Upper GI Surgery Common MCQ

Treatment modalities of achalasia cardia include: Botulinum toxin injection, Heller’s myotomy, Oesophageal dilatation, and Peroral endoscopic myotomy. Nissen fundoplication is used for GORD, not achalasia.

The most probable finding on proctoscopy is Hemorrhoids. Painless fresh per rectal bleeding in a young patient with a normal DRE is most commonly due to internal hemorrhoids. Rectal cancer is less likely in this age group and usually has other symptoms. Sigmoidal diverticulitis typically presents with left lower quadrant pain. Ulcerative colitis would likely have a history of diarrhea and mucus discharge. Anal fissure is very painful.

Regarding acute anal fissure: Lateral internal sphincterotomy is performed to treat intractable fissures. Local application of nitroglycerine gel is used in treatment. Most are located at the 6 o’clock position of the anal canal. Diagnosis is clinical, proctoscopy is painful and not first line. Most acute fissures heal with conservative management.

The most appropriate management is Sigmoid decompression with flatus tube. The ‘coffee bean’ sign on abdominal X-ray is classic for sigmoid volvulus. In the absence of peritonitis, initial management involves endoscopic decompression. Emergency laparotomy is indicated if there is evidence of strangulation, perforation, or if endoscopic decompression fails. Monitoring for 48 hours is not appropriate in the presence of absolute constipation and distension. Phosphate enema is used for fecal impaction, not volvulus. Sigmoid colectomy is the definitive treatment but is usually performed electively after successful decompression.

A persistent filling defect in the esophagus is most likely to indicate carcinoma of the oesophagus. Narrowing with a bird-beak appearance suggests achalasia. Dilation of the upper esophagus suggests obstruction, but is less specific for cancer. Air-fluid levels suggest obstruction, not specifically cancer. Aspirated contrast suggests a fistula, not carcinoma.

Features of acute perforation of a peptic ulcer include: Absence of liver dullness (due to free gas under the diaphragm), generalized abdominal tenderness, and fluid in the peritoneal cavity. Hematemesis is more typical of upper GI bleeding, and a palpable abdominal mass is not a feature of acute perforation.

(Bailey & Love’s, 28th ed., Ch. 58)

Regarding hemorrhoids: Straining while defecation is a predisposing factor. Thrombosed hemorrhoids can be managed conservatively (initially). They are prolapsed anal cushions. Hemorrhoids are not premalignant.

The most possible clinical diagnosis is Perforated peptic ulcer. Sudden severe abdominal pain, signs of peritonitis (guarding, tenderness), and systemic upset in a patient on NSAIDs (for rheumatoid arthritis) strongly suggest a perforated peptic ulcer. Acute cholecystitis presents with right upper quadrant pain. Acute diverticulitis causes left lower quadrant pain. Acute pancreatitis causes epigastric pain. Ruptured aortic aneurysm causes back/abdominal pain and shock.

Barrett’s esophagus is indeed the replacement of normal squamous epithelium with columnar epithelium. PPIs are a mainstay of treatment to manage the underlying reflux. Radiofrequency ablation is a treatment for high-grade dysplasia. Regular endoscopic surveillance is recommended for low-grade dysplasia.

Reflux surgery (fundoplication) is considered for refractory GORD, not specifically for high-grade dysplasia.

H. pylori can be diagnosed by: Serology, Stool antigen test, Urea breath test, Rapid urease test, and Histology.

Barrett’s esophagus is a precursor lesion for esophageal adenocarcinoma. It involves a change from squamous to columnar epithelium. While associated with GORD, it’s not associated with achalasia cardia. Diagnosis involves endoscopy and biopsy, not pH monitoring. It can be asymptomatic. (ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus)

The most likely diagnosis is Ischemic colitis. The patient’s age, atrial fibrillation, sudden onset of abdominal pain, and rectal bleeding are classic signs of ischemic colitis. The elevated white blood cell count supports this. Angiodysplasia usually presents with painless bleeding. Carcinoma of the colon typically presents with more gradual changes in bowel habits. Diverticulitis causes localized pain and fever. Ulcerative colitis presents with chronic diarrhea and bloody stools.

Late gastric carcinoma is a recognized complication of partial gastrectomy, even many years later. The long-standing alteration in gastric anatomy and bile reflux can increase the risk. The presentation with anorexia, vomiting, and loss of appetite in a patient with this history is concerning for malignancy. (Bailey & Love’s, 28th ed., Ch. 60)

A peptic ulcer with everted edges, central necrosis, and contact bleeding, particularly with a history of weight loss and anemia, is highly suspicious for gastric cancer. Biopsy is crucial, as benign ulcers typically have smooth, regular margins. (Bailey & Love’s, 28th ed., Ch. 60)

Factors contributing to lower esophageal sphincter (LOS) function include the Angle of His, intra-abdominal pressure, the left crus of the diaphragm, and the mucosal arrangement of the lower esophagus. The celiac plexus is part of the autonomic nervous system, not directly involved in LOS function. (Bailey & Love’s, 28th ed., Ch. 57)

Mesenteric ischemia is a critical consideration in this patient demographic. Chronic mesenteric ischemia typically presents in older patients with atherosclerotic disease

The most likely diagnosis is acute ischemic colitis. The patient’s age, history of atrial fibrillation (a risk factor for thromboembolism), acute onset of severe generalized abdominal pain with few abdominal signs, and elevated inflammatory markers and lactate levels are highly suggestive of mesenteric ischemia. While perforated duodenal ulcer can cause severe abdominal pain, it typically presents with more pronounced peritonitis. Acute cholangitis presents with right upper quadrant pain, fever, and jaundice. Acute pancreatitis presents with severe epigastric pain. Diverticular disease, while common in this age group, usually causes left lower quadrant pain and altered bowel habits.

The best investigation is Flexible sigmoidoscopy. Given the patient’s age, per rectal bleeding, and incomplete evacuation, colorectal cancer is a significant concern. Flexible sigmoidoscopy allows direct visualization of the rectum and sigmoid colon, where most colorectal cancers occur. If sigmoidoscopy is normal and symptoms persist, a full colonoscopy would be needed. Barium swallow and capsule endoscopy are for upper GI. CT is for staging. Stool occult blood is a screening test, not diagnostic.

The combination of alarm symptoms (weight loss) and persistent upper GI symptoms necessitates prompt investigation. Patients with alarm symptoms (e.g.

The most likely site of pathology is the Ileum. Chronic diarrhea, macrocytic anemia, numbness of extremities, and fatigue point towards malabsorption. The ileum is the primary site of vitamin B12 absorption, and its dysfunction (e.g., in Crohn’s disease) can lead to B12 deficiency, causing macrocytic anemia and neurological symptoms. The ascending colon is more associated with iron deficiency anemia. The jejunum is involved in the absorption of most nutrients, and its dysfunction would cause a broader range of deficiencies. The stomach is related to B12 absorption, but intrinsic factor is produced here, the absorption happens in the terminal ileum. Transverse colon mainly absorbs water and electrolytes.

The condition is most likely an Intersphincteric abscess. The increasing pain with coughing and straining, and the patient’s inability to tolerate examination, suggest an abscess. An intersphincteric abscess is located between the internal and external anal sphincters, causing significant pain. A fissure in ano causes pain during and after defecation. Grade II hemorrhoids are usually painless. A perianal hematoma causes acute, localized pain at the anal verge.

The features that favor Crohn’s disease over ulcerative colitis include Anal fissures and Recurrent abdominal pain. While both can cause altered bowel habits, blood, and mucus, Crohn’s is more associated with penetrating disease (fissures) and abdominal pain. Episodes of intestinal obstruction are more common in Crohn’s. Polyarthralgia can occur in both. Recurrent UTIs are not a typical distinguishing feature.

For a young patient with typical symptoms of uncomplicated GORD, empirical treatment with a PPI is appropriate initial management. Endoscopy is not routinely indicated in the absence of alarm symptoms. (NICE guideline NG3, Dyspepsia and gastro-oesophageal reflux disease: investigation and management)

The most appropriate investigation to confirm the diagnosis of achalasia cardia is Oesophageal manometry. Manometry measures the pressure and coordination of esophageal muscle contractions, and in achalasia, it shows absent peristalsis and failure of the lower esophageal sphincter to relax. Upper GI endoscopy is used to rule out mechanical obstruction. 24-hour pH measurement is for GORD. Barium swallow can suggest achalasia (bird’s beak) but is not definitive. Endoscopic biopsy rules out other causes.

In small intestinal obstruction: Continuous abdominal pain indicates strangulation, a surgical emergency. It is commonly caused by post-op adhesions. Passage of flatus does not exclude complete obstruction. Abdominal distension is a late feature. Elevated serum amylase is more associated with pancreatic disease, but can be mildly elevated in SBO.

*H. pylori* is a major cause of antral gastritis, duodenal ulcers, gastric carcinoma, and gastric lymphoma. It is not a cause of reflux oesophagitis. (Bailey & Love’s, 28th ed., Ch. 58)

The most likely diagnosis is Mallory Weiss syndrome. Haematemesis preceded by vomiting is classic for Mallory-Weiss, a tear in the oesophageal mucosa. GORD, oesophageal carcinoma, and oesophagitis don’t typically cause significant haematemesis after vomiting. Oesophageal varices cause profuse bleeding, but not typically preceded by vomiting.

The patient presents with signs of sepsis (fever, tachycardia, tachypnea) and hypotension, indicating septic shock. The initial management of septic shock involves rapid fluid resuscitation… A crystalloid solution (e.g.

Peptic ulcers are more common in the gastric antrum and proximal duodenum. They can cause microcytic anemia due to chronic blood loss. They can recur and typically do not occur in Meckel’s diverticulum. Bleeding is more commonly from the gastroduodenal artery (posterior duodenal ulcer) or left gastric artery (lesser curve gastric ulcer). (Bailey & Love’s, 28th ed., Ch. 58)

Tarry stools (melena) indicate upper gastrointestinal bleeding. NSAIDs are a well-established cause of peptic ulcer disease and upper GI bleeding.” (Bailey & Love’s”

The most likely diagnosis is Perianal hematoma. The acute onset of a painful lump at the anal verge after straining is characteristic of a perianal hematoma, which is a collection of blood outside the anal canal. An acute anal fissure would cause severe pain during and after defecation, with blood on the stool, not a lump. A fistula-in-ano presents with a chronic discharging sinus. A perianal abscess is more painful and may be associated with fever. Second-degree hemorrhoids are internal and would not present as an acute, painful external lump.

Basal atelectasis is a very common cause of postoperative hypoxemia, especially after abdominal surgery. The combination of pain, reduced diaphragmatic excursion (especially in obese patients), and the supine position contribute to lung collapse at the bases. This is a restrictive defect. (Bailey & Love’s, 28th ed., Ch. 33)

The most probable diagnosis is CA of rectum. The symptoms described (loose stools, urgency, incomplete evacuation, tenesmus, and rectal bleeding) are highly suggestive of rectal cancer. These symptoms arise from the tumor’s location in the rectum. While ulcerative colitis can present with similar symptoms, the patient’s age (70 years) makes rectal cancer more likely, and the examination findings (normal except for blood) are less typical of extensive colitis. CA of the cecum usually presents with iron deficiency anemia or a right-sided mass. Diverticular disease typically causes left lower quadrant pain and altered bowel habits, not usually tenesmus or a sense of incomplete evacuation. Solitary rectal ulcer, while causing bleeding and tenesmus, doesn’t usually present with such a long history of loose stools.

Causes of massive fresh bleeding per rectum include Angiodysplasia of the colon and Diverticular disease of the colon. These are common causes of significant lower GI bleeding, especially in older patients. Mallory-Weiss syndrome causes upper GI bleeding. Meckel’s diverticulum can cause bleeding, but it’s more common in children. Radiation proctitis typically causes chronic, not massive, bleeding.

Regarding familial adenomatous polyposis (FAP): By adolescence, patients with FAP manifest with multiple polyps. FAP is associated with desmoid tumors. FAP is managed by total colectomy, often with ileal pouch-anal anastomosis, not APR in all cases. FAP is equally seen in males and females.

Given the patient’s age, comorbidities, and poor functional status, the focus is on palliation. For patients with advanced esophageal cancer

Painful perianal conditions include: Acute fissure in ano, Perianal hematoma, and Perianal abscess. Carcinoma of the rectum is usually painless initially. Uncomplicated fistula in ano is not typically associated with severe pain.

Regarding GORD, Obesity is a risk factor, Oily food is a causative factor, and PPIs are therapeutic. Barium swallow is not the investigation of choice. Intestinal metaplasia is a consequence of Barrett’s esophagus, not directly of GORD.

The most likely diagnosis is Ca of rectum. The combination of altered bowel habits (loose stools), obstructive symptoms (incomplete evacuation), and rectal bleeding strongly suggests rectal cancer, especially in a 70-year-old man. Sigmoid cancer can cause similar symptoms, but rectal cancer often presents earlier with tenesmus. Solitary rectal ulcer typically causes more localized rectal discomfort and bleeding. Caecum cancer usually presents with anemia or a right-sided mass. Ulcerative colitis would have a longer history and more diffuse colonic involvement.

Endoscopic ultrasound (EUS) is the most accurate test for assessing the local (T) stage of esophageal cancer. It provides detailed images of the esophageal wall and surrounding structures. (Bailey & Love’s, 28th ed., Ch. 59)

Staging of esophageal cancer involves several modalities: CECT of the chest and abdomen, endoscopic ultrasound (EUS) for local staging, PET/CT for distant metastases, and upper GI endoscopy for visualization and biopsy. (Bailey & Love’s, 28th ed., Ch. 59)

Possible causes of massive bleeding per rectum include Diverticular disease of the colon, Carcinoma of the caecum, and Angiodysplasia of the colon. Duodenal ulcer causes upper GI bleeding. Ileocecal intussusception typically presents with abdominal pain and vomiting, more common in children.

The best management option is Chemotherapy. With metastatic disease, the goal of treatment is palliation. Chemotherapy can improve symptoms and prolong survival. Laser therapy and stenting can palliate dysphagia, but do not treat the systemic disease. Surgical resection is not indicated with distant metastases.

Fresh painful PR bleeding occurs in Anal fissure and Thrombosed hemorrhoids. Rectal polyps and angiodysplasia typically cause painless bleeding. Perianal abscess is associated with significant pain, but the bleeding is usually less prominent and associated with purulent discharge.

Regarding Barrett’s oesophagus, Histology shows intestinal metaplasia and Radio frequency ablation is a treatment option. Achalasia cardia is *not* a predisposing factor. Barium swallow does not show bird’s beak appearance. It is a *pre*-malignant, not a malignant, condition.

Premalignant conditions in the upper GIT include: Achalasia, Barrett’s esophagus, and Esophageal webs. Eosinophilic esophagitis and fundal gland polyps are generally not considered premalignant.

This patient has metastatic gastric cancer. The management is primarily palliative. The management of malignant ascites and pleural effusion is primarily symptomatic… Therapeutic paracentesis and/or indwelling peritoneal catheter placement can provide relief.” (UpToDate”

The best management option is Chemotherapy. Given the widespread metastatic disease (lungs), the primary goal is palliation and improving quality of life. Chemotherapy is the most effective systemic treatment for metastatic esophageal cancer. Radiotherapy and stenting can help with local symptoms like dysphagia, but do not address the systemic disease. Esophagectomy is not indicated in the presence of distant metastases.

The most appropriate curative management for squamous cell carcinoma of the anus is Chemo-radiotherapy. This is the standard of care for anal cancer, as it offers better sphincter preservation and equivalent survival compared to surgery. Abdominoperineal resection is reserved for persistent or recurrent disease after chemoradiotherapy. Anterior resection is for rectal cancer. Primary radiation therapy alone is less effective than chemoradiotherapy. Transanal excision is for early rectal cancer, not anal cancer.

The most probable diagnosis is Meckel’s diverticulum. In a young patient presenting with recurrent, heavy, painless rectal bleeding, Meckel’s diverticulum containing ectopic gastric mucosa is a common cause. The gastric mucosa can ulcerate and bleed. Angiodysplasia is more common in older patients. Ulcerative colitis typically presents with diarrhea, abdominal pain, and mucus in the stool. Diverticular disease is rare in this age group. Iliocolic intussusception usually presents with acute abdominal pain and a palpable mass in infants.

Regarding ulcerative colitis: Crypt abscess is characteristic. It is more common in the left colon. Proctocolectomy improves extraintestinal manifestations. It is less common in smokers. Ulcerative colitis involves the mucosa and submucosa, not transmural.

The most probable diagnosis is CA in thoracic oesophagus. Smoking and betel chewing are risk factors for esophageal cancer, and dysphagia with loss of appetite strongly suggests this diagnosis. Thoracic esophagus is the most common site. CA in cervical esophagus is less common. CA in antrum or pylorus would present with gastric symptoms.

Pre-malignant lesions of the colon include Ulcerative colitis, Peutz Jegher syndrome, and Serrated adenoma. Crohn’s disease increases the risk of colon cancer, but is not considered a pre-malignant lesion. Diverticular disease is not associated with an increased risk of colon cancer.

Extra-intestinal manifestations of inflammatory bowel disease (IBD) include Ankylosing spondylitis, Large joint arthritis, Sclerosing cholangitis, and Uveitis. Erythema multiforme is not typically associated with IBD.

The main objective of neoadjuvant chemotherapy in this scenario is to Reduce the local recurrence. For rectal cancer, neoadjuvant chemoradiotherapy (often used interchangeably) is given to downstage the tumor and reduce the risk of local recurrence. It may increase survival, but that’s a secondary aim. It does not directly reduce liver metastasis or metachronous tumors.

Regarding the blood supply of the rectum and colon: The anal canal is a site of porto-systemic anastomosis. Superior sigmoidal veins drain to inferior mesenteric vein. Most of the venous drainage from the rectum is to the systemic circulation. The rectosigmoid junction is supplied by the inferior mesenteric artery. The hemorrhoidal artery is a branch of the internal iliac artery, not the inferior mesenteric artery.

The most appropriate next step in the management is Neoadjuvant chemoradiotherapy. For locally advanced rectal cancer (as indicated by MRI) that is located in the lower rectum, neoadjuvant chemoradiotherapy is the standard of care to downstage the tumor, reduce local recurrence, and improve the chances of sphincter preservation. Anterior resection or abdominoperineal resection would be performed *after* neoadjuvant therapy. Neoadjuvant chemotherapy alone is less effective than chemoradiotherapy for local disease control. Hartmann’s procedure is not typically the first-line treatment for resectable rectal cancer.

Endoscopic resection (e.g., radiofrequency ablation) is the preferred treatment for high-grade dysplasia in Barrett’s esophagus. This aims to remove the dysplastic tissue and reduce the risk of cancer progression. (ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus)

The most appropriate next step in management is Neoadjuvant chemo-radiotherapy. For locally advanced rectal cancer, neoadjuvant chemoradiotherapy is the standard of care. It downstages the tumor, increases the chance of sphincter preservation, and reduces local recurrence. APR (abdominoperineal resection) and AR (anterior resection) are surgical options, but they are typically performed after neoadjuvant therapy in locally advanced cases. A stent may be used for palliation in obstructing tumors, not as primary treatment. Neoadjuvant chemotherapy alone is less effective than chemoradiotherapy for local disease control.

The most appropriate management is Defunctioning colostomy and palliative chemotherapy. The patient has metastatic colorectal cancer (liver metastasis). The primary goal is palliation. A defunctioning colostomy can relieve the obstructive symptoms from the rectosigmoid tumor. Palliative chemotherapy is indicated for systemic disease. Resection of the primary tumor (Hartmann’s or anterior resection) and liver resection are not indicated in this setting of metastatic disease. Stenting alone does not address the systemic disease.

The most likely diagnosis is Haemorrhoids. Painless, fresh PR bleeding after defecation, especially with a history of constipation and a normal digital rectal exam, strongly suggests internal hemorrhoids. An acute anal fissure would cause significant pain. Rectal carcinoma usually presents with altered bowel habits and may be painful. Diverticulosis is typically painless and causes more massive bleeding. Ulcerative colitis causes bloody diarrhea, not isolated bleeding after defecation.

Mallory-Weiss syndrome is characterized by longitudinal mucosal tears at the gastroesophageal junction caused by forceful retching or vomiting

In a patient with signs of peritonitis (tender, rigid abdomen) and a history of peptic ulcer disease, the most appropriate next step is an erect chest X-ray to look for pneumoperitoneum, which confirms perforation. (Bailey & Love’s, 28th ed., Ch. 58)

Regarding drains: Drains can be used to diagnose anastomotic leak (by noting the characteristics of the fluid). Drains can be used to diagnose bleeding. Drains do not impair anastomotic healing. Drains may increase the risk of infection. Drains should be removed when drainage is minimal.

The most important next step in the management of this patient is H. pylori eradication therapy. Even if a gastric ulcer appears benign on biopsy, H. pylori infection is a common cause and should be treated. Repeat endoscopy and biopsy are indicated if the ulcer does not heal after H. pylori eradication or if there is a change in symptoms. PPIs are part of the treatment, but eradication is key. Surgery is not indicated for a benign ulcer.

Regarding small intestinal obstruction: Persistent severe pain indicates strangulation. The commonest cause is adhesions. Bowel opening does not exclude complete obstruction. Elevated serum amylase does not exclude obstruction. The level of obstruction is assessed by a supine and erect abdominal X-ray.

Conditions presenting with recurrent sinuses/fistulae include Actinomycosis, Crohn’s disease, and Hydradenitis suppurativa. Anal fissures typically do not cause recurrent fistulae. Tuberculosis can cause fistulae, but it’s less common in developed countries.

Regarding familial adenomatous polyposis (FAP): It is diagnosed when there are more than 100 polyps in the colon during colonoscopy. It is common to have extraintestinal manifestations (e.g., desmoid tumors). 100% of affected individuals have a positive family history, but it may not be apparent due to new mutations. Total proctocolectomy is the *prophylactic* treatment. Screening should begin in adolescence, around 10-12 years of age, not 25.

The best management option is NG decompression + feeding jejunostomy. Given the widespread metastases and new symptoms of vomiting, weight loss, and malaise, the focus is palliation. NG decompression will relieve the vomiting, and a feeding jejunostomy will provide nutritional support. Palliative gastrojejunostomy might be considered if gastric outlet obstruction is the main cause of vomiting, but a feeding jejunostomy addresses nutritional needs as well. Palliative gastrectomy is too invasive. Neoadjuvant chemoradiotherapy and radiotherapy are not the primary options for a patient with widespread metastases.

Gas bubbles above the liver shadow on chest X-ray (pneumoperitoneum) in a patient with acute abdominal pain and guarding is pathognomonic for a perforated peptic ulcer. (Bailey & Love’s, 28th ed., Ch. 58)

In a patient with dysphagia and a normal endoscopy, esophageal manometry is the next appropriate investigation. This helps to assess esophageal motility disorders such as achalasia. (Bailey & Love’s, 28th ed., Ch. 57)

An INR of 2.8 indicates significant coagulopathy, which increases the risk of bleeding during ERCP. Patients with an elevated INR should be corrected prior to invasive procedures like ERCP. Fresh frozen plasma (FFP) provides immediate correction of clotting factors. Intravenous vitamin K can also be given

The initial management of severe pain and fresh PR bleeding is Topical GTN (glyceryl trinitrate). This presentation is highly suggestive of an acute anal fissure. GTN promotes vasodilation, increasing blood flow to the area and aiding healing, while also reducing anal sphincter spasm and pain. Lateral sphincterotomy is a surgical treatment for chronic or intractable fissures, not the initial management. Botox injections are also used for chronic fissures. Manual anal dilatation is no longer recommended. Colonoscopy is not indicated for the initial management of a suspected acute anal fissure.