosis is
also a relatively common entity, seen in 2–8% of cholecystectomy specimens.

Although gallbladder carcinoma(3%) is less common than adenomyomatosis and other benign
etiologies of focal gallbladder wall thickening, it is an aggressive cancer with 5 year survival rates of
5–10% . However 5 year survival rates up to 100% have been reported for stage T1 tumor following
cholecystectomy. Thus distinguishing early stage gallbladder cancer from benign disease is crucial.

Among given options, A is more suitable.

For a suspected carcinoma GB in preop imaging(Focal gallbladder wall thickening) , usually start
with cholecystectomy & intraop frozen biopsy then proceed.

Ref: Corwin MT, Khera SS, Loehfelm TW, Yang NT, Fananapazir G. Incidentally Detected Focal Fundal
Gallbladder Wall Thickening at Contrast-Enhanced Computed Tomography: Prevalence and Computed
Tomography Features of Malignancy. J Comput Assist Tomogr. 2019 Jan/Feb;43(1):149-154. doi:
10.1097/RCT.0000000000000802. PMID: 30371615; PMCID: PMC6331261.

30. A case of acute pancreatitis with worsening of clinical picture. CT image showed infected necrosis
with collection. What is the initial line of management?

A. Laparoscopic lavage of retroperitoneum

B. Conservative
C. Internal drainage
D. Percutaneous drainage

A. Percutaneous drainage

A companion study to this was published in 2018 wherein endoscopic management was compared to
the “step-up approach”. While the endoscopic approach was nonsuperior to the minimally invasive
surgical approach regarding mortality and most secondary endpoints, it was associated with fewer
pancreatic fistulae, reduced cumulative hospital length of stay, and lower cost.
Currently, an endoscopic drainage with a large-bore stent and possible endoscopic debridement with
or without percutaneous drainage can avoid an operation in most patients. If the endoscopic and/or
percutaneous management fails, a minimally invasive operation will usually be more straightforward
and the results improved. Regardless of which route is taken, physiologic and nutritional support of
the patient will have a large impact on outcome. 

Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 56.

31. After bariatric surgery, blood sugar control is attained much earlier than weight loss. What is the
reason behind this?

A. Elevation of GLP-1 levels

B. Malabsorption of carbohydrates
C. Less intake of food
D. All of the above

A. Elevation of GLP-1 levels

GLP-1 is part of a family of peptides involved in the synthesis, secretion, and regulation of insulin:
the incretins. In the enteroinsular axis, GLP-1 has many physiologic functions, including the
stimulation of insulin secretion by the pancreas, an increase in the insulin sensitivity of pancreatic
cells (α-cells and β-cells), and inhibition of glucagon secretion. Many studies have shown that GLP-1
is a major driver of insulin secretion after bariatric surgery. GLP-1 has been found to be consistently
elevated (peak and postprandial AUC) in response to both RYGB and LSG, with significant higher
magnitude in RYGB than LSG. More important, the effect of both RYGB and LSG on postprandial
GLP-1 secretion is not observed in subjects with an equivalent degree of weight loss achieved only by
caloric restriction. These results provide further evidence of a metabolic effect for bariatric
surgery that is independent of weight loss. 

Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 48.

32. A patient with extrahepatic portal venous obstruction presented with cholangitis. ERCP and
stenting was done. He had portal biliopathy and developed strictures again. What will be the next best
line of management?

A. Change plastic to metallic stent

B. Regular exchange of stent every three months
C. Shunt procedure
D. Followup

C. Shunt procedure
Ref: Dhiman RK, Behera A, Chawla YK, Dilawari JB, Suri S. Portal hypertensive biliopathy.
Gut. 2007 Jul;56(7):1001-8. doi: 10.1136/gut.2006.103606. Epub 2006 Dec 14. PMID: 17170017;
PMCID: PMC1994341.

33. Which of these is an indication for endoscopic therapy of bleeding peptic ulcer?

A. Clots in stomach
B. Adherent clot over ulcer
C. Visible vessel over base of ulcer
D. Non bleeding ulcer bed

C. Visible vessel over base of ulcer

The Forrest classification was developed to assess the risk of rebleeding based on endoscopic
findings and groups patients into high, intermediate, and low risk of rebleeding. Endoscopic therapy
is recommended for ulcers with active bleeding as well as those with a visible ulcer (Forrest I–
IIa). In cases with an adherent clot (Forrest IIb), the clot is removed and the ulcer evaluated. Ulcers
with a clean base or black spot secondary to hematin deposition (Forrest IIc–III) do not require
endoscopic treatment and are managed medically. Approximately 25% of patients undergoing EGD
for UGIB will require an endoscopic intervention.18 If the endoscopy is unable to achieve
hemostasis, angiography should be performed. Surgery is the next step if angiography fails or is not
available. 
Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 47.

34. A patient with GERD was symptomatic for 4years taking PPIs for 2 years. 6months back
endoscopy was done and showed lax LES. What should be the next line of investigation ?

A. Barium swallow
B. Serum gastrin levels
C. 24 hours ambulatory ph assessment with manometry
D. Endoscopy

C. 24 hours ambulatory ph assessment with manometry

Ambulatory pH monitoring quantifies distal esophageal acid exposure and is the “gold
standard” test to diagnose GERD. A 24-hour pH monitoring is conducted with a thin catheter that is
passed into the esophagus through the patient’s nares. The simplest catheter is a dual-probe pH
catheter, which contains two solidstate electrodes that are spaced 10 cm apart and detect fluctuations
in pH between 2 and 7. To ensure valid study results, the distal electrode must be placed 5 cm
proximal to the LES; the location of the LES is identified on esophageal manometry. Alternatively,
48-hour ambulatory pH monitoring can be performed using an endoscopically placed wireless pH
monitor. Ambulatory pH monitoring generates a large amount of data concerning esophageal acid
exposure, including total number of reflux episodes (pH <4), longest episode of reflux, number of
episodes lasting longer than 5 minutes, and percentage of time spent in reflux in the upright and
supine positions. A formula assigns each of these data points a relative weight according to its
capacity to cause esophageal injury, and the composite DeMeester score is calculated. Abnormal
distal esophageal acid exposure is defined by a DeMeester score of 14.7 or higher.

Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 43.

35. On evaluating a patient with chronic weight loss, CT showed short segment thickening of the
jejunal wall, With aneurysmal dilatation of jejunum. Multiple enlarged mesenteric nodes were
present. What’s the diagnosis?

A. Lymphoma
B. Tuberculosis
C. Adenocarcinoma
D. Eosinophilic enteritis

A. Lymphoma
 Ref: Devita, Hellman and Rosenberg’s Cancer- Principles and Practice of Oncology, 10th
edition, chapter 54.

36. Which of the following viruses is implicated in Post Transplant Lympho proliferative Disease?

a. HTLV -1
b. HHV-8
c. EBV
d. HPV

c. EBV
PTLD is an abnormal proliferation of B lymphocytes, usually in response to Epstein–Barr virus
infection. The condition presents in a variety of ways including as an infectious mononucleosis-type
illness or lymphadenopathy, or with involvement of extranodal sites such as the tonsils,
gastrointestinal tract, lung, liver or the transplanted organ. PTLD occurs in around 1–3% of kidney
and liver transplant recipients and the incidence is considerably higher in children. Those patients at
most risk are those who have received aggressive immunosuppression. PTLD is a serious condition
with an overall mortality rate of up to 50%. If it is identified at an early stage, reduction or cessation
of immunosuppressive therapy may cause disease regression and result in a cure. Chemotherapy is
often given and antiviral therapy, surgery and radiotherapy may also have a role in treating
established disease. Disseminated PTLD and central nervous system (CNS) involvement have a very
poor prognosis.

Ref: Bailey & Love's Short Practice of Surgery, 27th Edition, Chapter 82.

37. On evaluating a person with obstructive jaundice, MRCP showed the presence of intrahepatic
calculi in the left hepatic duct and left lobe atrophy.CBD was normal. What would be the ideal
procedure for him?

a. ERCP and stenting

b. Left lobe resection
c. Bile duct exploration , stone retrieval and hepaticojejunostomy
d. Percutaneous biliary drainage

b. Left lobe resection

Generally, the indications for partial hepatectomy are stones localised in a unilateral hemiliver,
severe biliary strictures, atrophy, and the presence of ICC. Intrahepatic stones limited to the
left lobe, accounting for about half of cases, represent a good indication for liver resection
alone from the perspectives of cure and treatment time (Shah et al, 2012). The incidence of
residual stones after hepatectomy is usually lower than after endoscopic lithotripsy. Stones
recur at rates of 0% to 18% in cases without bilateral disease. Moreover, resection of atrophic
liver and areas of strictures is expected to reduce the future incidence of ICC (Jan et al,
1996; Uenishi et al, 2009). Jan and colleagues (1996) reported significantly superior results
with hepatectomy versus nonsurgical treatment (stone recurrence: 9.5% vs. 29.6%, secondary
biliary cirrhosis: 2.1% vs. 6.8%, and late development of ICC: 0% vs. 2.8%).

Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 39.

38. Which of the following does not follow UCSF criteria?

A. Single tumor 7.5cm

B. 2 tumors largest 3cms
C. No vascular involvement
D. All of the above
A. Single tumor 7.5cm

UCSF criteria

Over time, other criteria emerged for predicting the results of transplantation for HCC, beginning with
that proposed by the University of California, San Francisco (UCSF) (single tumor ≤6.5 cm or ≤3
tumors with the largest tumor diameter ≤4.5 cm and total tumor diameter ≤8 cm).

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 132.
39. The source of bleeding in Dieulafoy lesions is usually from which of these vessels?

A. Right gastric artery

B. Left gastric artery
C. RGEA
D. LGEA

B. Left gastric artery

Angiography is useful when endoscopic methods fail to localise the lesion. It is especially useful for
lesions in the colon or rectum where the view could be obscured by active bleeding and poor bowel
preparation. There is no specific diagnostic criterion to diagnose a Dieulafoy's lesion on angiography
as typical features are variable, but the diagnosis is suggested on demonstration of a tortuous and
ectatic artery. The findings include extravasation of contrast from what is seen as a normal looking
blood vessel. For gastric lesions, the demonstration of tortuous vessels in the territory of the left
gastric artery lacking early venous return is suggestive.

Ref: Baxter M, Aly EH. Dieulafoy's lesion: current trends in diagnosis and management. Ann R
Coll Surg Engl. 2010 Oct;92(7):548-54. doi: 10.1308/003588410X12699663905311. PMID:
20883603; PMCID: PMC3229341.

40. A 22 years old presented to you with rectal prolapse. Evaluation revealed grossly redundant
sigmoid colon. What surgery would you offer?

A. Delorme’s procedure
B. Thiersch procedure
C. Resection rectopexy
D. Any one of the above

A. Resection rectopexy

Resection rectopexy.
Resection rectopexy is a technique first described by Frykman and Goldberg in 1969 and
popularised in the United States in the past 35 years. Lack of artificial mesh, ease of
operation, and reduction of redundant sigmoid colon are the principle advantages of the
procedure. Recurrence rates are low, ranging from 2% to 5%, and major complication rates
range from 0% to 20% and relate to obstruction or anastomotic leak. Basically, the sigmoid
colon and rectum are mobilised to the level of the levators. The lateral ligaments are divided,
elevated from the deep pelvis, and sutured to the presacral fascia. Again, as in anterior mesh
repairs, anterior mobilisation has gotten renewed interest because of the observed lower
incidence of recurrence with this technique. The mesentery of the sigmoid colon is then
divided, with preservation of the IMA, and a tension-free anastomosis is created. A revised
version of this procedure involves preservation of the lateral stalks and unilateral fastening of
the rectal mesentery to the sacrum at the level of the sacral promontory. Sigmoid resection is
a unique feature of this procedure. It appears to reduce constipation by 50% in those who complain
preoperatively of this symptom in some studies. Interestingly, in patients who complain of
incontinence before surgery, this symptom consistently improves in approximately 35%, even
with the sigmoid resection. A variant of this procedure involves forgoing the sigmoid
resection in those who report no history of constipation and whose predominant complaint is
fecal incontinence and doing the mobilisation and rectopexy alone.
Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 51

41. Screening colonoscopy in a 45 year old male with a family history of colonic cancer, identified
the presence of about 70 polys in the colon. What should he be advised?
A. Colonoscopy followup
B. COX inhibitors
C. Colectomy and ileorectal anastomosis
D. Followup with CEA

C. Colectomy and IRA

Attenuated Familial Adenomatous Polyposis.

Attenuated FAP (aFAP) describes a subset of patients with a germline APC mutation in whom the
colorectal phenotype is weak, or “attenuated.” These patients are clinically defined as having less
than 100 synchronous colorectal adenomas. They present at a later age than patients with classical
FAP and develop CRC 10 to 20 years older. APC mutations associated with attenuated polyposis
tend to be at either extremity of the gene. With extreme 3 prime mutations there is a predilection
for severe desmoid disease, and sometimes there are no colorectal adenomas at all (hereditary
desmoid disease). Patients with aFAP are at the same, if not greater, risk of upper GI polyposis as
those with classical FAP. Desmoid disease is common in those with 3 prime mutations but can also
happen with 5 prime mutations. Colorectal surgery tends to occur later and is almost always
colectomy and IRA. Patients with very mild colorectal polyposis may be treated with colonoscopy
every year rather than colectomy. There is an overlap in phenotype between aFAP and MutYH-
associated polyposis (MAP), and with otherwise undefined oligopolyposis.

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 165.

42. Which one of these statements regarding gallstone ileus is false?

a. Usual site of obstruction is terminal ileum

b. Rigler's triad is seen in 10-15% of patients
c. Pneumobilia is an ubiquitous finding
d. Gallstones can cause intermittent obstruction

B. Rigler's triad is seen in 10-15% of patients

The classic plain abdominal film triad of small bowel obstruction, pneumobilia, and ectopic
gallstone is considered pathognomonic of gallstone ileus (Rigler et al, 1941); however, the
triad is encountered in only 30% to 35% of cases (Balthazar & Schechter, 1978).
Pneumobilia is often not appreciated even in retrospect.

Gallstone Ileus - A misnomer, gallstone ileus is in fact a mechanical intestinal obstruction secondary
to a gallstone. A large stone in the dependent portion of the gallbladder fistulizes into the adjacent
duodenum, passing directly into the intestine. This usually happens in older patients and can be
caused by inflammation or simply pressure necrosis. The most common site for obstruction is in
the terminal ileum before entering the cecum. The common presentation is an elderly patient with
some history of biliary tree disorder, with no past surgical history or hernia, with a sudden mechanical
small intestine obstruction. Although most patients will have constant pain from the obstruction,
others can present with only episodic discomfort because the gallstone only intermittently obstructs
the intestinal tract. Plain radiographs usually demonstrate air-fluid levels consistent with a small
bowel obstruction, although the offending stone may or may not be identified. Pneumobilia, which
may sometimes be identified only by CT scan, is a ubiquitous finding because the fistula that
permitted a stone to pass into the duodenum allows air to enter the biliary tree.
Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 55

Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 42

43. Name the given shunt

A. ECF fistula
B. Warrens
C. Sarfeh
D. Rex
D. REX shunt

Rex shunt involves rerouting the splanchnic venous blood through an autologous graft from the
superior mesenteric vein (SMV) into the Rex recess of the left portal vein, curing portal hypertension

Ref: Yaying Eileen Xu, Craig A. McBride, Peter Hodgkinson,

Meso - Rex shunt using the inferior mesenteric vein in a paediatric patient,
Journal of Pediatric Surgery Case Reports,
Volume 61, 2020, 101613, ISSN 2213-5766, https://doi.org/10.1016/j.epsc.2020.101613.

44. Which of these cells are responsible for distal gastric motility?
A. Interstitial cells of cajal
B. G cells
C. I cells
D. Both A and B

A. Interstitial cell of cajal

Gastric Motility
Gastric motility is regulated on three main levels: extrinsic neural control, intrinsic neural control, and
myogenic control. The extrinsic neural controls are mediated through parasympathetic (vagus) and
sympathetic pathways, whereas the intrinsic controls involve the enteric nervous system and
interstitial cells of Cajal. In contrast, myogenic control resides in the excitatory membranes of the
gastric smooth muscle cells.
Fasting Gastric Motility: The electrical basis of gastric motility begins with the depolarization of
pacemaker cells located in the mid-body of the stomach along the greater curvature. Once initiated by
the interstitial of Cajal, slow waves travel at 3 cycles/minute in a circumferential and antegrade
fashion toward the pylorus.

Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 49.

45. Endotherapy that was attempted for bleeding esophageal varices, failed to control the bleeding.
Which will be the next line of management at this stage?

A. Repeat endoscopy
B. Use a Sengstaken blakemore tube
C. Shunt surgery
D. TIPS

A. Repeat endoscopy
Ref: Sleisenger and Fordtran's Gastrointestinal and Liver Disease 11th edition, Chapter 92.

46. A Patient with ulcerative colitis on treatment with steroids, developed fever, severe abdominal
pain and distention with bleeding PR. His heart rate was 108/min, Bp 110/70mmHg. Abdomen was
distended with diffuse tenderness. Blood parameters HB 11%, TC 19000cell/cumm, Platelets
1.90lakhs. What should be the next line of management?

A. X-Ray
B. CT abdomen
C. Laparotomy
D. Emergency colonoscopy

C. Laparotomy
TOXIC MEGACOLON
Toxic megacolon, which is dilation (5 to 6 cm) of the colon, due to inflammation-induced paralysis
of the colon or obstruction proximal to severe disease, is a potentially life-threatening condition.
Patients are very ill and often manifest high fever, abdominal pain and tenderness,tachycardia, and
leukocytosis. Prompt resuscitation and medical therapy are essential. Early decision to operate is life
saving.

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 162.

47. For a patient with intrahepatic cholangiocarcinoma serum bilirubin was 15. He was having a non
cirrhotic liver with remaining hepatic volume more than 20%. Resection was planned. What is to do
next?
A. PTBD from C/l side
B. PVE from c/l side
C. PVE from I/l side
D. PVE with ha embolisation

A. PTBD from C/l side

Patient is having obstructive jaundice with an adequate FLR . Hence to relieve obstruction,
contralateral PTBD advocated.

Minimum Acceptable Future Liver Remnant Volumes and Growth Parameters After Portal Vein
Embolization.

Liver volume characteristic Minimum acceptable value

Minimum acceptable FLRStandard liver Normal liver parenchyma ≥20%

volumes Prior chemotherapy ≥30%
C-P A cirrhosis ≥40%

Degree of hypertrophy after PVE ≥5%

Kinetic growth rate after PVE ≥2%

Ref: Dixon M, Cruz J, Sarwani N, Gusani N. The Future Liver Remnant : Definition,
Evaluation, and Management. Am Surg. 2021 Feb;87(2):276-286. doi:
10.1177/0003134820951451. Epub 2020 Sep 15. PMID: 32931301.

48. What is this space occupying lesion found on this contrast imaging?
A. Liver cell adenoma
B. Hemangioma
C. FNH
D. Hepatoma

B. Hemangioma

Portal venous phase helical computed tomography and centripetal contrast enhancement.

Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 90A.

49. What is the optimum management for a pancreatic head tumour that has more than 180 degrees
contact with superior mesenteric vein without any distant metastasis?

a. Whipple's procedure
b. Neoadjuvant therapy
c. Palliative biliary stenting
d. None of the above

B. Neoadjuvant therapy
Ref: NCCN Guidelines Version 2.2021

50. A 43 year old female presented with clinical features of pheochromocytoma. She was found to
have von Hippel Lindau syndrome,on further evaluation. If she has a mass arising from her pancreas,
what could it usually be?

A. Serous cystadenoma
B. Mucinous cystadenoma
C. Adenocarcinoma
D. Neuroendocrine tumour

A. Neuroendocrine tumor

VHL is an autosomal dominant syndrome caused by inactivation of the VHL gene, which is
thought to play a role in angiogenesis (Yao et al, 2007). VHL predisposes patients to a
number of cancers: renal cell carcinoma, pheochromocytoma, cerebellar and spinal
hemangioblastoma, retinal angioma, endolymphatic sac neoplasms, epididymal cystadenoma, as
well as cystic and solid pancreatic neoplasms (Blansfield et al, 2007). Between 10% and 15%
of VHL patients will develop PNETs, although the most common pancreatic manifestation of
this syndrome is simple cysts (Charlesworth et al, 2012; Schimmack et al, 2011).

Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 65.
51. A patient who had undergone a Whipple's procedure for pancreatic head cancer had 150ml of
blood in the drain on 5th postoperative day. What would be the next line of action ?
A. Wait and watch
B. Usg abdomen
C. CT angiography
D. Emergency exploration

C. CT angiography

Haemorrhage is seen in less than 10% of patients after pancreatectomy but is associated with
high mortality (Puppala et al, 2011). Major bleeding is seen on average 19 days after surgery
and is usually preceded by a smaller sentinel bleed (Otah et al, 2002). Therefore even a small
amount of increased bleeding from surgical drains or GI bleeding more than 3 days after
pancreatic surgery should be evaluated immediately. Bleeding can be due to vessel injury
during surgery or due to pancreatic fluid eroding the vessel wall. In hemodynamically stable
patients, CT angiography can identify the bleeding vessel. A CT angiogram is most likely
to be positive if performed when the patient is actively bleeding. Hemodynamically unstable
patients should proceed directly to catheter angiography and intervention, or to the operating
room.

Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 27.

52. Anti Helicobacter pylori drugs were started for a person with the intent of curing a tumour in his
stomach. What should be the tumour he is treated for?

A. MALToma
B. Diffuse Large B cell Lymphoma
C. Burkitt's Lymphoma
D. Gastrointestinal Stromal Tumour

A. MALToma

Given the strong association with H. pylori and the low-grade MALT lymphoma, patients should
be evaluated for active infection. Patients with early-stage MALT lymphomas and active H.
pylori infection may be effectively treated by H. pylori eradication alone. Successful eradication
results in remission in more than 75% of cases. However, careful follow-up is necessary, with repeat
endoscopy in 2 months to document clearance of the infection and biannual endoscopy for 3 years to
document regression. Some patients continue to demonstrate the lymphoma clone after H. pylori
eradication, suggesting that the lymphoma became dormant rather than disappearing. The presence of
transmural tumor extension, nodal involvement, transformation into a large cell phenotype, and
nuclear BCL-10 expression all predict failure after H. pylori eradication alone. Additionally,
some patients with MALT lymphoma are H. pylori–negative. In these patients, consideration should
be given to radiation therapy (if all the involved sites can be encompassed in a single field) and
chemotherapy. A recent MALT lymphoma prognostic index was developed which identified
three primary risk factors: age of 70 or above, stage IV disease, and elevated lactate dehydrogenase
(LDH) level.
Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 49.

53. On assessing a gentleman for hepatocellular carcinoma, he was found to have diabetes mellitus
and and polyarthritis. He hints that his mother passed away due to advanced liver cancer. What couple
is the probable syndromic association?

A. Hemochromatosis
B. Wilson's disease
C. Alpha 1 antitrypsin deficiency
D. Gilbert's syndrome

A. Hemochromatosis

The principal manifestations of hemochromatosis include hepatomegaly (liver cirrhosis progress to

HCC) , abdominal pain, abnormal skin pigmentation (particularly in sun-exposed areas), deranged
glucose homeostasis or diabetes mellitus (due to destruction of pancreatic islets), cardiac
dysfunction (arrhythmias, cardiomyopathy), and atypical arthritis.
With hemosiderin deposition in joint linings, an acute synovitis may develop. Excessive deposition
of calcium pyrophosphate damages the articular cartilage, producing a disabling polyarthritis
referred to as pseudogout. The testes may be small and atrophic, secondary to pituitary
involvement and reduced gonadotropin and testosterone levels.

Ref : Robbins & Cotran Pathologic Basis of Disease 10th edition, Chapter 18.

54. Which of these is the most common worm found in common bile duct on imaging?

a. Round worm
b. Hook worm
c. Thread worm
d. Tape worm

A. Round worm

Ascaris (round worm) is the commonest helminth to be found within CBD.

Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 45.

56. What should be the definitive management for a patient with this MRCP image?
A. Excision with HJ
B. Excision with choledochojejunostomy
C. Cystojejunostomy
D. Palliative stenting

A. Excision with HJ

Biliary strictures.

Chronic scarring and fibrosis of the head of the pancreas result in external compression of the
intrapancreatic portion of the common bile duct. Up to one third of patients with chronic
pancreatitis develop radiologic evidence of bile duct dilation; however, significant biliary obstruction
occurs in 6% of patients. Biliary strictures typically appear as a long symmetrical narrowing that
involves the intrapancreatic portion of the common bile duct in MRCP or ERCP. IV fluid and
antibiotic therapy and temporary bile duct decompression with plastic stents is indicated for
patients who present with cholangitis. Pancreaticoduodenectomy is indicated for patients in whom
malignant disease cannot be excluded before surgery. A Roux-en-Y hepaticojejunostomy is an
alternative treatment for patients without evidence of malignant disease or significant scarring
that precludes resection of the head of the pancreas. 
Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 56.

57. On evaluation of a patient with colorectal malignancy, imaging showed the presence of tiny liver
metastasis. However, diagnostic laparoscopy revealed a liver with a normal surface. What can be done
to confirm the metastasis at this stage?

a. ICG administration
b. Abort the procedure and do an MRI
c. Laparoscopic Ultrasound
d. Abort the procedure and do PET-CT

C. Laparoscopic Ultrasound
After a thorough inspection of the peritoneal cavity for ascites, carcinomatosis, and signs of
portal hypertension attention is turned to the liver for signs of superficial lesions, steatosis,
cholestasis, cirrhosis, or other gross pathology. Laparoscopic ultrasound is crucial, and a
thorough knowledge of liver anatomy and both B-mode and Doppler ultrasonography is
mandatory for accurate laparoscopic liver resections (Vigano et al, 2013).

Laparoscopic staging can be used in the evaluation of colorectal metastases (Rahusen et al,
1999). Approximately one half of all patients with new diagnoses of colorectal cancer will
subsequently develop liver metastases, yet only 20% are candidates for curative hepatic
resection. Most authors agree that hepatic cirrhosis, extrahepatic tumor spread, and significant
bilobar disease are relative contraindications for hepatic resection. In a large series of patients
with colorectal metastases identified as resection candidates who underwent SL with IOUS,
Thaler (2005) reported that a change in the preoperatively determined plan occurred in 67%
(46/69) of patients. Of those in whom resection was considered impossible, 18 were
untreatable altogether, and 28 patients had alternative treatments (i.e., regional therapy or a
palliative hepatic arterial infusion pump) (Thaler et al, 2005). Of 36 patients in whom
radiofrequency ablation was planned, 14 had procedures altered by SL/IOUS (Thaler et al,
2005).

Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 23, 105.

58. A patient with squamous malignancy in the middle third of oesophagus who underwent chemo
radiation 3 months ago, now presented with progressive dysphagia. Endoscopic biopsy showed
squamous cell malignancy with underlying fibrosis. What should be the ideal line of management?

A. Palliative stenting
B. Surgery
 C. Chemoradiotherapy
D. End of life care

B. Surgery

Indications of surgery
(1) Radical resection of esophageal carcinoma is suitable for patients with stage I, stage
II, and partial stage III (except for the cervical segment). Patients with locally
advanced disease stages are recommended to undergo neoadjuvant therapy.
(2) Salvage surgery for esophageal cancer is suitable for patients with local recurrence
after radiotherapy, no distant metastasis, resectable tumors after assessment, and for
those who can tolerate surgery in general.

Indications for Surgery

a. Early stage disease T1/T2, N0
b. Locally advanced disease T3/T4a, N+ following neoadjuvant treatment
c. Residual disease following chemoradiation if disease is resectable and patient is in good
performance status
d. Local recurrence following radical chemoradiation if there is no evidence of distant disease and
patient is in good performance status.

Ref:https://main.icmr.nic.in/sites/default/files/guidelines/Esophagus%20final%20ICMR2014_0.
pdf

59. Which of the following is non-dysplastic Barrett's oesophagus?

A. Intestinal metaplasia with glands
B. Presence of cardiac cells just after squamous cells
C. Cardiac epithelium encroaching
D. All of the above

We are not sure about the options and exact answer

A standardized system to distinguish between nondysplastic Barrett, highgrade dysplasia, and

adenocarcinoma has been developed by consensus and is termed the
Miami classification.
Nondysplastic Barrett esophageal mucosa has a uniform villiform architecture and columnar
epithelial cells with dark goblet cells, demonstrates minimal intracellular fluorescence, and has
an organized cellular architecture.
In contrast, dysplastic Barrett esophagus demonstrates intense intracellular fluorescence,
heterogeneous cellular sizes, and disorganized cellular architecture with irregularly shaped crypts and
dilated capillary vessels.
In esophageal adenocarcinoma, there is complete loss of crypt and villiform architecture with
irregular and dilated capillaries.
Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 10.

60. Which of the following is correct regarding biliary cysts?

A. Type 1 shows both intrahepatic and extrahepatic malignancy
B. Type 4 shows only extrahepatic malignancy
C. Both are true
D. None

A. Type 1 shows both intrahepatic and extrahepatic malignancy

Carcinoma in Bile Duct Cyst:
The association of bile duct carcinoma with congenital biliary dilatation was first reported by Irwin
and Morison40 in 1944. Tumors may develop anywhere within the intrahepatic and extrahepatic
bile ducts, but more than one-half occur within the dilated part of the bile duct itself. The
incidence of hepatobiliary malignancies associated with congenital biliary dilatation ranges
from 3.2% to 39.4%. Malignant degeneration according to age at initial operation has also been
reported, and it has been estimated that the risk of cancer in patients who had congenital biliary
dilatation diagnosed in the first decade is 0.7%, whereas in those who had congenital biliary
dilatation diagnosed at 11 to 20 years of age and at more than 20 years of age it is 6.8% and 14.3%,
respectively.

Ref: Shackelford, Surgery of the Alimentary Tract, 8th edition, Chapter 116.

61. Cholangiographic image was given intrahepatic bile duct variation was asked. First 2 images were
pointing towards trifurcation but further images revealed it as right posterior sectoral duct joining
CHD.
Ref: Sabiston Textbook of Surgery, 21st edition, Chapter 55.

Ref: Blumgart's Surgery of the Liver, Biliary Tract and Pancreas, 6th edition, Chapter 2.

Thank you for using Surgtest MCQ banks and video lectures
for NEET SS.