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General Surgery Board Review Samples

Below you will find a sampling of the general surgery and high yield board review questions. Many of the questions include pearls of wisdom and key buzzwords, statistics, and numbers you need for your exam success. Many of the questions are case-style like you would find on the boards, others test rapid recall for key clinical situations, and key buzzwords you just have to know to get through your exam quickly and score your best!

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1. The 27 Year Old Female With Pain in the Iliac Fossa

A twenty seven year old lady presented with pain in right iliac fossa and around umbilicus, associated with nausea, vomiting, constipation, malaise and low grade fever of 12 hours duration. On examination there was tenderness at umbilical region and right iliac fossa at Mcburneyís point. Her periods are normal and there is no history of vaginal discharge. Her routine blood counts showed raised leukocyte count with 78% polymorphs. Urine examination and biochemistry were normal. The vital signs are blood pressure 110/70 mm Hg, temperature 99.5 F, pulse 90 per minute, and respiration 14 per minute. Since x-ray abdomen and ultrasonography revealed nothing, clinical diagnosis of acute appendicitis was kept. Abdomen was explored by Grid-iron incision. Surprisingly appendix was normal so ileum was explored. A diverticular structure about 2 feet from ileo-colic junction was found which was inflamed. What is the right statement about this structure?

|A| It is a congenital anomaly which is found in 10% of population, out of which 2% become symptomatic.
|B| The muscle coat is absent in this structure, since it is a false diverticulum.
|C| Most common complications of this structure is iron deficiency anemia, malabsorption, foreign body impaction and strangulation in a hernia.
|D| Sometimes heterotopic tissue is found in this structure, especially when it is symptomatic. Most commonly it is colonic.
|E| It arises from the antimesenteric border of the ileum resulting from an incomplete obliteration of the yolk stalk.

 

|CORRECT ANSWER| E

|EXPLANATION|
Meckelís diverticulum occurs in approximately 2% of population and is the most common congenital anomaly of the gastrointestinal tract. Meckel's is frequently referred as the "disease of 2's as it occurs in 2% of the population, out of which 2% become symptomatic, sex ratio is  2:1 male to female, and most of the time symptoms will occur before the age of 2 years. Anatomically, it is usually 2 inches in length, found 2 feet from the ileocecal valve, commonly contains 2 types of ectopic tissue, gastric & pancreatic, and has 2 main complications of bleeding & obstruction.

It is due to total or partial persistence of the vitelline duct also called as omphalomesenteric duct or yolk stalk.

Meckelís diverticulum is a true diverticulum made up of all layers of intestinal wall. Heterotopic tissue is found in approximately 50-80% of symptomatic Meckelí diverticula. Gastric mucosa with parietal cell is the most common heterotopic tissue and comprises 80% of cases; pancreas and mucosa of the colonic, duodenal, or jejunal type are encountered with lesser frequency.

The most common clinical problem associated with Meckelís diverticulum is bleeding, which usually presents as melena or bright red blood per rectum. The usual source of the bleeding is a chronic ileal ulcer associated with heterotopic gastric tissue within the diverticulum.

The second most common symptom associated with a Meckelís diverticulum is intestinal obstruction. The cause of this obstruction may be either volvulus of the small bowel around a diverticulum that is attached to the anterior abdominal wall or intussusception.

Finally the next most common complication is diverticulitis. It often presents as the picture of acute appendicitis and failure to establish a prompt diagnosis may lead to perforation of the diverticulum, peritonitis, and death. As a corollary to prompt intervention in patients with Meckelís diverticulitis, when a patient is operated upon for acute appendicitis and the appendix is found to be normal, it is imperative that the distal 90 cm. of terminal be inspected for the presence of a Meckelís diverticulum, which, if present, should be resected.

 The least common complications of Meckelís diverticulum include iron deficiency anemia, malabsorption, foreign body impaction, perforation and incarceration or strangulation of the diverticulum in a hernia (Littreís hernia).

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2. A 33 Year Old Gravid Woman With Severe Lower Abdominal Pain

A pregnant lady came with pain right lower abdomen, nausea, vomiting, anorexia and slight fever of 12 hours duration. The pain started with vague abdominal discomfort, was persistent and continuous but not severe, with occasional mild epigastric cramps. She is discomforted on walking, moving, or coughing. She is 33 years old and this is her second pregnancy. The third trimester of pregnancy has just commenced. On examination there is very well localized tenderness to one finger palpation and guarding just above the right iliac fossa. Vital parameters are normal and investigations show only mild leukocytosis. Urine and other investigations are normal. Which statement is true for this patient?

|A| Treatment of choice for this patient is conservative, as third trimester of pregnancy is a contraindication for surgery.
|B| Prescription of antacids should be considered to rule out acid-peptic disease and she can be reviewed after some hours, even if appendicitis is considered in the differential.
|C| Immediate appendectomy is treatment of choice for this patient, otherwise complications will arise.
|D| Since pain and tenderness are not present at Mcburneyís point, diagnosis of acute appendicitis does not exist.
|E| Acute pyelitis of pregnancy and torsion of an ovarian cyst are more common and acute appendicitis is extremely rare diagnosis in pregnancy.

 

|CORRECT ANSWER| C

|EXPLANATION|
The incidence of appendicitis in during pregnancy parallels that in nonpregnant women of the same age. Appendicitis is the most common extrauterine condition requiring an abdominal operation during pregnancy.  During the first 6 months of pregnancy, symptoms of appendicitis do not differ much from those in the nonpregnant woman. This fact needs emphasis, since the manifestations of appendicitis often are assumed to be markedly different, even during early pregnancy.

Appendectomy should be performed upon suspicion of the presence of appendicitis, just as if the pregnancy is not present. If performed before the appendix ruptures, appendectomy often does not disturb the pregnancy. Furthermore, the effects of a negative laparotomy are sufficiently minor that early operation for acute appendicitis should be carried out whenever the diagnosis is entertained.

During the third trimester, the clinical picture is slightly altered; displacement and lateral rotation of the cecum and appendix by the enlarged uterus leads to localization of pain higher in the abdomen or in the right flank. In addition, appendicitis during the final trimester tends to be more serious, since delay in diagnosis leads to an increased incidence of perforation, and the normal responses within the peritoneal cavity are impaired. The displaced omentum often is unable to reach the area of the inflamed appendix to help contain the infection. In addition, contractions of the nearby uterus serve to impair localization. Rupture is often followed by diffuse peritonitis.

Premature labor occurs in about half of women who develop appendicitis during the third trimester; the prognosis for the infant in cases of uncomplicated appendicitis is directly related to the infantís birth weight. In cases of appendicitis with peritonitis and other septic complications, fetal loss is much higher and is due not only to prematurity but also to the effects of sepsis on the fetus.

Acute pyelitis of pregnancy and torsion of an ovarian cyst, when they occur during pregnancy, can be difficult to distinguish from appendicitis. However confusing differential diagnosis may be, one fact must be kept in mind: the mortality of appendicitis in pregnancy is due to delayed diagnosis and operation. Early appendectomy is the treatment of choice for appendicitis at all stages of pregnancy.


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3. A 69 Year Old Woman With Dysphagia

A 69-year-old, white woman presented to her family physicianís office with a complaint of one and a half years of progressive dysphagia. She has lost about 15 lb weight in this duration. Although she can drink liquids without difficulty, she feels a ďsticky sensationĒ in the middle of his throat when she eats solid food. She also regurgitates food particles for as long as 2-3 days after she has eaten the meal. On physical examination, the patientís vital signs are within normal range. Examination of the oropharynx is normal. She has no neck mass or other abnormality. Examination of the thorax and the abdomen is unremarkable. The antero-posterior and lateral barium-swallow views of the upper esophagus demonstrate a large outpouching at the posterior aspect of the pharyngoesophageal junction that retains barium. What is the correct statement regarding this condition?

|A| This is a congenital condition.
|B| It contains all layers of esophagus.          
|C| It occurs at an area of potential weakness of muscles.
|D| The condition usually occurs in children and adolescents.
|E| This is usually anterior outpouching.

 

|CORRECT ANSWER| C

|EXPLANATION|
It was named by Friedrich Albert von Zenker. A pharyngeal pouch is a pulsion diverticulum of the pharyngeal mucosa through Killian's dehiscence, an area of weakness between the two parts of the inferior pharyngeal constrictor - the thyropharyngeus and the cricopharyngeus - at their posterior margin.

The pouch probably arises as a result of a relative obstruction at the level of the cricopharyngeus. At first, it develops posteriorly but then it protrudes to one side, usually the left. As it enlarges, it displaces the oesophagus laterally.

A pharyngeal pouch arises as a result of increased cricopharyngeal pressure over a long period of time. Spasm or failure of relaxation results in increased pressure during deglutition by contraction of the pharyngeal constrictor muscles at the start of swallowing.

The esophageal mucosa and submucosa herniates posteriorly between the cricopharyngeus muscle and the inferior pharyngeal constrictor muscles; therefore, Zenkerís is a false diverticulum as all the layers of esophagus are not present. True diverticula contain all layers of the intestinal tract wall. False diverticula, also known as pseudodiverticula, occur when herniation of mucosa and submucosa through a defect in the muscular wall occurs. This is an acquired condition.

Most esophageal diverticula occur in middle-aged adults and elderly people, although presentation in infants and children is rarely seen. Zenkerís diverticula typically present in people older than 50 years and especially present during the seventh and eighth decades of life.

|REFERENCES|

1.Dahnet W. Radiology review manual. Philadelphia, PA: Lippincott, Williams and Wilkins; 1999:720.
2. Ellis FH Jr. Pharyngoesophageal (Zenkerís) diverticulum. Adv Surg 1995; 28:171-189.

 

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