Q1 In cholangitis which of the following is not associated with adverse outcome
a) Male sex
b) Advancing Age
c) Liver abscess
d) Renal failure
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Q2. Parenteral nutrition leads to liver failure in 15% of patients. All of the following prevents liver failure except
a) Prevent Sepsis and bacterial overgrowth
b) Give mixed fuels with less than 30% fat
c) Avoid overfeeding
d) Avoid Zinc and Molybedynum
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Q3 Most common site for carcinoid tumor is
a) Duodenum
b) Jejunum
c) Ileum
d) Appendix
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Q4. True about ileostomy output is
a) Sodium excretion is two to three times that of normal stool
b) Contents of ileostomy are alkaline
c) Usually it starts functioning in 24 hours
d) Uric Acid renal calculus formation is more common than cholelithiasis
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Q5. Most common cause of nausea and vomiting in patients with carcinoma head of pancreas is
a) Tumor infiltration of coeliac nerve plexus
b) Direct tumor infiltration of duodenum
c) Tumor infiltration around Superior Mesentary artery
d) External Compression of duodenum

Answers

1. a
Seven indpenedent risk factors that predict mortality in a case of cholangitis are
1. Acute renal failure
2. Liver abscess
3. Female sex
4. Age
5. Cirrhosis
6. High malignant stricture
7. PTC (Percutaneous Transhepatic Cholangiography)
Ref Book- Blumgart 4th edition page 923
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2) d
Parenteral nutrition leading to liver failure is a long term problem in patients undergoing surgery for short bowel syndrome. It can be avoided by giving as large a portion as possible by enteral method, prevent bacterial overgrowth and sepsis. Bacterial overgrowth occurs because of stasis and impaired motility or due to intestinal obstruction. Avoid giving excessive fat, and preventing and treating nutritional deficiencies
Ref Book: Shackelford's Surgery of Alimentary canal
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3. d
Carcinoid tumors are those which are derived from enterochromaffin cells which belong to APUD system.Gastrointestinal carcinoids are distributed via embryologic origins: foregut, midgut, and hindgut. Foregut carcinoids account for approximately 7% of all carcinoids, whereas midgut and hindgut carcinoids represent 62% and 30% of all carcinoids, respectively. Because of the preponderance of APUD cells within the ileum and appendix, the most common sites are the appendix (35%) and small intestine (23%), followed by the rectosigmoid (12%) and colon (6%).
Carcinoid tumors have five histologic patterns: insular, trabecular, glandular, undifferentiated, and mixed


Clinical features of Carcinoid tumor in foregut
Gastric carcinoids arise from enterochromaffin-like cells and are classified into three groups. Type I consists of gastric carcinoids associated with chronic atrophic gastritis type A. This group represents 75% of all gastric carcinoids and is marked by a lack of parietal cells, achlorhydria, and hypergastrinemia. The tumors are often less than 1 cm in diameter, diffusely involve the stomach, and metastasize in 10% of all cases, with an overall 5-year survival rate approaching 100%

Patients with type I gastric carcinoid are often 70 to 80 years of age and female with symptoms of abdominal pain. Carcinoid syndrome is not seen, and these tumors usually follow an indolent course.


Type II gastric carcinoid tumors are associated with Zollinger-Ellison syndrome and familial multiple endocrine neoplasia type I syndrome. Patients in this group, 5% of those with gastric carcinoids, are younger (in their sixth decade of life), exhibit no evidence of carcinoid syndrome, and have a tumor size less than 1.5 cm with an equal gender distribution. Although metastases develop in up to 25%, the clinical course is usually indolent.


(type III) consists of sporadic carcinoid tumors. Patients in this group have larger tumors, and hepatic metastases develop in more than 65%. This group of patients (15% to 25% of those with gastric carcinoids) is associated with the development of an atypical carcinoid syndrome and have a 5-year survival rate near 50%. Indicators of tumor aggressiveness include angiolymphatic invasion, clinicopathologic type, mitotic index, Ki-67 grade, and tumor size.


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4. a


An ileostomy starts to function 48 to 72 hours after construction. A mature ileostomy produces between 400 and 700 mL of effluent per day. This volume remains relatively constant for an individual. The contents are weakly acidic (pH 6.1 to 6.5). Sodium excretion is 60 to 120 mEq/day, which is two to three times higher than in normal feces.
Cholelithiasis occurs in 30% and Renal stones in 10%
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5.a
Nausea and vomiting occurs in upto 50% of patients in carcinoma head of pancreas. Obstructive jaundice in 90%. The most common cause of nausea and vomiting is motility disturbance of stomach and duodenum due to infiltration of coeliac nerve plexus. Rest of the choices are other causes. Small intestine motility disturbcance can occur due to tumor infiltrating the SMA ( Superior Mesentary Artery)
Blumgart: Surgery of the Liver, Biliary Tract and Pancreas, 4th ed.


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