Week 2 Surgery Exam
All of the following stimulate gastric acid secretion EXCEPT:
Acetylcholine
Somatostatin
Duodenal gastrin
Gastric distension
Intraluminal protein
Other
Please Specify:
A 43-year old male came in due to acute abdomen. He underwent exploratory laparotomy for perforated peptic ulcer disease at the prepyloric area. What type is this using the Modified Johnson Classification?
TYPE IV
TYPE I
TYPE II
TYPE III
The recommended surgery in the treatment of gastric ulcer with perforation in a high-risk patient is which of the following?
Highly selective vagotomy and wedge excision
Oversew and patch with biopsy
Vagotomy and antrectomy
Distal Gastrectomy
Infection with Helicobacter pylori has been associated with all BUT which of the following?
Gastric ulcer
Mucosa-associated lymphoid tissue (MALT) lymphoma
Chronic gastritis
Duodenal ulcer
Gastroesophageal reflux disease (GERD)
A 65 year-old female patient diagnosed with gastric cancer who presented with gastric outlet obstruction and prolonged vomiting has which of the following metabolic abnormalities?
Hypochloremic, hypokalemic metabolic alkalosis
Hyperchloremic, hyperkalemic metabolic acidosis
Hyperchloremic, metabolic acidosis
Hypochloremic, metabolic alkalosis hypokalemic hyperkalemic
Hyponatremic, hypokalemic metabolic acidosis
Which of the following gastric ulcer types according to the Modified Johnson classification is classified as NSAID induced?
Type V
Type I
Type IV
Type II
Type III
What is the diagnostic gold standard for gastric cancer?
Endoscopic ultrasound
Upper GI endoscopy + Biopsy
PET scan
By CEA determination
Which of the following tests is best to document eradication of H. Pylori infection in patients with peptic ulcer disease?
Rapid urease test
Urea breath test
H. Pylori serology
Culture and sensitivity testing
Histologic examination of mucosa
A 78 year-old man taking NSAIDs for arthritis arrived at the ED with a 6 hours history of severe abdominal pain. He presented with stable vital signs and acute abdomen and pneumoperitoneum. What should be the next step in the management?
Antisecretory drugs, broad-spectrum antibiotics, and surgery if he fails to improve in 6 hours
Esophagogastroduodenoscopy (EGD)
CT scan of the abdomen with contrast
Surgery
Antisecretory drugs, antibiotics for H. pylori, and surgery if he fails to improve in 6 hours
Surgical treatment of gastric adenocarcinoma involves gastrectomy and lymphadenectomy. Some studies state that adequate lymphadenectomy requires a D2 dissection during gastric resection. Which of the following refers to the D2 group of lymph nodes?
Greater curvature perigastric nodes
Para-aortic and paracolic nodes
Hepatoduodenal and mesenteric root nodes
Lesser curvature perigastric nodes
Nodes around the celiac axis, splenic hilum, and splenic artery
Which of the following location of gastric ulcer is associated with low to normal acid production?
High on lesser curve
Lesser curve at incisura
Prepyloric
Gastric body with duodenal ulcer
None of the choices
76 year-old male underwent abdominal CT scan for a palpable mass at the epigastric area. Upon review of the CT images, you informed him that he has gastric cancer but the tumor is unresectable. The following are the criteria for unresectability for gastric cancers, EXCEPT:
Invasion or encasement of the splenic vessels
Disease infiltration of the root of the mesentery or para-aortic lymph node
Carcinomatosis
Distant metastasis
None of these
Which of the following tests is NOT appropriate for the initial detection of H. Pylori infection
Culture and sensitivity testing
H. Pylori serology
Histologic examination of mucosa
Rapid urease test
Urea breath test
The goal of gastric adenocarcinoma surgery is to achieve an R0 resection, which means that you need to have a grossly negative margin of at least __ cm.
5 cm
3 cm
1 cm
4 cm
2 cm
You performed an exploratory laparotomy on a 43 year-old smoker who you diagnosed with a perforated peptic ulcer disease. Intraoperatively, you found a perforated gastric ulcer. What additional steps do you need to perform at the time of operative intervention besides closure of the perforation?
Pyloroplasty
Gastrojejunostomy
Excision or biopsy of the ulcer
Feeding jejunostomy
Gastrostomy tube placement
Which of the following chemotherapeutic agents is given to patients with metastatic and unresectable gastrointestinal stromal tumor?
Doxorubicin
Cisplatin
Cyclophosphamide
Imatinib
5-FU
Which of the following is a factor which decreases the risk for developing gastric carcinoma?
Aspirin intake
Pernicious anemia
Smoking
H. Pylori infection
These types of gastric ulcer are associated with normal or INCREASED gastric acid secretion.
IV and V
III and IV
I and II
II and III
The following are established indications for diagnosis and treatment of H. pylori, except.
Active peptic ulcer disease
After endoscopic resection of early gastric cancer
GERD
Gastric mucosa-associated lymphoid tissue lymphoma
In the continuum of gastric carcinogenesis, which cellular charge comes immediately before the development of cancer from normal gastric mucosa?
Intestinal metaplasia
Dysplasia
Chronic superficial gastritis
Atrophic gastritis
Which of the following statements is true with regard to the arterial blood supply of the stomach?
The inferior phrenic and short gastric arteries provide significant blood supply to the body of the stomach.
A replaced right hepatic artery may originate from the left gastric artery
The left gastroepiploic artery commonly arises from the left gastric artery.
The stomach is extremely susceptible to ischemia because of poor collateral circulation.
Ligation of the left gastric artery can result in acute left-sided hepatic ischemia
Which cell type is matched with the correct primary anatomic location?
Endocrine cell - gastric corpus and fundus
Parietal cell - gastric cardia
Delta cell - duodenum
Chief cell - gastric cardia
G cell - gastric antrum
A 24-year old female came in due to epigastric pain 2 hours after eating. She further disclosed that sometimes the pain awakens her from sleep. What is your primary impression?
Perforated Peptic ulcer
Duodenal ulcer
Gastric ulcer
GERD
Which of the types in the Modified Johnsons Classification of ulcers is associated with acid hypersecretion
I
III
V
IV
A patient is noted with a tumor in the proximal gastric area. What is the recommended surgical procedure for this type of tumor location?
Subtotal gastrectomy
Total gastrectomy
Partial gastrectomy
Antrectomy
Helicobacter pylori infection primarily mediates duodenal ulcer pathogenesis by which of the following mechanisms?
Upregulation o parietal cell acid production
Antral alkalinization leading to inhibition of somatostatin release
Local inflammation with autoimmune response
Direct stimulation of gastrin release
Which of the Types in the Modified Johnsons Classification of ulcers is associated with NSAID intake/ induced
IV
V
II
I
All are indications for surgical treatment for Peptic Ulcer Disease, Except
Obstructing Peptic Ulcer
Perforated Peptic Ulcer Disease
Bleeding Peptic Ulcer Disease
Recurrent Epigastric Pain
Which of the following is secreted by gastric parietal cells?
Ghrelin
Intrinsic factor
Gastrin-releasing peptide
Pepsinogen
What is the most common indication for surgery in PUD?
Perforation
Intractability or non healing
Obstruction
Bleeding
Regular use of aspirin or NSAIDs is recommended to prevent or reduce progression of premalignant gastric lesions
True
False
A 45-year-old male is brought to the ER. He was at grocery today when he collapsed and was found to be diaphoretic and experiencing extreme abdominal pain. He reports that he had been experiencing recurrent abdominal pain for 6 months. He takes no medication. Vitals are normal. Abdominal examination reveals diffuse tenderness with guarding and rebound. Chest Xray reveals subdiaphragmatic air. Which of the following actions is the best next step?
Laparoscopic appendectomy
Conservative management
Upper GI endoscopy
Exploratory laparotomy
Patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin need concomitant acid suppressing medication if which of the following is present?
Age over 50
Heavy alcohol consumption
Concurrent steroid intake
All of the above
Which dietary component is highly associated with the development of gastric cancer?
Bicarbonates
Fats
Proteins
Nitrates
Which of the following is a precancerous lesion with the highest risk to develop intestinal type non cardia gastric adenocarcinoma?
Gastric ulcer
Reflux gastritis
Atrophic gastritis
H. Pylori infection
Which of the following organs is a known site of gastric cancer metastasis?
Soft muscle tissues
Kidneys
Bone
Peritoneum
Which of the following statements is true with regard to the arterial blood supply of the stomach?
Ligation of the left gastric artery can result in acute left-sided hepatic ischemia
The stomach is extremely susceptible to ischemia because of poor collateral circulation
The inferior phrenic and short gastric arteries provide significant blood supply to the body of the stomach
A replaced right hepatic artery may originate from the left gastric artery
The left gastroepiploic artery commonly arises from the left gastric artery
Which is NOT a possible complication of gastric carcinoma?
Gastrointestinal obstruction
Gastrointestinal adhesions
Gastrointestinal bleeding
Gastrointestinal fistula formation
Which of the following is the recommended management of gastric intestinal metaplasia?
Test for H. pylori
Short term repeat endoscopy and biopsy
Observation
This is the multistep histological progression from active chronic gastric inflammation to intestinal-type gastric adenocarcinoma
Lynch syndrome
Kras cascade
Correa cascade
Adeno-carcinoma pathway
Which of the following is the recommended treatment for metastatic gastric cancer?
Targeted therapy with trastuzumab
Endoscopic mucosal resection
Neoadjuvant therapy with 5FU
Complete surgical resection
This is the multistep histological progression from active chronic gastric inflammation to intestinal-type gastric adenocarcinoma
Correa cascade
Adeno-carcinoma pathway
Lynch syndrome
Kras cascade
Which of the following is a molecular classification of gastric cancer under the Cancer Genome Atlas?
Poorly cohesive gastric cancer
Mucinous gastric cancer
Tubular gastric cancer
Gastric cancer with test result positive for Epstein-Barr virus
Which of the following patient subgroups would benefit from repeat endoscopy after 1 year for risk stratification?
Patients with existing gastric ulcer who are H. Pylori negative
Patients with existing gastric ulcer who are H. Pylori positive
Individuals with family history of gastric cancer
Individuals who are have full eradication of H. Pylori infection
What should be done of a patient who ingested caustic substance have third degree burn in the esophagus?
Esophageal stripping
Exploratory laparotomy
Open thoracotomy
Esophagoendoscopy
What is the basic pathology of achalasia?
Esophageal dilatation I
Failure of the LES to relax on pharyngeal swallowing
Hypertension of the LES
All of the above
Which of the following increases the risk of esophagitis in a patient with gastroesophageal reflux
Total time the esophageal mucosa is exposed to fluid with a pH of 4
Total time the esophageal mucosa is exposed to fluid with pH >7
Total time the esophageal mucosa is exposed to bile salts
All of the above
Which of the following type of substance dissolves tissues and penetrate more deeply?
Solvents
Reagents
Alkalis
Acids
What is the hallmark physical examination finding in gastroesophageal reflux?
Cachexia
Upper abdominal mass
Normal physical examination
Caput medusae
Which of the following increases LES pressure?
Secretin
Gastrin
Somatostatin
Glucagon
The following are true of esophageal carcinoma, except:
Tumors in the cervical esophagus is almost always squamous carcinoma
Tumors in the upper thoracic is esophagus almost always squamous carcinoma
Tumors in the upper thoracic esophagus is almost always adenocarcinoma
Tumors in the cardia is always squamous carcinoma
What is the basic pathology of achalasia?
All of the above
Hypertension of the LES
Failure of the LES to relax on pharyngeal swallowing
Esophageal dilation
What is the most common type of cancer identified and is thought to be the result of longstanding retained undigested fermenting food in the body of the esophagus causing mucosal irritation?
Esophageal adenocarcinoma
Columnar adenocarcinoma
Squamous cell carcinoma
Transitional cell cancer
Achalasia is also known to be a premalignant condition of the esophagus
True
False
What type of injury does ingestion of acids do to the esophagus?
Third degree chemical burn
Liquefactive necrosis
Coagulative necrosis
Deep thermal burn
Which of the following increases the risk of esophagitis in a patient with gastroesophageal reflux?
Total time the esophageal mucosa is exposed to the fluid with pH >7
Total time the esophageal mucosa is exposed to fluid with pH 4
Total time the esophageal mucosa is exposed to bile salts
All of the above
What is the focus of treatment in the acute phase of caustic injury?
Prevention of perforation
Controlling immediate tissue injury
Both
Neither
Which of the following manometric findings is indicative of an incompetent LES?
Which of the following manometric findings is indicative of an incompetent LES?
Average sphincter length 2 cm
Average LES pressure 20 mmHg
Average intra abdominal esophagus 4cm
The primary reason that reflux is common after big meal is which of the following?
Hyperperistalsis of the stomach
Increased gastrin production
Shortening of the LES
Increased acid production
The preoperative test most heavily correlated with the ability to tolerate an esophagectomy is which of the following?
Thallium imaging
Functional vital capacity
Ability to climb a flight of stairs
Forced expiratory volume in 1 sec
A patient who ingested lye will have which of the following injuries on the first 1-4 days?
Granulation tissue fills the defect left by the sloughed mucosa
The superficial necrotic tissue sloughs
Cicatrization and scarring of tissues
Living tissue surrounding the area of necrosis develops and intense inflammatory reaction
Which of the following patients would not be considered a candidate for esophagectomy?
47 year old woman with mid-esophageal cancer and an involved cervical lymph node
70 year old female with a small GEJ cancer and three pathologic lymph nodes nearby on endoscopic ultrasound
60 year old man with large GEJ carcinoma with invasion into the pleura with malignant effusion
55 year old man with GEJ adenocarcinoma confined to the muscularis mucosa
What type of achalasia would present with chest pain?
Active achalasia type 2
Passive achalasia type 1
Dilated achalasia type 4
Spastic achalasia type 3
Caustic injuries in adults and teenagers may denote which type of injury?
Deliberate
Coercive
Accidental
Chronic
A 60 year old male came to your clinic due to dysphagia grade 3, all of the following are considered as initial diagnostic tool, EXCEPT:
CT Scan neck and abdomen
Endoscopy with biopsy
Barium swallow
PET scan
Which test most accurately assess the T stage of esophageal cancer?
High resolution CT scan
MRI
Esophagoduodenoscopy
Endoscopic ultrasonography
Which among the following is the accepted pathologic cause of achalasia?
Barrets esophagus
trauma
Idiopathic or infectious neurogenic degeneration
Caustic ingestion
What is the appropriate treatment for a patient with esophageal cancer whose clinical evaluation and staging revealed tumor suspected not to be through the wall and/or less than 8 lymph nodes involved?
Palliative surgery
Chemoradiation
Pre operative chemoradiation followed by en bloc resection
Curative en bloc resection
Which of the following is the goal of giving proton pump inhibitor to patients with gastroesophageal reflux?
Relieve symptoms
Prevent recurrence
Promote healing
All of the above
It is the major abnormality of achalasia?
Absence of peristalsis in the esophageal body
Spontaneous contractions
Incomplete LES relaxation
Multi peaked contractions
Which of the following must be ruled out when a patient with probable gastroesophageal reflux present with chest pain?
Diaphragmatic hernia
Cardiac disease
Aspiration pneumonia
Esophageal cancer
What is the primary pathology in gastroesophageal reflux?
Mucosal integrity
Vascularization
Motility
Cellular maturation
What is the primary treatment of achalasia?
Myotomy
Corticosteroids
Esophagectomy
Diverticulopexy
What is the primary role of the upper GI endoscopy in GER?
Evaluate the specific details of the esophageal mucosa
Measure the pressure of the LES
Determine the incidence of gastric acid of the esophageal mucosa
Locate the site of the associated sliding hernia
What is the role of an esophageal stent in patients with caustic esophageal injury?
To prevent sepsis
To prevent bleeding
To prevent stricture
To prevent perforation
The following are primary esophageal motility disorders, EXCEPT:
Achalasia
Nutcracker esophagus
DES
Progressive systemic sclerosis
A patient with gastric adenocarcinoma presents with gastric outlet obstruction but is deemed unresectable. What will be the best immediate option?
Gastrojejunostomy
Total gastrectomy
Radiotherapy
Chemotherapy
What is Billroth 1 reconstruction?
Esophagojejunostomy
Esophagoduodenostomy
Gastrojejunostomy
Gastroduodenostomy
a patient who ingested caustic substance should not be given neutralizing agents due to which reason?
Coagulation necrosis of the tissues
Additional thermal injury to the tissues
Liquefactive action of the agents to the mucosa
All of the answers are correct
A 50 year male smoker consulted due to severe epigastric pain and dysphagia. An endoscopy was done and there was not of inflammatory mucosa in the distal esophagus. The biopsy obtained showed the presence of goblet cells. What is the diagnosis of this patient?
Peptic ulcer disease
Reflux esophagitis
Barrett's esophagus
Esophageal adenocarcinoma
What is Billroth 2 reconstruction?
Gastroduodenostomy
Gastrojejunostomy
Esophagoduodenostomy
Esophagojejunostomy
All of the following cranial nerves are involved in the swallowing mechanism, EXCEPT:
V
VII
VIII
X
Most common surgical procedure for achalasia
Heller myotomy
Nissin fundoplication
Esophageal sleeve resection
Sleeve gastrectomy
Which is NOT a characteristic of heartburn associated with GERD?
Worse when bending down
Occurs 30 to 60 minutes
Worse when with tight clothing
Worse when lying down
What are the necessary normal anatomic protection from GERD?
LES compliance
Normal esophageal body
Normal gastric reservoir
All of the choices are correct
Free air was noted in a chest X-ray and CT scan after caustic injury. What is the significance of this finding?
Esophageal stricture
Esophageal bleeding
Esophageal perforation
Esophageal cancer
What is the gold standard for the diagnosis of GERD?
Manometry
PH probe
Histology
Endoscopy
What is NOT a manometric finding of achalasia?
Flaccid LES
Incomplete LES relaxation
Increase LES pressure
No peristalsis
Which is NOT an indication for the surgical treatment of GERD
Avoidance of lifetime medication
No correct choice
Failure of medical treatment
Refractory complications
The incidence of metastatic Barretts Esophagus progressing to adenocarcinoma is
Less than 0.1% per year
1 to 3% per year
3-5% per year
0.2 to 0.5% per year
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