Surgery - General Flashcards

Question

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 1

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.

Answer 2

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).

Answer 3

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.

Answer 4

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.

Answer 5

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.

Answer 6

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).

Answer 7

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.

Answer 8

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.

Answer 9

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.).

Answer 10

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.).

Answer 11

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.).

Answer 12

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.

Answer 13

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.).

Answer 14

ANSWER D) only 1st answer is correct

Answer 15

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.

Answer 16

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.).

Answer 17

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.).

Answer 18

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.

Answer 19

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.

Answer 20

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.

Answer 21

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.).

Answer 22

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.

Answer 23

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.

Answer 24

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.

Answer 25

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.

Answer 26

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.

Answer 27

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.

Answer 28

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.

Answer 29

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.).

Answer 30

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.

Answer 31

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.

Answer 32

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).

Answer 33

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.)

Answer 34

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.

Answer 35

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.

Answer 36

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.

Answer 37

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.

Answer 38

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.

Answer 39

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.

Answer 40

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 41

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 42

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 43

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 44

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 45

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 46

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 47

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 48

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 49

ANSWER SUR - 1.95 - stenosing papillitis - B) EST SUR - 1.96 - chronic pancreatitis complicated by long distal part stenosis of the common bile duct - D) modified pancreas head resection SUR - 1.97 - duodenum obstruction caused by irresectable pancreas head cancer - A) GEA SUR - 1.98 - cholestasis complicated by liver abscess - C) EST + biliary stent implantation GEA (gastroenteroanastomosis) endoscopic sphincterotomy (EST),

Answer 50

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 51

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 52

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 53

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 54

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 55

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 56

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 57

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 58

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 59

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 60

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 61

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 62

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 63

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 64

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 65

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 66

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 67

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 68

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 69

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 70

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 71

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 72

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 73

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 74

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 75

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 76

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 77

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 78

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 79

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 80

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 81

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 82

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 83

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 84

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 85

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 86

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 87

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 88

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 89

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 90

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 91

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 92

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 93

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 94

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 95

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 96

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 97

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 98

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 99

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 100

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 101

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 102

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 103

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 104

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 105

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 106

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 107

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 108

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 109

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 110

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 111

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 112

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 113

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 114

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 115

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 116

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 117

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 118

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 119

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 120

ANSWER D) urgent gastroscopy

Answer 121

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 122

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 123

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.