GI SURGERY (ACUTE ABDOMEN AND PERITONITIS + GI)

Question 1

Peritonitis caused by perforation of the gastric and duodenal ulcer:
A) is exclusively chemical because the content of stomach and duodenum is sterile
B) initially chemical, but bacterial peritonitis develops within hours due to overinfection
C) bacterial origin from the beginning
D) caused by anaerobic pathogens

Answer 1

B) initially chemical, but bacterial peritonitis develops within hours due to overinfection

The secretion produced by the mucous membrane of a healthy and ulcerative stomach is highly acidic and therefore practically sterile. In the case of perforation of gastroduodenal peptic ulcers, the fluid entering into the free abdominal cavity causes a violent chemical reaction on the large surface of the peritoneum, resulting in knifelike epigastric pain and diffuse reaction of the abdominal wall. The latter manifests itself in abdominal hardening of the abdominal wall, called „défense musculaire”. The fluid that entered into the abdomen is quickly overinfected, while the secretion of the duodenum containing the bile and the pancreatic fluid is not sterile. On the other hand the lack of the the acid content of the stomach will be resulted in the free passing of the flora of the mouth and esophagus containing highly pathogenic bacterias. The resulting peritonitis and sepsis can only be prevented by immediate surgery. Surgery means by closing the ulcerative perforation opening, removing the abdominal fluid (“aspiration”), and rinsing the abdominal cavity several times.

Question 2

The most common place for gastroduodenal ulcers is:
A) the fundus of the stomach
B) the lesser curvature of the stomach in the middle third
C) the posterior wall of the antrum
D) the anterior wall of the duodenum directly below the pylorus

Answer 2

D) the anterior wall of the duodenum directly below the pylorus

Digestion of gastroduodenal peptic ulcer is the most often a complication of ulcers on the anterior wall of the duodenum. One of the reasons for this phenomenon is that peptic ulcers occur most frequently in the first 1-2 cm part of the duodenum bulb following pylori. The other reason is that the front wall of the duodenum is connected to the abdominal cavity in contrast to the posterior wall that is situated in the retroperitoneum. Posterior wall ulcers can adhere or penetrate to the underlying retroperitoneal organs ie. to the the pancreas or head of the pancreas, so here the destruction caused by the ulcer does not pass into the free abdominal cavity. Howevere the penetration to pancreas can be resulted in the erosion of the pancreaticoduodenal artery. This anatomic situation is the explanation of the most common complication of duodenal ulcers occurs in free abdominal perforation, while bleeding is a typical complication of posterior wall ulcers.

Question 3

The optimal time for surgery of gastroduodenal ulcer perforation:
A) within 48 hours after the onset of complaints
B) within 24 hours after the onset of complaints
C) within 6 hours after the onset of complaints
D) scheduled in advance after the investigation is completed

Answer 3

C) within 6 hours after the onset of complaints

Surgical treatment of gastroduodenal peptic ulcer perforation is one of the most urgent surgical intervention. Symptoms of the disease meets the criteria of an acute abdominal disaster, and if the correct surgical intervention is not performed within 6 hours, the rapidly progressing peritonitis can cause sepsis, septic shock, and death of the patient. If the surgical therapy is missed, the chances of survival after 24 hours of perforation will dramatically decrease. There is no effective conservative treatment of perforation of gastroduodenal ulcer.

Question 4

Mallory-Weiss Syndrome:
A) vomiting related stomach rupture of fundus and peritonitis
B) severe inflammation on the mucosa of the fundus
C) rupture of the wall in the middle third of the lesser curvature of the stomach and peritonitis
D) serious bleeding from the rupture of the gastroesophageal mucosa during severe vomiting

Answer 4

D) serious bleeding from the rupture of the gastroesophageal mucosa during severe vomiting

Vomiting is a disorder of co-ordination of the sphincters regulating the passage of the stomach causing intense stomach contractions, while pylorus and cardia are beeing closed. In that situation, a sudden increase in the pressure can occur int the cavity of the gut. Intracavital pressure does not stretch the stomach wall alike. The thick muscular antrum and corpus are resistant, and the thin-walled fundus is extremely dilated and strained. These factors lead to a rupture of the mucous membrane of the fundus nearby the cardia and resulting in acute bleeding. The rupture of the mucosa and bleeding of the fundus is called Mallory-Weiss syndrome. Note that in the esophagus the same vomiting mechanism causes rupture of all the layers of the wall (Boerhaave syndrome), in contrast to the stomach, where no interruption of all layers of the wall is ever detected.

Question 5

The most common cause of peritonitis related to gastric disorders:
A) perforation of peptic ulcer
B) bacterial phlegmone of gastric wall
C) perforation caused by Crohn’s disease
D) tumor-induced perforation caused by tumor disintegration

Answer 5

A) perforation of peptic ulcer

Peptic ulcer is the most common disease affects the gastric mucosa. Bacterial phlegmon of the wall f the stomach and Crohn’s disease limited to the stomach are extremely rare, so perforation or other complication of it is exceptional. Perforation is a very rare complication of gastric carcinoma, but in practice it is more common than the previous two diseases.

Question 6

When is the surgical treatment required for solitaire liver abscess ?
A) In case of failure of the percutan drainage
B) Only surgical intervention is an effective method for treating liver abscess
C) Never

Answer 6

A) In case of failure of the percutan drainage

In the surgical treatment of abscesses, such as liver abscess, UH- or CT-controlled drainage is becoming increasingly prominent. The method is less invasive and its effectiveness is close to surgical treatment. Therefore surgical treatment comes into wiev in the case of failure of the percutan drainage.

Question 7

Which statement is correct?
A) The stomach of patients with peptic ulcers contains a large amount of pathogen bacteria.
B) The use of non-steroid anti-inflammatory drugs (NSAIDs) predisposes to gastric carcinoma.
C) Anterior wall ulcers of the duodenum tend to perforation, posterior wall ulcers tend to bleed.
D) Malignancy is a dangerous and frequent complication of duodenal ulcers.

Answer 7

C) Anterior wall ulcers of the duodenum tend to perforation, posterior wall ulcers tend to bleed.

The content of stomach of patients with ulcers do not contain pathogen bacteria, NSAID does not predispose to carcinoma and transformation of duodenal ulcers to cancers are literary rarities.

Question 8

The most common acute complication of gastric lymphoma is:
A)  	perforation
B)  	cachexia
C)  	sepsis
D)  	bleeding

Answer 8

D) bleeding

Presence of primary solitary or partial phenomen of disseminated non-Hodgkin’s lymphoma (NHL) in the stomach is common (15-20%). 4 - 6% of primary malignant gastric tumors are NHL. In 80-90% of cases, the disease causes ulceration of the mucosa. 18% of patients suffer from acute complications (bleeding, perforation, stenosis), the most common of which is bleeding.

Question 9

Causes of peritonitis associated with infected pancreatitis, except:
A) Hematogen spreading
B) Rupture of abscess
C) Penetration
D) Propagation through anatomically preformed route

Answer 9

A) Hematogen spreading

Peritonitis, a complication of bacterially over infected pancreatitis due to anatomical conditions, always occurs when the process spreads directly to the peritoneum. The direction and target organ of the hematogen spread is not peritoneum; it can occur in the liver.

Question 10

Necrotising pancreatitis may be associated with peritonitis except:
A)  	Localised peritonitis
B)  	Secunder peritonitis
C)  	Fibrinopurulent peritonitis
D)  	Primary peritonitis

Answer 10

D) Primary peritonitis

Peritonitis associated with necrotizing pancreatitis is always a consequential process, and therefore the primary peritonitis cannot be used for this purpose. Primary peritonitis refers to the inflammatory process on the peritoneal surfaces, without prior or concurrent disease of an other abdominal organ. This disease is also called “spontaneous” peritonitis. Pathomechanism is the inflammation of the peritoneum by hematogen spread or direct translocation (“migration) of bacterias from the large bowel, but can develop from urinary tract, female genitalia etc. as an ascending infection. Special forms include pneumococcus-, Streptococcus-, gonococcus- peritonitis and tuberculous peritonitis.

Question 11

Complications of large bowel diverticulitis, except:
A)  	Obstruction of large bowel
B)  	Malignant transformation
C)  	Bleeding
D)  	Small pelvic abscess
E)  	Colon perforation - peritonitis

Answer 11

B) Malignant transformation

Colon diverticulitis may result in a variety of complications, mimicking tumor resulted in colon ileus, but bleeding, perforation, abscess forming and diffuse peritonitis is frequent as well. Transforming to malignant urmo is not known yet.

Question 12

We find necrotic small intestine during the operation of incarcerated hernia. What to do?
A) surgery is postponed and elective surgery is performed later
B) performing hernioplasty
C) removing the necrotic section and make an anastomosis between intact intestinal ends
D) the necrotic small intestine is placed in front of the abdominal wall

Answer 12

C) removing the necrotic section and make an anastomosis between intact intestinal ends

Surgical treatment of incarcerated hernia is a life-saving, urgent intervention. The incarcerated bowel usually dies, which is the source of peritonitis, and the lethality of untreated disease is very high. The postponation of the operation is malpractice. The closure of the herinal ring or defect (hernioplasty) does not solve the source of the peritonitis (i.e.. removal the necrotic part of the bowel) and does not restore the continuity of the digestive tract. Placing the necrotic small bowel in front of the abdominal wall eliminates the source of peritonitis and also provides defecation. However, this is an obsolete process that should be avoided if possible. The correct procedure is the resection of the deceased intestine and restoration of the continuity of the bowel (anastomosis). This is followed by the closure of the hernial gate, or by reconstruction of the abdominal wall (hernioplasty).

Question 13

Possible cause of perforation of appendix:
A)  	bacterial inflammation
B)  	benign tumor lesion
C)  	carcinoid
D)  	helmets
E)  	typhus

Answer 13

A) bacterial inflammation

The most common of the diseases of the appendix vermifromis is the inflammation of the bacterial infection, so called appendicitis. This process is almost the only reason for the perforation of the appendix. Intestinal helminthiasis can be a predisposing factor to appendicitist, but does not cause perforation alone. Carcinoid and benign tumors may occur in theappendix and may cause suspicions of appendicitis but do not cause perforation. Typhus abdominalis is a disease of the small intestine that can cause perforation, today it is a rare disease. Sometimes it may cause suspicion of appendicitis, but it does not cause appendicitis and its perforation.

Question 14

When is the periappendicular infiltrate diagnose probable:
A) The complains started 3 hours ago
B) The complains started 6 weeks ago, without fever, and haven’t been treated
C) The complains started 2 days ago, did got fever, did vomit, has leukocytosis
D) When right lower abdominal resistance is palpable, the stool is Weber-positiv, apyretic
E) When in the last 5 days right lower abdominal pain, vomiting, fever is present and painful right lower abdominal resistance can be detected

Answer 14

E) When in the last 5 days right lower abdominal pain, vomiting, fever is present and painful right lower abdominal resistance can be detected

Periappendicular infiltration is a complicated form of advanced appendicitis, which requires 5-7 days to develop. The six weeks existed right lower quadrant abdominal resistance, without the general symptoms of inflammation (pain, vomiting, fever, leukocytosis), possibly with Weber positivity refers to tumor, therefore a colonoscopy should be performed. In case of 1-4 days existed symptoms indicating appendicitis, immediate surgery should be done. After 5-7 day “appendicitis like” anamnesis the developed painful, circumscribed resistance with fever and with abdominal sonography (or with CT) detected solid structure inflammatory conglomerate composes the periappendicular infiltration.

Question 15

The most common cause of big bowel ileus:
A)  	Ring tumor of the sigma
B)  	Cecal tumor
C)  	Diverticulitis conglomerate
D)  	Villous adenoma
E)  	Abdominal adhesions

Answer 15

A) Ring tumor of the sigma

Diameter of the colon in the sigma area is the smallest (4-5 cm), and this section most often develops shrinking circular “ring” tumors. This explains the experiential fact that sigma adenocarcinomas are the most common cause of large bowel ileus. The large diameter (10-13 cm) coecum tumors are predominantly polypoid lesions that grow to the lumen, which often grow to a very large extent without causing passage disturbances. In the case of diverticulitis, the inflammatory symptoms dominate and the passage disorder is less common. A typical symptom of the villous adenomas is large-scale mucus passage, or bleeding, so they are usually detected before they cause ileus. Adhesive ileus is more likely to be a disorder of small bowel that is mobile, and can be easily refracted, clamped, or twisted aroud the axis. Adhesions rarely cause large bowel ileus.

Question 16

Which statement is true?
A) The fecal peritonitis is a banal complication of colon surgery.
B) The fecal peritonitis is an extremely dangerous complication of colon surgery.
C) The peritonitis caused by diverticulitic perforation is milder than the peritonitis caused by appendicitis.
D) After rich meal evolved foreign body colon-perforation’s treatment is the suture of the opening.

Answer 16

B) The fecal peritonitis is an extremely dangerous complication of colon surgery.

Due to the presence of pathogen bacterias in the colon safe sutures can only be made after mechanical preparation and antibiotic profilaxis. In the case of colon perforation caused by any etiology after eating, treating the opening primere suture is a wrong procedure, which means the patient’s endangerment. The colon contains the most dangerous pathogenic aerobic and anaerobic bacteria (fecalflora) of the human body. In any case where the abdominal cavity is contaminated by colon content, severe septic peritonitis (fecalperitonitis) occurs, followed by a septic shock. The bacterial flora of the appendix is similar to the colon, therefore appendicitis and diverticulitis caused peritonitis is equally dangerous.

Question 17

Which statement is correct?
A) The Hartmann’s procedure is the most common elective large bowel surgery.
B) The Hartmann’s procedure advantage is, that there is no need of an anus preternaturalis to assure the emptying of stool.
C) The essence of Hartmann’s procedure is the resection of the tumorous part of the colon, with closure of the aboral blind-ended colonic stump and formation of an end colostomy with the oral colonic stump.
D) The Hartmann’s procedure is a palliative operation, and it leaves the colontumor on its place till the definitive treatment.
E) By the Hartmann’s procedure we restore the continuity of the bowel with an anastomosis.

Answer 17

C) The essence of Hartmann’s procedure is the resection of the tumorous part of the colon, with closure of the aboral blind-ended colonic stump and formation of an end colostomy with the oral colonic stump.

The French surgeon Hartmann worked out a surgical procedure for the treatment of ileus caused of sigmatumors, which he described in 1928. The procedure involves the removal of the tumorous colon, the closure of the aboral stump and the making of a one end anus praeternaturalis (colostomy). The Hartmann procedure is the most commonly performed acute colon surgery, which eliminates the risk of life, restores the passage and allows for the oncologically adequate removal of the tumor. There is no colon anastomosis left in the abdominal cavity because it would not be safe in ileus condition. Following the disappearance of the ileus, with proper bowel preparation - after mechanical cleansing of the bowel and antibiotic profilaxis - the unification of the bowel ends and the closure of the colostomy can be performed securely in a second elective surgery. Based on all these A, B, D and E statements are false.

Question 18

Typical symptom of large bowel ileus:
A) progressively evolving abdominal distension
B) seizures with enormous pain
C) seizures like occurring fecal vomiting
D) sudden complete stop of bowel sounds
E) diffuse firm abdominal muscle guarding

Answer 18

A) progressively evolving abdominal distension

Large bowel ileus is sneeking, presented with slowly progressing symptoms, characterized by gradually developing abdominal bloating. The large area of the gastrointestinal tract over blockage can compensate for long time the colon stenosis and obstruction caused by bowel content congestion. In the case of colon obstruction the symptoms like pain, seizures and vomiting only appear after several days of complete blockage. Stormy symptoms are characteristic of small bowel ileus. Fecal vomiting is also a result of progressed small bowel ileus, which does not occur in colon obstruction. The full outage of bowel sounds can be a sign of diffuse peritonitis and extensive bowel necrosis. The diffuse plank hard abdomen is a characteristic symptom of gastroduodenal ulcer perforation.

Question 19

It can cause pelveoperitonitis and life-threatening sepsis:
A)  	ruptured tubal pregnancy
B)  	ruptured ovarian chocolate cyst
C)  	gonorrhea
D)  	for more years uncontrolled IUD

Answer 19

D) for more years uncontrolled IUD

The intrauterine contraceptive device (IUD or “spiral”), which has been uncontrolled for several years, especially in women with promiscuity, as a result of chronic endimetritis superinfection and the foreign body induced sepsis causes pyometros. Later the abdominal cavity will be infected, in the more severe cases pyometric rupture, fierce flow of pelveoperitonitis, or septic shock may occur. Ruptured extrauterine pregnancy may cause abdominal hemorrhage and bleeding shock, but not peritonitis. Gonococcal peritonitis is a mild, rare, pelvic-localized, circumscribed process that is a complication of ascending gonorrhea adnexitis. The rupture of “Chocolate” –cyst can cause acute abdominal symptoms without inflammatory signs and does not lead to peritonitis.

Question 20

Which entering technique should be selected by the treatment of diffuse peritonitis with unknown etiology
A) laparoscopy with 3-4 workchanels
B) curved transverse supraumbilical incision (Chevron)
C) transverse laparotomy infraumbilical
D) right pararectal laparotomy
E) total median laparotomy

Answer 20

E) total median laparotomy

Complete median laparotomy is recommended in all cases where the entire abdomen needs to be seen, when the cause of the acute abdomen is unknown and if the entire abdomen is needed to be flushed. In the case of diffuse peritonitis all these factors persist. Neither a laparoscopic approach nor the listed intrusion forms can be considered because they are not suitable for the full exploration of the abdominal cavity, for the palpation of the organs, for the approaching the subphrenic spaces, the Douglas cavity, the intermesenterial and retroperitoneal spaces and organs, exploration of the omental bursa, performing an intervention involving more than one organ, rinsing each corner of the abdomen and correct drainage positioning.

Question 21

Diagnostic methods for gastroduodenal ulcer perforation:

1) abdominal x-ray with barium based contrast material
2) native abdominal fluoroscopy
3) gastrodoudenoscopy
4) by swallowing water souble contrast material to prove leakage

A)  	the 1st, 2nd and 3rd answers are correct
B)  	the 1st and 3rd answers are correct
C)  	the 2nd and 4th answers are correct
D)  	only the 4th answer is correct
E)  	all of the answers are correct

Answer 21

C) the 2nd and 4th answers are correct

In the case of suspected perforation of the gastroduodenal ulcer, the use of barium as a contrast agent is a mistake because when entering the abdominal cavity it causes peritonitis or aggravates the existing peritonitis. This rule is valid for all the X-ray examinations of the digestive tract susceptible to perforation. It is not appropriate to perform gastroduodenoscopy because the air supplied to the bowel lumen for evolving the field of vision by the examination may cause distension of the wall, further rupture, or progression of the perforation. The abdominal native x-ray is a nececcery sorce of information wich can detect the free abdominal air as the evidence of the perforation. Water-soluble (hydrosoluble) contrast agents can be used without risk to radiological visualization the site of exit.

Question 22

Which laboratory test can confirm the etiology of pancreatitis caused peritonitis?

1) serum lipase
2) stool elastase
3) serum amylase
4) blood glucose determination

A)  	the 1st, 2nd and 3rd answers are correct
B)  	the 1st and 3rd answers are correct
C)  	the 2nd and 4th answers are correct
D)  	only the 4th answer is correct
E)  	all of the answers are correct

Answer 22

B) the 1st and 3rd answers are correct

The raise of the serum-lipase and serum-amilase (with leukocytosis), in contrast with the anamnestic details and clinical symptoms, is capable in making the diagnosis of acute pancreatitis. These values do not always correlate with the severity of the disease. The serum-elastase level isn’t significant, and the blood sugar level isn’t a specific characteristic of pancreatitis. However the consequence of pancreatitis could be diabetes.

Question 23

The following investigations could verify the propagation of necrotizing pancreatitis:

1) CT
2) abdominal X-ray
3) sonography
4) ERCP

A)  	the 1st, 2nd and 3rd answers are correct
B)  	the 1st and 3rd answers are correct
C)  	the 2nd and 4th answers are correct
D)  	only the 4th answer is correct
E)  	all of the answers are correct

Answer 23

B) the 1st and 3rd answers are correct

CT and abdominal sonography is suitable method for verification the propagation of the necrotizing pancreatitis. We use these modalities for diagnosting the desease, as well as to check the progression of the process. ERCP is only capable of the fill and illustrate the ductsystem of the organ, but it isn’t suitable for the measurement of the tissue damage. The inflammation or the necrosis of the organ is anyway a contraindication of the ERCP. Abdominal x-ray is irrelevant in the diagnosis of necrotizing pancreatitis.

Question 24

Relevant diagnostic modality in small intestine ileus:

1) anamnestic data
2) physical examination
3) plain abdominal radiography
4) laboratory findings

A)  	the 1st, 2nd and 3rd answers are correct
B)  	the 1st and 3rd answers are correct
C)  	the 2nd and 4th answers are correct
D)  	only the 4th answer is correct
E)  	all of the answers are correct

Answer 24

A) the 1st, 2nd and 3rd answers are correct

Plain abdominal radiography (multiple intestinal fluid levels), physical examination (meteoristic abdomen, high-pitched abdominal sounds, hyperperistalsis, succussion splash, diffuse abdominal pain) and medical history gives key information in small bowel ileus. Laboratory findings are not specific in small bowel ileus.

Question 25

Adequate treatment of mechanical ileus:

1) conservative intestinal movement triggering
2) laxatives, enema
3) sympatholytic treatment
4) treat the obstruction with surgery if possible

A)  	the 1st, 2nd and 3rd answers are correct
B)  	the 1st and 3rd answers are correct
C)  	the 2nd and 4th answers are correct
D)  	only the 4th answer is correct
E)  	all of the answers are correct

Answer 25

D) only the 4th answer is correct

The listed therapies in the first three points don’t treat the causes of mechanical bowel obstruction. Only surgery can solve the mechanical bowel obstruction.

Question 26

The content of the small bowel:

1) is dilute
2) contains bacteria
3) contains more bacteria than the stomach
4) contains more bacteria than the colon

A)  	the 1st, 2nd and 3rd answers are correct
B)  	the 1st and 3rd answers are correct
C)  	the 2nd and 4th answers are correct
D)  	only the 4th answer is correct
E)  	all of the answers are correct

Answer 26

A) the 1st, 2nd and 3rd answers are correct

The content of the small bowel is a dilute material which contains bacteria. Pathogenic bacteria are present in the duodenum as well and the quantity of the bacteria is growing as we go along aborally. However the quantity and the spectrum of the species of pathogenic bacteria are much lower than in the large bowels.

Question 27

Two most common complications of Meckel’s diverticulum:

1) bleeding
2) invagination
3) inflammation
4) perforation

A)  	the 1st, 2nd and 3rd answers are correct
B)  	the 1st and 3rd answers are correct
C)  	the 2nd and 4th answers are correct
D)  	only the 4th answer is correct
E)  	all of the answers are correct

Answer 27

B) the 1st and 3rd answers are correct

All four complication can happen in Meckel’s diverticulum but bleeding and inflammation is more frequent than invagination and perforation.

Question 28

What is the most common reason of liver abscesses?

1) appendicitis
2) large bowel inflammation
3) trauma
4) biliary cause

A)  	the 1st, 2nd and 3rd answers are correct
B)  	the 1st and 3rd answers are correct
C)  	the 2nd and 4th answers are correct
D)  	only the 4th answer is correct
E)  	all of the answers are correct

Answer 28

D) only the 4th answer is correct

The etiology of liver abscess can be liver or biliary disease but statistically the most frequent cause is a biliary disease.

Question 29

Typical symptom of appendicitis, except:

1) Lumbar pain
2) Right lower abdominal quadrant pain
3) Odorous eructation
4) Nausea, vomiting

A)  	the 1st, 2nd and 3rd answers are correct
B)  	the 1st and 3rd answers are correct
C)  	the 2nd and 4th answers are correct
D)  	only the 4th answer is correct
E)  	all of the answers are correct

Answer 29

B) the 1st and 3rd answers are correct

Typically in the case of appendicitis the pain first appears in the epigastrial area then it moves to the right lower abdominal quadrant and it gets worse as the disease progrediates. Other tipical symptom is vomiting. Lumbar pain and odorous eructation is not common in appendicitis.

Question 30

Which treatment is not adequate for liver abscess?

1) US guided drainage
2) CT guided drainage
3) Surgical drainage
4) Marsupialization

A)  	the 1st, 2nd and 3rd answers are correct
B)  	the 1st and 3rd answers are correct
C)  	the 2nd and 4th answers are correct
D)  	only the 4th answer is correct
E)  	all of the answers are correct

Answer 30

D) only the 4th answer is correct

Surgical oncotomy, CT or US guided drainage are effective for treating liver abscesses. Marsupialization to the skin or into another organ are not used techniques.

Question 31

The diagnosis is most likely appendicitis if

1) irregular menstruation is present
2) painful urination is present with pain radiating to the thigh
3) extreme leukocytosis is present
4) odorous vaginal discharge is present
5) high fever is present
6) watery diarrhea is present
7) ascites is present
8) empty rectal ampulla is present

A) none of the answers are correct
B) all of the answers are correct
C) the 3rd, 5th and 7th answers are correct
D) the 3rd and 8th answers are correct
E) the 4th, 6th and 7th answers are correct

Answer 31

A) none of the answers are correct

The listed phenomenon are not the symptoms of the appendicitis. The 1st is common for gynecological diseases, the 2nd indicates the presence of ureter stone, the 3rd is a common symptom for pancreatitis, the 4th is typical for female genital inflammation, the 5th is typical for flu and the 8th is the symptom of large bowel ileus.

Question 32

The diagnosis of appendicitis is cumbersome in case of:

1) menstruation
2) elder patients
3) pregnancy
4) infancy
5) diabetes mellitus
6) cardial decompensation
7) constipation
8) renal diseases

A) the 2nd, 4th and 5th answers are correct
B) the 2nd, 3rd and 4th answers are correct
C) the 4th, 5th and 6th answers are correct
D) the 5th, 6th and 7th answers are correct
E) the 6th, 7th and 8th answers are correct

Answer 32

B) the 2nd, 3rd and 4th answers are correct

The diagnoses of appendicitis is problematic in the presence of concurrent pregnancy (because of the dislocation of intraabdominal organs), in case of old patient (because of weak systemic reaction), or in case of infancy. The other listed factors are nor relevant in the diagnosis of appendicitis.

Question 33

These large bowel diseases can cause peritonitis, except:

1) irritable bowel disease
2) ulcerative colitis
3) Crohn’s disease
4) diverticulitis
5) polyposis
6) tumorous obstruction
7) carcinoid
8) villous adenoma

A) the 1st, 2nd, 3rd and 4th answers are correct
B) the 3rd, 4th, 5th and 6th answers are correct
C) the 1st, 5th, 7th and 8th answers are correct
D) the 4th, 5th, 6th and 7th answers are correct
E) the 5th, 6th, 7th and 8th answers are correct

Answer 33

C) the 1st, 5th, 7th and 8th answers are correct

Question 34

The bacterial flora of large bowel content:

1) is not rich in pathogenic bacteria
2) is very rich in dangerous pathogenic bacteria species
3) is almost only contains anaerobe bacteria
4) aerobe and anaerobe species are equally present
5) enema can completely clear the bowel from bacteria
6) mechanical bowel preparation is not needed if antibiotic prophylaxis is given (enema, laxatives etc.)

A) the 1st and 3rd answers are correct
B) the 1st and 5th answers are correct
C) the 2nd and 4th answers are correct
D) the 3rd and 6th answers are correct

Answer 34

C) the 2nd and 4th answers are correct

Large bowel has abundant pathogenic anaerob and aerob bacterial flora. Preoperative bowel preparation does not make the large bowel bacteria free but mechanical bowel preparation and antibiotic prophylaxis creates lower pathogenic bacterium count and it helps to keep postoperative septic complications rate below 5 %

Question 35

Which of the following modalities are recommended for searching occult abdominal abscess in postoperative septic condition?

1) abdominal US
2) abdominal CT
3) abdominal contrast x-ray
4) irrigoscopy
5) plain abdominal x-ray
6) gastroscopy
7) colonoscopy

A) the 1st and 2nd answers are correct
B) the 3rd and 4th answers are correct
C) the 4th and 5th answers are correct
D) the 6th and 7th answers are correct

Answer 35

A) the 1st and 2nd answers are correct

Question 36

What to do in low abdominal pain and tenderness in a female patient?

1) local cooling
2) antibiotic therapy
3) gynecological examination
4) exclusion or verification of appendicitis
5) immediate removal of IUD
6) immediate surgery
7) anti-inflammatory therapy
8) therapeutic decision only after the 3, 4 and 5 point

A) the 1st, 3rd, 5th and 7th answers are correct
B) the 2nd ,4th ,6th and 7th answers are correct
C) the 3rd, 4th, 5th and 8th answers are correct
D) the 2nd, 5th, 6th and 7th answers are correct
E) the 4th, 5th, 6th and 7th answers are correct

Answer 36

C) the 3rd, 4th, 5th and 8th answers are correct

In case of low abdominal pain gynecological exam is obligatory. Excluding appendicitis is essential before any treatment and the removal of IUD (the most common cause of pelvic inflammation) is also advisable. Other exams and treatments can be perforemd after the consensus of the surgeon and the gynecologist.

Question 37

What to do in the treatment of diffuse peritonitis?

1) microbiological sampling to be able to start targeted antibiotic therapy
2) immediate surgery to clear the cause of the peritonitis
3) abdominal flushing (lavage) after eliminating the source of the peritonits
4) fasting, liquid administration, anti-inflammatory treatment
5) local cooling, gastric tube, bowel movement triggering, enema
6) rigorous conservative treatment
7) stabilization of general condition, liquid and electrolyte supplementation, observation and surgery if the patient’s condition improves

A)  	the 1st and 4th answers are correct
B)  	2nd and 3rd answers are correct
C)  	4th and 5th answers are correct
D)  	4th, 5th and 6th answers are correct
E)  	5th and 7th answers are correct

Answer 37

B) 2nd and 3rd answers are correct

In case of diffuse peritonitis the only treatment which can save the patient’s life is urgent surgical elimination of the source of the peritonitis.

Question 38

Peptic ulcer perforation should be operated immediately because the mortality of anaerobe intraabdominal infections is high
A) both of them are correct, and there is a cause-effect relation between them
B) both of them are correct , but there is no cause-effect relation between them
C) the first part alone is correct, but the second part is not true
D) the first part is not true, but the second part alone is correct
E) both parts are incorrect

Answer 38

B) both of them are correct , but there is no cause-effect relation between them

Peptic ulcer perforation should be operated immediately because of consequent chemical and bacterial (not only anaerobe) peritonitis which can be lethal. Without reference to the aforementioned it is true that anaerobe intraabdominal infections are dangerous.

Question 39

Perforated appendicitis causes serious peritonitis because the bacterial flora of the large and small bowels are equally infectious.
A) both of them are correct, and there is a cause-effect relation between them
B) both of them are correct , but there is no cause-effect relation between them
C) the first part alone is correct, but the second part is not true
D) the first part is not true, but the second part alone is correct
E) both parts are incorrect

Answer 39

C) the first part alone is correct, but the second part is not true

The perforation of appendicitis can cause serious peritonitis because its bacterial flora is similar to the large bowel

Question 40

IUD can cause serious pelvic sepsis and pelviperitonitis that is why it has to be removed before every abdominal surgery
A) both of them are correct, and there is a cause-effect relation between them
B) both of them are correct , but there is no cause-effect relation between them
C) the first part alone is correct, but the second part is not true
D) the first part is not true, but the second part alone is correct
E) both parts are incorrect

Answer 40

C) the first part alone is correct, but the second part is not true

IUD can be the cause of pelviperitonitis however regularly controlled IUD which does not show any sign of inflammation should not be removed before every abdominal surgery.

Question 41

Colorectal surgery should not be done without antibiotic prophylaxis because this way only palliative intervention can be performed.
A) both of them are correct, and there is a cause-effect relation between them
B) both of them are correct , but there is no cause-effect relation between them
C) the first part alone is correct, but the second part is not true
D) the first part is not true, but the second part alone is correct
E) both parts are incorrect

Answer 41

C) the first part alone is correct, but the second part is not true

Antibiotic prophylaxis is obligatory before every colorectal surgery. Omission of the prophylaxis is an error.

Question 42

Antibiotic prophylaxis is only given in urgent colorectal surgery to prevent antibiotic resistance
A) both of them are correct, and there is a cause-effect relation between them
B) both of them are correct , but there is no cause-effect relation between them
C) the first part alone is correct, but the second part is not true
D) the first part is not true, but the second part alone is correct
E) both parts are incorrect

Answer 42

E) both parts are incorrect

Antibiotic profilaxis is obligatory before every colorectal surgery. If the infection has already happened (for example large bowel perforation) the antibiotic medication is not only prophylactic anymore but it treats the infections as well. The indication of surgery (scheduled or emergency) does not have any impact on antibiotic resistance.

Question 43

The acute treatment of painful thrombotic haemorrhoids is:
A) use of laxatives and sit bath
B) haemorrhoidectomy
C) incision of the thrombosed haemorrhoids and the removal of the thrombus
D) rubber band ligation of haemorrhoids
E) local administration of sclerosing injection

Answer 43

C) incision of the thrombosed haemorrhoids and the removal of the thrombus

In this acute process, conservative treatment does not provide a quick and satisfactory solution. Rubber band ligation is particularly painful and, therefore, not a feasible surgical solution. The administration of sclerosing injection is pointless, since it can lead to the occlusion of haemorrhoids, which has already occurred; moreover, it has also been accompanied by thrombophlebitis. In theory, the removal of the haemorrhoids can solve the problem. However, this surgery cannot be carried out with emergency in all cases. The incision of the thrombosed haemorrhoids and the removal of the clot bring immediate relief and can be carried out almost anywhere.

Question 44

If there is no inguinal metastasis, the appropriate primary treatment of squamous cell carcinoma of the anus is:
A) radio-chemotherapy
B) supervoltage irradiation
C) cytostatic treatment
D) local excision with inguinal lymph node dissection
E) abdominoperineal resection with bilateral inguinal dissection

Answer 44

A) radio-chemotherapy

Squamous cell carcinomas of the anus can give metastasis in the upper rectal, pelvic and inguinal lymph nodes, as well. Contrary to the earlier surgical method, the primary treatment of this tumour is radiochemotherapy. The surgical approach is considered only in patients suffering from residual diseases.

Question 45

In a patient with a suspicion of appendicitis, in addition to intact appendix and cecum, regional enteritis is detected. The appropriate action to be taken is:
A)  	ileum biopsy to confirm enteritis
B)  	ileo-hemicolectomy
C)  	appendectomy
D)  	no further intervention
E)  	bypass ileotransversostomy

Answer 45

C) appendectomy

If a patient with a suspicion of appendicitis is operated using McBurney’s incision, the healthy appendix also needs to be removed so that the characteristic skin incision will not be misleading in the event of an acute abdominal catastrophe. The healthy appendix can be safely removed, and, then, the internal medicine treatment can be started immediately.

Question 46

A patient with ulcerative colitis presents in severe condition, with high fever, bloody stool, and abdominal tenderness. Plain abdominal x-ray shows an extremely dilated colon with no free intra-abdominal air. The appropriate action to be taken is:
A) insertion of nasogastric probe, fluid replacement, antibiotic and steroid therapy
B) colectomy + creating a mucus fistula + creating an ileostomy
C) coecostomy
D) colonography
E) colonoscopy

Answer 46

B) colectomy + creating a mucus fistula + creating an ileostomy

Toxic megacolon is a rare, but severe complication of IBD (inflammatory bowel disease), and can lead to death. The complete removal of the inflamed colon, which is the underlying cause, is an adequate therapy prior to perforation.

Question 47

All of the following treatment options are appropriate for the treatment of second-degree haemorrhoids, EXCEPT:
A)  	suppositories, ointments
B)  	radical excision
C)  	sclerotization
D)  	rubber band ligation
E)  	sitz bath

Answer 47

B) radical excision

A patient with second-degree haemorrhoids can be treated with several methods. The most effective method is rubber band ligation. However, the less radical therapies, such as the use of suppositories, ointments, cryotherapy, sclerotization, can also help with the complaints. Radical excision is far too invasive at such an early stage.

Question 48

All of the following statements are valid regarding villous adenomas. EXCEPT:
A) their lobuli give a typical macroscopic image
B) they may cause significant potassium loss
C) their malignant potential is lower than other adenomas’
D) their malignant potential increases proportionally with their size
E) they are accompanied by significant mucus production

Answer 48

C) their malignant potential is lower than other adenomas’

Out of the three known forms of adenomas (tubular, villous and tubulovillous), villous adenomas have the greatest malignant potential. The other answers are typical characteristics of villous adenomas.

Question 49

In the case of colorectal cancer causing no occlusion and solitary liver metastasis, the action that needs to be taken is:
A) radiotherapy of colorectal cancer
B) resection of colorectal carcinoma
C) local electrocoagulation
D) resection of the rectum and the removal of liver metastasis
E) creation of ileostomy

Answer 49

D) resection of the rectum and the removal of liver metastasis

In the case of a tumour that does not cause an obstruction and, therefore, is probably less extensive, only the radical removal results in recovery. This includes the removal of solitary liver metastasis even at the same time, which significantly increases survival chances. Radiotherapy alone serves only as palliation, and can possibly be considered as an adjuvant of surgical treatment. Either the disruption of the surface of the tumour or the local disruption of the tumour can serve no purpose. Ileostomy alone is only performed locally in the case of unresectable tumours.

Question 50

What is UICC?
A) the international cancer organization of the United Nations
B) bowel stapler used to preserve the rectum
C) an international anti-cancer organization
D) chemotherapy regimen for colorectal cancer
E) a rare form of granulomatous colitis

Answer 50

C) an international anti-cancer organization

UICC is an acronym made up of the initials of the French name of the International Union Against Cancer (Union Internationale Contre le Cancer).

Question 51

All of the following statements are valid regarding ulcerative colitis. EXCEPT:
A)  	severe bleeding
B)  	macroscopically coherent lesion
C)  	large, deep ulcers
D)  	responds well to drug therapy
E)  	perforation may occur

Answer 51

C) large, deep ulcers

Ulcerative colitis is characterized by bleeding that causes anaemia and originates from coherent superficial ulcers in the affected colon. In most cases, full or partial remission can be achieved with drug therapy, but in cases that do not respond to conservative therapy, toxic megacolon, which is a severe condition prone to perforation, can rarely develop.

Question 52

Current treatment of acute cholecystitis is:
A) targeted antibiotic therapy and the application of ice packs
B) cholecystectomy within the first 48 hours following the onset of symptoms
C) radiation therapy to reverse the inflammatory process
D) anti-inflammatory, IV steroid treatment, combined with contact dissolution therapy

Answer 52

B) cholecystectomy within the first 48 hours following the onset of symptoms

In case of cholecystitis, acute cholecystectomy can be performed within 48 or even, according to the latest literature, 72 hours. According to our current knowledge, this is the most cost-effective therapy. Conservative treatment is also accepted, of course. This is particularly justified if the patient has a number of comorbidities or is receiving drug therapy (e.g. Syncumar treatment), which will considerably increase the risk of emergency surgery.

Question 53

What is Courvoisier’s sign?
A)  	painful, hydropic gallbladder
B)  	painless, palpable gallbladder
C)  	palpable pancreatic head tumour
D)  	palpable pseudocyst

Answer 53

B) painless, palpable gallbladder

This symptom can be present in the case of pancreatic head and periampullary tumours, when the ductus choledochus gradually becomes narrower and the gallbladder dilates and becomes palpable due to cholestasis. Since there is no inflammation, pain is typically not present.

Question 54

Actions that need to be taken in the case of acute upper gastrointestinal haemorrhage are:
A) inserting a venous cannula, hematocrit (HCT) monitoring
B) fluid and blood replacement
C) esophagogastroscopy
D) all
E) A and B answers

Answer 54

D) all

In the majority of the cases, acute upper gastrointestinal haemorrhage results in severe loss of blood, and may lead to a haemorrhagic shock. Before organizing endoscopy for diagnostic purposes, it is extremely important to monitor the patient’s condition, and if necessary, to replace fluid and blood loss, and to perform oesophagogastroscopy in order to determine the exact source of bleeding and, if necessary, to control the bleeding.

Question 55

All of the following statements are physical signs of an advanced gastric cancer, EXCEPT:
A)  	positive Blumer's shelf finding
B)  	presence of ascites
C)  	palpable tumour in the epigastrium
D)  	presence of Virchow’s lymph node
E)  	palpable inguinal lymph node

Answer 55

E) palpable inguinal lymph node

Stomach cancer rarely has physical signs at the resectable stage. Occasionally, resistance can be palpated in the epigastrium, which is already in stage T4. In the majority of the cases, it can be removed, but often only with the so-called extended resection. Out of the distant metastases, the lumpy liver is palpable in the case of liver metastasis. Virchow’s lymph node in the left supraclavicular fossa is a distant lymph node metastasis. The hard resistance that is palpable in the pouch of Douglas with rectal examination is called Blumer’s shelf. It develops as a result of the fact that the tumour has metastasized to the peritoneum. In such cases, the patient already has ascites, which is the consequence of peritoneal cancer. In rare cases, the cause of ascites may be liver cirrhosis. Therefore, in doubtful cases, laparoscopy is to be performed before inoperability is established. Palpable inguinal lymph nodes do not necessarily indicate a malignant tumour of the stomach, which is a common clinical diagnosis, especially, in the case of inflammatory diseases of the lower extremities.

Question 56

The functional disorder of the oesophagus caused by Tripanosoma cruzii infection is:
A)  	oesophagus diverticulum
B)  	achalasia
C)  	reflux disease
D)  	diffuse oesophageal spasm

Answer 56

B) achalasia

The aetiology of achalasia is unknown. The destruction of intramural ganglion cells in the oesophageal smooth muscle is likely to play a role in its pathogenesis. Chagas disease, which is common in South America and caused by the protist Trypanosoma cruzi, shows identical clinical and radiological symptoms.

Question 57

The most common oesophagus diverticulum is:
A)  	Zenker’s diverticulum
B)  	epiphrenic diverticulum
C)  	middle third traction diverticulum
D)  	Meckel-diverticulum

Answer 57

A) Zenker’s diverticulum

Several types of diverticula (pulsion, traction) can develop, out of which pharyngoesophageal diverticulum, or Zenker’s diverticulum, which occurs primarily in the elderly, is the most common. Meckel diverticulum can be found in the small intestine.

Question 58

In the case of massive, shock-inducing gastrointestinal haemorrhage, the most urgent action that needs to be taken is:
A)  	localization of bleeding
B)  	volume replacement
C)  	angiography
D)  	coagulation test

Answer 58

B) volume replacement

All the given answers play an important role in diagnosing and treating shock-inducing gastrointestinal bleeding. However, the most urgent task is to prevent the development of a life-threatening condition resulting from hypotension caused by the substantial blood loss. Therefore, immediate volume replacement is essential.

Question 59

In portal hypertension, the following factors influence the development of ascites. EXCEPT:
A) increase in intravascular pressure in the portal system
B) hypoproteinemia
C) spider naevi
D) water electrolyte imbalances

Answer 59

C) spider naevi

Due to portal hypertension, fluid absorption through the peritoneum is inhibited; the plasma oncotic pressure decreases due to hypoproteinaemia. Thereby, the balance of the fluid flow between the intra and extravascular space is disturbed. Spider naevi are not involved in the formation of ascites.

Question 60

The following procedures are surgical procedures performed due to portal hypertension in order to reduce direct bleeding. EXCEPT:
A) sclerotization of oesophageal varices
B) splenorenal shunt
C) oesophageal transection
D) endoscopic ligature

Answer 60

B) splenorenal shunt

The answers are the treatment options of acute bleeding; whereas, splenorenal shunt is not a surgical procedure that can reduce direct bleeding, but an indirect treatment option of portal hypertension.

Question 61

The following collateral systems play an important role in portal hypertension. EXCEPT:
A) gastroesophageal collateral network
B) epigastric vein - internal thoracic vein system
C) haemorrhoid collaterals
D) umbilical veins
E) retroperitoneal network

Answer 61

B) epigastric vein - internal thoracic vein system

The epigastric vein -internal thoracic vein means the connection between the femoralis communis vein and the subclavian vein. In other words, in the case of the occlusion of inferior vena cava, the collateral system is important. Thus, its role is not significant in the case of portal hypertension; whereas, all the other listed venous collateral systems have a crucial role in this disorder.

Question 62

Which of the following cases of portal hypertension is an indication for surgery?
A) in patients with cirrhosis, in the case of oesophageal varices, if there is a history of bleeding
B) in the case of oesophageal varices for prophylactic purposes
C) in the case of ascites that cannot be influenced by internal medicine treatment
D) in the case of persistent icterus and poor liver functions
E) in poor general health condition

Answer 62

A) in patients with cirrhosis, in the case of oesophageal varices, if there is a history of bleeding

Answer A is the correct one. Because surgery is premature for oesophageal varices presenting without symptoms. At the same time, ascites that cannot be influenced by internal medicine treatment are indicative of hepatic decompensation, and surgical outcomes are extremely poor at this stage. The same applies to answers D and E.

Question 63

The prognosis of the treatment of the patient with acute oesophageal bleeding is good. EXCEPT if:
A)  	his consciousness is intact
B)  	he is not disoriented
C)  	he does not have cachexia
D)  	he has icterus
E)  	he has no ascites

Answer 63

D) he has icterus

If acute oesophageal bleeding is caused by portal hypertension, the icterus indicates hepatic decompensation, which considerably impairs the prognosis. Maintained consciousness, good general health condition and lack of ascites indicate satisfactory liver function, and, in this case, the prognosis of surgical treatment is also good.

Question 64

The following disorders cause paralytic ileus. EXCEPT:
A)  	mesenteric artery occlusion
B)  	hypokalaemia
C)  	pancreatitis
D)  	gastrointestinal bleeding
E)  	perforation

Answer 64

D) gastrointestinal bleeding

Mesenteric artery occlusion, except for the first phase of the disease, typically leads to bowel paralysis, and so does hypokalaemia. Both pancreatitis and perforation cause paralysis reflex. The correct answer is D, because, quite the contrary, bleeding into the bowel lumen can lead to hyperperistaltics.

Question 65

The most common cause of portal hypertension is:
A) extrahepatic portal vein obstruction
B) cirrhosis
C) increased visceral arterial circulation
D) post hepatic venous outflow obstruction
E) right-sided heart failure

Answer 65

B) cirrhosis

All answers can play a role in the development of portal hypertension, but the most common cause is cirrhosis, during which intrahepatic fibrosis leads to the significant impairment of hepatic circulation and, due to the increased resistance, portal hypertension develops.

Question 66

Which of the test methods listed below can detect colorectal cancer with the greatest accuracy?
A)  	tumour marker test
B)  	colorectal thermography
C)  	stool analysis
D)  	colonoscopy

Answer 66

D) colonoscopy

Several diagnostic methods can be used in the diagnosis of colorectal cancer. The greatest diagnostic accuracy is given by the endoscopic coloscopy, which can be used to remove benign lesions and to collect samples for histological analysis in case of tumours. Other test methods, such as tumour marker test, thermography, stool analysis, are less specific or sensitive procedures

Question 67

The following factors influence the prognosis of oesophageal cancer. EXCEPT:
A)  	tumour stage
B)  	feasibility of R0 resection
C)  	type of therapy
D)  	age of the patient

Answer 67

D) age of the patient

While estimating the prognosis of oesophageal cancer, several parameters can be analysed, such as age, sex, aetiology, tumour localization, stage, histology, degree of differentiation, chosen therapy (neoadjuvant therapy, 2- or 3-field lymphadenectomy, thoracotomy without oesophageal dissection). It is worth evaluating the factors under consideration with multivariate analysis to give prognosis. Based on the literature, the prognostic factors in order of importance are the following: tumour staging, the feasibility of R0-resection, chosen therapy, and the rate of cancerous and non-cancerous tumours. Age does not significantly affect disease specific survival rates.

Question 68

The routine treatment of bile duct stones causing jaundice is:
A) ERCP, endoscopic sphincterotomy and stone extraction
B) contact dissolution therapy
C) unblocking extrahepatic bile ducts surgically from laparotomy
D) removal of stones with percutaneous trans hepatic approach

Answer 68

A) ERCP, endoscopic sphincterotomy and stone extraction

In clinical practice, the least invasive and the most effective method to remove bile duct stones is endoscopy. The other options listed in the answers, such as chemotherapy through a catheter, surgical removal, or percutaneous transhepatic stone extraction, involve significant risks, and their effectiveness is far below the endoscopic removal.

Question 69

The following conditions presumably contribute to the development of oesophageal cancer. EXCEPT:
A)  	achalasia
B)  	corrosive stricture
C)  	diffuse oesophageal spasm
D)  	Barrett-oesophagus

Answer 69

C) diffuse oesophageal spasm

Out of the tumours of the gastrointestinal tract, the greatest number of suspected pathogenic factors are known in the aetiology of oesophageal cancer; such as smoking, regular alcohol consumption, and the consumption of foods or drinking water containing nitrosamine. The incidence of oesophageal cancer is significantly higher in many oesophageal diseases compared to normal population. 30 to 50 years after the corrosive injury, the risk of the development of scar cancer in the surgical scar is 2000 times greater than in the same age group. In achalasia, this risk is 20-30 times higher 15 to 20 years after the onset of the disease. The risk of developing oesophageal adenocarcinoma resulting from Barrett-oesophagus is similar to the latter.

Question 70

The most accurate method of diagnosing bleeding oesophageal varices is:
A) swallowing test
B) esophagoscopy
C) selective angiography
D) oesophageal balloon tamponade (Blakemore tube)
E) splenoportography

Answer 70

B) esophagoscopy

Question 71

The following conditions are common complications of choledochus stones. EXCEPT:
A)  	pancreatitis
B)  	mechanical icterus
C)  	cholangitis
D)  	liver cancer

Answer 71

D) liver cancer

Bile duct stones can lead to many complications, such as pancreatitis, mechanical icterus, and cholangitis. Malignant degeneration rarely occurs in the case of bile duct stones; it is not considered as a pathological factor especially in the aetiology of liver cancer.

Question 72

What is Charcot’s triad?
A) a combination of fever, jaundice and abdominal pain
B) a combination of jaundice and painless hydrops
C) a combination of hydrops, Biliary colic and chills

Answer 72

A) a combination of fever, jaundice and abdominal pain

In Charcot’s triad, which indicates cholangitis, cramping abdominal pain, jaundice and fever, which is often accompanied by chills, occur simultaneously. These three symptoms occur in 70% of cholangitis, and are the most common complications of choledocholithiasis.

Question 73

Which of the following statements is NOT true for LC (laparoscopic cholecystectomy)?
A) Bleeding can be so severe that the surgical intervention needs to be converted to an open surgery.
B) The so-called benefit-cost ratio is considerably more favourable than in open cholecystectomy.
C) The removal of the hydropic gallbladder is not possible during LC, because the gallbladder is too tight to be grabbed well with the instruments.
D) In patients with severe arrhythmia, “pneumoperitoneum” made during LC may be unfavourable.

Answer 73

C) The removal of the hydropic gallbladder is not possible during LC, because the gallbladder is too tight to be grabbed well with the instruments.

Answer A: vascular injuries that can only be treated safely with a surgical procedure may occur but not often, so this is true. Answer B is also true, laparoscopic cholecystectomy (LC) combines much faster recovery with much lower healthcare costs. Answer C is not true, because gallbladder hydrops can be punctured and the content can be drained. Answer D, which says that pneumoperitoneum in LC is less favourable in patients with severe arrhythmia, is also true.

Question 74

Which of the following interventions would you recommend to a patient with combined gallstones as the least invasive and the lowest-risk intervention?
A) first step is the removal of the gall bladder and, in case of jaundice, choledochus exploration
B) LC after successful EST
C) open cholecystectomy and choledochus exploration with Kehr’s drainage
D) open cholecystectomy and drainage surgery (eg choledochoduodenostomy or choledochojejunostomy).

Answer 74

B) LC after successful EST

A significant proportion of choledochus stones spontaneously passes after EST. If the choledochus stone passes after the less invasive EST, then LC, which is also less invasive, can be performed. In benign bile duct disorders, such as choledochus stones, drainage surgery is not to be performed because regular, ascending infections cause complications over the years.

Question 75

When is PTC contraindicated?

1) if the patient suffers from coagulopathy which is not corrected
2) if intrahepatic stones are also formed
3) if the intrahepatic bile ducts are narrowed
4) if only biliary draining is planned

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 75

B) 1st and 3rd answers are correct

Percutaneous transhepatic cholangiography, as the name suggests, is performed by penetrating an intrahepatic bile duct through the skin. If a patient who needs PTC has coagulopathy, the puncture of the liver and the abdominal wall may result in severe bleeding complications. If the patient does not have sufficiently dilated bile ducts, there is little chance that the physician can manage to hit a normal diameter bile duct with the needle. If we are planning biliary drainage, the thin cannula used for drainage is to be inserted using the needle used for the PTC. Intrahepatic stone formation is one of the diseases that can be diagnosed with PTC.

Question 76

Prognosis for bleeding gastroduodenal ulcer depends on:

1) intensity of bleeding
2) activity of bleeding
3) patient’s age
4) site of bleeding

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 76

E) all of the answers are correct

The prognosis of gastroduodenal bleeding depends on: a) the bleeding activity that is classified according to the Forrest stages. In case of spurting bleeding, rapid intervention is needed, and the prognosis is worse, because even if endoscopy is used to stop the bleeding, there is a high risk of recurrent bleeding. (b) the intensity of bleeding, which can be characterized by Hgb and Htc values measured upon admission, and the amount of transfusion needed to improve circulatory and laboratory parameters. c) the site of the bleeding – the prognosis of ulcers in the vicinity of large arteries (lesser curvature-artery, a. gastrica sinistra; back wall, gastroduodenal artery near the pylorus) is bad, because active bleeding can reoccur, and the risk of recurrent bleeding is high. d) the age of the patient: elderly patients do not tolerate circulatory changes, a lot of transfusion and surgeries well.

Question 77

Possible complication for gastroesophageal reflux disease is:

1) reflux laryngitis
2) aspirational pneumonia
3) oesophageal adenocarcinoma
4) Schatzki ring

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 77

E) all of the answers are correct

The importance of gastroesophageal reflux is given by two fundamental aspects. On the one hand, the patient may have serious complaints and, on the other hand, it can lead to life-threatening complications. The complications are: - oesophagitis, - peptic stricture, - oesophageal ulcer, which may bleed, penetrate, perforate, - Barrett’s oesophagus, which can also lead to oesophageal adenocarcinoma, - lung infections due to aspiration, - Schatzki ring, - reflux laryngitis, - oesophageal motility disorders, - reflux stomatitis.

Question 78

Possible therapy options for treating first-stage achalasia

1) Calcium channel blocker medications
2) balloon dilation
3) Heller myotomy
4) botulinum toxin injections

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 78

E) all of the answers are correct

The treatment of achalasia depends on the stage of the disease. In stage I the administration of Ca-channel blockers is a possible option; it is effective in 10-15% of the cases. Out of the endoscopic methods, balloon dilation is the most common and effective in 60-70% of the cases. Endoscopic injection of botulinum toxin is recommended for high-risk patients, because although it is 90% effective, the effect rarely lasts for more than 1-1 ½ year. Surgical treatment (Heller myotomy) has the highest efficiency (about 90-95%) in the treatment of achalasia.

Question 79

Resection of the terminal ileum results in:

1) anaemia
2) loss of biliary acids
3) loss of Vitamin B12
4) low levels of serum Fe

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 79

A) 1st, 2nd and 3rd answers are correct

Terminal ileum is the primary site of the absorption of vitamin B12, the lack of which causes megaloblastic pernicious anaemia. Bile acids are also absorbed primarily here. The insufficient absorption leads to impaired enterohepatic circulation of the bile acids, and due to the decreased bile acid secretion fat digestion also becomes impaired. Undigested fatty acids cause diarrhoea in the colon whose mucous membrane is irritated by bile acids. Iron is absorbed elsewhere (duodenum).

Question 80

Risk for colorectal cancer is increased in the following conditions:

1) familial polyposis
2) pseudomembranous colitis
3) Gardner syndrome
4) juvenile polyposis

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 80

B) 1st and 3rd answers are correct

Familial polyposis and Gardner’s syndrome are congenital, genetically-determined obligatory precancerous conditions; the development of cancer can be expected in young adulthood. Pseudomembranous colitis is a bacterial inflammation, which can be completely treated using the appropriate therapy. In the case of juvenile polyposis, the polyps have a histological profile similar to that observed in hamartomas and, as usually in the case of hamartomas, there is no malignant transformation potential.

Question 81

In acute pancreatitis, the following may refer to unfavourable prognosis:

1) extended necrosis
2) high levels of serum amylase
3) infection
4) meteorism

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 81

B) 1st and 3rd answers are correct

In acute necrotizing pancreatitis, the presence of infection is the main risk factor, which increases the frequency of local and systemic complications and mortality (the latter is around 20% in this case). The bacterial infection of necrosis can be observed in 40-70%, and its extent is closely related to the extent of necrosis. If, for example, more than 50% of the pancreas necrotized, the likelihood of infection is approximately 40%. The serum amylase level does not correlate with the severity, it can even be normal in total necrosis (there is nothing that can produce enzyme). Meteorism is a symptom of bowel paralysis observed in acute pancreatitis and can be seen in the form of oedema.

Question 82

The following may mimic the manifestations of acute appendicitis:

1) mesenteric lymphadenitis
2) acute cholecystitis
3) perforated duodenal ulcer
4) right-sided ureterolithiasis

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 82

E) all of the answers are correct

Lower right abdominal pain may be due to various abdominal pathologies in addition to appendicitis, which may mislead even a diagnostic expert. For example, an elongated, enlarged and inflamed gall bladder, or the succus leaking from a perforated duodenal ulcer along the right colon with a stimulating effect on the peritoneum. Peritoneal symptoms may also be caused by renal stone obstructing the ureter, or by the infectious inflammation of the mesenteric lymph nodes.

Question 83

Symptoms of diffuse peritonitis are:

1) tachycardia
2) oliguria
3) muscular defense
4) diarrhoea involving hyperperistaltics

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 83

A) 1st, 2nd and 3rd answers are correct

In diffuse peritonitis, several litres of fluid may accumulate in the peritoneal cavity either through the peritoneum which becomes permeable due to the inflammation, or due to the perforation of a cavity organ which leaks. Due to hypovolaemia, tachycardia associated with centralized circulation and oliguria due to reduced renal perfusion are accompanying symptoms. Due to parietal peritoneal anxiety, muscular defense develops which involves the development of reflex paralysis in the intestines causing no passage of gas or stools.

Question 84

The following are common complications of acute pancreatitis, except:

1) pseudocyst formation
2) ARDS
3) diabetes mellitus
4) bleeding varix of the oesophagus

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 84

D) only 4th answer is correct

Acute pancreatitis may be accompanied by several local or systemic complications. Pancreatic pseudocysts are common sequelae of acute pancreatitis, but in severe cases ARDS and diabetes mellitus may also develop at an early stage. Bleeding oesophageal varices do not accompany pancreatitis.

Question 85

Observable symptoms during perforation of duodenal ulcer:

1) sudden onset epigastric pain
2) free peritoneal fluid on ultrasound examination
3) free peritoneal gas present on plain abdominal X-ray picture
4) hyperperistaltic bowel sounds

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 85

A) 1st, 2nd and 3rd answers are correct

Sudden onset, stabbing epigastric pain is a characteristic clinical sign of perforated duodenal ulcer. X-ray examination shows free intraperitoneal gas under the diaphragm, and ultrasound test may reveal free fluid within the peritoneal cavity. Therefore, the first three answers are correct, and the fourth one is incorrect, since in case of perforation, reflex paralysis characteristically occurs in the peritoneal cavity.

Question 86

Signs and symptoms of gallstone ileus:

1) intermittent cramping abdominal pain
2) air present within the biliary tract
3) intestinal gas-fluid levels on X-ray examination
4) tenesmus

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 86

A) 1st, 2nd and 3rd answers are correct

In gallstone ileus, cholecystoenteric fistula develop, therefore radiological examination detects air within the biliary tract. Consistent with symptoms of obstructive ileus, the patient experiences intermittent cramping pain. Plain X-ray pictures of the abdomen show intestinal gas-fluid levels. The first three answers are correct, and the fourth one is incorrect, since tenesmus refers to defecation urge, which is not included in gallstone ileus symptoms.

Question 87

The following statements are true when tarry stools occur:

1) it may even be caused by only 50 ml of blood
2) it is more often indicative of upper GI bleeding
3) the black colour may be due to reaction between gastric acids and hemoglobin
4) it may be detected for a few days even after the bleeding has stopped

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 87

E) all of the answers are correct

Tarry stool is primarily caused by upper gastrointestinal bleeding, and the black colour results from the oxidation of hemoglobin by gastric acids. Significantly marked upper GI bleeding may cause defecation of bright red blood since the large quantity of blood acts to increase peristalsis and there is not enough gastric acid to react with the total amount of hemoglobin. If less than 50 ml of blood is excreted, then usually occult bleeding is the cause, which is not detectable with the naked eye. Since the intestinal content stays within the intestines for several days, the melaena may also be detected even after the bleeding has stopped.

Question 88

Familial polyposis is characterised by:

1) risk of malignancy
2) number of the polyps are between 10–20
3) correct treatment involves total proctocolectomy
4) may be treated effectively with colposcopic excision

A)  	1st, 2nd and 3rd answers are correct
B)  	1st and 3rd answers are correct
C)  	2nd and 4th answers are correct
D)  	only 4th answer is correct
E)  	all of the answers are correct

Answer 88

B) 1st and 3rd answers are correct

Familial hereditary polyposis is a condition when several hundred or even a thousand polyps develop within the colon lining, which cannot be completely removed through colonoscopy. Since it is an obligatory precancerous condition, only the total removal of the colon and rectum may prevent further inevitably developing colorectal carcinoma.

Question 89

Colonic diverticulitis complications are:

1) ileus in the large intestine
2) malignant abnormality
3) life-threatening bleeding
4) pelvic abscess
5) perforation of the large intestine

A) 1st, 2nd and 3rd answers are correct
B) 1st, 3 and 4th answers are correct
C) 1st, 3 and 5th answers are correct
D) 1st, 4th and 5th answers are correct
E) 2nd, 4th and 5t answers are correct
F) 3rd, 4th and 5th answers are correct

Answer 89

D) 1st, 4th and 5th answers are correct

Thickening of the diverticular intestinal portion will cause narrowing of the lumen and may lead to ileus development. Due to the microscopic perforations, bacteria may invade the peritoneum causing abscess formation, but occasionally microscopic and macroscopic perforation may also occur. Severe bleeding is more characteristic of diverticulosis than of diverticulitis, when malignant abnormalities are not likely.

Question 90

Which factors increase the probability of the presence of stones at the choledochus?

1) elevated serum bilirubin levels
2) elevated levels of serum alkaline phosphatase (above 39 IU)
3) diameter of choledochus lumen exceeds 12 mm
4) familial hyperlipidaemia
5) if biliary drainage detects Giardia lamblia
6) occurrence of jaundice in patient history

A) 1st, 2nd and 6th answers are correct
B) 1st, 2nd, 3rd and 6th answers are correct
C) 1st, 4th and 5th answers are correct
D) 3rd, 5th and 6th answers are correct
E) 4th and 5th answers are correct

Answer 90

B) 1st, 2nd, 3rd and 6th answers are correct

Increased serum bilirubin levels may occur due to partial or total obstruction in the common bile duct, which may be caused by the presence of stones. Increased alkaline phosphatase level in the serum is a clinical laboratory sign of bile drainage failure, which may also refer to stones in the common bile duct. The diameter of the common bile duct exceeds 12 mm, which usually indicates obstruction which may be caused by stones or other bile drainage failure in the common bile duct. Positive history of jaundice may also refer to a prior mechanical jaundice. Familial hyperlipidaemia and Giardia lamblia infection are not directly related to the possible presence of stones in the common bile duct.

Question 91

Gastric cancer is incurable if:

1) carcinosis peritonei is present
2) multiple liver metastases are present
3) the tumour affects the left adrenal gland and hilus of the spleen
4) the tumour affects the body and tail of the pancreas

A) 1st, 2nd and 3rd answers are correct
B) 1st, 2nd and 4th answers are correct
C) 1st and 2nd answers are correct
D) 1st, 3rd and 4th answers are correct
E) 1st, 2nd, 3rd and 4th answers are correct

Answer 91

C) 1st and 2nd answers are correct

A T4 stage tumour, despite the fact that it affects one or more of the surrounding organs, is not unresectable, therefore the stomach and the spleen may be removed. The body and tail of the pancreas is also resectable, as well as the left adrenal gland, a section of the transverse colon, the left lobe of the liver, a part of the esophagus and of the diaphragm, and a few inches from the duodenum. If there is a solitaire metastasis in the liver, its removal may be indicated when all the tumours are removed within the abdominal cavity, although its role in improving survival rates is still not fully understood. If there are multiple metastases in the liver, extended liver resection or removal of multiple metastases are not considered. The tumour is also inoperable if there is metastasis in a distal lymph nodes or if peritoneal carcinosis is present in the abdominal cavity.

Question 92

Development of colon carcinoma is enhanced by:

1) high animal fat content diet
2) fibre rich diet
3) prior cholecystectomy
4) ulcerative colitis
5) presence of polyps bigger than 3 cm

A) 1st, 2nd, 3rd and 5th answers are correct
B) 1st, 3rd and 4th answers are correct
C) 1st, 2nd and 3rd answers are correct
D) 1st, 3rd, 4th and 5th answers are correct
E) 1st, 4th and 5th answers are correct
F) 2nd, 4th and 5th answers are correct
G) 3rd, 4th and 5th answers are correct

Answer 92

E) 1st, 4th and 5th answers are correct

Recent studies conducted on large samples of population confirm that a high fat content and low fibre diet increases the risk for developing colon cancer. The risk of postoperative malignant colon cancers following cholecystectomy is not completely clear, since study data are contradictory. When active ulcerative colitis persists for 15 or 20 years, it will almost always cause development of carcinoma. In polyps with a diameter exceeding 3 cm, dysplasia is significantly increased, which will also result in carcinoma development.

Question 93

What is the role of coloscopy in the diagnosis of colon diseases?

1) It ensures accurate visualization of mucosal lesions
2) It provides biopsies from mucosal lesions
3) It can be used to remove small sized mucosal lesions
4) It provides basis for assessing the depth of a tumour and its adjacent relationships

A) 1st, 2nd, and 3rd answers are correct
B) 1st and 3rd are answers correct
C) 1st and 2nd are answers correct
D) 3rd and 4th are answers correct

Answer 93

A) 1st, 2nd, and 3rd answers are correct

Colonoscopy ensures the direct visual examination of the total colon and rectum. In addition to imaging analysis, it provides biopsy samples and an option for total removal of mucosal lesions (eg. polyps). On the other hand, it is not applicable to assess lesion depth or explore its adjacent relationships.

Question 94

Which type of operation may be assigned to the following diagnoses:
A)  	Esophageal transection
B)  	Heller operation
C)  	Antireflux operation
D)  	Torek operation
E)  	cricopharyngeomyotomy

SUR - 4.65 - 	achalasia cardiae
SUR - 4.66 - 	reflux oesophagitis
SUR - 4.67 - 	oesophageal perforation
SUR - 4.68 - 	cervical dysphagia
SUR - 4.69 - 	oesophageal varicosity

Answer 94

SUR - 4.65 - B)
SUR - 4.66 - C)
SUR - 4.67 - D)
SUR - 4.68 - E)
SUR - 4.69 - A)

Question 95

Match the diagnoses with the items represented by numbers:
A) acute cholangitis
B) gangrenous cholecystitis
C) enter biliary fistula
D) spontaneous rupture of hepatic adenoma
E) pancreatic head cancer

SUR - 4.70 - Courvoisier’s gallbladder
SUR - 4.71 - Charcot’s triad
SUR - 4.72 - haemobilia and GI bleeding may occur
SUR - 4.73 - air bubbles in the biliary ducts
SUR - 4.74 - air bubbles within the wall of the gallbladder and gallbladder bed

Answer 95

SUR - 4.70 - E)
SUR - 4.71 - A)
SUR - 4.72 - D)
SUR - 4.73 - C)
SUR - 4.74 - B)

Question 96

In acute necrotic pancreatitis there is no specific medication therapy, therefore, antibiotics are not given.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 96

C) the statement is true, but the explanation is false;

The first half of the sentence is true. None of the pharmaceutical medications (used in the treatment of acute pancreatitis, such as Trasylol, atrophin, calcitonin, steroid, glucagon and somatostatin) have been proved to be effective during the course of disease. The second half of the sentence is not true, because antibiotics are given in case of necrosis. Antibiotic therapy has been proved to decrease or postpone the risk of later infection.

Question 97

Helicobacter pylori plays an important role in the etiology of gastric lymphomas, therefore, a number of gastric lymphomas may be cured when Helicobacter pylori is eradicated.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 97

A) both the statement and the explanation are true and a causal relationship exists between them;

Helicobacter pylori bacteria play an important role in the etiology of gastroduodenal ulceration, gastric cancer and as well as gastric lymphomas. When a lymphoma is a ’malt’ lymphoma and is at an early stage, eradication of Helicobacter pylori may achieve a 60 to 70% success rate, and may avoid the need for surgical treatment. Eradication may not be effective in later stages of the disease, only chemoradiotherapy or surgical resection may be considered.

Question 98

The secretin test provides significant assistance in the differential diagnostics between Zollinger–Ellison syndrome and hypergastrinaemia, since Z-E syndrome is usually associated with an elevation in gastrin levels due to the effect of secretin.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 98

A) both the statement and the explanation are true and a causal relationship exists between them;

Gastrin level value is normally below 200 ng/ml. If it exceeds 1000 ng/ml, it is a clear indication of Zollinger—Ellison syndrome. If the value ranges between 200 and 1000, it indicates hypergastrinaemia, which may be due to several factors, such as a proton pump inhibitor treatment, superselective or truncal vagotomy, or incarcerated antrum in the duodenal stump following gastric resection. Accurate differential diagnosis must be made to determine the underlying cause of the hypergastrinaemia. The secretin test is used in differential diagnostics by reducing the level of gastrin in hypergastrinaemia, and paradoxically, elevating it in Zollinger-Ellison syndrome.

Question 99

Chronic pancreatitis leads to progressive parenchyma damage, therefore, pain will disappear after some time.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 99

C) the statement is true, but the explanation is false;

The first section is true, because the inflammation will subsequently damage both the exocrine and endocrine cells. The second section is false, because in the majority of cases, pain will not relieve even after the ’burn out’ of the pancreas, since the causative factors of pain include the inflammation of scar nerves, which will persist with both exocrine and endocrine insufficiency.

Question 100

The mortality rate for Whipple surgery may be as low as 5% with a highly experienced surgeon, therefore, patients with pancreatic tumour at the age 70 may also undergo this operation.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 100

A) both the statement and the explanation are true and a causal relationship exists between them;

Both sections are correct, and they are also correlated. With increasing surgical experience, improving anaesthesia and intensive therapy procedures, major clinical centres reach a low mortality rate with this operation. A patient’s advanced age is no longer a contraindication for surgery in these centres, where high success rates may still be achieved.

Question 101

Distension and gas-fluid levels observed on plain abdominal x-ray picture does not indicate intestinal obstruction in all cases, because gas-fluid levels often presents with enteritis, and distension may also be due to the effect of medications.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 101

A) both the statement and the explanation are true and a causal relationship exists between them;

Abdominal distension and gas on plain abdominal X-ray picture does not always indicate definite intestinal obstruction, because intestinal paralysis may also manifest with a similar clinical picture. Gas-fluid levels often occur in enteritis or with pharmaceutical treatment therefore, both statements are true and are closely related.

Question 102

Opiate pain relievers may hide abdominal symptoms, therefore, analgesics are not given in case of acute abdominal conditions.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 102

C) the statement is true, but the explanation is false;

Opiate pain relievers have a central nervous systemic effect, through which they may alleviate the localized abdominal symptoms or eliminate the patient’s pain completely. Therefore, their use is contraindicated when the diagnosis is unsure. Analgesics may be administered after the cause of acute abdominal condition has been cleared. The statement is true, but the explanation is false.

Question 103

In intestinal occlusion, a large quantity of fluids and electrolytes is lost, therefore, endotoxin producing microbes may potentially accumulate in the intestines.
A) both the statement and the explanation are true and a causal relationship exists between them;
B) both the statement and the explanation are true but there is no causal relationship between them;
C) the statement is true, but the explanation is false;
D) the statement is false, but the explanation itself is true
E) both the statement and the explanation are false

Answer 103

B) both the statement and the explanation are true but there is no causal relationship between them;

In case of intestinal obstruction, distension causes a significant loss of body fluids and electrolytes. Another fact is that endotoxin producing microbes potentially may thrive and multiply in the intestinal lumen, but it may be due to several other causes (for example, effect of medication etc). Thus, both statements are true, but there is no strong logical relationship between them.