Surgery - General Flashcards

Question 1

Q

SUR - 1.1
A surgery is performed with diagnostic intent:
A) if the nature of the disease cannot be otherwise confirmed
B) if no further costly investigations can be carried out
C) if the patient refuses to undergo any other therapeutic intervention
D) in the majority of the surgical interventions

Answer

A

ANSWER
A) if the nature of the disease cannot be otherwise confirmed

EXPLANATION
We perform a surgery with diagnostic intent if the diagnosis could not be established with any of the preoperative non-invasive and invasive diagnostic modalities, and further diagnostic progress can only be achieved by surgical exploration of the patient.

Question 2

Q

SUR - 1.2
A surgery is considered curative:
A) in all the cases
B) if the cause of the disease can be completely eliminated with the surgery
C) if it is not aimed to prevent a disease
D) when peritoneal carcinomatosis is found

Answer

A

ANSWER
B) if the cause of the disease can be completely eliminated with the surgery

EXPLANATION
A surgery is considered curative if both the preoperative examinations and the surgical exploration confirms that the target lesion (e.g. a cancer with its metastases, if any) can be completely removed. Do not forget; however, that it’s the outcome of the disease that will ultimately determine the radicality of the surgery.

Question 3

Q

SUR - 1.3
All these methods are used to prevent thromboembolic complications in the perioperative period, except one:
A) Na-heparin
B) Colfarit (acidum acetylsalicylicum)
C) Ca-heparin
D) compression stockings

Answer

A

ANSWER
B) Colfarit (acidum acetylsalicylicum)

EXPLANATION
One of the most frequent complications after a surgical intervention is thromboembolization (with an average risk of around 20-30% after abdominal surgeries, and 50-60% after major orthopedic and trauma surgeries). Thromboembolic prophylaxis should be carried out in patients at a high risk (e.g. history of thrombosis or myocardial infarction, elderly people, obesity, undergoing long surgery). Methods include medical therapy: conventional and low-molecular-weight heparin administered subcutaneously (started before the surgery!), and physical modalities: early mobilization, use of compression stockings, pillowing up the lower extremities. Acetylsalicylic acid (e.g. Colfarit) decreases the risk of thromboembolism by inhibiting platelet aggregation. Its effect starts around 15 minutes after administration and lasts for 3-7 days. Its side effects (e.g. bleeding complications) cannot be suspended and the patient may require platelet transfusion, thus these drugs are not suitable for preoperative prophylaxis.

Question 4

Q

SUR - 1.4
All those means, methods and interventions with which we try to prevent the contamination of the pathogens are collectively called as:
A) disinfection
B) asepsis
C) antisepsis
D) sterilization

Answer

A

ANSWER
B) asepsis

EXPLANATION
All those interventions, actions and methods with which we try to prevent the contamination of the pathogens are collectively called asepsis. To reach this goal, all the instruments and materials we use during an intervention must be made free of germs (sterilization). Antisepsis means all the actions taken against the already present contamination, which can be most effectively achieved by disinfection. (See also SEB-1.65.)

Question 5

Q

SUR - 1.5
Principles of the modern antibiotic therapy:
A) broad-spectrum antibiotics are given in the proper dose
B) antibiotic treatment is always targeted
C) carefully selected antibiotics are given in the proper dose for the proper time
D) carefully selected antibiotics are given in the proper dose for the longest possible time

Answer

A

ANSWER
C) carefully selected antibiotics are given in the proper dose for the proper time

EXPLANATION
Ideally antibiotic treatment should always be targeted. However, this is rarely the case due to time constraints or the unavailability of a culture sample. Thus, targeted antibiotic therapy is started only if possible, in other cases we use a broad-spectrum antibiotic agent against the presumed pathogen for the required period of time.

Question 6

Q

SUR - 1.7
Which of the following solutions CANNOT be used for disinfection of the skin around the wound?
A) iodine
B) petrol
C) alcohol
D) sublimate

Answer

A

ANSWER
B) petrol

EXPLANATION
Iodine, alcohol and sublimate are antibacterial by nature (see also SEB-1.4.), while benzol has no such effect. Benzol, however, is a good solvent of fats and thus can be used for removing dirt.

Question 7

Q

SUR - 1.8
Instruments used before any invasive intervention have to be:
A) disinfected using H2O2 solution
B) disinfected using a solution containing alcohol and tensides or invert soap
C) sterilized (e.g. autoclave or gas sterilization, radiation sterilization)
D) sterilized (e.g. ultraviolet or infrared light)

Answer

A

ANSWER
C) sterilized (e.g. autoclave or gas sterilization, radiation sterilization)

EXPLANATION
We call a medical intervention invasive if it penetrates a natural barrier of the body. Such barriers include: Skin, mucosa, openings of the hollow viscera (e.g. pharynx, urethra, anus, vagina, Eustachian tube, etc.). Any instrument used for an invasive medical intervention has to be sterilized to prevent the pathogens from entering the already vulnerable area. The accepted methods of sterilizing are steam sterilization in an autoclave, or gas sterilization using ethylene dioxide or formaldehyde. Single-use instruments are factory sterilized using irradiation. Boiling or dry heat sterilization usually cannot eliminate all the germs. Ultraviolet or infrared light has sterilizing effect. For non-invasive intervention we can use disinfected or sterilized instruments (see also SEB-1.4.).

Question 8

Q

SUR - 1.9
After any invasive intervention, the used instruments have to be:
A) rinsed under running water using soap and brush
B) soaked for disinfection and removal of blood residues
C) sterilized in a dry heat sterilizer
D) disassembled and sterilized

Answer

A

ANSWER
B) soaked for disinfection and removal of blood residues

EXPLANATION
Instruments used for invasive interventions (see also SEB-1.13.) can be contaminated with pathogens from the patient or the hospital environment. Their inner or outer surfaces can come into contact with body fluids (e.g. blood, lymph, stool, etc.) which dry or clot there. The proteins in these fluids can also clot and get precipitated by the agents used for disinfection. Pathogen within these protein traps may be resistant to the effects of sterilizing. Thus, soaking should be done with chemicals that – usually enzymatically - dissolve blood and the precipitated proteins. The temperature and duration of soaking depends on the chemicals used. After soaking, machine washing, ultrasound or manual cleaning is done, followed by reassembly and testing. Some of these steps require manual workforce. To protect the cleaning staff, soaking and pre-disinfection should be performed at the same cleaning session or consecutively. Answer A does not match the desired workflow at all. Answer C is partially correct, but it misses the step before sterilizing and also only mentions a single method of sterilizing. Answer D refers only to later steps of the workflow and misses the step before sterilizing. The term “after use” in the question is best answered by option B.

Question 9

Q

SUR - 1.10
Clinical signs of bleeding, except:
A) tachycardia
B) drop of blood-pressure
C) dry mouth
D) polyuria

Answer

A

ANSWER
D) polyuria

EXPLANATION
Decrease of circulating blood volume after a major bleeding leads to hypotension, which – through different compensating mechanisms of the body – often leads to tachycardia and development of dry mouth. A bleeding patient is weak, may feel dizzy or collapse; the parasympathetic condition, polyuria is the least characteristic finding during a major bleeding.

Question 10

Q

SUR - 1.11
Which is the most probable cause of a gastrointestinal bleeding presenting in the form of hematemesis?
A) recto-sigmoid cancer
B) duodenal cancer
C) erosive gastritis
D) hemorrhagic enteritis

Answer

A

ANSWER
C) erosive gastritis

EXPLANATION
The duodenojejunal ligament (Treitz) acts as a division line between the frequent bleeding sources of the gastrointestinal tract. Any GI bleeding proximal to this will lead to hematemesis or melena, while more distal bleeding sources will only lead to rectal bleeding, usually melena. Thus, in the case of hematemesis, esophageal or gastroduodenal bleeding sources are the most obvious targets. From these bleeding sources erosive gastritis is frequent, while a duodenal cancer is a rare disease. Erosions of the gastric mucosa usually develop quickly but may also heal quickly. Its underlying pathomechanism is not yet fully understood, but a sudden increase in the acid output seems an important risk factor, which in turn can be caused by stress or other processes in the central nervous system

Question 11

Q

SUR - 1.12
Which is the most frequent cause of primary hyperparathyroidism?
A) parathyroid hyperplasia
B) parathyroid adenoma
C) parathyroid cancer
D) chronic renal failure

Answer

A

ANSWER
B) parathyroid adenoma

EXPLANATION
Primary or autonomous hyperparathyroidism is based on an uncontrolled increase in the parathyroid hormone production, and in the majority of the cases (85-90%) is the result of a solitary parathyroid adenoma. In only 10-15% of the cases do we find multiple adenomas or hyperplasia of all the glands. From the solitary masses 1-3% turns out to be carcinoma. In patients undergoing hemodialysis due to chronic renal failure secondary hyperparathyroidism may develop, since the excessive loss of calcium from the kidneys will lead to compensatory feedback mechanisms.

Question 12

Q

SUR - 1.13
From the following options which symptom is NOT characteristic of primary hyperparathyroidism?
A) hypercalcemia
B) oliguria
C) short QT interval
D) hypophosphatemia

Answer

A

ANSWER
B) oliguria

EXPLANATION
The clinical signs of primary hyperparathyroidism (pHPT) include general muscle weakness, bone pain, nausea, vomiting, constipation, abdominal pain, polydipsia, polyuria and increased blood pressure. Characteristic laboratory parameters are hypercalcemia (dominantly high ionized calcium levels), high serum intact parathormone levels, hypophosphatemia, hypercalciuria, increased alkaline phosphatase and one can see short QT intervals on the ECG. In the case of pHPT densitometry reveals decreased mineral content of the bones and X-Ray usually shows subperiosteal demineralization in the fingers, skull and vertebrae, while density of the spongiosa may even be higher. Kidney stones often develop - in 5-10% of the recurrent or bilateral cases (even up to 15% for calcium stones) its pHPT laying in the background.

Question 13

Q

SUR - 1.14
The development of metastases in malignant diseases:
A) correlates with the size of the cancer
B) correlates with the time elapsed from the appearance of the cancer
C) depends on the biologic characteristics of the cancer and does not correlate with its volume
D) depends on the location of the primary cancer

Answer

A

ANSWER
C) depends on the biologic characteristics of the cancer and does not correlate with its volume

EXPLANATION
Certain malignancies – depending on their biologic nature – develop metastases early. Metastases are usually associated with an advanced disease stage. Sometimes huge, locally advanced tumors do not give distant metastases, while in other cases the presence of multiple metastases dominates the clinical picture and often the small primary cancer is discovered only later. It can also happen that despite a histologically confirmed metastasis the occult primary cancer will never be identified.

Question 14

Q

SUR - 1.15
Generally speaking, the aim of lymph node dissection in malignant diseases is:
A) to eliminate the pathways of further lymphatic
B) to remove the regional metastases as best as possible
C) to improve the lymphatic drainage of the involved tissues
D) to make the radical removal of the primary cancer possible

Answer

A

ANSWER
B) to remove the regional metastases as best as possible

EXPLANATION
The main principle of oncologic surgery is to get the body rid of the tumor mass as radically as possible. To achieve this goal, surgical resection should be performed with an ample safety margin, together with the en-bloc removal of the regional lymph nodes alongside the main lymphatic pathways and any regional cancer spreading. This is even more important in the case of cancers which are likely to spread via the lymphatics.

Question 15

Q

SUR - 1.16
Select the correct (most appropriate) answer.
A) Fibroadenoma is the most common benign lesion of the breast in hormonally active women.
B) Fibroadenomas never turn malignant.
C) Fibroadenomas are never removed surgically, cytological examination is enough.
D) Fibrocystic breast lesion (mastopathy) is very common in non-lactating women.

Answer

A

ANSWER
A) Fibroadenoma is the most common benign lesion of the breast in hormonally active women.

EXPLANATION
Benign lesions of the breasts include fibroadenomas which are the most frequent benign lesion in hormonally active women. Fibroadenomas – arising from the epithelial layer – are usually palpable, well defined, mobile firm lesions.

Question 16

Q

SUR - 1.17
Select the correct (most appropriate) answer.
A) The TNM score has only a limited role in the staging of breast cancer; other classifications are becoming more important
B) About 80% of all breast cancers are invasive ductal carcinomas
C) About 70-80% of all breast cancers are invasive lobular carcinomas
D) The proportion of ductal and lobular breast carcinomas is roughly the same (45–45%)

Answer

A

ANSWER
B) About 80% of all breast cancers are invasive ductal carcinomas

Question 17

Q

SUR - 1.18
Which type of hernia is the most prone to incarceration?
A) femoral hernia with a wide orifice
B) complex ventral incisional hernia
C) inguinal hernia with a narrow orifice
D) non-reducible umbilical hernia

Answer

A

ANSWER
C) inguinal hernia with a narrow orifice

EXPLANATION
Hernia incarceration is most frequent in hernias with a narrow orifice. In conditions where the abdominal pressure is increased, any kind of hernia is more prone to incarceration. The question focused on the ‘narrow orifice’, as compared to the ‘multilocular’ and ‘wide orifice’ hernias.

Question 18

Q

SUR - 1.19
The most frequent type of surgery of the repair of an inguinal hernia is:
A) Fabricius surgery
B) Kocher surgery
C) Nissen–Rosetti surgery
D) Lichtenstein surgery
E) Bassini-Kirschner surgery

Answer

A

ANSWER
D) Lichtenstein surgery

EXPLANATION
Today the most widely accepted inguinal hernia repair is the tension-free Lichtenstein surgery which comes with the lowest recurrence rate. Previously the standard technique was the Bassini surgery, which was not tension-free, and the rate of recurrence could be as high as 10-15%

Question 19

Q

SUR - 1.20
During a laparoscopic surgical intervention
A) the abdominal cavity is inflated with oxygen
B) the increased intra-abdominal pressure has to be taken into account when considering the indication of surgery
C) any intraoperative bleeding complication necessitates a conversion to open procedure
D) antibiotic prophylaxis is compulsory before every surgery

Answer

A

ANSWER
B) the increased intra-abdominal pressure has to be taken into account when considering the indication of surgery

EXPLANATION
Answer A: For filling up the abdominal cavity such gas must be used which is inert and non-flammable so that electrocautery devices can be safely used. Thus, it cannot contain oxygen. The most commonly used gas is CO2, although xenon is currently also recommended, particularly in oncologic surgery. Answer C: An intraoperative bleeding can often be managed by laparoscopic means, e.g. using small clips or electrocautery device on the bleeders. Obviously, a clean operating field and good visualization is a must. If the bleeding cannot be laparoscopically controlled, we have to convert to an open procedure immediately. Answer D: Antibiotic prophylaxis before laparoscopic surgeries follows the same principles as of the open surgical procedures. That is, antibiotics are not administered in an obligatory way, but rather selectively before the presumably contaminated (e.g. perforated appendicitis, bowel resection) or long surgeries (e.g. pancreatic resection).

Question 20

Q

SUR - 1.21
During a laparoscopic hernia repair:
A) The defect of the abdominal wall is covered by a synthetic mesh
B) The defect of the abdominal wall is closed by plastic clips
C) The hernia contents are pushed back into the abdominal cavity from the outside
D) The defect of the abdominal wall is actually not closed

Answer

A

ANSWER
A) The defect of the abdominal wall is covered by a synthetic mesh

EXPLANATION
The two most commonly used laparoscopic inguinal hernia repair is the transabdominal preperitoneal (TAPP) and the total extraperitoneal (TEP) approach. During both procedures we place a mesh between the peritoneum and the abdominal wall covering the defect(s). The hernia orifice cannot be closed by clips. Before covering the effect, the hernia contents are pulled back into the abdominal cavity from the inside.

Question 21

Q

SUR - 1.22
Which one of the following statements is not true for abdominal abscesses?
A) often caused by perforation of some hollow viscera
B) treatment is primarily surgical exploration + drainage
C) drainage of the abscess can be done percutaneously with US, CT or MR guidance
D) interintestinal abscesses only develop on basis of Crohn’s disease

Answer

A

ANSWER
D) interintestinal abscesses only develop on basis of Crohn’s disease

EXPLANATION
Intra-abdominal abscesses can be rather diverse based on their location and origin. An inter-intestinal abscess – accumulation of pus in a cavity confined by bowels – is just a type of this disease family. The general treatment principle for any kind of abscess is the exploration of the purulent cavity, letting out all the pus and keeping the cavity open until its healing. Surgical exploration or percutaneous drainage with some form of imaging guidance are both commonly accepted techniques.

Question 22

Q

SUR - 1.23
Which of the following statements is true?
A) Hernia repairs are categorized as clean-contaminated surgeries
B) The average suppuration rate after clean-contaminated surgeries is around 5-15%
C) The average suppuration rate after clean-contaminated surgeries is <8-22%.
D) The average suppuration rate after clean-contaminated surgeries is >2-8%.

Answer

A

ANSWER
D) The average suppuration rate after clean-contaminated surgeries is >2-8%.

EXPLANATION
We consider a surgery clean-contaminated if the gastrointestinal, genitourinary and/or respiratory tracts are opened under controlled conditions without significant. After such surgeries the risk of infection is inevitably increased, regardless of how careful the surgical manipulation or isolation of the operating field was.

Question 23

Q

SUR - 1.24
Which of the following signs is the least characteristic of a pancreatic cancer?
A) loss of appetite
B) asymptomatic jaundice
C) newly discovered diabetes
D) fever

Answer

A

ANSWER
D) fever

EXPLANATION
Malignant diseases of the exocrine pancreas will also eventually affect the endocrine function (islet cells) due to the transformation of the pancreatic tissue. Thus, clinical signs of the growing pancreatic mass can be general (loss of appetite, fatigue, weakness), but a sudden onset of diabetes mellitus should be an alarming sign, too. A cancer in the head of the pancreas often infiltrates the intrapancreatic part of the common bile duct, gradually leading to the development of jaundice. As compared to the stone-related, rapidly developing, symptomatic jaundice, malignant jaundice is usually painless. In cancer patients fever is a less characteristic sign, but may develop in complicated cases (e.g. biliary obstruction in a head of the pancreas cancer leading to cholangitis or even hepatic abscess).

Question 24

Q

SUR - 1.25
Relatives of a 63-year-old male patient discover jaundice on him. All of the following presumed diagnoses are reasonable, except one:
A) infective hepatitis
B) pancreatic cancer
C) chronic pancreatitis
D) Crigler–Najjar syndrome
E) choledocholithiasis

Answer

A

ANSWER
D) Crigler–Najjar syndrome

EXPLANATION
Based on the clinical data and etiology (alcohol abuse), the patient can have liver cirrhosis, some form of chronic hepatitis or chronic pancreatitis. Painless jaundice is often caused by a head of the pancreas cancer (see also SEB-1.29.). Similarly, an acquired infective hepatitis or even choledocholithiasis cannot be ruled out. Crigler-Najjar syndrome, however, is a fetal metabolic disorder leading to hyperbilirubinemia (see also SEB-1.169. - 1.180.).

Question 25

Q

SUR - 1.26
The most common pathway of metastatic spreading in colonic cancer is:
A) via the inferior mesenteric vein
B) via the portal vein
C) lymphogenic spreading
D) intraluminar spreading

Answer

A

ANSWER
C) lymphogenic spreading

EXPLANATION
Colorectal cancer has the potential to give hematogenous metastases when penetrating the vessels of the bowel-wall as they grow. The major supplying vessels of the colon – e.g. both the superior and inferior mesenteric veins – both reach the liver via the portal vein. In colorectal cancer, however, the most common means of spreading is through the lymphatics. If the cancer infiltrates all layers of the colonic wall, lymphatic spreading is present in 90% of the cases.

Question 26

Q

SUR - 1.27
What do we call as neoadjuvant chemotherapy?
A) irradiation administered during the surgery
B) cytostatic treatment administered after the surgery
C) cytostatic treatment administered before the surgery
D) cytostatic treatment administered during the surgery

Answer

A

ANSWER
C) cytostatic treatment administered before the surgery

EXPLANATION
Neoadjuvant chemotherapy means cytostatic treatment administered before a surgical intervention. In certain types of cancer (e.g. primary liver, colorectal, breast, stomach, etc.) neoadjuvant treatment may reduce the size of the cancer and slow its spreading. In some cases, an otherwise inoperable cancer becomes surgically resectable. Chemotherapy can be systemic or local (e.g. selective chemoperfusion of the supplying artery of the given organ).

Question 27

Q

SUR - 1.28
Proper treatment of a furuncle on the face:
A) incision, excochleation
B) expression of the pus
C) moist packing and antibiotics
D) excision

Answer

A

ANSWER
C) moist packing and antibiotics

EXPLANATION
The venous system of the face has a direct connection with the basilar plexus in the head. Thus, any facial infection has to be treated with special care. Incision and excision are often unfavorable due to cosmetic reasons. The popular ‘self-made popping’ is strictly contraindicated.

Question 28

Q

SUR - 1.29
Which histologic type of the thyroid cancer has generally the best prognosis?
A) medullary cancer
B) papillary cancer
C) follicular cancer
D) anaplastic cancer

Answer

A

ANSWER
B) papillary cancer

EXPLANATION
From the thyroid cancers the papillary type grows very slowly and is rare to give metastases. Thus, the papillary type is considered the most ‘benign’ of the malignant cancers.

Question 29

Q

SUR - 1.30
Primary varicosity:
A) develops always after deep vein thrombosis
B) is a result of superficial thrombophlebitis
C) is always treated surgically
D) is a hereditary, degenerative condition of the superficial veins

Answer

A

ANSWER
D) is a hereditary, degenerative condition of the superficial veins

EXPLANATION
Primary varicosity is a hereditary, degenerative process which manifests eventually over the time. It is based on the gradual weakening of the mesenchymal tissue; the main predisposing factors are age, unhealthy lifestyle, obesity, pregnancy, etc. Based on the severity of the disease, treatment can be conservative or surgical.

Question 30

Q

SUR - 1.31
The Perthes test:
A) assesses the condition of the valves in the greater saphenous vein
B) assesses the rate of blood flow towards the deep veins
C) is a sign of deep-vein thrombosis when dorsalflexion of the foot induces calf pain
D) if negative, phlebography has to be performed next

Answer

A

ANSWER
B) assesses the rate of blood flow towards the deep veins

EXPLANATION
The Perthes test is a clinical test for assessing the patency of the deep femoral vein. After placing a rubber compression band on the leg of the standing patient (under the knee or sometimes also unto the thighs -, he/she is asked to walk for some time. Emptying (collapse) of the superficial veins means a good flow towards the deep veins – this we call a negative Perthes test. If the test is positive, further evaluation tests (e.g. venous Doppler US, phlebography) are needed when planning a varicectomy. (Other references in the question A: Trendelenburg test, C: Homan’s sign).

Question 31

Q

SUR - 1.32
In which disease is it most common to find an enlarged, palpable gallbladder?
A) Klatskin tumor
B) papilla of Vater carcinoma
C) cancer in the body of the pancreas
D) hepaticolithiasis

Answer

A

ANSWER
B) papilla of Vater carcinoma

EXPLANATION
In the case of a hilar or intrahepatic Klatskin tumor or biliary tract stone, the obstruction is proximal to the gallbladder, thus the gallbladder can empty freely. If the cancer is in the body of the pancreas, the distal bile duct is usually not compressed, and the gallbladder is cannot be palpated. The characteristic „Courvoisier sign” is most often present in head of the pancreas or papilla of Vater malignancies.

Question 32

Q

SUR - 1.33
All of these lesions can be drained by ultrasonic guidance, except one:
A) pancreas pseudocysts
B) retention cysts of the liver
C) meningeal cysts
D) retroperitoneal cysts
E) hydatid cysts

Answer

A

ANSWER
C) meningeal cysts

EXPLANATION
Ultrasound guided percutaneous puncture and drainage is a commonly accepted method for the treatment of various fluid accumulations in the abdominal cavity, retroperitoneum or in certain organs. Recently even hydatid cysts (liver Echinococcus cysts) can be drained by interventional radiological means. A meningeal cyst is located in the skull; thus, it cannot be routinely punctured.

Question 33

Q

SUR - 1.34
What is the definition of an in situ cancer?
A) if the tumor grows towards the lumen of an organ
B) if the tumor does not penetrate the serosal layer of the organ
C) if the tumor is confined to one tissue layer of the organ
D) if the tumor does not give regional metastases

Answer

A

ANSWER
C) if the tumor is confined to one tissue layer of the organ

EXPLANATION
During carcinogenesis the tumor mass develops in one of the tissue layers of the given organ or tissue. This first stage we call an in situ cancer. Further expansion through the wall of the organ can happen towards the lumen of the organ (endophytic) or towards the outer surface (exophytic). There is no correlation between the size of the cancer and its tendency to give metastases (see also SEB-1.19. and SEB-1.149.).

Question 34

Q

SUR - 1.35
Select the examples of an absolute indication of surgery:
1) an injury that is so severe that the life of the patient can only be saved with a surgical intervention
2) deepening jaundice
3) intestinal obstruction
4) certain cases of gallstone disease

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

A

ANSWER
C) 2nd and 4th answers are correct

EXPLANATION
Answer 1 and 3: Vital (immediate) indication of surgery usually refers to perforation of a hollow viscera with consequent peritonitis, major acute bleeding, bowel incarceration, or any other medical condition where the life of the patient can only be saved with an immediate surgery. In such cases delaying the surgical intervention can lead to irreversible organ damage, development of sepsis and eventually death. Answer 2 and 4: Absolute surgical indication means that the disease is to be treated surgically – although not necessarily immediately -, otherwise permanent organ damage may develop, and the process may lead to the death of the patient. Cholelithiasis in itself is not an absolute indication, but it may lead to pancreatitis, cholangitis, cholecystitis and perforation and as such, a symptomatic cholelithiasis is considered an absolute surgical indication (see also SEB-1.42. and SEB-1.81., 1.82., 1.83., 1.84.).

Question 35

Q

SUR - 1.36
A surgery is performed by vital indication in the case of:
1) incarcerated hernia with signs of intestinal obstruction
2) perforation of a hollow abdominal viscera
3) ruptured aortic aneurysm
4) bleeding from a superficial vein on the lower extremity

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

A

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

EXPLANATION
In the case of an immediate, vital indication of surgery the timing is essential (e.g. gastrointestinal perforation, acute major bleeding, etc.). The life of the patient can only be saved by an immediate intervention, there are no other treatment options, nor there is time to thoroughly investigate the patient. If possible, the vital parameters have to be stabilized, obviously (see also SEB-1.41.).

Question 36

Q

SUR - 1.37
Possible causes of a complete postoperative abdominal wound disruption:
1) protein deficiency
2) improper surgical technique
3) postoperative abdominal distension
4) early mobilization

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

A

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

EXPLANATION
Wound dehiscence is the consequence of several predisposing factors and usually develops on the 5-8. postoperative day. It happens most often in cachectic patients, but adiposity, protein loss, the presence of ascites or sudden postoperative intra-abdominal pressure changes (e.g. coughing) or improper surgical technique is also a risk factor. Often wound suppuration lay in the background. Early mobilization is, however, not a predisposing factor. Dehiscence is often preceded by clear-bloody discharge from the wound. In the case of a total disruption, abdominal viscera may prolapse. Treatment is urgent reoperation. After suppuration and dehiscence, closure of the abdominal cavity can be challenging.

Question 37

Q

SUR - 1.38
Anastomotic leakage is one of the most serious complications after a gastrointestinal surgery. The following factors play a role in the prevention of it:
1) antibiotics administered in therapeutic dose
2) the created anastomosis should be free of tension
3) at least two layers of suture should be made for the anastomosis
4) only tissues (e.g. bowel ends) with good blood supply should be approximated

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

A

ANSWER
C) 2nd and 4th answers are correct

EXPLANATION
A fundamental principle of gastrointestinal surgery is that a reliable bowel anastomosis should have good blood supply, should not be under tension and the placement of sutures must be perfect. The type of anastomosis (manual or instrumental, one layer or two layers, etc.) is secondary. Antibiotic treatment will not prevent the development of anastomotic insufficiency (see also SEB-1.123.).

Question 38

Q

SUR - 1.40
We are speaking of radical (R0) resection if:
1) both the surgeon and the pathologist states that there is no residual tumor left behind
2) the tumor can be physically resected but histological assessment confirms microscopic residual tumor
3) the tumor can be physically resected but metastatic lymph nodes are left behind
4) there is a visible tumor mass left behind at the end of the surgery

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

Answer

A

ANSWER
D) only 1st answer is correct

Question 39

Q

SUR - 1.41
Clinical signs of an incarcerated hernia:
1) the hernia becomes swollen and rigid
2) the hernia becomes painful
3) signs of bowel obstruction
4) the hernia cannot be reduced to the abdominal cavity

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

A

ANSWER
E) all of the answers are correct

EXPLANATION
An incarcerated hernia most often presents as a tender, non-reducible mass and the symptoms develop fairly rapidly. If there are bowels in the hernia sac, clinical signs of bowel obstruction can be seen. If left untended, incarceration will lead to perforation of the affected bowel loop and eventually peritonitis will develop.

Question 40

Q

SUR - 1.42
Characteristics of the lateral/indirect inguinal hernia:
1) it is less prone to incarceration
2) can cause intermittent groin pain
3) it never extends into the scrotum
4) it is often congenital

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

A

ANSWER
C) 2nd and 4th answers are correct

EXPLANATION
Lateral (indirect) inguinal hernias are especially prone to incarceration since the hernia has to pass through the long, curvy and relatively narrow inguinal canal. Medial (direct) hernias, on the other hand, has only a short hernial sac – if any -, and their orifice is usually wide. The characteristic intermittent pain or discomfort associated with inguinal hernias is caused by the stretching of the mesentery of the trapped bowel loop. Lateral hernias often develop in the persisting tunica vaginalis (congenital hernia) and thus the hernia sac can reach the scrotum itself (inguinoscrotal hernia) (see also SEB-1.23.).

Question 41

Q

SUR - 1.43
Benefits of a laparoscopic surgery over an open procedure include:
1) less postoperative pain
2) shorter hospital stay
3) faster recovery
4) better exposure of the abdominal cavity

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

A

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

EXPLANATION
During a laparoscopic surgery we make small – 5-10mm long – incisions on the abdomen to introduce the surgical instruments. The integrity of the abdominal wall is only minimally disrupted, thus postoperative pain is small. Since the abdominal cavity is not opened up, the peritoneum does not come into contact with the outside air and surgical manipulation is less likely to irritate the peritoneum, leading to a decreased risk of postoperative bowel paralysis – a common condition after open procedures. The patient can be mobilized and discharged from the hospital earlier. Overall, laparoscopic surgeries are a much smaller burden on the patients. The only real disadvantage of the laparoscopic approach is the limited ability to explore the abdominal cavity. Since the surgeon cannot feel around with his/her hands among the viscera, the small and less obvious lesions can stay undetected. If in doubt, the surgeon can increase the efficacy of exploration by using intraoperative laparoscopic ultrasound scan (see also SEB-1.125. and SEB-1.134.).

Question 42

Q

SUR - 1.44
What are those areas where the laparoscopic surgical approach has the most obvious benefits?
1) gallstone disease
2) inguinal hernia
3) gastroesophageal reflux disease (GERD)
4) adrenal adenoma

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

A

ANSWER
E) all of the answers are correct

EXPLANATION
Laparoscopic approach is ideal in those cases when the intervention is relatively uncomplicated and technically not too challenging, still requiring a long incision for proper exposure. All the answers meet these criteria. By performing a laparoscopic surgery, we can minimize tissue damage and still achieve the same results as of an open procedure.

Question 43

Q

SUR - 1.45
Choose the correct (most appropriate) answer(s).
1) The average suppuration rate after a contaminated surgery does not exceed 20%.
2) An emergency subtotal gastric resection performed due to a bleeding ulcer is considered a contaminated surgery.
3) Biliary tract surgeries are considered contaminated only if the bile is confirmed to be bacterially infected.
4) No antibiotic prophylaxis is needed before a contaminated surgery since antibiotics should only be administered based on the culture reports.

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

A

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

EXPLANATION
A surgery is considered contaminated – for example – if we open a purulent mass or fluid accumulation, open the large bowels during a scheduled surgery. The risk of postoperative septic complications can reach 10-20 percent even with antibiotic prophylaxis administered. Thus, preoperative antibiotic prophylaxis is absolutely indicated in these cases.

Question 44

Q

SUR - 1.46
Choose the correct (most appropriate) answer(s).
1) Staphylococcus species are often found in samples taken from purulent skin infections and abdominal abscesses.
2) Anaerobic bacteria can also cause septic skin lesions.
3) Furuncles most often develop from Staphylococcus infection.
4) Folliculitis is the purulent inflammation of the hair follicles.

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

A

ANSWER
E) all of the answers are correct

EXPLANATION
Answers 1., 2. and 3. are correct and general enough in themselves. Answer 4. is also an adequate definition.

Question 45

Q

SUR - 1.47
When diabetes mellitus is diagnosed, the further investigations has to be carried out:
1) quantitative glucose assessment from collected urine
2) sugar profile assessment
3) glucose acetone assessment from fragmented urine using test strips
4) glucose tolerance test

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

A

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

EXPLANATION
The commonly accepted diagnostic method of an asymptomatic diabetes mellitus or decreased glucose tolerance is the glycated hemoglobin test and the glucose tolerance test. In manifest diabetes mellitus they are unnecessary to be performed. To determine or adjust the required amounts of antidiabetic agents in diabetic patients, a complete glucose profile has to be the set up (measuring the serum glucose levels at different times and after meals, fractioned urine glucose and acetone tests and assessment of daily glucose loss (see also SEB-1.169.—1.180.).

Question 46

Q

SUR - 1.48
If a patient develops jaundice, which of the following investigations would you perform first?
1) abdominal CT
2) MR cholangiography
3) HIDA scan
4) abdominal ultrasound

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

A

ANSWER
D) only 4th answer is correct

EXPLANATION
Being cheap, non-invasive, widely-available and involving no irradiation, abdominal ultrasound is the first choice of imaging study in the case of a suspected biliary obstruction. Other, more sophisticated imaging options are reserved for answering specific clinical questions.

Question 47

Q

SUR - 1.49
The following diseases can mimic the signs of acute abdomen:
1) diabetes mellitus
2) porphyrin metabolism disorders
3) lead poisoning
4) steroid administration

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

A

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

EXPLANATION
Diabetic ketoacidosis leads to the loss of fluids and electrolytes. As a result of the severe metabolic disorder, vomiting and gastric paralysis can develop, which – together with the muscle cramps coming from exsiccosis – can easily mimic the signs of acute abdomen. Thorough diagnostic investigations, careful assessment of the laboratory parameters, and proper treatment is of utmost importance. However, in diabetic patients acute inflammatory abdominal diseases can develop with minimal or atypical clinical signs. Congenital or acquired porphyrin metabolic disorders or lead toxicity can also cause strong, colic abdominal pain. A thorough evaluation of the personal and family history of the patient must be done in all the cases.

Question 48

Q

SUR - 1.50
After which surgeries do we have to administer drug replacement therapy?
1) partial thyroid resection
2) total pancreatectomy
3) subtotal gastric resection
4) total gastrectomy

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

A

ANSWER
C) 2nd and 4th answers are correct

EXPLANATION
After a total pancreatectomy the patient inevitably becomes diabetic due to removal of all the islet cells (islets of Langerhans). After a total gastrectomy the complete loss of intrinsic factor production – required for the proper absorption of vitamin B12 – necessitates postoperative parenteral vitamin B12 substitution. After a partial thyroid or gastric resection hormone replacement is not always needed.

Question 49

Q

SUR - 1.51
Postoperative thyrotoxic crisis
1) it can develop after the surgery of hyperthyroidism
2) it can develop after the surgery of hypothyroidism
3) it is a life-threatening condition
4) recovery can occur spontaneously
5) rarely develops with adequate preoperative medication

A) 1, 2 and 3 answers are correct
B) 1, 3 and 4 answers are correct
C) 1, 4 and 5 answers are correct
D) 1, 3 and 5 answers are correct
E) 2, 3 and 4 answers are correct

Answer

A

ANSWER
D) 1, 3 and 5 answers are correct

EXPLANATION
Most severe complication of hyperthyroidism is thyrotoxic crisis, which can occur spontaneously in untreated cases or if the treatment is inadequate (e.g. neglected preparation before surgery). It is a severe, life-threatening condition which demands immediate specific treatment.

Question 50

Q

SUR - 1.52
Absolute indication of tracheostomy
1) prolonged intubation
2) bilateral paresis of the recurrent laryngeal nerve
3) polyp of the vocal cord
4) destructive trauma of the larynx
5) severe laryngeal edema

A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 2 and 4 answers are correct
D) 1, 3 and 4 answers are correct
E) 2, 4 and 5 answers are correct

Answer

A

ANSWER
A) 1, 2, 4 and 5 answers are correct

EXPLANATION
Cricothyrotomy (coniotomy) is a common method to ensure the permeability of the respiratory tract in case of the occlusive conditions of the larynx. Permanent usage of orotracheal tubes can cause the irreversible destruction of vocal cords. To prevent this damage tracheostomy is necessary in case of extended mechanical ventilation.

Question 51

Q

SUR - 1.53
Principle conditions of primary wound healing
1) tight wound suture
2) good blood supply
3) sterile wound dressing
4) intact innervation
5) viable wound edges

A) 1, 2 and 3 answers are correct
B) 1, 4 and 5 answers are correct
C) 2, 3 and 4 answers are correct
D) 2, 3 and 5 answers are correct

Answer

A

ANSWER
D) 2, 3 and 5 answers are correct

EXPLANATION
Intact wound edges and good blood supply is necessary to achieve primary wound healing. Tight wound suture causes ischemia. It is necessary to cover the wound with sterile dressing at least 24 hours. Meanwhile a serous protection layer can develop between the wound edges which protects the body from desiccation and also gives protection against bacterial invasion. Intact innervation does not take part directly in wound healing.

Question 52

Q

SUR - 1.54
Sign of wound infection
1) wound is covered with dry slough
2) hyperemia of the wound edges
3) edema of the wound edges
4) suffusion around the wound
5) septic fever

A) 1, 2 and 3 answers are correct
B) 1, 4 and 5 answers are correct
C) 2, 3 and 4 answers are correct
D) 2, 3 and 5 answers are correct

Answer

A

ANSWER
D) 2, 3 and 5 answers are correct

EXPLANATION
Clump occurs from the bleeding of wound edges. After desiccation it forms cinder which is not pathological. First sign of wound infection is local inflammation, which can be seen as hyperemia and edema of wound edges. Septic fever can occur if abscess develop without the ability of spontaneous pus depletion. Suffusion is a flat-long bruise in the subcutaneous tissue without containing pus.

Question 53

Q

SUR - 1.55
Characteristics of steam sterilization
1) the process is done at above 1 Atm pressure and above 105 °C temperature
2) vacuum pumps suck out air before the chamber is filled with pressurized steam
3) to ensure sterility indicators should be taped on medical packaging
4) Surgical instruments should be placed in aluminum foil package
5) after the process the chamber should be cleaned with sodium hypochlorite (bleach)

A) 1, 2 and 3 answers are correct
B) 1, 3 and 4 answers are correct
C) 2, 3 and 5 answers are correct
D) 3, 4 and 5 answers are correct

Answer

A

ANSWER
A) 1, 2 and 3 answers are correct

EXPLANATION
Function of autoclave depends on the effect of pressurized saturated steam. The minimal effective pressure is 1.1 Atm, and the most commonly used maximum limit of over-pressure is 2.5 Atm. In order to preserve saturation and avoid cooling air is needed to be removed before filling the chamber with steam. Sterilization is signed for user by coloration of an indicator. Coloration of an indicator is used to sign whether the sterilization process and bagging of loaded instruments is completed (see also SEB-1.4.).

Question 54

Q

SUR - 1.56
In case of lacerated wound which involves the gluteal muscle
1) wound edges should be excised
2) prophylactic antibiotics (in this case Sulfaguanidine) should be administered
3) wound cavity should be rinsed with H2O2-solution
4) the wound should only be closed if a drain tube is left in the cavity
5) wound closure should be done with running intracutaneous suture

A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 2 and 4 answers are correct
D) 1, 3 and 4 answers are correct

Answer

A

ANSWER
D) 1, 3 and 4 answers are correct

EXPLANATION
Excision of wound edges and cleaning of wound cavity (debridement) is compulsory. Diluted H2O2 (at least 3%) is appropriate for cleaning and disinfection. In spite of the previous processes wound cavity should be considered contaminated so leaving a tube in the cavity is mandatory for preventing an abscess. Sulphaguanidine is not suitable for wound management because of its spectrum of activity and because it is a non-absorbable material. Intracutaneous running suture tightly closes the wound which is unfavorable because watertight closure should be avoided. Infected wound should be closed loosely or just converge the edges or treated it in a totally opened state.

Question 55

Q

SUR - 1.57
Tetanus prophylaxis is mandatory:
1) erysipelas
2) congelation
3) gunshot wound
4) bite wound
5) hydradenitis

A) 1, 2 and 3 answers are correct
B) 1, 3 and 4 answers are correct
C) 2, 3 and 4 answers are correct
D) 3, 4 and 5 answers are correct

Answer

A

ANSWER
C) 2, 3 and 4 answers are correct

EXPLANATION
Tetanus prophylaxis is mandatory in every type of lacerated, bitten or gunshot wounds. In these cases the skin is damaged and soft tissues are contaminated (see also SEB-1.11). Tetanus prophylaxis is also necessary in case of congelation because of the extensive soft tissue damage. Antibiotics are notable for treating inflamed skin lesions.

Question 56

Q

SUR - 1.58
Requirements of primary wound healing
1) debridement
2) good blood supply
3) intact innervation
4) Donati-type suturing
5) proper macrophage function

A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 2 and 4 answers are correct
D) 1, 2 and 5 answers are correct
E) 2, 4 and 5 answers are correct

Answer

A

ANSWER
D) 1, 2 and 5 answers are correct

EXPLANATION
Criteria of primary wound healing: sharp wound edges, non-tight edges, lack of foreign or contaminated parts in the cavity. Appropriate blood supply of the damaged area and its surrounding is pivotal for complete and primary wound healing (see also SEB-1.63. and SEB-1.66).

Question 57

Q

SUR - 1.59
Steps of wound management
1) analgesia
2) tetanus prophylaxis
3) wound excision
4) wound cleaning
5) wound closure, dressing

A) 2–1–4–3–5
B) 3–1–4–5–2
C) 4–1–3–5–2
D) 2–4–3–1–5

Answer

A

ANSWER
C) 4–1–3–5–2

EXPLANATION
The first step in the management of open wounds is removing rough contaminations. The next step is disinfection the site of local anesthesia and inject local anesthetics. Lacerated wound edges should be excised then closed (suture- clips- or sticking with or without leaving a tube) if criteria of closure are fulfilled. Tetanus prophylaxis is mandatory after wound dressing (see also SEB- 1.66., 1.67., 1.68.)

Question 58

Q

SUR - 1.60
Local signs of wound infection
1) bulge
2) innervation problem
3) hyperemia
4) functional problems
5) local tetanic spasm

A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 1, 3 and 4 answers are correct
D) 1, 2 and 5 answers are correct
E) 2, 4 and 5 answers are correct

Answer

A

ANSWER
C) 1, 3 and 4 answers are correct

EXPLANATION
Classic signs of inflammation published by Galenus are tumor, rubor, calor, dolor and functio laesa, which means bulge, erythema, warm, pain and loss of function, often subfebrility or fever. 1. 3. and 4. are wrong choices so the best answer is C.

Question 59

Q

SUR - 1.61
Typical blood test parameters of a patient with crural phlegmon
1) eosinophilia
2) leukocytosis
3) elevated serum creatinine
4) increased erythrocyte sedimentation rate
5) severe anemia

A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 2 and 4 answers are correct
D) 1, 2 and 5 answers are correct
E) 2, 4 and 5 answers are correct

Answer

A

ANSWER
C) 2 and 4 answers are correct

EXPLANATION
Crural phlegmon is a moderate pyogenic inflammation. Leukocytosis and increased erythrocyte sedimentation rate can be detected in this condition as in all other inflammations. Eosinophilia can be seen only in specific - non-pyogenic - infections. Anemia and elevated serum creatinine are side-effects of severe septic conditions.

Question 60

Q

SUR - 1.63
Choose the most appropriate answers
1) Most of breast cancers grow slowly
2) Most of breast cancers grow rapidly
3) Lymphatic drainage of the breast is three-level
4) Patient survival is most favorable in the case of papillary breast cancer
5) Hematogenous spreading is non-existent in breast cancer

A) 1, 3 and 4 answers are correct
B) 2, 3 and 5 answers are correct
C) 2, 4 and 5 answers are correct
D) 3, 4 and 5 answers are correct

Answer

A

ANSWER
A) 1, 3 and 4 answers are correct

EXPLANATION
There is a strong correlation between the histological type and growth rate of breast cancers. Proliferation rate is commonly slow, especially in hormone-receptor positive tumors. Lymphatic drainage of the breast is three-level: a., lymph nodes lateral to the pectoralis minor muscle b., lymph nodes between the medial and lateral edges of the pectoralis minor muscle, and interpectoral lymph nodes (Rotter) c., lymph nodes medial to the pectoralis minor muscle (UICC). Patient survival and prognosis is the most favorable in case of papillary cancer.

Question 61

Q

SUR - 1.64
Choose the most appropriate answers
1) Breast cancer do not develop in males
2) Considering the type of breast cancers patient survival is worst in case of inflammatory carcinoma
3) Hormone-receptor positive breast cancers progress faster
4) Hormone-receptor positive breast cancers progress slower
5) Hormone-receptors are not important in the progression of breast cancer so screening of these receptors are not necessary

A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 2 and 4 answers are correct

Answer

A

ANSWER
C) 2 and 4 answers are correct

EXPLANATION
Inflammatory breast cancer has the worst outcome among breast cancers. Prognostic factors are: size of tumor, grade, time of dissemination (metastases), receptor status (e.g. receptor positive tumors growth rate is lower) etc.

Question 62

Q

SUR - 1.66
Post-thrombotic syndrome:
1) chronic venous circulatory insufficiency of the lower extremities
2) develops years after a deep vein thrombosis
3) totally unrelated to crural ulcers
4) leads to development of varicosity in the majority of cases
5) compression stockings are a major part of the conservative treatment

A) 1, 2, 4 and 5 answers are correct
B) all the answers are correct
C) 2 and 4 answers are correct
D) 1, 3 and 4 answers are correct
E) 2, 4 and 5 answers are correct

Answer

A

ANSWER
A) 1, 2, 4 and 5 answers are correct

EXPLANATION
Post-thrombotic syndrome is a chronic insufficiency of venous circulation in the lower extremities, which develops years after deep vein thrombosis. In the acute phase blood flows from the deep veins through perforator veins towards the superficial venous system, which irreversibly damages the valves in the perforator veins. The process can lead to secondary varicosity. Spontaneous recanalization occurs in the deep veins after the acute phase. Fibrosis causes valve destruction in the deep veins which leads to venous stasis and the increase of venous pressure. Increasing venous pressure causes trophic lesions and eventually crural ulcers. Conservative treatment contains compression therapy (in order to decrease venous pressure), lifestyle changes and pharmacotherapy.

Question 63

Q

SUR - 1.67
Main symptoms in obstructive jaundice1) pale stool
2) dark urine
3) yellowish sclera
4) flatulence
5) fatigue

A) 1, 2 and 3 answers are correct
B) 1, 3 and 4 answers are correct
C) 1, 4 and 5 answers are correct
D) 2, 3 and 4 answers are correct

Answer

A

ANSWER
A) 1, 2 and 3 answers are correct

EXPLANATION
Mechanical jaundice is caused by the disorder of bile excretion which leads to pale stool and dark urine. The first sign of mechanical jaundice is the yellowish color of the sclera. However, absorption problems also develop due to interruption of bile acid drainage, the first three signs are predominantly specific for mechanical jaundice.

Question 64

Q

SUR - 1.68
The following parameters are elevated in obstructive jaundice
1) total bilirubin
2) conjugated bilirubin
3) CRP
4) alkaline phosphatase
5) GGT

A) 1, 2, 4 and 5 answers are correct
B) all of the answers are correct
C) 2 and 4 answers are correct
D) 1, 3 and 4 answers are correct
E) 2, 4 and 5 answers are correct

Answer

A

ANSWER
A) 1, 2, 4 and 5 answers are correct

EXPLANATION
Obstructive liver enzymes (direct bilirubin, alkaline phosphatase and gamma-glutamyltransferase) and total bilirubin increase in obstructive (mechanical) icterus. Increase of CRP- level can be measured in inflammatory diseases. If obstructive jaundice is complicated with cholangitis, CRP can be elevated but CRP is not a specific parameter of mechanical jaundice.

Answer 65

A

ANSWER
A) 1, 2 and 3 answers are correct

EXPLANATION
Gastroduodenal ulcers are the most common cause of massive gastrointestinal bleeding. Ulcer bleeding also must be excluded in known cirrhotic patients. Other important causes of bleeding can be alcoholic or erosive gastritis. Mallory-Weiss syndrome and Barrett-esophagus are less common causes of gastrointestinal bleeding, which are rare in patients with cirrhosis.

Answer 66

A

ANSWER
D) 3 and 4 answers are correct

EXPLANATION
Malignant skin tumor originated from the basal cells of the skin typically occurs in elderly patients. Its clinical significance is that it is unlikely to disseminate, grows slowly and rarely recurs after excision.

Answer 67

A

ANSWER
SUR - 1.71 - abdominal wall hernia causing many symptoms - B)

SUR - 1.72 - significant but asymptomatic stenosis of internal carotid artery - D)

SUR - 1.73 - severe damage of central nerve system - C)

SUR - 1.74 - perforated acute appendicitis - A)

Answer 68

A

ANSWER

SUR - 1.75 - serous fluid collection in the wound - C)
SUR - 1.76 - wound infection - B)
SUR - 1.77 - pulmonary embolism - D)
SUR - 1.78 - total wound dehiscence - A)

Answer 69

A

ANSWER
SUR - 1.79 - suggested in fever conditions caused by catheter implacement - C)

SUR - 1.80 - taken by the suspicion of tuberculosis - D)

SUR - 1.81 - taken for verifying pathogens in recurrent fever conditions - A)

SUR - 1.82 - suggested sample of postoperative wound infections - B)

Answer 70

A

ANSWER

SUR - 1.83 - internal hernia - D)
SUR - 1.84 - incarcerated hernia - B)
SUR - 1.85 - postoperative abdominal wall hernia - A)
SUR - 1.86 - opened hernia ring - C)

Answer 71

A

ANSWER

SUR - 1.87 - minimal invasive surgery - D)

SUR - 1.88 - provides detailed intraoperative technique - B)

SUR - 1.89 - requires specific surgical training - A)

SUR - 1.90 - preservation of the integrity of abdominal wall - C)

Answer 72

A

ANSWER
SUR - 1.91 - main symptom is pain caused by significantly increased interstitial pressure - C)

SUR - 1.92 - response reaction develops within 30 days - A)

SUR - 1.93 - excision of necrotized tissues to vital layers is the prevention of infections - D)

SUR - 1.94 - it assures the expected effect with the help of mechanical bowel cleansing - B)

Answer 73

A

ANSWER
SUR - 1.95 - stenosing papillitis - B)

SUR - 1.96 - chronic pancreatitis complicated by long distal part stenosis of the common bile duct - D)

SUR - 1.97 - duodenum obstruction caused by irresectable pancreas head cancer - A)

SUR - 1.98 - cholestasis complicated by liver abscess - C)

Answer 74

A

ANSWER
C) the first is correct in itself, but the second is incorrect

EXPLANATION
We call a tumor resectable if the lesion can be removed without compromising the survival of the patient. Resectability is mainly a technical question - unresectable is a tumor that technically cannot be removed by the surgeon. If the tumor can be resected, the procedure can be curative or palliative. Thus, the term ‘resectability’ is related to the tumor, while the term ‘operability and inoperability’ refers to the patient. Operability varies from patient to patient, depending on the patient’s condition and reserves, and the progression of the disease. With the development of anesthesia and intensive care, with the introduction of new surgical techniques, more and more patients and cases are now considered operable (see also SEB-1.2).

Answer 75

A

ANSWER
B) both are correct, but there is no causal relationship between the two parts

EXPLANATION
A surgery is called curative when the tumor - possibly with its metastases - can be completely removed, and no tumor tissue is left behind. Of course, radicality will be ultimately determined by the long-term results and the disease-free interval. Palliative surgery is when the patient cannot be made completely tumor-free, but with some surgical intervention (e.g. resection, internal bypass, stoma or stenting) the symptoms and complaints caused by the tumor can be reduced. In oncologic surgery, a curative surgery is usually radical and extensive, although sometimes even a complicated and mutilating surgery cannot reach complete oncological radicality.

Answer 76

A

ANSWER
C) the first is correct in itself, but the second is incorrect

EXPLANATION
In accordance with the oncological principles, during a colon cancer surgery - together with the primary cancer itself - the respective part of the mesocolon with the lymphatics and lymph nodes along the supplying vessels are also removed. For this reason, all right-sided tumors – e.g. coecum, ascending colon or hepatic flexure - the entire right side of the colon has to be resected and the bowel continuity is restored with an ileo-transversostomy. The multilayer anastomosis may impair the blood supply of the bowel stumps. The safety of anastomosis does not depend on the number of suture lines, but rather on the combination of good blood supply, tension-free suturing and good surgical technique. The type of anastomosis (manual or instrumental, one layer or two layers, etc.) is secondary (see also SEB-1.44).

Answer 77

A

ANSWER
A) both are correct, with a causal relationship between the two parts

EXPLANATION
The bite wound is an animal or human induced wound with a characteristic bite pattern. Because of the nature of the intrusion, wound edges are torn, and the risk of infection is high due to the presence of bacteria in the saliva. Thus, a bite wound should always be considered highly contaminated. Careful care should be taken during treatment and the wound should be left open. On should always think of giving tetanus prophylaxis, and even rabies vaccination must be considered, as well.

Answer 78

A

ANSWER
A) both are correct, with a causal relationship between the two parts

EXPLANATION
The abdominal cavity has to be checked even during a laparoscopic intervention, but a thorough exploration is not always possible. Thus, preoperative examination is particularly important before such operations (see also SEB-1.53 and SEB-1.134).

Answer 79

A

ANSWER
A) both are correct, with a causal relationship between the two parts

EXPLANATION
The purpose of the surgical antibiotic prophylaxis is to prevent intraoperative bacterial contamination, so an effective antibiotic regimen in therapeutic dosage should be present from the beginning of the operation at the surgical area. That is why antibiotic prophylaxis should be started before the surgery.

Answer 80

A

ANSWER
D) the first is incorrect, the second is correct in itself

EXPLANATION
The surgery of a non-reducible hernia is not a vital indication, as the bowels are fixed in the hernia sac, but their vitality is not yet compromised. In comparison, the blood supply and viability of the organs in an incarcerated hernia are impaired (see also SEB-1.51).

Answer 81

A

ANSWER
A) both are correct, with a causal relationship between the two parts

EXPLANATION
In old age, the incidence of malignant diseases increases. The first sign of a large bowel obstruction may be the increase in abdominal pressure that can lead to hernia formation and even incarceration. In elderly patients the presence of any underlying diseases should be carefully taken into consideration.

Answer 82

A

ANSWER
D) the first is incorrect, the second is correct in itself

EXPLANATION
The laparoscopic technique reduces the surgical stress and maintains the integrity of the abdominal wall by not exposing the peritoneum to the outside air. However, the surgical indication circle remained unchanged, only the surgical technique is different with these interventions. If a proper indication is present, the patient and the surgeon will more likely choose a procedure that is less stressful than the conventional approach (see also SEB-1.53).

Answer 83

A

ANSWER
A) both are correct, with a causal relationship between the two parts

EXPLANATION
The disadvantage of the laparoscopic technique is that the surgeon loses the ability to touch the organs with his/her hands. As a result, the chance to thoroughly explore the abdominal cavity is decreased. In order to minimize the risk of missing a possible lesion in any of the organs, a more careful preoperative evaluation of the patient and his/her complaints is necessary. This is especially true in the case of cholelithiasis when the symptoms are actually associated with some other concomitant malignant disease (e.g. pancreas, stomach, and colon), and not the gallstones themselves (see also SEB-1.53 and SEB-1.125).

Answer 84

A

ANSWER
B) both are correct, but there is no causal relationship between the two parts

EXPLANATION
The two statements are two separate definitions, with no logical correlation between them.

Answer 85

A

ANSWER
C) the first is correct in itself, but the second is incorrect

EXPLANATION
The first statement is the correct definition, while the explanation is false because the most common pathogen in furuncles is the Staphylococcus species.

Answer 86

A

ANSWER
B) both are correct, but there is no causal relationship between the two parts

EXPLANATION
The imaging modalities (US, CT) basically detect the size or structural changes of the examined organs, and their relation to surrounding organs/tissues. Just by the morphologic information it is sometimes difficult to differentiate between a tumor and other benign disorders. Different diagnostic methods can provide different kinds of information that complement each other, but the histological confirmation cannot be replaced.

Answer 87

A

ANSWER
D) the first is incorrect, the second is correct in itself

EXPLANATION
The differential diagnostic role of ultrasonography is fundamental in mechanical icterus, and as a non-invasive method it should necessarily precede the other modalities (see also SEB-1.58). As a further diagnostic step, ERCP (endoscopic retrograde cholangio-pancreaticography) should be carried out since it can be used as a therapeutic modality, as well (e.g. EST, or stone extraction with Dormia’s basket in choledocholithiasis) (see also SEB-1.113-1.116).

Answer 88

A

ANSWER
C) the first is correct in itself, but the second is incorrect

EXPLANATION
Due to impaired carbohydrate metabolism and consequent neuropathy, diabetic microangiopathy and reduced immune function, infections are difficult to treat in patients with diabetic foot. However, diabetic microangiopathy will not necessarily lead to arteriosclerosis of the major arteries.

Answer 89

A

ANSWER
D) the first is incorrect, the second is correct in itself

EXPLANATION
Treatment of diuretic therapy-resistant ascites may be surgical (peritoneovenous shunt). The simple drainage of ascites results in high protein loss and the ascites will be reproduced. Moreover, the risk of infection is high due to repeated punctures. Therefore, large amounts of ascites that does not respond to conservative treatment should be treated with peritoneovenous shunting.

Answer 90

A

ANSWER
B) both are correct, but there is no causal relationship between the two parts

EXPLANATION
When opening body cavity linings (peritoneum, pleura, pericardium, dura) the defect should always carefully be closed since any wound infection can easily spread to the whole of that cavity because the barrier is not intact. In the abdomen, if the peritoneum and thus the abdominal wall is damaged, hernias are more likely to develop in these weakened areas. Of course, there is no correlation between the two statements.

Answer 91

A

ANSWER
A) both are correct, with a causal relationship between the two parts

EXPLANATION
Of the plasma expanders (gelatin, dextran, hydroxyethyl starch), dextran may cause false results with blood group determination; therefore, blood must be taken from the patient before the plasma expanders are administered.

Answer 92

A

ANSWER
E) both are incorrect

EXPLANATION
Modern sharp instruments can be sterilized by all known and accepted methods. In the past, we used dry heat sterilizer or some cold method to protect the edge of the instruments. Apart from the raw material itself, the extent and rate of rusting of an instrument are influenced by the temperature and the chemical environment (gas, liquid). Each sterilization procedure accelerates the rusting to some extent, against which maybe a change in the raw material can be the solution. All the known methods, including ethylene oxide and dry heat sterilizing (usually at 56 °C) accelerate the rusting process.

Answer 93

A

ANSWER
C) the first is correct in itself, but the second is incorrect

EXPLANATION
In areas with very good blood supply - especially where it is important from an operational or cosmetic point of view - the usual excision can be omitted if the wound is relatively clean and thus the risk of infection is considered low. Eyelids and the surrounding areas, the face and genitals typically belong to these areas. The reproduction ability of the bacteria is independent of the time factor. However, in an area with good blood supply, the growth of anaerobic pathogens is inhibited if the tissue damage is limited. Good blood supply also provides favorable conditions for the immune system.

Answer 94

A

ANSWER
B) both are correct, but there is no causal relationship between the two parts

EXPLANATION
In general, a histologically proven gastric lymphoma diagnosed in an early stage is not a surgical disease, since this is typically a cancer where good results can be achieved by chemotherapy. There is no direct correlation between the sensitivity to treatment and the site of the primary cancer.

Answer 95

A

ANSWER
A) both are correct, with a causal relationship between the two parts

EXPLANATION
At the onset of gastrointestinal bleeding, the compensatory mechanisms of the body are immediately initiated: the induced tachycardia, peripheral vasoconstriction and the fluid influx from the extracellular space to the bloodstream can compensate the volume loss and the patient can be relatively asymptomatic. However, the increase in volume loss may lead to the depletion of these compensatory mechanisms, unless the lost volume is resuscitated

Answer 96

A

ANSWER
B) both are correct, but there is no causal relationship between the two parts

EXPLANATION
Usually the hematocrit (Htc) is used to control the extent of blood loss. Immediately after the start of bleeding the Htc values can be near normal. This is because circulatory redistribution and peripheral vasoconstriction is induced to compensate for the loss of volume. Later the body compensates for the loss of circulating volume by fluid uptake from the extracellular space, at which point Htc values can start to drop.

Answer 97

A

ANSWER
E) both are incorrect

EXPLANATION
The type with the worst prognosis of thyroid cancer is the undifferentiated anaplastic carcinoma: the chances of healing are minimal; survival can only be hoped from a radical surgery performed at the earliest stage possible. This type of cancer does not respond to chemotherapy or irradiation. It does not take up iodine, thus isotope therapy is also ineffective.

Answer 98

A

ANSWER
E) both are incorrect

EXPLANATION
Treatment of in situ carcinomas is controversial. In some cases, local excision may be sufficient (e.g., in colonic polyps - in situ cancer found in tubulovillous adenoma with high-grade dysplasia – if the base was tumor-free, or in high risk patients who are not fit for surgery for some reason: age, co-morbidities, etc. According to the traditional surgical teachings, in order to achieve oncological radicality the organ in which the in situ cancer was discovered must be removed with an extensive resection. Excision lines must have ample safety margins, that is at least 5-5 cm in each direction from the borders of the malignancy. Recently some publications advocate a decrease in radicality in the treatment of early cancers (e.g. endoscopic mucosectomy for in situ cancer with strict follow-up protocols, etc.). There is no direct correlation between the tumor size and its location, and an in situ carcinoma can also give metastases.

Answer 99

A

ANSWER
D) the first is incorrect, the second is correct in itself

EXPLANATION
Primary liver cancer can develop in any segment of the liver. Development of metastases does not depend on the location of the primary tumor, but rather on its biological behavior. Liver cancer can spread rapidly either via hematogenous or lymphatic pathways and may give distant metastases. Thus, the most frequent metastatic organ is the lung, but metastases can develop in the abdominal cavity and even in the liver itself.

Answer 100

A

ANSWER
C) the first is correct in itself, but the second is incorrect

EXPLANATION
The surgical treatment of breast cancer can be supplemented with chemotherapy, hormone and radiotherapy in the postoperative phase. The factors determining the treatment plan are as follow (in order of significance): lymph nodes, menopause, and hormone receptors. The hormone receptor status is not important for the surgical plan, but for the postoperative oncotherapy.

Answer 101

A

ANSWER
A) both are correct, with a causal relationship between the two parts

EXPLANATION
Modern breast surgery requires a multidisciplinary approach to preoperative evaluation, surgical treatment and postoperative follow up, for which a proper cooperation between the surgeon, the pathologist and the oncologist is required.

Answer 102

A

ANSWER
E) both are incorrect

EXPLANATION
The first step of treatment in Grave’s-Basedow disease is internal medicine. However, in the case of ineffective medication, or contraindication the use of radioiodine and in relapsing hyperthyroidism, bilateral subtotal resection is performed.

Answer 103

A

ANSWER
C) the first is correct in itself, but the second is incorrect

EXPLANATION
During a bilateral thyroid resection, the parathyroid glands are also often removed, resulting in a decrease in the serum Ca levels. Thyroxine, on the other hand, does not affect calcium metabolism.

Answer 104

A

ANSWER
E) both are incorrect

EXPLANATION
Secondary varices are the result of an acute deep vein thrombosis. If there they have no significant collateral function - proven by functional flow tests -, they can be surgically removed.

Answer 105

A

ANSWER
B) both are correct, but there is no causal relationship between the two parts

EXPLANATION
Thrombophlebitis occurs more frequently in varicose veins than in intact vessels. This is explained by the injured vessel wall structure, the slowed circulation in the varicose bays and the frequent mechanical injuries affecting the dilated, superficial vessels right under the skin. Differentiation of superficial and deep vein thrombosis is extremely important since the course of the disease, complications and therapy are all fundamentally different.

Answer 106

A

ANSWER
D) the first is incorrect, the second is correct in itself

EXPLANATION
In the case of biliary tract stones, endoscopic stone extraction is the least risky option, even if icterus is present. By supplementing vitamin K, the risk of bleeding can be reduced. The risk of abdominal surgery for choledocholithiasis is far greater than that of an endoscopic intervention, which difference is particularly significant in the elderly.

Answer 107

A

ANSWER
A) both are correct, with a causal relationship between the two parts

EXPLANATION
Pancreas insulinoma are small, hormonally active tumors. They usually have an average size of about 1 cm which is at threshold of the resolution of the typical imaging modalities (preoperative ECHO, CT). Non-palpable tumors during an abdominal surgery can be detected by an intraoperative ultrasound detector placed on the pancreatic surface.

Answer 108

A

ANSWER
E) both are incorrect

EXPLANATION
Tumor markers alone are rarely sufficient to diagnose a malignant disease. The trend of the values of individual tumor markers (e.g. a marker level drops after tumor surgery, then increases again in tumor recurrence), however, is a sensitive tool for monitoring cancer behavior even in the follow-up period.

Answer 109

A

ANSWER
C) Answers 1 and 3 are correct

EXPLANATION
The patient has coughing attacks after drinking liquids which should raise the suspicion for an esophago-bronchial fistula or dysphagia. His smoking and alcohol abuse history, and his poor general condition can be a sign that malignancy lies in the background of the esophago-bronchial fistula. Diagnosis is possible by swallowing X-ray examination with water-soluble contrast media. In esophago-bronchial fistulas aspiration pneumonia is common, therefore chest radiography should be always performed. (Blood tests and abdominal ultrasound is also important since spontaneous esophago-bronchial fistula, periodic dysphagia, vomiting and desquamation are associated with esophageal tumors, but these tests do not affect the patient’s immediate care.) The patient has dysphagia, so he is unable to feed, he has pneumonia, and he needs hospitalization because of his respiratory complaints. (Antibiotics, mucolytic and other adjuvant therapies as well as oral or parenteral nutrition should be carried out hospital settings.) Swallowing X-ray revealed an occlusion. Although we know that is most often occurs in esophageal cancer, we still have to confirm the suspicion as the next step. Biopsy is usually taken during endoscopy. (Chest, mediastinal CT scan can provide further information on extent of the malignancy; bronchoscopy may reveal tracheal involvement the presence/location of the suspected fistulae, while an abdominal ultrasound can detect distant metastases – dominantly liver metastases. Bacteriological culture is relevant if the patient’s pneumonia is not responding to the administered antibiotics, and targeted antibiotic therapy is planned. These latter investigations are only secondary to endoscopy.) The patient has a stenosing cancer in the esophagus, infiltrating the trachea and leading to the development of an esophago-bronchial fistula. As such, this cancer is inoperable, and the esophagus can only be removed together with the trachea. Of the palliative solutions, the endoscopic tube implantation is the best choice since the tube covers the fistula eliminating the possibility of aspiration, ensures the patency of the esophagus and thus making oral feeding possible. (A feeding tube does not eliminate the possibility of aspiration, antibiotic, mucolytic and analgesic drugs are only adjuvant therapy for the development of esophago-bronchial fistula.)

Answer 110

A

ANSWER
D) Answer 3 is correct

EXPLANATION
The patient has coughing attacks after drinking liquids which should raise the suspicion for an esophago-bronchial fistula or dysphagia. His smoking and alcohol abuse history, and his poor general condition can be a sign that malignancy lies in the background of the esophago-bronchial fistula. Diagnosis is possible by swallowing X-ray examination with water-soluble contrast media. In esophago-bronchial fistulas aspiration pneumonia is common, therefore chest radiography should be always performed. (Blood tests and abdominal ultrasound is also important since spontaneous esophago-bronchial fistula, periodic dysphagia, vomiting and desquamation are associated with esophageal tumors, but these tests do not affect the patient’s immediate care.) The patient has dysphagia, so he is unable to feed, he has pneumonia, and he needs hospitalization because of his respiratory complaints. (Antibiotics, mucolytic and other adjuvant therapies as well as oral or parenteral nutrition should be carried out hospital settings.) Swallowing X-ray revealed an occlusion. Although we know that is most often occurs in esophageal cancer, we still have to confirm the suspicion as the next step. Biopsy is usually taken during endoscopy. (Chest, mediastinal CT scan can provide further information on extent of the malignancy; bronchoscopy may reveal tracheal involvement the presence/location of the suspected fistulae, while an abdominal ultrasound can detect distant metastases – dominantly liver metastases. Bacteriological culture is relevant if the patient’s pneumonia is not responding to the administered antibiotics, and targeted antibiotic therapy is planned. These latter investigations are only secondary to endoscopy.) The patient has a stenosing cancer in the esophagus, infiltrating the trachea and leading to the development of an esophago-bronchial fistula. As such, this cancer is inoperable, and the esophagus can only be removed together with the trachea. Of the palliative solutions, the endoscopic tube implantation is the best choice since the tube covers the fistula eliminating the possibility of aspiration, ensures the patency of the esophagus and thus making oral feeding possible. (A feeding tube does not eliminate the possibility of aspiration, antibiotic, mucolytic and analgesic drugs are only adjuvant therapy for the development of esophago-bronchial fistula.)

Answer 111

A

ANSWER
C) Answers 4 and 5 are correct

EXPLANATION
The patient has coughing attacks after drinking liquids which should raise the suspicion for an esophago-bronchial fistula or dysphagia. His smoking and alcohol abuse history, and his poor general condition can be a sign that malignancy lies in the background of the esophago-bronchial fistula. Diagnosis is possible by swallowing X-ray examination with water-soluble contrast media. In esophago-bronchial fistulas aspiration pneumonia is common, therefore chest radiography should be always performed. (Blood tests and abdominal ultrasound is also important since spontaneous esophago-bronchial fistula, periodic dysphagia, vomiting and desquamation are associated with esophageal tumors, but these tests do not affect the patient’s immediate care.) The patient has dysphagia, so he is unable to feed, he has pneumonia, and he needs hospitalization because of his respiratory complaints. (Antibiotics, mucolytic and other adjuvant therapies as well as oral or parenteral nutrition should be carried out hospital settings.) Swallowing X-ray revealed an occlusion. Although we know that is most often occurs in esophageal cancer, we still have to confirm the suspicion as the next step. Biopsy is usually taken during endoscopy. (Chest, mediastinal CT scan can provide further information on extent of the malignancy; bronchoscopy may reveal tracheal involvement the presence/location of the suspected fistulae, while an abdominal ultrasound can detect distant metastases – dominantly liver metastases. Bacteriological culture is relevant if the patient’s pneumonia is not responding to the administered antibiotics, and targeted antibiotic therapy is planned. These latter investigations are only secondary to endoscopy.) The patient has a stenosing cancer in the esophagus, infiltrating the trachea and leading to the development of an esophago-bronchial fistula. As such, this cancer is inoperable, and the esophagus can only be removed together with the trachea. Of the palliative solutions, the endoscopic tube implantation is the best choice since the tube covers the fistula eliminating the possibility of aspiration, ensures the patency of the esophagus and thus making oral feeding possible. (A feeding tube does not eliminate the possibility of aspiration, antibiotic, mucolytic and analgesic drugs are only adjuvant therapy for the development of esophago-bronchial fistula.)

Answer 112

A

ANSWER
C) Answer 2 is correct

EXPLANATION
The patient has coughing attacks after drinking liquids which should raise the suspicion for an esophago-bronchial fistula or dysphagia. His smoking and alcohol abuse history, and his poor general condition can be a sign that malignancy lies in the background of the esophago-bronchial fistula. Diagnosis is possible by swallowing X-ray examination with water-soluble contrast media. In esophago-bronchial fistulas aspiration pneumonia is common, therefore chest radiography should be always performed. (Blood tests and abdominal ultrasound is also important since spontaneous esophago-bronchial fistula, periodic dysphagia, vomiting and desquamation are associated with esophageal tumors, but these tests do not affect the patient’s immediate care.) The patient has dysphagia, so he is unable to feed, he has pneumonia, and he needs hospitalization because of his respiratory complaints. (Antibiotics, mucolytic and other adjuvant therapies as well as oral or parenteral nutrition should be carried out hospital settings.) Swallowing X-ray revealed an occlusion. Although we know that is most often occurs in esophageal cancer, we still have to confirm the suspicion as the next step. Biopsy is usually taken during endoscopy. (Chest, mediastinal CT scan can provide further information on extent of the malignancy; bronchoscopy may reveal tracheal involvement the presence/location of the suspected fistulae, while an abdominal ultrasound can detect distant metastases – dominantly liver metastases. Bacteriological culture is relevant if the patient’s pneumonia is not responding to the administered antibiotics, and targeted antibiotic therapy is planned. These latter investigations are only secondary to endoscopy.) The patient has a stenosing cancer in the esophagus, infiltrating the trachea and leading to the development of an esophago-bronchial fistula. As such, this cancer is inoperable, and the esophagus can only be removed together with the trachea. Of the palliative solutions, the endoscopic tube implantation is the best choice since the tube covers the fistula eliminating the possibility of aspiration, ensures the patency of the esophagus and thus making oral feeding possible. (A feeding tube does not eliminate the possibility of aspiration, antibiotic, mucolytic and analgesic drugs are only adjuvant therapy for the development of esophago-bronchial fistula.)

Answer 113

A

ANSWER
B) Answers 1, 3, 4 and 5 are correct

EXPLANATION
In nosocomial category A (e.g. sterile or clean surgery) no pathogen is to be expected in the surgical area. This group includes surgeries where no hollow organs are opened and there is no inflammation present. (Without this exception even an abscess surgery could fall into this category!) Moreover, in clean surgeries there cannot be thread granuloma, or other foreign substances in the surgery area. Examples of these surgeries are hernia repairs, vascular and endocrine surgeries, diagnostic laparoscopic or open interventions. In the case of nosocomial category ‘A’ the rate of wound suppuration is <1%. From a surgical point of view, only categories C and D justify the administration of prophylactic antibiotics. In the case of a blocked bacterial filter, the required overpressure in the operating room is reduced – the inflow of air is significantly less - while the outflow stays unchanged. Fluid condensation from the air in the ducts of air conditioners can lead to the proliferation of bacteria. Condense fluid is mainly produced in significant quantities when the air conditioner is operated periodically. Final disinfection should be carried out after every nosocomial epidemic and its efficacy must be confirmed with multiple cultures. The causes of the epidemic should be identified during and after the nosocomial epidemic. In addition to human factors, contamination often has technical reasons. During the epidemic and the consequent investigations, the significant medical facilities (operating rooms, outpatient offices, etc.) and patient rooms, as well as service areas are contaminated. After a thorough cleaning, disinfection of all the surfaces, mechanical equipment, airspace and devices is required to restore the aseptic conditions. Tissues dissected during a surgery themselves cannot defend against infections. The infection can come from the air of the operating room, from the hands or clothes of the surgical team, from instruments and materials used during the surgery, or from the bloodstream of the patient (endogenous infection). During the operation of an infected area, proper surgical technique should be used to avoid the direct or indirect contamination of the surgical site with pathogens. Since none of the above factors can be completely eliminated, wound infection is always a part of the surgical risk. The frequency of wound infection is one of the oldest quality indicators used beside surgical mortality and effectiveness (resectability, total healing rate). It represents the training and attention of the staff at the department, the functionality of the devices, the adequacy of the cleaning, sterilizing, surgical, and wound care processes. It affects the department’s antibiotics strategies and the internal quality control methods. Because of its complex nature, if wound infection rate starts to rise a thorough investigation of the possible causes must be carried out. The lack of monitoring of this indicator is a fundamental deficiency.

Answer 114

A

ANSWER
D) Closing disinfection should be performed after each nosocomial infection and the result should be checked by bacteriological examination.

EXPLANATION
In nosocomial category A (e.g. sterile or clean surgery) no pathogen is to be expected in the surgical area. This group includes surgeries where no hollow organs are opened and there is no inflammation present. (Without this exception even an abscess surgery could fall into this category!) Moreover, in clean surgeries there cannot be thread granuloma, or other foreign substances in the surgery area. Examples of these surgeries are hernia repairs, vascular and endocrine surgeries, diagnostic laparoscopic or open interventions. In the case of nosocomial category ‘A’ the rate of wound suppuration is <1%. From a surgical point of view, only categories C and D justify the administration of prophylactic antibiotics. In the case of a blocked bacterial filter, the required overpressure in the operating room is reduced – the inflow of air is significantly less - while the outflow stays unchanged. Fluid condensation from the air in the ducts of air conditioners can lead to the proliferation of bacteria. Condense fluid is mainly produced in significant quantities when the air conditioner is operated periodically. Final disinfection should be carried out after every nosocomial epidemic and its efficacy must be confirmed with multiple cultures. The causes of the epidemic should be identified during and after the nosocomial epidemic. In addition to human factors, contamination often has technical reasons. During the epidemic and the consequent investigations, the significant medical facilities (operating rooms, outpatient offices, etc.) and patient rooms, as well as service areas are contaminated. After a thorough cleaning, disinfection of all the surfaces, mechanical equipment, airspace and devices is required to restore the aseptic conditions. Tissues dissected during a surgery themselves cannot defend against infections. The infection can come from the air of the operating room, from the hands or clothes of the surgical team, from instruments and materials used during the surgery, or from the bloodstream of the patient (endogenous infection). During the operation of an infected area, proper surgical technique should be used to avoid the direct or indirect contamination of the surgical site with pathogens. Since none of the above factors can be completely eliminated, wound infection is always a part of the surgical risk. The frequency of wound infection is one of the oldest quality indicators used beside surgical mortality and effectiveness (resectability, total healing rate). It represents the training and attention of the staff at the department, the functionality of the devices, the adequacy of the cleaning, sterilizing, surgical, and wound care processes. It affects the department’s antibiotics strategies and the internal quality control methods. Because of its complex nature, if wound infection rate starts to rise a thorough investigation of the possible causes must be carried out. The lack of monitoring of this indicator is a fundamental deficiency.

Answer 115

A

ANSWER
E) Wound infection is part of the surgical risk.

EXPLANATION
In nosocomial category A (e.g. sterile or clean surgery) no pathogen is to be expected in the surgical area. This group includes surgeries where no hollow organs are opened and there is no inflammation present. (Without this exception even an abscess surgery could fall into this category!) Moreover, in clean surgeries there cannot be thread granuloma, or other foreign substances in the surgery area. Examples of these surgeries are hernia repairs, vascular and endocrine surgeries, diagnostic laparoscopic or open interventions. In the case of nosocomial category ‘A’ the rate of wound suppuration is <1%. From a surgical point of view, only categories C and D justify the administration of prophylactic antibiotics. In the case of a blocked bacterial filter, the required overpressure in the operating room is reduced – the inflow of air is significantly less - while the outflow stays unchanged. Fluid condensation from the air in the ducts of air conditioners can lead to the proliferation of bacteria. Condense fluid is mainly produced in significant quantities when the air conditioner is operated periodically. Final disinfection should be carried out after every nosocomial epidemic and its efficacy must be confirmed with multiple cultures. The causes of the epidemic should be identified during and after the nosocomial epidemic. In addition to human factors, contamination often has technical reasons. During the epidemic and the consequent investigations, the significant medical facilities (operating rooms, outpatient offices, etc.) and patient rooms, as well as service areas are contaminated. After a thorough cleaning, disinfection of all the surfaces, mechanical equipment, airspace and devices is required to restore the aseptic conditions. Tissues dissected during a surgery themselves cannot defend against infections. The infection can come from the air of the operating room, from the hands or clothes of the surgical team, from instruments and materials used during the surgery, or from the bloodstream of the patient (endogenous infection). During the operation of an infected area, proper surgical technique should be used to avoid the direct or indirect contamination of the surgical site with pathogens. Since none of the above factors can be completely eliminated, wound infection is always a part of the surgical risk. The frequency of wound infection is one of the oldest quality indicators used beside surgical mortality and effectiveness (resectability, total healing rate). It represents the training and attention of the staff at the department, the functionality of the devices, the adequacy of the cleaning, sterilizing, surgical, and wound care processes. It affects the department’s antibiotics strategies and the internal quality control methods. Because of its complex nature, if wound infection rate starts to rise a thorough investigation of the possible causes must be carried out. The lack of monitoring of this indicator is a fundamental deficiency.

Answer 116

A

ANSWER
B) The frequency of wound infection is a quality indicator.

EXPLANATION
In nosocomial category A (e.g. sterile or clean surgery) no pathogen is to be expected in the surgical area. This group includes surgeries where no hollow organs are opened and there is no inflammation present. (Without this exception even an abscess surgery could fall into this category!) Moreover, in clean surgeries there cannot be thread granuloma, or other foreign substances in the surgery area. Examples of these surgeries are hernia repairs, vascular and endocrine surgeries, diagnostic laparoscopic or open interventions. In the case of nosocomial category ‘A’ the rate of wound suppuration is <1%. From a surgical point of view, only categories C and D justify the administration of prophylactic antibiotics. In the case of a blocked bacterial filter, the required overpressure in the operating room is reduced – the inflow of air is significantly less - while the outflow stays unchanged. Fluid condensation from the air in the ducts of air conditioners can lead to the proliferation of bacteria. Condense fluid is mainly produced in significant quantities when the air conditioner is operated periodically. Final disinfection should be carried out after every nosocomial epidemic and its efficacy must be confirmed with multiple cultures. The causes of the epidemic should be identified during and after the nosocomial epidemic. In addition to human factors, contamination often has technical reasons. During the epidemic and the consequent investigations, the significant medical facilities (operating rooms, outpatient offices, etc.) and patient rooms, as well as service areas are contaminated. After a thorough cleaning, disinfection of all the surfaces, mechanical equipment, airspace and devices is required to restore the aseptic conditions. Tissues dissected during a surgery themselves cannot defend against infections. The infection can come from the air of the operating room, from the hands or clothes of the surgical team, from instruments and materials used during the surgery, or from the bloodstream of the patient (endogenous infection). During the operation of an infected area, proper surgical technique should be used to avoid the direct or indirect contamination of the surgical site with pathogens. Since none of the above factors can be completely eliminated, wound infection is always a part of the surgical risk. The frequency of wound infection is one of the oldest quality indicators used beside surgical mortality and effectiveness (resectability, total healing rate). It represents the training and attention of the staff at the department, the functionality of the devices, the adequacy of the cleaning, sterilizing, surgical, and wound care processes. It affects the department’s antibiotics strategies and the internal quality control methods. Because of its complex nature, if wound infection rate starts to rise a thorough investigation of the possible causes must be carried out. The lack of monitoring of this indicator is a fundamental deficiency.

Answer 117

A

ANSWER
D) Crigler-Najjar syndrome

EXPLANATION
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice. Accelerated erythrocyte sedimentation rate, moderate anemia, poor kidney function, and elevated blood glucose levels in a previously asymptomatic patients can be signs of a malignant disease in the background. Septic cholangitis is characterized by fever, pain and increased white blood cell count in the lab tests. In hepatitis the AST and ALT levels are significantly elevated. In a mechanical icterus caused by chronic pancreatitis and biliary tract stones, there are no accompanying complications, like impaired kidney function, increased blood glucose levels. The pain present in the back or under the right ribcage. Of the laboratory tests, tumor marker tests might help establishing the diagnosis if a malignant origin is suspected. In the case of diabetes mellitus, the glucose tolerance test is no longer required if the serum glucose level is already elevated. However, to assess the current state of the carbohydrate metabolism and to set up the treatment regimen and dosage (oral antidiabetics, insulin), the blood glucose profile has to be established, and the hemoglobin A1C, glucose acetone in the urine fractions and the glucose excretion tests have to be performed. As a widely available, inexpensive, non-invasive examination abdominal ultrasound is the first choice of imaging options although - regarding the pancreas -, it’s mostly useful only in the detection of malignant masses. In the diagnosis of pancreatic cancers, CT and ERCP are the other main imaging options. With CT scan the extent and relation of the mass to the surrounding organs can be precisely determined. With ERCP, by directly injecting contrast material into the Wirsungian and/or common bile duct, the investigator can obtain precise information regarding the nature of the obstruction. By combining these two examinations the efficacy of the diagnostic procedure is significantly improved. Another advantage of ERCP is that it can be used to insert a biliary endoprosthesis, which can relieve the icterus in the case of malignant obstruction. (The blurry image of scintigraphy cannot help the diagnosis significantly, while i.v. cholecystography may provide information on gall bladder filling, but this does not bring you closer to clarifying the present case.) If the biliary tract is occluded by stones, the icterus usually develops rapidly and thus the bile ducts do not have time to get homogenously dilated. In distal common bile duct cancers and in chronic pancreatitis the outline of the biliary tract is also inhomogenous and the narrowing usually affects a long segment. In chronic calcifying pancreatitis, the pancreas is diffusely echogenic, showing the calcification in the parenchyma and/or the stones within the pancreatic ducts. In the case of an acute exacerbation, the entire pancreas is enlarged, its structure becomes inhomogenous, and is often surrounded by fluid accumulation. A tumor of the papilla of Vater - if detected in these studies -, is primarily localized within the lumen of the duodenum. In diseases in the papilla of Vater the obstruction is right at the end of the Wirsungian or common bile duct, and not after a relatively long normal section. Only a histological/cytological report can give a definitive preoperative diagnosis. In the case of fine-needle biopsy, only a positive finding can be accepted due to the large false negative rate associated with this modality. If biopsy is negative but the imaging studies raise the suspicion for malignancy, surgical exploration and intraoperative biopsy can be considered. Antibiotic treatment is not required, since it will not affect the morphologic alterations found in chronic pancreatitis. Even if repeated biopsies are negative, it cannot be accepted as a definitive diagnosis, the same way as with a negative cytology result. Pancreatic tumors are only sensitive to high doses of radiation. During extracorporeal irradiation, the radiation sensitivity of the intestines surrounding the target organ is significantly lower. Pancreatic cancer cells are only moderately sensitive to cytostatic agents. If the lesion cannot be surgically removed, no real cure/improvement can be expected from cytostatic treatment. If the patient needs some sort of palliative intervention, endoscopic or surgical internal biliary bypass (endoprothesis, choledocho-duodenostomy, choledocho-jejunostomy) should be chosen, rather than percutaneous drainage, which makes the patient lose a lot of bile.

Answer 118

A

ANSWER
D) diagnosis: obstructive icterus, pancreatic tumor? - internal medicine

EXPLANATION
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice. Accelerated erythrocyte sedimentation rate, moderate anemia, poor kidney function, and elevated blood glucose levels in a previously asymptomatic patients can be signs of a malignant disease in the background. Septic cholangitis is characterized by fever, pain and increased white blood cell count in the lab tests. In hepatitis the AST and ALT levels are significantly elevated. In a mechanical icterus caused by chronic pancreatitis and biliary tract stones, there are no accompanying complications, like impaired kidney function, increased blood glucose levels. The pain present in the back or under the right ribcage. Of the laboratory tests, tumor marker tests might help establishing the diagnosis if a malignant origin is suspected. In the case of diabetes mellitus, the glucose tolerance test is no longer required if the serum glucose level is already elevated. However, to assess the current state of the carbohydrate metabolism and to set up the treatment regimen and dosage (oral antidiabetics, insulin), the blood glucose profile has to be established, and the hemoglobin A1C, glucose acetone in the urine fractions and the glucose excretion tests have to be performed. As a widely available, inexpensive, non-invasive examination abdominal ultrasound is the first choice of imaging options although - regarding the pancreas -, it’s mostly useful only in the detection of malignant masses. In the diagnosis of pancreatic cancers, CT and ERCP are the other main imaging options. With CT scan the extent and relation of the mass to the surrounding organs can be precisely determined. With ERCP, by directly injecting contrast material into the Wirsungian and/or common bile duct, the investigator can obtain precise information regarding the nature of the obstruction. By combining these two examinations the efficacy of the diagnostic procedure is significantly improved. Another advantage of ERCP is that it can be used to insert a biliary endoprosthesis, which can relieve the icterus in the case of malignant obstruction. (The blurry image of scintigraphy cannot help the diagnosis significantly, while i.v. cholecystography may provide information on gall bladder filling, but this does not bring you closer to clarifying the present case.) If the biliary tract is occluded by stones, the icterus usually develops rapidly and thus the bile ducts do not have time to get homogenously dilated. In distal common bile duct cancers and in chronic pancreatitis the outline of the biliary tract is also inhomogenous and the narrowing usually affects a long segment. In chronic calcifying pancreatitis, the pancreas is diffusely echogenic, showing the calcification in the parenchyma and/or the stones within the pancreatic ducts. In the case of an acute exacerbation, the entire pancreas is enlarged, its structure becomes inhomogenous, and is often surrounded by fluid accumulation. A tumor of the papilla of Vater - if detected in these studies -, is primarily localized within the lumen of the duodenum. In diseases in the papilla of Vater the obstruction is right at the end of the Wirsungian or common bile duct, and not after a relatively long normal section. Only a histological/cytological report can give a definitive preoperative diagnosis. In the case of fine-needle biopsy, only a positive finding can be accepted due to the large false negative rate associated with this modality. If biopsy is negative but the imaging studies raise the suspicion for malignancy, surgical exploration and intraoperative biopsy can be considered. Antibiotic treatment is not required, since it will not affect the morphologic alterations found in chronic pancreatitis. Even if repeated biopsies are negative, it cannot be accepted as a definitive diagnosis, the same way as with a negative cytology result. Pancreatic tumors are only sensitive to high doses of radiation. During extracorporeal irradiation, the radiation sensitivity of the intestines surrounding the target organ is significantly lower. Pancreatic cancer cells are only moderately sensitive to cytostatic agents. If the lesion cannot be surgically removed, no real cure/improvement can be expected from cytostatic treatment. If the patient needs some sort of palliative intervention, endoscopic or surgical internal biliary bypass (endoprothesis, choledocho-duodenostomy, choledocho-jejunostomy) should be chosen, rather than percutaneous drainage, which makes the patient lose a lot of bile.

Answer 119

A

ANSWER
D) Only the 4th answer is correct

EXPLANATION
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice. Accelerated erythrocyte sedimentation rate, moderate anemia, poor kidney function, and elevated blood glucose levels in a previously asymptomatic patients can be signs of a malignant disease in the background. Septic cholangitis is characterized by fever, pain and increased white blood cell count in the lab tests. In hepatitis the AST and ALT levels are significantly elevated. In a mechanical icterus caused by chronic pancreatitis and biliary tract stones, there are no accompanying complications, like impaired kidney function, increased blood glucose levels. The pain present in the back or under the right ribcage. Of the laboratory tests, tumor marker tests might help establishing the diagnosis if a malignant origin is suspected. In the case of diabetes mellitus, the glucose tolerance test is no longer required if the serum glucose level is already elevated. However, to assess the current state of the carbohydrate metabolism and to set up the treatment regimen and dosage (oral antidiabetics, insulin), the blood glucose profile has to be established, and the hemoglobin A1C, glucose acetone in the urine fractions and the glucose excretion tests have to be performed. As a widely available, inexpensive, non-invasive examination abdominal ultrasound is the first choice of imaging options although - regarding the pancreas -, it’s mostly useful only in the detection of malignant masses. In the diagnosis of pancreatic cancers, CT and ERCP are the other main imaging options. With CT scan the extent and relation of the mass to the surrounding organs can be precisely determined. With ERCP, by directly injecting contrast material into the Wirsungian and/or common bile duct, the investigator can obtain precise information regarding the nature of the obstruction. By combining these two examinations the efficacy of the diagnostic procedure is significantly improved. Another advantage of ERCP is that it can be used to insert a biliary endoprosthesis, which can relieve the icterus in the case of malignant obstruction. (The blurry image of scintigraphy cannot help the diagnosis significantly, while i.v. cholecystography may provide information on gall bladder filling, but this does not bring you closer to clarifying the present case.) If the biliary tract is occluded by stones, the icterus usually develops rapidly and thus the bile ducts do not have time to get homogenously dilated. In distal common bile duct cancers and in chronic pancreatitis the outline of the biliary tract is also inhomogenous and the narrowing usually affects a long segment. In chronic calcifying pancreatitis, the pancreas is diffusely echogenic, showing the calcification in the parenchyma and/or the stones within the pancreatic ducts. In the case of an acute exacerbation, the entire pancreas is enlarged, its structure becomes inhomogenous, and is often surrounded by fluid accumulation. A tumor of the papilla of Vater - if detected in these studies -, is primarily localized within the lumen of the duodenum. In diseases in the papilla of Vater the obstruction is right at the end of the Wirsungian or common bile duct, and not after a relatively long normal section. Only a histological/cytological report can give a definitive preoperative diagnosis. In the case of fine-needle biopsy, only a positive finding can be accepted due to the large false negative rate associated with this modality. If biopsy is negative but the imaging studies raise the suspicion for malignancy, surgical exploration and intraoperative biopsy can be considered. Antibiotic treatment is not required, since it will not affect the morphologic alterations found in chronic pancreatitis. Even if repeated biopsies are negative, it cannot be accepted as a definitive diagnosis, the same way as with a negative cytology result. Pancreatic tumors are only sensitive to high doses of radiation. During extracorporeal irradiation, the radiation sensitivity of the intestines surrounding the target organ is significantly lower. Pancreatic cancer cells are only moderately sensitive to cytostatic agents. If the lesion cannot be surgically removed, no real cure/improvement can be expected from cytostatic treatment. If the patient needs some sort of palliative intervention, endoscopic or surgical internal biliary bypass (endoprothesis, choledocho-duodenostomy, choledocho-jejunostomy) should be chosen, rather than percutaneous drainage, which makes the patient lose a lot of bile

Answer 120

A

ANSWER
A) Answer 1, 2 and 3 are correct

EXPLANATION
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice. Accelerated erythrocyte sedimentation rate, moderate anemia, poor kidney function, and elevated blood glucose levels in a previously asymptomatic patients can be signs of a malignant disease in the background. Septic cholangitis is characterized by fever, pain and increased white blood cell count in the lab tests. In hepatitis the AST and ALT levels are significantly elevated. In a mechanical icterus caused by chronic pancreatitis and biliary tract stones, there are no accompanying complications, like impaired kidney function, increased blood glucose levels. The pain present in the back or under the right ribcage. Of the laboratory tests, tumor marker tests might help establishing the diagnosis if a malignant origin is suspected. In the case of diabetes mellitus, the glucose tolerance test is no longer required if the serum glucose level is already elevated. However, to assess the current state of the carbohydrate metabolism and to set up the treatment regimen and dosage (oral antidiabetics, insulin), the blood glucose profile has to be established, and the hemoglobin A1C, glucose acetone in the urine fractions and the glucose excretion tests have to be performed. As a widely available, inexpensive, non-invasive examination abdominal ultrasound is the first choice of imaging options although - regarding the pancreas -, it’s mostly useful only in the detection of malignant masses. In the diagnosis of pancreatic cancers, CT and ERCP are the other main imaging options. With CT scan the extent and relation of the mass to the surrounding organs can be precisely determined. With ERCP, by directly injecting contrast material into the Wirsungian and/or common bile duct, the investigator can obtain precise information regarding the nature of the obstruction. By combining these two examinations the efficacy of the diagnostic procedure is significantly improved. Another advantage of ERCP is that it can be used to insert a biliary endoprosthesis, which can relieve the icterus in the case of malignant obstruction. (The blurry image of scintigraphy cannot help the diagnosis significantly, while i.v. cholecystography may provide information on gall bladder filling, but this does not bring you closer to clarifying the present case.) If the biliary tract is occluded by stones, the icterus usually develops rapidly and thus the bile ducts do not have time to get homogenously dilated. In distal common bile duct cancers and in chronic pancreatitis the outline of the biliary tract is also inhomogenous and the narrowing usually affects a long segment. In chronic calcifying pancreatitis, the pancreas is diffusely echogenic, showing the calcification in the parenchyma and/or the stones within the pancreatic ducts. In the case of an acute exacerbation, the entire pancreas is enlarged, its structure becomes inhomogenous, and is often surrounded by fluid accumulation. A tumor of the papilla of Vater - if detected in these studies -, is primarily localized within the lumen of the duodenum. In diseases in the papilla of Vater the obstruction is right at the end of the Wirsungian or common bile duct, and not after a relatively long normal section. Only a histological/cytological report can give a definitive preoperative diagnosis. In the case of fine-needle biopsy, only a positive finding can be accepted due to the large false negative rate associated with this modality. If biopsy is negative but the imaging studies raise the suspicion for malignancy, surgical exploration and intraoperative biopsy can be considered. Antibiotic treatment is not required, since it will not affect the morphologic alterations found in chronic pancreatitis. Even if repeated biopsies are negative, it cannot be accepted as a definitive diagnosis, the same way as with a negative cytology result. Pancreatic tumors are only sensitive to high doses of radiation. During extracorporeal irradiation, the radiation sensitivity of the intestines surrounding the target organ is significantly lower. Pancreatic cancer cells are only moderately sensitive to cytostatic agents. If the lesion cannot be surgically removed, no real cure/improvement can be expected from cytostatic treatment. If the patient needs some sort of palliative intervention, endoscopic or surgical internal biliary bypass (endoprothesis, choledocho-duodenostomy, choledocho-jejunostomy) should be chosen, rather than percutaneous drainage, which makes the patient lose a lot of bile.

Answer 121

A

ANSWER
D) Only the 4th answer is correct

EXPLANATION
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice. Accelerated erythrocyte sedimentation rate, moderate anemia, poor kidney function, and elevated blood glucose levels in a previously asymptomatic patients can be signs of a malignant disease in the background. Septic cholangitis is characterized by fever, pain and increased white blood cell count in the lab tests. In hepatitis the AST and ALT levels are significantly elevated. In a mechanical icterus caused by chronic pancreatitis and biliary tract stones, there are no accompanying complications, like impaired kidney function, increased blood glucose levels. The pain present in the back or under the right ribcage. Of the laboratory tests, tumor marker tests might help establishing the diagnosis if a malignant origin is suspected. In the case of diabetes mellitus, the glucose tolerance test is no longer required if the serum glucose level is already elevated. However, to assess the current state of the carbohydrate metabolism and to set up the treatment regimen and dosage (oral antidiabetics, insulin), the blood glucose profile has to be established, and the hemoglobin A1C, glucose acetone in the urine fractions and the glucose excretion tests have to be performed. As a widely available, inexpensive, non-invasive examination abdominal ultrasound is the first choice of imaging options although - regarding the pancreas -, it’s mostly useful only in the detection of malignant masses. In the diagnosis of pancreatic cancers, CT and ERCP are the other main imaging options. With CT scan the extent and relation of the mass to the surrounding organs can be precisely determined. With ERCP, by directly injecting contrast material into the Wirsungian and/or common bile duct, the investigator can obtain precise information regarding the nature of the obstruction. By combining these two examinations the efficacy of the diagnostic procedure is significantly improved. Another advantage of ERCP is that it can be used to insert a biliary endoprosthesis, which can relieve the icterus in the case of malignant obstruction. (The blurry image of scintigraphy cannot help the diagnosis significantly, while i.v. cholecystography may provide information on gall bladder filling, but this does not bring you closer to clarifying the present case.) If the biliary tract is occluded by stones, the icterus usually develops rapidly and thus the bile ducts do not have time to get homogenously dilated. In distal common bile duct cancers and in chronic pancreatitis the outline of the biliary tract is also inhomogenous and the narrowing usually affects a long segment. In chronic calcifying pancreatitis, the pancreas is diffusely echogenic, showing the calcification in the parenchyma and/or the stones within the pancreatic ducts. In the case of an acute exacerbation, the entire pancreas is enlarged, its structure becomes inhomogenous, and is often surrounded by fluid accumulation. A tumor of the papilla of Vater - if detected in these studies -, is primarily localized within the lumen of the duodenum. In diseases in the papilla of Vater the obstruction is right at the end of the Wirsungian or common bile duct, and not after a relatively long normal section. Only a histological/cytological report can give a definitive preoperative diagnosis. In the case of fine-needle biopsy, only a positive finding can be accepted due to the large false negative rate associated with this modality. If biopsy is negative but the imaging studies raise the suspicion for malignancy, surgical exploration and intraoperative biopsy can be considered. Antibiotic treatment is not required, since it will not affect the morphologic alterations found in chronic pancreatitis. Even if repeated biopsies are negative, it cannot be accepted as a definitive diagnosis, the same way as with a negative cytology result. Pancreatic tumors are only sensitive to high doses of radiation. During extracorporeal irradiation, the radiation sensitivity of the intestines surrounding the target organ is significantly lower. Pancreatic cancer cells are only moderately sensitive to cytostatic agents. If the lesion cannot be surgically removed, no real cure/improvement can be expected from cytostatic treatment. If the patient needs some sort of palliative intervention, endoscopic or surgical internal biliary bypass (endoprothesis, choledocho-duodenostomy, choledocho-jejunostomy) should be chosen, rather than percutaneous drainage, which makes the patient lose a lot of bile.

Answer 122

A

ANSWER
B) Answer 2 and 3 are correct

EXPLANATION
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice. Accelerated erythrocyte sedimentation rate, moderate anemia, poor kidney function, and elevated blood glucose levels in a previously asymptomatic patients can be signs of a malignant disease in the background. Septic cholangitis is characterized by fever, pain and increased white blood cell count in the lab tests. In hepatitis the AST and ALT levels are significantly elevated. In a mechanical icterus caused by chronic pancreatitis and biliary tract stones, there are no accompanying complications, like impaired kidney function, increased blood glucose levels. The pain present in the back or under the right ribcage. Of the laboratory tests, tumor marker tests might help establishing the diagnosis if a malignant origin is suspected. In the case of diabetes mellitus, the glucose tolerance test is no longer required if the serum glucose level is already elevated. However, to assess the current state of the carbohydrate metabolism and to set up the treatment regimen and dosage (oral antidiabetics, insulin), the blood glucose profile has to be established, and the hemoglobin A1C, glucose acetone in the urine fractions and the glucose excretion tests have to be performed. As a widely available, inexpensive, non-invasive examination abdominal ultrasound is the first choice of imaging options although - regarding the pancreas -, it’s mostly useful only in the detection of malignant masses. In the diagnosis of pancreatic cancers, CT and ERCP are the other main imaging options. With CT scan the extent and relation of the mass to the surrounding organs can be precisely determined. With ERCP, by directly injecting contrast material into the Wirsungian and/or common bile duct, the investigator can obtain precise information regarding the nature of the obstruction. By combining these two examinations the efficacy of the diagnostic procedure is significantly improved. Another advantage of ERCP is that it can be used to insert a biliary endoprosthesis, which can relieve the icterus in the case of malignant obstruction. (The blurry image of scintigraphy cannot help the diagnosis significantly, while i.v. cholecystography may provide information on gall bladder filling, but this does not bring you closer to clarifying the present case.) If the biliary tract is occluded by stones, the icterus usually develops rapidly and thus the bile ducts do not have time to get homogenously dilated. In distal common bile duct cancers and in chronic pancreatitis the outline of the biliary tract is also inhomogenous and the narrowing usually affects a long segment. In chronic calcifying pancreatitis, the pancreas is diffusely echogenic, showing the calcification in the parenchyma and/or the stones within the pancreatic ducts. In the case of an acute exacerbation, the entire pancreas is enlarged, its structure becomes inhomogenous, and is often surrounded by fluid accumulation. A tumor of the papilla of Vater - if detected in these studies -, is primarily localized within the lumen of the duodenum. In diseases in the papilla of Vater the obstruction is right at the end of the Wirsungian or common bile duct, and not after a relatively long normal section. Only a histological/cytological report can give a definitive preoperative diagnosis. In the case of fine-needle biopsy, only a positive finding can be accepted due to the large false negative rate associated with this modality. If biopsy is negative but the imaging studies raise the suspicion for malignancy, surgical exploration and intraoperative biopsy can be considered. Antibiotic treatment is not required, since it will not affect the morphologic alterations found in chronic pancreatitis. Even if repeated biopsies are negative, it cannot be accepted as a definitive diagnosis, the same way as with a negative cytology result. Pancreatic tumors are only sensitive to high doses of radiation. During extracorporeal irradiation, the radiation sensitivity of the intestines surrounding the target organ is significantly lower. Pancreatic cancer cells are only moderately sensitive to cytostatic agents. If the lesion cannot be surgically removed, no real cure/improvement can be expected from cytostatic treatment. If the patient needs some sort of palliative intervention, endoscopic or surgical internal biliary bypass (endoprothesis, choledocho-duodenostomy, choledocho-jejunostomy) should be chosen, rather than percutaneous drainage, which makes the patient lose a lot of bile.

Answer 123

A

ANSWER
D) pancreas cancer

EXPLANATION
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice. Accelerated erythrocyte sedimentation rate, moderate anemia, poor kidney function, and elevated blood glucose levels in a previously asymptomatic patients can be signs of a malignant disease in the background. Septic cholangitis is characterized by fever, pain and increased white blood cell count in the lab tests. In hepatitis the AST and ALT levels are significantly elevated. In a mechanical icterus caused by chronic pancreatitis and biliary tract stones, there are no accompanying complications, like impaired kidney function, increased blood glucose levels. The pain present in the back or under the right ribcage. Of the laboratory tests, tumor marker tests might help establishing the diagnosis if a malignant origin is suspected. In the case of diabetes mellitus, the glucose tolerance test is no longer required if the serum glucose level is already elevated. However, to assess the current state of the carbohydrate metabolism and to set up the treatment regimen and dosage (oral antidiabetics, insulin), the blood glucose profile has to be established, and the hemoglobin A1C, glucose acetone in the urine fractions and the glucose excretion tests have to be performed. As a widely available, inexpensive, non-invasive examination abdominal ultrasound is the first choice of imaging options although - regarding the pancreas -, it’s mostly useful only in the detection of malignant masses. In the diagnosis of pancreatic cancers, CT and ERCP are the other main imaging options. With CT scan the extent and relation of the mass to the surrounding organs can be precisely determined. With ERCP, by directly injecting contrast material into the Wirsungian and/or common bile duct, the investigator can obtain precise information regarding the nature of the obstruction. By combining these two examinations the efficacy of the diagnostic procedure is significantly improved. Another advantage of ERCP is that it can be used to insert a biliary endoprosthesis, which can relieve the icterus in the case of malignant obstruction. (The blurry image of scintigraphy cannot help the diagnosis significantly, while i.v. cholecystography may provide information on gall bladder filling, but this does not bring you closer to clarifying the present case.) If the biliary tract is occluded by stones, the icterus usually develops rapidly and thus the bile ducts do not have time to get homogenously dilated. In distal common bile duct cancers and in chronic pancreatitis the outline of the biliary tract is also inhomogenous and the narrowing usually affects a long segment. In chronic calcifying pancreatitis, the pancreas is diffusely echogenic, showing the calcification in the parenchyma and/or the stones within the pancreatic ducts. In the case of an acute exacerbation, the entire pancreas is enlarged, its structure becomes inhomogenous, and is often surrounded by fluid accumulation. A tumor of the papilla of Vater - if detected in these studies -, is primarily localized within the lumen of the duodenum. In diseases in the papilla of Vater the obstruction is right at the end of the Wirsungian or common bile duct, and not after a relatively long normal section. Only a histological/cytological report can give a definitive preoperative diagnosis. In the case of fine-needle biopsy, only a positive finding can be accepted due to the large false negative rate associated with this modality. If biopsy is negative but the imaging studies raise the suspicion for malignancy, surgical exploration and intraoperative biopsy can be considered. Antibiotic treatment is not required, since it will not affect the morphologic alterations found in chronic pancreatitis. Even if repeated biopsies are negative, it cannot be accepted as a definitive diagnosis, the same way as with a negative cytology result. Pancreatic tumors are only sensitive to high doses of radiation. During extracorporeal irradiation, the radiation sensitivity of the intestines surrounding the target organ is significantly lower. Pancreatic cancer cells are only moderately sensitive to cytostatic agents. If the lesion cannot be surgically removed, no real cure/improvement can be expected from cytostatic treatment. If the patient needs some sort of palliative intervention, endoscopic or surgical internal biliary bypass (endoprothesis, choledocho-duodenostomy, choledocho-jejunostomy) should be chosen, rather than percutaneous drainage, which makes the patient lose a lot of bile.

Answer 124

A

ANSWER
C) pancreatic tumor

EXPLANATION
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice. Accelerated erythrocyte sedimentation rate, moderate anemia, poor kidney function, and elevated blood glucose levels in a previously asymptomatic patients can be signs of a malignant disease in the background. Septic cholangitis is characterized by fever, pain and increased white blood cell count in the lab tests. In hepatitis the AST and ALT levels are significantly elevated. In a mechanical icterus caused by chronic pancreatitis and biliary tract stones, there are no accompanying complications, like impaired kidney function, increased blood glucose levels. The pain present in the back or under the right ribcage. Of the laboratory tests, tumor marker tests might help establishing the diagnosis if a malignant origin is suspected. In the case of diabetes mellitus, the glucose tolerance test is no longer required if the serum glucose level is already elevated. However, to assess the current state of the carbohydrate metabolism and to set up the treatment regimen and dosage (oral antidiabetics, insulin), the blood glucose profile has to be established, and the hemoglobin A1C, glucose acetone in the urine fractions and the glucose excretion tests have to be performed. As a widely available, inexpensive, non-invasive examination abdominal ultrasound is the first choice of imaging options although - regarding the pancreas -, it’s mostly useful only in the detection of malignant masses. In the diagnosis of pancreatic cancers, CT and ERCP are the other main imaging options. With CT scan the extent and relation of the mass to the surrounding organs can be precisely determined. With ERCP, by directly injecting contrast material into the Wirsungian and/or common bile duct, the investigator can obtain precise information regarding the nature of the obstruction. By combining these two examinations the efficacy of the diagnostic procedure is significantly improved. Another advantage of ERCP is that it can be used to insert a biliary endoprosthesis, which can relieve the icterus in the case of malignant obstruction. (The blurry image of scintigraphy cannot help the diagnosis significantly, while i.v. cholecystography may provide information on gall bladder filling, but this does not bring you closer to clarifying the present case.) If the biliary tract is occluded by stones, the icterus usually develops rapidly and thus the bile ducts do not have time to get homogenously dilated. In distal common bile duct cancers and in chronic pancreatitis the outline of the biliary tract is also inhomogenous and the narrowing usually affects a long segment. In chronic calcifying pancreatitis, the pancreas is diffusely echogenic, showing the calcification in the parenchyma and/or the stones within the pancreatic ducts. In the case of an acute exacerbation, the entire pancreas is enlarged, its structure becomes inhomogenous, and is often surrounded by fluid accumulation. A tumor of the papilla of Vater - if detected in these studies -, is primarily localized within the lumen of the duodenum. In diseases in the papilla of Vater the obstruction is right at the end of the Wirsungian or common bile duct, and not after a relatively long normal section. Only a histological/cytological report can give a definitive preoperative diagnosis. In the case of fine-needle biopsy, only a positive finding can be accepted due to the large false negative rate associated with this modality. If biopsy is negative but the imaging studies raise the suspicion for malignancy, surgical exploration and intraoperative biopsy can be considered. Antibiotic treatment is not required, since it will not affect the morphologic alterations found in chronic pancreatitis. Even if repeated biopsies are negative, it cannot be accepted as a definitive diagnosis, the same way as with a negative cytology result. Pancreatic tumors are only sensitive to high doses of radiation. During extracorporeal irradiation, the radiation sensitivity of the intestines surrounding the target organ is significantly lower. Pancreatic cancer cells are only moderately sensitive to cytostatic agents. If the lesion cannot be surgically removed, no real cure/improvement can be expected from cytostatic treatment. If the patient needs some sort of palliative intervention, endoscopic or surgical internal biliary bypass (endoprothesis, choledocho-duodenostomy, choledocho-jejunostomy) should be chosen, rather than percutaneous drainage, which makes the patient lose a lot of bile.

Answer 125

A

ANSWER
A) pancreas tumor

EXPLANATION
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice. Accelerated erythrocyte sedimentation rate, moderate anemia, poor kidney function, and elevated blood glucose levels in a previously asymptomatic patients can be signs of a malignant disease in the background. Septic cholangitis is characterized by fever, pain and increased white blood cell count in the lab tests. In hepatitis the AST and ALT levels are significantly elevated. In a mechanical icterus caused by chronic pancreatitis and biliary tract stones, there are no accompanying complications, like impaired kidney function, increased blood glucose levels. The pain present in the back or under the right ribcage. Of the laboratory tests, tumor marker tests might help establishing the diagnosis if a malignant origin is suspected. In the case of diabetes mellitus, the glucose tolerance test is no longer required if the serum glucose level is already elevated. However, to assess the current state of the carbohydrate metabolism and to set up the treatment regimen and dosage (oral antidiabetics, insulin), the blood glucose profile has to be established, and the hemoglobin A1C, glucose acetone in the urine fractions and the glucose excretion tests have to be performed. As a widely available, inexpensive, non-invasive examination abdominal ultrasound is the first choice of imaging options although - regarding the pancreas -, it’s mostly useful only in the detection of malignant masses. In the diagnosis of pancreatic cancers, CT and ERCP are the other main imaging options. With CT scan the extent and relation of the mass to the surrounding organs can be precisely determined. With ERCP, by directly injecting contrast material into the Wirsungian and/or common bile duct, the investigator can obtain precise information regarding the nature of the obstruction. By combining these two examinations the efficacy of the diagnostic procedure is significantly improved. Another advantage of ERCP is that it can be used to insert a biliary endoprosthesis, which can relieve the icterus in the case of malignant obstruction. (The blurry image of scintigraphy cannot help the diagnosis significantly, while i.v. cholecystography may provide information on gall bladder filling, but this does not bring you closer to clarifying the present case.) If the biliary tract is occluded by stones, the icterus usually develops rapidly and thus the bile ducts do not have time to get homogenously dilated. In distal common bile duct cancers and in chronic pancreatitis the outline of the biliary tract is also inhomogenous and the narrowing usually affects a long segment. In chronic calcifying pancreatitis, the pancreas is diffusely echogenic, showing the calcification in the parenchyma and/or the stones within the pancreatic ducts. In the case of an acute exacerbation, the entire pancreas is enlarged, its structure becomes inhomogenous, and is often surrounded by fluid accumulation. A tumor of the papilla of Vater - if detected in these studies -, is primarily localized within the lumen of the duodenum. In diseases in the papilla of Vater the obstruction is right at the end of the Wirsungian or common bile duct, and not after a relatively long normal section. Only a histological/cytological report can give a definitive preoperative diagnosis. In the case of fine-needle biopsy, only a positive finding can be accepted due to the large false negative rate associated with this modality. If biopsy is negative but the imaging studies raise the suspicion for malignancy, surgical exploration and intraoperative biopsy can be considered. Antibiotic treatment is not required, since it will not affect the morphologic alterations found in chronic pancreatitis. Even if repeated biopsies are negative, it cannot be accepted as a definitive diagnosis, the same way as with a negative cytology result. Pancreatic tumors are only sensitive to high doses of radiation. During extracorporeal irradiation, the radiation sensitivity of the intestines surrounding the target organ is significantly lower. Pancreatic cancer cells are only moderately sensitive to cytostatic agents. If the lesion cannot be surgically removed, no real cure/improvement can be expected from cytostatic treatment. If the patient needs some sort of palliative intervention, endoscopic or surgical internal biliary bypass (endoprothesis, choledocho-duodenostomy, choledocho-jejunostomy) should be chosen, rather than percutaneous drainage, which makes the patient lose a lot of bile

Answer 126

A

ANSWER
A) FNAB with positive result for cancer

EXPLANATION
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice. Accelerated erythrocyte sedimentation rate, moderate anemia, poor kidney function, and elevated blood glucose levels in a previously asymptomatic patients can be signs of a malignant disease in the background. Septic cholangitis is characterized by fever, pain and increased white blood cell count in the lab tests. In hepatitis the AST and ALT levels are significantly elevated. In a mechanical icterus caused by chronic pancreatitis and biliary tract stones, there are no accompanying complications, like impaired kidney function, increased blood glucose levels. The pain present in the back or under the right ribcage. Of the laboratory tests, tumor marker tests might help establishing the diagnosis if a malignant origin is suspected. In the case of diabetes mellitus, the glucose tolerance test is no longer required if the serum glucose level is already elevated. However, to assess the current state of the carbohydrate metabolism and to set up the treatment regimen and dosage (oral antidiabetics, insulin), the blood glucose profile has to be established, and the hemoglobin A1C, glucose acetone in the urine fractions and the glucose excretion tests have to be performed. As a widely available, inexpensive, non-invasive examination abdominal ultrasound is the first choice of imaging options although - regarding the pancreas -, it’s mostly useful only in the detection of malignant masses. In the diagnosis of pancreatic cancers, CT and ERCP are the other main imaging options. With CT scan the extent and relation of the mass to the surrounding organs can be precisely determined. With ERCP, by directly injecting contrast material into the Wirsungian and/or common bile duct, the investigator can obtain precise information regarding the nature of the obstruction. By combining these two examinations the efficacy of the diagnostic procedure is significantly improved. Another advantage of ERCP is that it can be used to insert a biliary endoprosthesis, which can relieve the icterus in the case of malignant obstruction. (The blurry image of scintigraphy cannot help the diagnosis significantly, while i.v. cholecystography may provide information on gall bladder filling, but this does not bring you closer to clarifying the present case.) If the biliary tract is occluded by stones, the icterus usually develops rapidly and thus the bile ducts do not have time to get homogenously dilated. In distal common bile duct cancers and in chronic pancreatitis the outline of the biliary tract is also inhomogenous and the narrowing usually affects a long segment. In chronic calcifying pancreatitis, the pancreas is diffusely echogenic, showing the calcification in the parenchyma and/or the stones within the pancreatic ducts. In the case of an acute exacerbation, the entire pancreas is enlarged, its structure becomes inhomogenous, and is often surrounded by fluid accumulation. A tumor of the papilla of Vater - if detected in these studies -, is primarily localized within the lumen of the duodenum. In diseases in the papilla of Vater the obstruction is right at the end of the Wirsungian or common bile duct, and not after a relatively long normal section. Only a histological/cytological report can give a definitive preoperative diagnosis. In the case of fine-needle biopsy, only a positive finding can be accepted due to the large false negative rate associated with this modality. If biopsy is negative but the imaging studies raise the suspicion for malignancy, surgical exploration and intraoperative biopsy can be considered. Antibiotic treatment is not required, since it will not affect the morphologic alterations found in chronic pancreatitis. Even if repeated biopsies are negative, it cannot be accepted as a definitive diagnosis, the same way as with a negative cytology result. Pancreatic tumors are only sensitive to high doses of radiation. During extracorporeal irradiation, the radiation sensitivity of the intestines surrounding the target organ is significantly lower. Pancreatic cancer cells are only moderately sensitive to cytostatic agents. If the lesion cannot be surgically removed, no real cure/improvement can be expected from cytostatic treatment. If the patient needs some sort of palliative intervention, endoscopic or surgical internal biliary bypass (endoprothesis, choledocho-duodenostomy, choledocho-jejunostomy) should be chosen, rather than percutaneous drainage, which makes the patient lose a lot of bile.

Answer 127

A

ANSWER
A) consider surgical exploration due to a suspected cancer

EXPLANATION
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice. Accelerated erythrocyte sedimentation rate, moderate anemia, poor kidney function, and elevated blood glucose levels in a previously asymptomatic patients can be signs of a malignant disease in the background. Septic cholangitis is characterized by fever, pain and increased white blood cell count in the lab tests. In hepatitis the AST and ALT levels are significantly elevated. In a mechanical icterus caused by chronic pancreatitis and biliary tract stones, there are no accompanying complications, like impaired kidney function, increased blood glucose levels. The pain present in the back or under the right ribcage. Of the laboratory tests, tumor marker tests might help establishing the diagnosis if a malignant origin is suspected. In the case of diabetes mellitus, the glucose tolerance test is no longer required if the serum glucose level is already elevated. However, to assess the current state of the carbohydrate metabolism and to set up the treatment regimen and dosage (oral antidiabetics, insulin), the blood glucose profile has to be established, and the hemoglobin A1C, glucose acetone in the urine fractions and the glucose excretion tests have to be performed. As a widely available, inexpensive, non-invasive examination abdominal ultrasound is the first choice of imaging options although - regarding the pancreas -, it’s mostly useful only in the detection of malignant masses. In the diagnosis of pancreatic cancers, CT and ERCP are the other main imaging options. With CT scan the extent and relation of the mass to the surrounding organs can be precisely determined. With ERCP, by directly injecting contrast material into the Wirsungian and/or common bile duct, the investigator can obtain precise information regarding the nature of the obstruction. By combining these two examinations the efficacy of the diagnostic procedure is significantly improved. Another advantage of ERCP is that it can be used to insert a biliary endoprosthesis, which can relieve the icterus in the case of malignant obstruction. (The blurry image of scintigraphy cannot help the diagnosis significantly, while i.v. cholecystography may provide information on gall bladder filling, but this does not bring you closer to clarifying the present case.) If the biliary tract is occluded by stones, the icterus usually develops rapidly and thus the bile ducts do not have time to get homogenously dilated. In distal common bile duct cancers and in chronic pancreatitis the outline of the biliary tract is also inhomogenous and the narrowing usually affects a long segment. In chronic calcifying pancreatitis, the pancreas is diffusely echogenic, showing the calcification in the parenchyma and/or the stones within the pancreatic ducts. In the case of an acute exacerbation, the entire pancreas is enlarged, its structure becomes inhomogenous, and is often surrounded by fluid accumulation. A tumor of the papilla of Vater - if detected in these studies -, is primarily localized within the lumen of the duodenum. In diseases in the papilla of Vater the obstruction is right at the end of the Wirsungian or common bile duct, and not after a relatively long normal section. Only a histological/cytological report can give a definitive preoperative diagnosis. In the case of fine-needle biopsy, only a positive finding can be accepted due to the large false negative rate associated with this modality. If biopsy is negative but the imaging studies raise the suspicion for malignancy, surgical exploration and intraoperative biopsy can be considered. Antibiotic treatment is not required, since it will not affect the morphologic alterations found in chronic pancreatitis. Even if repeated biopsies are negative, it cannot be accepted as a definitive diagnosis, the same way as with a negative cytology result. Pancreatic tumors are only sensitive to high doses of radiation. During extracorporeal irradiation, the radiation sensitivity of the intestines surrounding the target organ is significantly lower. Pancreatic cancer cells are only moderately sensitive to cytostatic agents. If the lesion cannot be surgically removed, no real cure/improvement can be expected from cytostatic treatment. If the patient needs some sort of palliative intervention, endoscopic or surgical internal biliary bypass (endoprothesis, choledocho-duodenostomy, choledocho-jejunostomy) should be chosen, rather than percutaneous drainage, which makes the patient lose a lot of bile

Answer 128

A

ANSWER
C) surgical exploration and the evaluation of tumor resectability

EXPLANATION
In a 63-year-old patient, Crigler-Najjar syndrome is not plausible, since it is a fetal bilirubin metabolism disorder due to the lack of glucuronyl transferase (see also SEB-1.30). A significantly increased conjugated bilirubin level, usually together with increased ALP levels, is characteristic to occlusive jaundice. Accelerated erythrocyte sedimentation rate, moderate anemia, poor kidney function, and elevated blood glucose levels in a previously asymptomatic patients can be signs of a malignant disease in the background. Septic cholangitis is characterized by fever, pain and increased white blood cell count in the lab tests. In hepatitis the AST and ALT levels are significantly elevated. In a mechanical icterus caused by chronic pancreatitis and biliary tract stones, there are no accompanying complications, like impaired kidney function, increased blood glucose levels. The pain present in the back or under the right ribcage. Of the laboratory tests, tumor marker tests might help establishing the diagnosis if a malignant origin is suspected. In the case of diabetes mellitus, the glucose tolerance test is no longer required if the serum glucose level is already elevated. However, to assess the current state of the carbohydrate metabolism and to set up the treatment regimen and dosage (oral antidiabetics, insulin), the blood glucose profile has to be established, and the hemoglobin A1C, glucose acetone in the urine fractions and the glucose excretion tests have to be performed. As a widely available, inexpensive, non-invasive examination abdominal ultrasound is the first choice of imaging options although - regarding the pancreas -, it’s mostly useful only in the detection of malignant masses. In the diagnosis of pancreatic cancers, CT and ERCP are the other main imaging options. With CT scan the extent and relation of the mass to the surrounding organs can be precisely determined. With ERCP, by directly injecting contrast material into the Wirsungian and/or common bile duct, the investigator can obtain precise information regarding the nature of the obstruction. By combining these two examinations the efficacy of the diagnostic procedure is significantly improved. Another advantage of ERCP is that it can be used to insert a biliary endoprosthesis, which can relieve the icterus in the case of malignant obstruction. (The blurry image of scintigraphy cannot help the diagnosis significantly, while i.v. cholecystography may provide information on gall bladder filling, but this does not bring you closer to clarifying the present case.) If the biliary tract is occluded by stones, the icterus usually develops rapidly and thus the bile ducts do not have time to get homogenously dilated. In distal common bile duct cancers and in chronic pancreatitis the outline of the biliary tract is also inhomogenous and the narrowing usually affects a long segment. In chronic calcifying pancreatitis, the pancreas is diffusely echogenic, showing the calcification in the parenchyma and/or the stones within the pancreatic ducts. In the case of an acute exacerbation, the entire pancreas is enlarged, its structure becomes inhomogenous, and is often surrounded by fluid accumulation. A tumor of the papilla of Vater - if detected in these studies -, is primarily localized within the lumen of the duodenum. In diseases in the papilla of Vater the obstruction is right at the end of the Wirsungian or common bile duct, and not after a relatively long normal section. Only a histological/cytological report can give a definitive preoperative diagnosis. In the case of fine-needle biopsy, only a positive finding can be accepted due to the large false negative rate associated with this modality. If biopsy is negative but the imaging studies raise the suspicion for malignancy, surgical exploration and intraoperative biopsy can be considered. Antibiotic treatment is not required, since it will not affect the morphologic alterations found in chronic pancreatitis. Even if repeated biopsies are negative, it cannot be accepted as a definitive diagnosis, the same way as with a negative cytology result. Pancreatic tumors are only sensitive to high doses of radiation. During extracorporeal irradiation, the radiation sensitivity of the intestines surrounding the target organ is significantly lower. Pancreatic cancer cells are only moderately sensitive to cytostatic agents. If the lesion cannot be surgically removed, no real cure/improvement can be expected from cytostatic treatment. If the patient needs some sort of palliative intervention, endoscopic or surgical internal biliary bypass (endoprothesis, choledocho-duodenostomy, choledocho-jejunostomy) should be chosen, rather than percutaneous drainage, which makes the patient lose a lot of bile.

Answer 129

A

ANSWER
A) Answers 1, 2 and 4 are correct

EXPLANATION
Breast ultrasound and mammography are the basic methods of breast cancer screening, however in the recent years, MR has also been widely used as a diagnostic tool to increase the detection rate of multi-focal, nonpalpable breast lesions. Neither PET, nor CT scan is considered a routine radiological examination of breast cancer.

Answer 130

A

ANSWER
B) often gets superinfected

EXPLANATION
Breast cysts are the most common benign breast disorders, their size can reach several centimeters. In previous decades, symptomatic cysts have always been surgically removed. Nowadays pneumocystography is the most accepted diagnostic and therapeutic method. The rate of recurrence after draining the cyst content and the filling the cyst with air is around 10%. Cysts should only be treated surgically if there is an intracystic growth (papilloma) or they recur. Superinfection of the cysts is very rare.

Answer 131

A

ANSWER
C) is a primary tumor prevention method

EXPLANATION
The Breast Cancer Screening Program is the most effective secondary tumor prevention method in the high-risk population. Its main benefit is that any malignant lesions can be recognized at an early or even premalignant state. According to international statistics, breast cancer mortality can be reduced by nearly 20%.

Answer 132

A

ANSWER
B) excision with isotope localization + sentinel lymph node biopsy

EXPLANATION
In non-palpable invasive breast cancers, the purpose of surgical treatment is to remove the lesion according to oncological principles and to assess the axillary lymph node status by sentinel lymph node biopsy. At present, the most suitable method for this is the isotope labelled breast excision, which can be used to remove the primary lesion and the sentinel lymph node at the same time.

Answer 133

A

ANSWER
B) Answers 1, 3, 4 and 5 are correct

EXPLANATION
Based on the case history, this is probably a hyperthyroid goiter with signs of compression. The studies are aimed to clarify the stage of hyperfunction (hormone test), the reason (scintigraphy, ultrasonography) and the signs of compression (esophagus-, trachea compression, dislocation). Hot nodule refers to an autonomous adenoma. The patient should be treated to reach euthyroid status and the adenoma needs to be removed. We need to perform surgery after thyrostatic therapy. Since this is a benign tumor, there is no need for extended resection, enucleation is sufficient (radioiodine treatment is an alternative). The recurrent laryngeal nerve runs and enters the larynx behind the thyroid gland, innervating the vocal cords. In case of thyroid resection, nerve damage is a well-known surgical complication, resulting in unilateral vocal cord paralysis and symptomatic hoarseness.

Answer 134

A

ANSWER
D) thyreostatics and surgery

EXPLANATION
Based on the case history, this is probably a hyperthyroid goiter with signs of compression. The studies are aimed to clarify the stage of hyperfunction (hormone test), the reason (scintigraphy, ultrasonography) and the signs of compression (esophagus-, trachea compression, dislocation). Hot nodule refers to an autonomous adenoma. The patient should be treated to reach euthyroid status and the adenoma needs to be removed. We need to perform surgery after thyrostatic therapy. Since this is a benign tumor, there is no need for extended resection, enucleation is sufficient (radioiodine treatment is an alternative). The recurrent laryngeal nerve runs and enters the larynx behind the thyroid gland, innervating the vocal cords. In case of thyroid resection, nerve damage is a well-known surgical complication, resulting in unilateral vocal cord paralysis and symptomatic hoarseness.

Answer 135

A

ANSWER
B) lobectomy on the affected side

EXPLANATION
Based on the case history, this is probably a hyperthyroid goiter with signs of compression. The studies are aimed to clarify the stage of hyperfunction (hormone test), the reason (scintigraphy, ultrasonography) and the signs of compression (esophagus-, trachea compression, dislocation). Hot nodule refers to an autonomous adenoma. The patient should be treated to reach euthyroid status and the adenoma needs to be removed. We need to perform surgery after thyrostatic therapy. Since this is a benign tumor, there is no need for extended resection, enucleation is sufficient (radioiodine treatment is an alternative). The recurrent laryngeal nerve runs and enters the larynx behind the thyroid gland, innervating the vocal cords. In case of thyroid resection, nerve damage is a well-known surgical complication, resulting in unilateral vocal cord paralysis and symptomatic hoarseness.

Answer 136

A

ANSWER
B) recurrent nerve lesion.

EXPLANATION
Based on the case history, this is probably a hyperthyroid goiter with signs of compression. The studies are aimed to clarify the stage of hyperfunction (hormone test), the reason (scintigraphy, ultrasonography) and the signs of compression (esophagus-, trachea compression, dislocation). Hot nodule refers to an autonomous adenoma. The patient should be treated to reach euthyroid status and the adenoma needs to be removed. We need to perform surgery after thyrostatic therapy. Since this is a benign tumor, there is no need for extended resection, enucleation is sufficient (radioiodine treatment is an alternative). The recurrent laryngeal nerve runs and enters the larynx behind the thyroid gland, innervating the vocal cords. In case of thyroid resection, nerve damage is a well-known surgical complication, resulting in unilateral vocal cord paralysis and symptomatic hoarseness.

Answer 137

A

ANSWER
E) All of the answers are correct

EXPLANATION
Based on the symptoms, the patient had postoperative lower limb deep vein thrombosis. 5 to 7 days of bed rest reduces the possibility of a pulmonary embolism. Elevating the limb reduces venous pressure. Wearing elastic bandage or compression stockings reduces venous pressure and helps to fix any floating thrombus. Anticoagulation in the first days with heparin followed by a few days of combination of heparin and Warfarin treatment prevents the progression of thrombosis. After adjusting the therapeutic dose of Warfarin, heparin can be omitted (see also SEB-1.3). Chronic anticoagulation therapy is continued for months, and its termination is always considered individually. Fibrinolysis may also be applied in case of a proper indication (in this case, because of the previous surgery, only after the 10th postoperative day). The patient had acute deep vein thrombosis 5 years ago with symptoms such as swelling of the limb, pain – worsened by physical activity or coughing -, tight, shiny, pale skin, subfertility, tachycardia, and general distress. Symptoms of post-thrombotic syndrome include progressive edema, indurations, thickening of the subcutaneous tissue, development of secondary varicosity, crural ulcers due to impaired localized tissue nutrition, brownish pigmentation caused by hemosiderin deposition, eczema, and dermatosis. Crossectomy, stripping, and resection of the enlarged lateral branches are used to treat secondary varicosity. The ligation of the insufficient perforator veins is performed either by conventional surgery (according to Linton) after the longitudinal incision of the fascia or, more recently, by subfascial endoscopy.

Answer 138

A

ANSWER
C) acute deep vein thrombosis

EXPLANATION
Based on the symptoms, the patient had postoperative lower limb deep vein thrombosis. 5 to 7 days of bed rest reduces the possibility of a pulmonary embolism. Elevating the limb reduces venous pressure. Wearing elastic bandage or compression stockings reduces venous pressure and helps to fix any floating thrombus. Anticoagulation in the first days with heparin followed by a few days of combination of heparin and Warfarin treatment prevents the progression of thrombosis. After adjusting the therapeutic dose of Warfarin, heparin can be omitted (see also SEB-1.3). Chronic anticoagulation therapy is continued for months, and its termination is always considered individually. Fibrinolysis may also be applied in case of a proper indication (in this case, because of the previous surgery, only after the 10th postoperative day). The patient had acute deep vein thrombosis 5 years ago with symptoms such as swelling of the limb, pain – worsened by physical activity or coughing -, tight, shiny, pale skin, subfertility, tachycardia, and general distress. Symptoms of post-thrombotic syndrome include progressive edema, indurations, thickening of the subcutaneous tissue, development of secondary varicosity, crural ulcers due to impaired localized tissue nutrition, brownish pigmentation caused by hemosiderin deposition, eczema, and dermatosis. Crossectomy, stripping, and resection of the enlarged lateral branches are used to treat secondary varicosity. The ligation of the insufficient perforator veins is performed either by conventional surgery (according to Linton) after the longitudinal incision of the fascia or, more recently, by subfascial endoscopy.

Answer 139

A

ANSWER
D) post-thrombotic Syndrome

EXPLANATION
Based on the symptoms, the patient had postoperative lower limb deep vein thrombosis. 5 to 7 days of bed rest reduces the possibility of a pulmonary embolism. Elevating the limb reduces venous pressure. Wearing elastic bandage or compression stockings reduces venous pressure and helps to fix any floating thrombus. Anticoagulation in the first days with heparin followed by a few days of combination of heparin and Warfarin treatment prevents the progression of thrombosis. After adjusting the therapeutic dose of Warfarin, heparin can be omitted (see also SEB-1.3). Chronic anticoagulation therapy is continued for months, and its termination is always considered individually. Fibrinolysis may also be applied in case of a proper indication (in this case, because of the previous surgery, only after the 10th postoperative day). The patient had acute deep vein thrombosis 5 years ago with symptoms such as swelling of the limb, pain – worsened by physical activity or coughing -, tight, shiny, pale skin, subfertility, tachycardia, and general distress. Symptoms of post-thrombotic syndrome include progressive edema, indurations, thickening of the subcutaneous tissue, development of secondary varicosity, crural ulcers due to impaired localized tissue nutrition, brownish pigmentation caused by hemosiderin deposition, eczema, and dermatosis. Crossectomy, stripping, and resection of the enlarged lateral branches are used to treat secondary varicosity. The ligation of the insufficient perforator veins is performed either by conventional surgery (according to Linton) after the longitudinal incision of the fascia or, more recently, by subfascial endoscopy.

Answer 140

A

ANSWER
D) crossectomy, stripping, subfascial ligature of perforator veins

EXPLANATION
Based on the symptoms, the patient had postoperative lower limb deep vein thrombosis. 5 to 7 days of bed rest reduces the possibility of a pulmonary embolism. Elevating the limb reduces venous pressure. Wearing elastic bandage or compression stockings reduces venous pressure and helps to fix any floating thrombus. Anticoagulation in the first days with heparin followed by a few days of combination of heparin and Warfarin treatment prevents the progression of thrombosis. After adjusting the therapeutic dose of Warfarin, heparin can be omitted (see also SEB-1.3). Chronic anticoagulation therapy is continued for months, and its termination is always considered individually. Fibrinolysis may also be applied in case of a proper indication (in this case, because of the previous surgery, only after the 10th postoperative day). The patient had acute deep vein thrombosis 5 years ago with symptoms such as swelling of the limb, pain – worsened by physical activity or coughing -, tight, shiny, pale skin, subfertility, tachycardia, and general distress. Symptoms of post-thrombotic syndrome include progressive edema, indurations, thickening of the subcutaneous tissue, development of secondary varicosity, crural ulcers due to impaired localized tissue nutrition, brownish pigmentation caused by hemosiderin deposition, eczema, and dermatosis. Crossectomy, stripping, and resection of the enlarged lateral branches are used to treat secondary varicosity. The ligation of the insufficient perforator veins is performed either by conventional surgery (according to Linton) after the longitudinal incision of the fascia or, more recently, by subfascial endoscopy.

Answer 141

A

ANSWER
A) Answers 1, 2 and 4 are correct

EXPLANATION
In icterus the basic diagnostic modalities are the ultrasound and the lab tests for their cheapness and availability, and ERCP for its high sensitivity. The investigations should be performed in the following order: ultrasound, lab tests, ERCP. If colicky pain develops before jaundice than the most probable diagnosis is choledocholithiasis. With ERCP and then a relatively urgent laparoscopic cholecystectomy both choledocholithiasis and cholelithiasis can be treated effectively and with the least invasiveness. As a consequence of biliary tract stones and mechanical icterus, cholangitis, sepsis, secondary metabolic disorders and hepatic failure can develop. Mechanical ileus is not caused by choledocholithiasis - apart from the extremely rare cases of gallstone ileus. If symptoms of bowel obstruction develop, it may be more likely paralytic ileus associated to any of the abovementioned complications.

Answer 142

A

ANSWER
D) cholelithiasis and choledocholithiasis

EXPLANATION
In icterus the basic diagnostic modalities are the ultrasound and the lab tests for their cheapness and availability, and ERCP for its high sensitivity. The investigations should be performed in the following order: ultrasound, lab tests, ERCP. If colicky pain develops before jaundice than the most probable diagnosis is choledocholithiasis. With ERCP and then a relatively urgent laparoscopic cholecystectomy both choledocholithiasis and cholelithiasis can be treated effectively and with the least invasiveness. As a consequence of biliary tract stones and mechanical icterus, cholangitis, sepsis, secondary metabolic disorders and hepatic failure can develop. Mechanical ileus is not caused by choledocholithiasis - apart from the extremely rare cases of gallstone ileus. If symptoms of bowel obstruction develop, it may be more likely paralytic ileus associated to any of the abovementioned complications.

Answer 143

A

ANSWER
E) ERCP, stone extraction and laparoscopic cholecystectomy performed next day

EXPLANATION
In icterus the basic diagnostic modalities are the ultrasound and the lab tests for their cheapness and availability, and ERCP for its high sensitivity. The investigations should be performed in the following order: ultrasound, lab tests, ERCP. If colicky pain develops before jaundice than the most probable diagnosis is choledocholithiasis. With ERCP and then a relatively urgent laparoscopic cholecystectomy both choledocholithiasis and cholelithiasis can be treated effectively and with the least invasiveness. As a consequence of biliary tract stones and mechanical icterus, cholangitis, sepsis, secondary metabolic disorders and hepatic failure can develop. Mechanical ileus is not caused by choledocholithiasis - apart from the extremely rare cases of gallstone ileus. If symptoms of bowel obstruction develop, it may be more likely paralytic ileus associated to any of the abovementioned complications.

Answer 144

A

ANSWER
D) urgent gastroscopy

Answer 145

A

ANSWER
A) rectoscopy or colonoscopy

EXPLANATION
The source of melena causing anemia - because it is digested blood - can be usually found in the upper gastrointestinal tract. This is also supported by the patient’s history. Therefore, the first investigation should be urgent gastroscopy, and other diagnostic modalities should come only if endoscopy turns out to be negative. The next step is to confirm or rule out if the bleeding source was in the large bowels. Angiography can be useful in the diagnosis of rare, small bowel or endoscopically undetectable bleeding sources. During the endoscopic management of bleeding peptic ulcers, urgent hemostatic methods (sclerotherapy and/or clipping) should be tried first to minimize the blood loss. If, however, despite every endoscopic effort re-bleeding occurs, immediate surgery becomes necessary. Therefore, such cases should be observed and treated in a surgical ward or more so in a surgical intensive care unit.

Answer 146

A

ANSWER
C) Answers 1 and 3 are correct

EXPLANATION
The source of melena causing anemia - because it is digested blood - can be usually found in the upper gastrointestinal tract. This is also supported by the patient’s history. Therefore, the first investigation should be urgent gastroscopy, and other diagnostic modalities should come only if endoscopy turns out to be negative. The next step is to confirm or rule out if the bleeding source was in the large bowels. Angiography can be useful in the diagnosis of rare, small bowel or endoscopically undetectable bleeding sources. During the endoscopic management of bleeding peptic ulcers, urgent hemostatic methods (sclerotherapy and/or clipping) should be tried first to minimize the blood loss. If, however, despite every endoscopic effort re-bleeding occurs, immediate surgery becomes necessary. Therefore, such cases should be observed and treated in a surgical ward or more so in a surgical intensive care unit.

Answer 147

A

ANSWER
D) urgent surgery

EXPLANATION
The source of melena causing anemia - because it is digested blood - can be usually found in the upper gastrointestinal tract. This is also supported by the patient’s history. Therefore, the first investigation should be urgent gastroscopy, and other diagnostic modalities should come only if endoscopy turns out to be negative. The next step is to confirm or rule out if the bleeding source was in the large bowels. Angiography can be useful in the diagnosis of rare, small bowel or endoscopically undetectable bleeding sources. During the endoscopic management of bleeding peptic ulcers, urgent hemostatic methods (sclerotherapy and/or clipping) should be tried first to minimize the blood loss. If, however, despite every endoscopic effort re-bleeding occurs, immediate surgery becomes necessary. Therefore, such cases should be observed and treated in a surgical ward or more so in a surgical intensive care unit.

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Surgery - General Flashcards

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