Surgery - Acute abdomen and peritonitis Flashcards

1
Q

SUR - 3.1
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

A

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

EXPLANATION
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.

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2
Q

SUR - 3.2
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

A

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

EXPLANATION
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.

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3
Q

SUR - 3.3
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

A

ANSWER
C) within 6 hours after the onset of complaints

EXPLANATION
As explained in the note SEB-3.1. 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 (see SEB-3.1) 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.

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4
Q

SUR - 3.4
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

A

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

EXPLANATION
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.

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5
Q

SUR - 3.5
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

A

ANSWER
A) perforation of peptic ulcer

EXPLANATION
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.

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6
Q

SUR - 3.6
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

A

ANSWER
A) In case of failure of the percutan drainage

EXPLANATION
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.

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7
Q

SUR - 3.7
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.

A

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

EXPLANATION
Explanation of the correct answer has already been given in SEB-3.2.. 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

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8
Q

SUR - 3.8
The most common acute complication of gastric lymphoma is:
A) perforation
B) cachexia
C) sepsis
D) bleeding

A

ANSWER
D) bleeding

EXPLANATION
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.

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9
Q

SUR - 3.9
Causes of peritonitis associated with infected pancreatitis, except:
A) Hematogen spreading
B) Rupture of abscess
C) Penetration
D) Propagation through anatomically preformed route

A

ANSWER
A) Hematogen spreading

EXPLANATION
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.

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10
Q

SUR - 3.10
Necrotising pancreatitis may be associated with peritonitis except:
A) Localised peritonitis
B) Secunder peritonitis
C) Fibrinopurulent peritonitis
D) Primary peritonitis

A

ANSWER
D) Primary peritonitis

EXPLANATION
As explained in SEB-3.9. 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.

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11
Q

SUR - 3.11
Complications of large bowel diverticulitis, except:
A) Obstruction of large bowel
B) Malignant transformation
C) Bleeding
D) Small pelvic abscess
E) Colon perforation - peritonitis

A

ANSWER
B) Malignant transformation

EXPLANATION
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.

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12
Q

SUR - 3.13
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

A

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

EXPLANATION
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).

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13
Q

SUR - 3.14
Possible cause of perforation of appendix:
A) bacterial inflammation
B) benign tumor lesion
C) carcinoid
D) helmets
E) typhus

A

ANSWER
A) bacterial inflammation

EXPLANATION
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.

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14
Q

SUR - 3.17
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

A

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

EXPLANATION
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.

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15
Q

SUR - 3.18
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

A

ANSWER
A) Ring tumor of the sigma

EXPLANATION
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.

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16
Q

SUR - 3.19
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.

A

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

EXPLANATION
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.

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17
Q

SUR - 3.20
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.

A

ANSWER
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.

EXPLANATION
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.

18
Q

SUR - 3.22
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

A

ANSWER
A) progressively evolving abdominal distension

EXPLANATION
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.

19
Q

SUR - 3.23
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

A

ANSWER
D) for more years uncontrolled IUD

EXPLANATION
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.

20
Q

SUR - 3.24
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

A

ANSWER
E) total median laparotomy

EXPLANATION
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.

21
Q

SUR - 3.26
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 soluble 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

A

ANSWER
C) the 2nd and 4th answers are correct

EXPLANATION
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 necessary source of information which 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

22
Q

SUR - 3.28
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

A

ANSWER
B) the 1st and 3rd answers are correct

EXPLANATION
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.

23
Q

SUR - 3.29
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

A

ANSWER
B) the 1st and 3rd answers are correct

EXPLANATION
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.

24
Q

SUR - 3.32
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

A

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

EXPLANATION
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.

25
Q

SUR - 3.33
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

A

ANSWER
D) only the 4th answer is correct

EXPLANATION
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.

26
Q

SUR - 3.34
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

A

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

EXPLANATION
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.

27
Q

SUR - 3.35
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

A

ANSWER
B) the 1st and 3rd answers are correct

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

28
Q

SUR - 3.37
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

A

ANSWER
D) only the 4th answer is correct

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

29
Q

SUR - 3.40
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

A

ANSWER
B) the 1st and 3rd answers are correct

EXPLANATION
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. (see also SEB-3.15., 3.16., 3.17.).

30
Q

SUR - 3.41
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

A

ANSWER
D) only the 4th answer is correct

EXPLANATION
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

31
Q

SUR - 3.42
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

A

ANSWER
A) none of the answers are correct

EXPLANATION
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.

32
Q

SUR - 3.43
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

A

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

EXPLANATION
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.

33
Q

SUR - 3.44
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

A

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

EXPLANATION
Ulcerative colitis, Crohn’s disease, diverticulitis all can be the cause of peritonitis. The 1., 5., 7., and 8. factors don’t cause peritonitis.

34
Q

SUR - 3.45
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

A

ANSWER
C) the 2nd and 4th answers are correct

EXPLANATION
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 %

35
Q

SUR - 3.47
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

A

ANSWER
A) the 1st and 2nd answers are correct

EXPLANATION
Abdominal CT and US are good for diagnosing abdominal abscess, not like 3.,4.,5.,6.,7..

36
Q

SUR - 3.48
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

A

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

EXPLANATION
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.

37
Q

SUR - 3.49
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

A

ANSWER
B) 2nd and 3rd answers are correct

EXPLANATION
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.

38
Q

SUR - 3.51
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

A

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

EXPLANATION
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.

39
Q

SUR - 3.52
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

A

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

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

40
Q

SUR - 3.53
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

A

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

EXPLANATION
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.

41
Q

SUR - 3.54
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

A

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

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

42
Q

SUR - 3.55
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

A

ANSWER
E) both parts are incorrect

EXPLANATION
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