Surgery - Gastroenterology

Question 1

SUR - 4.2
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 1

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

EXPLANATION
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 2

SUR - 4.4
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 2

ANSWER
A) radio-chemotherapy

EXPLANATION
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 3

SUR - 4.5
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 3

ANSWER
C) appendectomy

EXPLANATION
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 4

SUR - 4.6
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 4

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

EXPLANATION
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 caus, is an adequate therapy prior to perforation.

Question 5

SUR - 4.7
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 5

ANSWER
B) radical excision

EXPLANATION
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 6

SUR - 4.8
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 6

ANSWER
C) their malignant potential is lower than other adenomas’

EXPLANATION
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 7

SUR - 4.9
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 7

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

EXPLANATION
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 8

SUR - 4.10
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 8

ANSWER
C) an international anti-cancer organization

EXPLANATION
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 9

SUR - 4.11
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 9

ANSWER
C) large, deep ulcers

EXPLANATION
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 10

SUR - 4.12
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 10

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

EXPLANATION
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 11

SUR - 4.13
What is Courvoisier’s sign?
A) painful, hydropic gallbladder
B) painless, palpable gallbladder
C) palpable pancreatic head tumour
D) palpable pseudocyst

Answer 11

ANSWER
B) painless, palpable gallbladder

EXPLANATION
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 12

SUR - 4.14
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 12

ANSWER
D) all

EXPLANATION
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 13

SUR - 4.15
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 13

ANSWER
E) palpable inguinal lymph node

EXPLANATION
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 14

SUR - 4.17
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 14

ANSWER
B) achalasia

EXPLANATION
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 15

SUR - 4.18
The most common oesophagus diverticulum is:
A) Zenker’s diverticulum
B) epiphrenic diverticulum
C) middle third traction diverticulum
D) Meckel-diverticulum

Answer 15

ANSWER
A) Zenker’s diverticulum

EXPLANATION
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 16

SUR - 4.19
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 16

ANSWER
B) volume replacement

EXPLANATION
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 17

SUR - 4.21
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 17

ANSWER
C) spider naevi

EXPLANATION
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 18

SUR - 4.22
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 18

ANSWER
B) splenorenal shunt

EXPLANATION
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 19

SUR - 4.23
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 19

ANSWER
B) epigastric vein - internal thoracic vein system

EXPLANATION
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 20

SUR - 4.24
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 20

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

EXPLANATION
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 21

SUR - 4.25
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 21

ANSWER
D) he has icterus

EXPLANATION
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 22

SUR - 4.26
The following disorders cause paralytic ileus. EXCEPT:
A) mesenteric artery occlusion
B) hypokalaemia
C) pancreatitis
D) gastrointestinal bleeding
E) perforation

Answer 22

ANSWER
D) gastrointestinal bleeding

EXPLANATION
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 23

SUR - 4.27
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 23

ANSWER
B) cirrhosis

EXPLANATION
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 24

SUR - 4.28
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 24

ANSWER
D) colonoscopy

EXPLANATION
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 25

SUR - 4.29
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 25

ANSWER
D) age of the patient

EXPLANATION
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 26

SUR - 4.30
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 26

ANSWER
A) ERCP, endoscopic sphincterotomy and stone extraction

EXPLANATION
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 27

SUR - 4.31
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 27

ANSWER
C) diffuse oesophageal spasm

EXPLANATION
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 28

SUR - 4.32
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 28

ANSWER
B) esophagoscopy

EXPLANATION
All of the listed diagnostic tools are important in the diagnosis of bleeding oesophageal varices, but the most important method is oesophagoscopy, which allows for the commencement of the local treatment (sclerotization).

Question 29

SUR - 4.33
The following conditions are common complications of choledochus stones. EXCEPT:
A) pancreatitis
B) mechanical icterus
C) cholangitis
D) liver cancer

Answer 29

ANSWER
D) liver cancer

EXPLANATION
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 30

SUR - 4.34
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 30

ANSWER
A) a combination of fever, jaundice and abdominal pain

EXPLANATION
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 31

UR - 4.35
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 31

ANSWER
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.

EXPLANATION
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 32

SUR - 4.36
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 32

ANSWER
B) LC after successful EST

EXPLANATION
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 33

SUR - 4.38
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 33

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
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 34

SUR - 4.39
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 34

ANSWER
E) all of the answers are correct

EXPLANATION
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 35

SUR - 4.40
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 35

ANSWER
E) all of the answers are correct

EXPLANATION
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 36

SUR - 4.41
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 36

ANSWER
E) all of the answers are correct

EXPLANATION
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 37

SUR - 4.43
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 37

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

EXPLANATION
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.

Dietary iron absorption is primarily performed through enterocyte cells on the duodenum and upper jejunum of the small intestine**

Question 38

SUR - 4.44
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 38

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
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 39

SUR - 4.45
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 39

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
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 40

SUR - 4.50
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 40

ANSWER
E) all of the answers are correct

EXPLANATION
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 41

SUR - 4.51
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 41

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

EXPLANATION
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 42

SUR - 4.52
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 42

ANSWER
D) only 4th answer is correct

EXPLANATION
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 43

SUR - 4.53
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 43

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

EXPLANATION
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 44

SUR - 4.54
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 44

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

EXPLANATION
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 45

SUR - 4.56
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 color 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 the 4th answer is correct
E) all of the answers are correct

Answer 45

ANSWER
E) all of the answers are correct

EXPLANATION
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 46

SUR - 4.57
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 46

ANSWER
B) 1st and 3rd answers are correct

EXPLANATION
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 47

SUR - 4.60
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 47

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

EXPLANATION
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 48

SUR - 4.61
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 48

ANSWER
C) 1st and 2nd answers are correct

EXPLANATION
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 49

SUR - 4.62
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 49

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

EXPLANATION
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 50

SUR - 4.64
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 50

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

EXPLANATION
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 51

SUR-4.65-4.69
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 51

ANSWER
SUR - 4.65 - achalasia cardiae - B)
SUR - 4.66 - reflux oesophagitis - C)
SUR - 4.67 - oesophageal perforation - D)
SUR - 4.68 - cervical dysphagia - E)
SUR - 4.69 - oesophageal varicosity - A)

Question 52

SUR-4.70-4.74
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 52

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

Question 53

SUR - 4.75
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 53

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

EXPLANATION
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 54

SUR - 4.76
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 54

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

EXPLANATION
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 55

SUR - 4.77
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 55

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

EXPLANATION
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 56

SUR - 4.78
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 56

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

EXPLANATION
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 57

SUR - 4.79
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 57

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

EXPLANATION
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 58

SUR - 4.80
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 58

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

EXPLANATION
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 59

SUR - 4.81
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 59

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

EXPLANATION
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 60

SUR - 4.82
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 60

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

EXPLANATION
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.