Download Question 1 : SC

Case 1267: Gastrointestinal Surgery MCQs
Authors and Affiliations
Hannah Pham
School of Medicine
University of Adelaide
A/Professor Peter Devitt
Head, Professorial Surgical Unit
Royal Adelaide Hospital
Adelaide, South AustraliaThese multiple choice questions are suitable for those students in their early
clinical years.
Case Overview
Learning Objectives
Students should have a working knowledge of the topics discussed in these MCQs.
Question 1 : SC
Question Information:
An endoscopy is performed in a 40-year-old man with a history of reflux refractory to maximal acidsuppressing therapy. The squamo-columnar junction is at 34 cm (normal 40) with gastric mucosal folds
starting at 38cm. Several biopsies taken between 34 - 38 cm show simple columnar epithelium with low
grade dysplasia.
Question:
Which one of the following is the most likely cause of this man†™s pathology?
Choice 1: Dysplasia Score : 0
Choice Feedback:
Incorrect.
Choice 2: Metaplasia Score : 1
Choice Feedback:
Correct.
Choice 3: Hyperplasia Score : 0
Choice Feedback:
Incorrect.
Choice 4: Hypertrophy Score : 0
Choice Feedback:
Incorrect.
Choice 5: Hypoplasia Score : 0
Choice Feedback:
Incorrect.
Question 2 : SC
Question Information:
An endoscopy is performed in a 40-year-old man with a history of reflux refractory to maximal acidsuppressing therapy. The squamo-columnar junction is at 34 cm (normal 40) with gastric mucosal folds
starting at 38cm. Several biopsies taken between 34 - 38 cm show simple columnar epithelium with low
grade dysplasia.
Question:
Which one of the following is the most appropriate management plan?
Choice 1: Endoscopic mucosal resection Score : 0
Choice Feedback:
Incorrect.
Choice 2: Chemotherapy Score : 0
Choice Feedback:
Incorrect.
Choice 3: Endoscopic surveillance Score : 1
Choice Feedback:
Correct. The presence of low grade dysplasia in a patient with Barrett's oesophagus increases the risk
of malignant change and the patient should be kept under regular endoscopic surveillance.
Choice 4: Radiofrequency ablation Score : 0
Choice Feedback:
Incorrect.
Choice 5: Laparoscopic fundoplication Score : 0
Choice Feedback:
Incorrect.
Question 3 : SC
Question Information:
An endoscopy is performed in a 40-year-old man with a history of reflux refractory to maximal acidsuppressing therapy. The squamo-columnar junction is at 34 cm (normal 40) with gastric mucosal folds
starting at 38cm. Several biopsies taken between 34 - 38 cm show simple columnar epithelium with low
grade dysplasia.
Question:
Which one of the following is this man most at risk of developing?
Choice 1: Squamous cell carcinoma Score : 0
Choice Feedback:
Incorrect.
Choice 2: Gastrointestinal stromal tumour Score : 0
Choice Feedback:
Incorrect.
Choice 3: Undifferentiated carcinoma Score : 0
Choice Feedback:
Incorrect.
Choice 4: Adenocarcinoma Score : 1
Choice Feedback:
Correct.
Choice 5: Small cell carcinoma Score : 0
Choice Feedback:
Incorrect.
Question 4 : SC
Question Information:
An obese 55-year-old man presents to his General Practitioner with dysphagia to solids for the last
three months. He has a history of gastro-oesophageal reflux disease treated with 40mg pantoprazole
daily. He denies weight loss, regurgitation, odynophagia, heartburn or dyspnoea. He has a 40 packyear smoking history, with a smoker†™s cough and consumes about three standard drinks of alcohol
a day. The physical examination is unremarkable apart from a husky voice and a non-tender 2cm mass
in the left supraclavicular fossa.
Question:
Which one of the following is the most appropriate initial investigation?
Choice 1: Endoscopy Score : 1
Choice Feedback:
Correct. With his history and the findings on physical examination, this patient almost certainly has a
carcinoma of the oesophagus. An endoscopy is the most appropriate initial investigation, both in terms
of a visual inspection of the upper digestive tract and the ability to obtain tissue for histological
examination.
Choice 2: Barium swallow Score : 0
Choice Feedback:
Incorrect.
Choice 3: Chest X-ray Score : 0
Choice Feedback:
Incorrect.
Choice 4: CT chest and abdomen Score : 0
Choice Feedback:
Incorrect.
Choice 5: Indirect laryngoscopy Score : 0
Choice Feedback:
Incorrect.
Question 5 : SC
Question Information:
An obese 55-year-old man presents to his General Practitioner with dysphagia to solids for the last
three months. He has a history of gastro-oesophageal reflux disease treated with 20mg pantoprazole
daily. He denies weight loss, regurgitation, odynophagia, heartburn or dyspnoea. He has a 40 packyear smoking history, with a smoker†™s cough and consumes about three standard drinks of alcohol
a day. The physical examination is unremarkable apart from a husky voice and a non-tender 2cm mass
in the left supraclavicular fossa. An endoscopy is performed, which shows extensive and circumferential
ulcerative oesophagitis immediately above a small (3 cm) hiatus hernia. Biopsies confirm severe
inflammatory changes only.
Question:
Which one of the following is the most appropriate management approach?
Choice 1: Increase pantoprazole to 40mg bd Score : 1
Choice Feedback:
Correct. He should also be given life-style advice - particularly with regard to getting his weight down to
within the normal range. Increasing the dose of proton-pump inhibitor and ensuring that he adheres to
this regimen should be the initial plan of management. Adding an H2-receptor antagonist or an antacid
will be less effective. There is no indication for surgery at this stage - this would only be considered if
the patient's symptoms persisted despite good medical treatment. At that stage, pH and manometric
studies would be considered.
Choice 2: Prescribe ranitidine in addition to pantoprazole Score : 0
Choice Feedback:
Incorrect.
Choice 3: Refer for surgery Score : 0
Choice Feedback:
Incorrect.
Choice 4: Prescribe an antacid Score : 0
Choice Feedback:
Incorrect.
Choice 5: Oesophageal pH and manometry Score : 0
Choice Feedback:
Incorrect.
Question 6 : SC
Question Information:
A 38-year-old obese woman presents with a one day history of fever, right upper quadrant abdominal
pain, and malaise. Apart from the oral contraceptive pill and simvastatin, she takes no other
medications. On examination, her sclera are icteric, pulse rate 105/min, blood pressure 90/50mmHg,
and temperature 38.5C. She is tender in the right upper quadrant.
Question:
Which one of the following is the most likely cause of her presentation?
Choice 1: Acute cholecystitis Score : 0
Choice Feedback:
Incorrect.
Choice 2: Cholangitis Score : 1
Choice Feedback:
Correct. This is the classic presentation of cholangitis.
Choice 3: Acute pancreatitis Score : 0
Choice Feedback:
Incorrect.
Choice 4: Biliary colic Score : 0
Choice Feedback:
Incorrect.
Choice 5: Drug-related hepatitis Score : 0
Choice Feedback:
Incorrect.
Question 7 : SC
Question Information:
A 38-year-old obese woman presents with a one day history of fever, right upper quadrant abdominal
pain, and malaise. Apart from the oral contraceptive pill and simvastatin, she takes no other
medications. On examination, her sclera are icteric, pulse rate 105/min, blood pressure 90/50mmHg,
and temperature 38.5C. She is tender in the right upper quadrant.
Question:
Which one of the following is the most likely causative organism?
Choice 1: Eschericia coli Score : 1
Choice Feedback:
Correct. The patient almost certainly has biliary sepsis and E. coli is the commonest bacterial species
found in gallstone-related biliary disease.
Choice 2: Klebsiella Score : 0
Choice Feedback:
Incorrect.
Choice 3: Enterococcus Score : 0
Choice Feedback:
Incorrect.
Choice 4: Streptococcus Score : 0
Choice Feedback:
Incorrect.
Choice 5: Enterobacter Score : 0
Choice Feedback:
Incorrect.
Question 8 : SC
Question Information:
A 38-year-old obese woman presents with a one day history of fever, right upper quadrant abdominal
pain, and malaise. Apart from the oral contraceptive pill and simvastatin, she takes no other
medications. On examination, her sclera are icteric, pulse rate 105/min, blood pressure 90/50mmHg,
and temperature 38.5C. She is tender in the right upper quadrant.
Question:
Which one of the following would be the most appropriate initial diagnostic investigation?
Choice 1: Endoscopy Score : 0
Choice Feedback:
Incorrect.
Choice 2: Ultrasound Score : 1
Choice Feedback:
Correct. The patient almost certainly has cholangitis and usual cause will be gallstones. Ultrasound is a
simple and cheap investigation, with a 95% sensitivity in the detection of gallstones. The sensitivity for
common bile ducts falls to about 40% - but that is of less importance if the ultrasound can pick up
stones in the gallbladder and a dilated common bile duct. By inference, such latter findings will strongly
support the diagnosis of a stone in the common bile duct.
Choice 3: CT abdomen Score : 0
Choice Feedback:
Incorrect.
Choice 4: ERCP Score : 0
Choice Feedback:
Incorrect.
Choice 5: MRCP Score : 0
Choice Feedback:
Incorrect.
Question 9 : SC
Question Information:
A 38-year-old obese woman presents with a one day history of fever, right upper quadrant abdominal
pain, and malaise. Apart from the oral contraceptive pill and simvastatin, she takes no other
medications. On examination, her sclera are icteric, pulse rate 105/min, blood pressure 90/50mmHg,
and temperature 38.5C. She is tender in the right upper quadrant.
Question:
Which one of the following antibiotic regimens is most appropriate for this patient?
Choice 1: Amoxicillin, gentamicin Score : 0
Choice Feedback:
Incorrect.
Choice 2: Amoxicillin, gentamicin, metronidazole Score : 1
Choice Feedback:
Correct. Whilst the most likely infecting organism will be E. coli, the treating team cannot afford the
luxury of waiting for blood cultures and sensitivities: the patient needs intravenous fluid resuscitation
and treatment with broad-spectrum antibiotics - focussing on gut-derived organisms. These will be E.
coli, Klebsiella sp and Bacteroides sp.
Choice 3: Cefoxitin, ampicillin, metronidazole Score : 0
Choice Feedback:
Incorrect.
Choice 4: Cefotaxime and metronidazol Score : 0
Choice Feedback:
Incorrect.
Choice 5: Piperacillin-tazobactam Score : 0
Choice Feedback:
Incorrect.
Synopsis
Recommended learning outcomes from this set of General Surgery MCQs include:
1. Barrett's oesophagus
2. Dysphagia
3. Cholangitis
Adelaide
October 2015