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Arab Board Surgery Final Written study materials
Arab Board Surgery Final Written study resources

Arab Board Surgery Final Written practice questions

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Question 1Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

A patient with poor dietary intake for several months undergoes elective surgery. Deficiency of which vitamin most directly impairs collagen synthesis and wound healing?

  1. Vitamin C Correct answer.
  2. Iron
  3. Vitamin K
  4. Thiamine

Explanation

Vitamin C is a cofactor for prolyl and lysyl hydroxylase, enzymes required for collagen hydroxylation and cross-linking. Deficiency therefore weakens newly formed collagen and delays wound healing. Vitamin K, iron and thiamine are important for coagulation, oxygen transport and energy metabolism respectively, but they are not direct cofactors for collagen synthesis.

Question 2Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

An adult presents with hypotension and tachycardia after a 2-hour period of vomiting and poor oral intake. Which fluid is most appropriate for initial resuscitation?

  1. Albumin 20%
  2. Balanced crystalloid Correct answer.
  3. 0.9% saline with 40 mmol/L potassium
  4. 5% dextrose

Explanation

Hypovolaemia from gastrointestinal losses is treated first with an isotonic balanced crystalloid to restore intravascular volume and interstitial fluid. Dextrose solutions distribute rapidly into total body water and do not expand plasma volume effectively. Albumin is not first-line for routine hypovolaemia, and potassium-containing fluids are avoided until urine output and potassium are known.

Question 3Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

In a stable adult recovering from major surgery, which hourly urine output is the minimum generally accepted as adequate?

  1. 1.5 mL/kg/h
  2. 0.1 mL/kg/h
  3. 0.2 mL/kg/h
  4. 0.5 mL/kg/h Correct answer.

Explanation

A urine output of at least 0.5 mL/kg/h in adults is widely used as a threshold for adequate renal perfusion. Lower rates suggest oliguria and should prompt assessment of volume status, obstruction and renal function. Outputs well above this may be appropriate in some patients but are not the minimum target.

Question 4Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

For a clean-contaminated elective operation, when should prophylactic intravenous antibiotics be given?

  1. At the time of skin closure
  2. Only after a positive wound culture
  3. Twenty-four hours before incision
  4. Within 60 minutes before incision Correct answer.

Explanation

Prophylactic antibiotics must achieve adequate tissue concentrations at the time of incision, so they are given within 60 minutes before skin opening. Giving them at closure or after culture results provides no protection against intraoperative contamination. Prolonged preoperative administration is not recommended for routine prophylaxis.

Question 5Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

Which pulmonary complication is most common in the first 48 hours after major abdominal surgery?

  1. Pleural effusion
  2. Pneumonia
  3. Pulmonary embolism
  4. Atelectasis Correct answer.

Explanation

Atelectasis is the most frequent early pulmonary complication after abdominal surgery because pain, anaesthesia and supine positioning reduce alveolar recruitment and clearance of secretions. It commonly presents with fever, tachypnoea and reduced oxygen saturation. Pulmonary embolism and pneumonia tend to occur later, and pleural effusion is less common as an isolated early event.

Question 6Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

What is the main effect of adding epinephrine to a local anaesthetic solution?

  1. It reverses established local anaesthetic toxicity
  2. It prolongs the block and reduces systemic absorption Correct answer.
  3. It increases the risk of immediate allergic reaction
  4. It shortens the duration of analgesia

Explanation

Epinephrine causes local vasoconstriction, which slows clearance of the local anaesthetic and reduces systemic absorption. This prolongs the block and lowers the risk of systemic toxicity. It does not reverse toxicity once established and is not used to shorten analgesia.

Question 7Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

Which description corresponds to ASA physical status III?

  1. A patient with severe systemic disease Correct answer.
  2. A patient with mild systemic disease
  3. A patient with severe systemic disease that is a constant threat to life
  4. A normal healthy patient

Explanation

ASA III denotes severe systemic disease that is not incapacitating but has a substantive impact on daily activity. ASA II is mild systemic disease, and ASA IV is severe disease that is a constant threat to life. ASA I is a healthy patient.

Question 8Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

During primary haemostasis under high shear stress, which plasma protein is most important for platelet adhesion to exposed subendothelial collagen?

  1. Fibrinogen (factor I)
  2. Coagulation factor VIII
  3. Activated thrombin
  4. Von Willebrand factor Correct answer.

Explanation

Von Willebrand factor binds both subendothelial collagen and platelet glycoprotein Ib, allowing platelets to adhere under high shear. It also carries factor VIII in the circulation. Fibrinogen supports platelet aggregation through glycoprotein IIb/IIIa, and thrombin converts fibrinogen to fibrin later in the process.

Question 9Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

Which laboratory test is most appropriate for monitoring unfractionated heparin therapy?

  1. Bleeding time
  2. Prothrombin time
  3. Activated partial thromboplastin time Correct answer.
  4. International normalized ratio

Explanation

Unfractionated heparin potentiates antithrombin and mainly inhibits thrombin and factor Xa, affecting the intrinsic and common pathways. The activated partial thromboplastin time is therefore used to monitor its effect. Prothrombin time and INR are used for warfarin, while bleeding time assesses platelet function.

Question 10Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

Two days after an open laparotomy, a patient has oliguria, tachycardia and a 3 kg weight gain despite no obvious bleeding. Which fluid shift best explains these findings?

  1. Third-space sequestration Correct answer.
  2. Diabetes insipidus
  3. Acute haemorrhage
  4. Primary hyperaldosteronism

Explanation

After major abdominal surgery, isotonic fluid can sequester in the peritoneal cavity, bowel wall and inflamed tissues as a non-functional third space. This reduces effective circulating volume and causes oliguria and tachycardia despite overall fluid gain. The sequestered fluid is not lost externally but is unavailable for perfusion until it is reabsorbed.

Question 11Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

A postoperative patient has a serum potassium of 7.2 mmol/L with peaked T waves on the ECG. Which treatment should be given first to protect the myocardium?

  1. Oral sodium polystyrene sulfonate
  2. Intravenous furosemide
  3. Intravenous insulin with glucose
  4. Intravenous calcium gluconate Correct answer.

Explanation

Intravenous calcium stabilises cardiac membranes and is the first treatment when hyperkalaemia produces ECG changes, because it reduces the risk of ventricular arrhythmia within minutes. Insulin with glucose and other measures lower serum potassium but act more slowly. Calcium does not lower the potassium concentration itself.

Question 12Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

A patient with severe hyponatraemia is treated with hypertonic saline. What is the maximum recommended rise in serum sodium over the first 24 hours?

  1. 6 mmol/L
  2. 20 mmol/L
  3. 8 to 10 mmol/L Correct answer.
  4. 4 mmol/L

Explanation

The serum sodium should generally rise by no more than 8 to 10 mmol/L in 24 hours to reduce the risk of osmotic demyelination. Faster correction is associated with pontine and extrapontine myelinolysis, especially in chronic hyponatraemia. The rate may need to be even slower in patients at high risk.

Question 13Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

Which electrolyte abnormality is most characteristic of refeeding syndrome?

  1. Hypophosphataemia Correct answer.
  2. Hypernatraemia
  3. Metabolic alkalosis
  4. Hypercalcaemia

Explanation

Refeeding syndrome occurs when reintroduced carbohydrate drives insulin release, promoting cellular uptake of phosphate, potassium and magnesium. Hypophosphataemia is the hallmark and can cause weakness, arrhythmias and respiratory failure. Electrolytes must be checked and replaced before and during refeeding in at-risk patients.

Question 14Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

A patient with septic shock remains hypotensive after adequate fluid resuscitation. Which vasopressor is recommended first?

  1. Dopamine
  2. Vasopressin
  3. Phenylephrine
  4. Norepinephrine Correct answer.

Explanation

Norepinephrine is the first-line vasopressor in septic shock because it increases vascular tone and cardiac output with fewer arrhythmias than dopamine. It is started after appropriate fluid resuscitation and titrated to mean arterial pressure. Vasopressin is usually added later to reduce norepinephrine requirements.

Question 15Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

A patient has rapidly spreading leg pain, swelling, crepitus and systemic toxicity with skin blistering. Which management is most appropriate?

  1. Hyperbaric oxygen as primary treatment
  2. Observation for 24 hours
  3. Broad-spectrum intravenous antibiotics alone
  4. Urgent debridement plus antibiotics Correct answer.

Explanation

Necrotising fasciitis is a surgical emergency; the priority is early and aggressive debridement of all necrotic tissue together with broad-spectrum antibiotics and supportive care. Antibiotics alone cannot penetrate devitalised tissue adequately. Hyperbaric oxygen may be adjunctive but never replaces surgery.

Question 16Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

During general anaesthesia with a volatile agent and succinylcholine, a patient develops masseter spasm, hypercapnia and rising temperature. Which drug is the specific treatment?

  1. Atropine
  2. Naloxone
  3. Dantrolene Correct answer.
  4. Flumazenil

Explanation

Malignant hyperthermia is a pharmacogenetic disorder of skeletal muscle calcium release triggered by volatile anaesthetics and succinylcholine. Dantrolene inhibits ryanodine receptor-mediated calcium release and is the specific antidote. Supportive measures include stopping triggers, cooling and treating hyperkalaemia and acidosis.

Question 17Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

On postoperative day 6 after a colorectal anastomosis, a patient develops fever, abdominal pain and leucocytosis. Which complication is most likely?

  1. Malignant hyperthermia
  2. Anastomotic leak Correct answer.
  3. Atelectasis
  4. Deep vein thrombosis

Explanation

An anastomotic leak typically presents around the end of the first postoperative week with fever, pain, ileus and leucocytosis, and may progress to peritonitis or sepsis. Atelectasis usually causes early fever within 48 hours, and malignant hyperthermia occurs during anaesthesia. DVT can cause fever but is less likely to produce this abdominal picture.

Question 18Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

Which prophylactic measure is most appropriate for a general surgical patient at moderate risk of venous thromboembolism without contraindications?

  1. Early ambulation alone
  2. Low-molecular-weight heparin Correct answer.
  3. Therapeutic warfarin
  4. Inferior vena cava filter

Explanation

Moderate-risk surgical patients benefit from pharmacological prophylaxis, usually low-molecular-weight heparin, combined with early ambulation and mechanical methods when appropriate. Early ambulation alone is generally reserved for low-risk patients. Inferior vena cava filters and therapeutic warfarin are not routine prophylactic measures.

Question 19Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

On postoperative day 6 after laparotomy, a patient has a sudden gush of serosanguineous fluid from the midline wound. Which is the most appropriate immediate action?

  1. Start antibiotics and observe
  2. Drain the wound at the bedside
  3. Reassure the patient and apply a dry dressing
  4. Urgent reoperation for fascial closure Correct answer.

Explanation

A sudden serosanguineous discharge often signals impending fascial dehiscence, even before bowel or omentum becomes visible. The patient should be taken urgently for exploration and fascial closure to prevent evisceration. Bedside drainage or observation risks catastrophic wound failure.

Question 20Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

A patient on long-term warfarin presents with an intracranial haemorrhage and an INR of 4.5. Which treatment is most appropriate for urgent reversal?

  1. Vitamin K alone
  2. Platelet transfusion
  3. Prothrombin complex concentrate plus vitamin K Correct answer.
  4. Protamine sulfate

Explanation

Urgent warfarin reversal in major bleeding requires rapid replacement of the vitamin K-dependent factors with prothrombin complex concentrate, together with intravenous vitamin K to sustain reversal. Vitamin K alone acts too slowly for acute intracranial haemorrhage. Protamine reverses heparin, and platelets are not the primary deficit in warfarin coagulopathy.

Question 21Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

A 70 kg adult with blunt trauma has a heart rate of 135/min, systolic blood pressure of 80 mmHg, confusion and a base deficit of 8 mmol/L. Which class of haemorrhagic shock is most likely?

  1. Class I
  2. Class II
  3. Class III Correct answer.
  4. Class IV

Explanation

Class III haemorrhagic shock corresponds to approximately 30-40% blood loss, with marked tachycardia, hypotension, altered mental status and a significant base deficit. Class II involves 15-30% loss and usually preserves systolic pressure, while class IV is over 40% loss with profound instability. These findings therefore fit class III.

Question 22Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

A patient scheduled for elective colectomy has a history of heart failure, insulin-dependent diabetes and a serum creatinine of 2.4 mg/dL. How many patient-specific Revised Cardiac Risk Index factors are present?

  1. Three Correct answer.
  2. One
  3. Two
  4. Four

Explanation

The Revised Cardiac Risk Index includes ischaemic heart disease, heart failure, cerebrovascular disease, insulin-requiring diabetes, preoperative creatinine above 2.0 mg/dL and high-risk surgery. This patient has heart failure, insulin-dependent diabetes and renal impairment, giving three patient-specific factors. The type of surgery is a separate index item and is not counted in the stem.

Question 23Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

A trauma patient receiving a massive transfusion develops perioral tingling, prolonged QT and hypotension. Which complication is most likely?

  1. Hyperkalaemia from stored blood
  2. Transfusion-related acute lung injury
  3. Citrate-induced hypocalcaemia Correct answer.
  4. Hypernatraemia from normal saline

Explanation

Citrate in stored blood chelates ionised calcium, and rapid large-volume transfusion can cause hypocalcaemia with perioral tingling, tetany, QT prolongation and hypotension. Ionised calcium should be monitored and replaced during massive transfusion. Hyperkalaemia and TRALI can also occur but produce different clinical patterns.

Question 24Basic Principles of Surgery and Perioperative Care (wound healing, haemostasis, fluid/electrolyte and nutritional support, shock, surgical infection, anaesthesia-related considerations, preoperative assessment and postoperative complications)

A patient with severe sepsis has oozing from cannula sites, platelets 60 × 10^9/L, prolonged PT and aPTT, low fibrinogen and raised D-dimer. Which diagnosis best explains these findings?

  1. Vitamin K deficiency
  2. Heparin-induced thrombocytopenia
  3. Von Willebrand disease
  4. Disseminated intravascular coagulation Correct answer.

Explanation

Disseminated intravascular coagulation causes widespread activation of coagulation with consumption of platelets and clotting factors, producing thrombocytopenia, prolonged PT and aPTT, low fibrinogen and raised D-dimer. It is commonly triggered by sepsis and presents with both bleeding and microvascular thrombosis. The combination of findings is not explained by a single factor deficiency or platelet antibody.

Question 25Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A 45-year-old woman has progressive dysphagia to both solids and liquids with regurgitation. Barium swallow shows a dilated oesophagus with smooth 'bird-beak' tapering at the gastro-oesophageal junction. Which manometric finding is most characteristic?

  1. Hypotensive lower oesophageal sphincter with normal oesophageal body peristalsis
  2. Hypertensive lower oesophageal sphincter with normal oesophageal body peristalsis
  3. Absent distal oesophageal peristalsis with failure of lower oesophageal sphincter relaxation Correct answer.
  4. Premature repetitive contractions with normal lower oesophageal sphincter relaxation

Explanation

Achalasia results from loss of myenteric ganglion cells, producing aperistalsis of the oesophageal body and failure of lower oesophageal sphincter relaxation. Manometry is the diagnostic gold standard; the bird-beak appearance on barium swallow supports but does not confirm the diagnosis.

Question 26Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A man develops sudden severe chest pain and subcutaneous emphysema after an episode of forceful vomiting. At which site does this condition most typically occur?

  1. Left posterolateral distal intrathoracic oesophagus Correct answer.
  2. Intra-abdominal oesophagus immediately above the cardia
  3. Right lateral wall of the mid-oesophagus
  4. Cervical oesophagus just below the cricopharyngeus

Explanation

Boerhaave syndrome is a spontaneous transmural rupture, usually of the left posterolateral wall of the distal oesophagus, classically after forceful vomiting. Mediastinal contamination produces the Mackler triad of vomiting, chest pain and subcutaneous emphysema.

Question 27Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A 40-year-old man has sudden severe epigastric pain; CT shows free air and a 5 mm perforation of the anterior duodenal bulb with minimal contamination. He is haemodynamically stable. Which operation is most appropriate?

  1. Primary closure with an omental (Graham) patch Correct answer.
  2. Truncal vagotomy combined with antrectomy
  3. Distal gastrectomy with Billroth II reconstruction
  4. Pyloric exclusion with gastrojejunostomy

Explanation

A small perforated duodenal ulcer in a stable patient is best treated by primary closure with an omental (Graham) patch. H. pylori eradication and proton pump inhibitor therapy are then given to prevent recurrence.

Question 28Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

Which CT feature best supports a diagnosis of acute appendicitis?

  1. Left iliac fossa fat stranding alone
  2. 6 mm ovarian cyst with a thin wall
  3. 4 mm appendix with intraluminal air
  4. 9 mm appendix with periappendiceal fat stranding Correct answer.

Explanation

An appendiceal diameter greater than 6 mm with wall thickening and periappendiceal fat stranding is the standard CT criterion for acute appendicitis. An appendicolith or fluid collection adds supportive evidence.

Question 29Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A patient has prolapsing haemorrhoids that require manual reduction back into the anal canal. What grade of haemorrhoid is this?

  1. Grade II
  2. Grade IV
  3. Grade I
  4. Grade III Correct answer.

Explanation

Haemorrhoids are graded by their prolapse behaviour: grade I do not prolapse, grade II prolapse and reduce spontaneously, grade III require manual reduction, and grade IV are irreducible.

Question 30Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A 30-year-old man has severe pain on defecation and a visible posterior midline anal fissure of three weeks' duration. What is the most appropriate first-line treatment?

  1. Botulinum toxin injection into the internal sphincter
  2. Topical glyceryl trinitrate with stool softeners and fibre Correct answer.
  3. Endoanal advancement flap repair
  4. Lateral internal sphincterotomy

Explanation

Acute anal fissure is initially managed medically with stool softeners, fibre supplementation and a topical vasodilator such as glyceryl trinitrate or diltiazem. Surgery is reserved for chronic fissures that fail medical therapy.

Question 31Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

During laparoscopic inguinal hernia repair, an indirect inguinal hernia is identified by a defect at which location?

  1. Lateral to the inferior epigastric vessels at the deep inguinal ring Correct answer.
  2. Through the obturator canal into the medial thigh
  3. Medial to the inferior epigastric vessels within Hesselbach's triangle
  4. Through the femoral canal below the iliopubic tract

Explanation

Indirect hernias enter the deep inguinal ring lateral to the inferior epigastric vessels, whereas direct hernias protrude medial to them through Hesselbach's triangle. This relationship is the key landmark during laparoscopic repair.

Question 32Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A 70-year-old with chronic constipation has marked abdominal distension; plain film shows a 'coffee bean' sign arising from the pelvis. There is no peritonitis. What is the initial management?

  1. Nasogastric decompression alone
  2. Intravenous antibiotics and observation
  3. Endoscopic detorsion and flatus tube decompression Correct answer.
  4. Emergency laparotomy and sigmoid resection

Explanation

Uncomplicated sigmoid volvulus is initially decompressed endoscopically with placement of a flatus tube, which resolves the episode in most patients. Because recurrence is common, elective sigmoid resection is usually advised afterwards.

Question 33Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

Which condition most strongly predisposes to oesophageal adenocarcinoma?

  1. Plummer-Vinson syndrome
  2. Barrett's oesophagus with intestinal metaplasia Correct answer.
  3. Caustic stricture of the oesophagus
  4. Achalasia of the cardia

Explanation

Oesophageal adenocarcinoma typically arises in Barrett's oesophagus with intestinal metaplasia, usually in the distal oesophagus. Squamous cell carcinoma is linked to smoking, alcohol, achalasia and caustic injury.

Question 34Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A 55-year-old has a 4 cm submucosal gastric mass; biopsy shows spindle cells that are positive for CD117. There is no evidence of metastasis. What is the most appropriate management?

  1. Complete surgical resection with clear margins and no lymphadenectomy Correct answer.
  2. Endoscopic mucosal resection of the lesion
  3. Adjuvant external beam radiotherapy to the tumour bed
  4. Gastrectomy with D2 lymphadenectomy

Explanation

Gastrointestinal stromal tumours metastasise by direct extension and haematogenously, and lymph node involvement is rare. The aim is complete R0 resection without capsule rupture, and lymphadenectomy is not indicated.

Question 35Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A patient with adhesive small bowel obstruction has no signs of strangulation. After 24 hours of nasogastric decompression, what is the role of enteral water-soluble contrast?

  1. It is contraindicated because it worsens the obstruction
  2. It is given intravenously as a therapeutic agent
  3. It can both predict resolution and reduce the need for surgery Correct answer.
  4. It mandates immediate laparotomy once it reaches the colon

Explanation

Water-soluble contrast given via the nasogastric tube is both diagnostic and therapeutic in adhesive small bowel obstruction. Appearance of contrast in the colon predicts resolution, and its use reduces the need for surgery.

Question 36Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A patient with ulcerative colitis has a transverse colon of 7 cm on plain film, fever of 39°C, tachycardia and abdominal tenderness without generalised peritonitis. What is the most appropriate initial management?

  1. Immediate panproctocolectomy
  2. High-dose loperamide with oral mesalazine
  3. Intravenous steroids, fluids and antibiotics with close monitoring Correct answer.
  4. Colonoscopy to define disease extent

Explanation

Toxic megacolon is initially managed medically with intravenous fluids, steroids, antibiotics and close monitoring. Colectomy is indicated for perforation, uncontrolled haemorrhage or failure to improve within 24 to 72 hours.

Question 37Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

Which statement best describes total mesorectal excision for a mid-rectal cancer?

  1. Resection limited to 2 cm distal to the tumour with no formal mesorectal dissection
  2. Routine en bloc internal iliac lymphadenectomy with the specimen
  3. Sharp dissection of the mesorectum in the avascular plane down to the pelvic floor Correct answer.
  4. Blunt finger dissection of the mesorectum from the sacral promontory

Explanation

Total mesorectal excision removes the rectum within an intact mesorectal envelope by sharp dissection in the avascular plane between the mesorectum and the parietal pelvic fascia. A clear circumferential resection margin is the strongest predictor of avoiding local recurrence.

Question 38Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A patient with acute sigmoid diverticulitis has a 4 cm pericolic abscess on CT and is clinically stable. What is the most appropriate management?

  1. Outpatient oral antibiotics alone
  2. Laparoscopic peritoneal lavage
  3. Image-guided percutaneous drainage plus antibiotics Correct answer.
  4. Urgent Hartmann's procedure

Explanation

A pericolic abscess of 4 cm or more in a stable patient is treated with percutaneous image-guided drainage and antibiotics. Surgery is reserved for perforation, generalised peritonitis or failure of drainage.

Question 39Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A 70-year-old woman has a painful lump below and lateral to the pubic tubercle. Which statement about this hernia is correct?

  1. It passes through the superficial inguinal ring
  2. It carries a high risk of strangulation and should be repaired promptly Correct answer.
  3. It lies lateral to the femoral vein within the femoral sheath
  4. It is an inguinal hernia and can be safely observed

Explanation

Femoral hernias emerge through the femoral canal, which lies below and lateral to the pubic tubercle and medial to the femoral vein. The narrow, rigid canal gives the highest risk of strangulation, so prompt repair is advised.

Question 40Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A 35-year-old with a five-day history of right lower quadrant pain has a 6 cm periappendiceal phlegmon on CT. There is no discrete drainable abscess and he is clinically stable. What is the most appropriate management?

  1. Percutaneous drainage of the phlegmon
  2. Intravenous antibiotics with observation and interval reassessment Correct answer.
  3. Immediate appendicectomy
  4. Right hemicolectomy

Explanation

An appendiceal phlegmon without a drainable abscess in a stable patient is treated with intravenous antibiotics and observation. Surgery is reserved for failure to improve, and interval appendicectomy is decided case by case.

Question 41Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A patient with melaena remains haemodynamically stable after resuscitation. What is the most appropriate next step in the management of this suspected non-variceal upper gastrointestinal bleed?

  1. Endoscopy within 24 hours with haemostasis and intravenous proton pump inhibitor Correct answer.
  2. Immediate exploratory laparotomy
  3. Oral iron therapy with ward observation
  4. Barium meal followed by elective endoscopy

Explanation

Upper GI endoscopy within 24 hours of resuscitation allows identification of the bleeding source and endoscopic haemostasis combined with proton pump inhibitor therapy. Surgery or embolisation is reserved for bleeding that cannot be controlled endoscopically.

Question 42Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A 4-year-old boy has painless rectal bleeding and a positive pertechnetate scan. What is the underlying cause of the bleeding?

  1. Ectopic gastric mucosa causing ulceration of the adjacent ileum Correct answer.
  2. Torsion of the diverticulum around its mesentery
  3. Incarceration of the diverticulum within the inguinal canal
  4. Ectopic pancreatic tissue causing local autodigestion

Explanation

Bleeding from a Meckel's diverticulum is caused by acid secretion from ectopic gastric mucosa ulcerating the adjacent ileal mucosa. The pertechnetate scan is positive because it is taken up by that gastric mucosa.

Question 43Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A fistula has an external opening situated anterior to the transverse anal line and 2 cm from the anal margin. According to Goodsall's rule, what track is most likely?

  1. A curved track running to the posterior midline
  2. A short direct radial track to the anal canal Correct answer.
  3. A track crossing to the opposite side of the anus
  4. A supralevator track opening into the rectum

Explanation

Goodsall's rule states that anterior external openings within about 3 cm of the anal margin usually track directly and radially. Posterior openings, and anterior openings further away, usually track in a curved fashion to the posterior midline.

Question 44Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

Chronic groin pain after open Lichtenstein inguinal hernia repair is most commonly attributed to injury of which nerve?

  1. Genitofemoral nerve
  2. Obturator nerve
  3. Ilioinguinal nerve Correct answer.
  4. Lateral femoral cutaneous nerve

Explanation

The ilioinguinal nerve lies in the inguinal canal and is the nerve most often injured or entrapped after open inguinal hernia repair. It is the commonest source of chronic post-herniorrhaphy groin pain.

Question 45Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A 28-year-old man with type II achalasia, an oesophageal diameter of 6 cm and no previous treatment is fit for surgery. Which definitive treatment offers the most durable symptom relief?

  1. Repeated pneumatic balloon dilatation every few months
  2. Endoscopic botulinum toxin injection into the lower oesophageal sphincter
  3. Long-term oral calcium channel blockers
  4. Laparoscopic Heller myotomy with a partial (Dor) fundoplication Correct answer.

Explanation

Laparoscopic Heller myotomy with a partial fundoplication provides the most durable symptom relief in young patients with achalasia and good oesophageal emptying. Botulinum toxin and medical therapy are temporary and reserved for patients unfit for definitive treatment.

Question 46Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A 75-year-old with atrial fibrillation has severe abdominal pain out of proportion to examination and a lactate of 4 mmol/L. CT angiography shows thrombus at the origin of the superior mesenteric artery with no established bowel infarction. What is the most appropriate management?

  1. Systemic thrombolysis alone
  2. Observation with systemic heparin alone
  3. Immediate bowel resection without revascularisation
  4. Revascularisation followed by assessment of bowel viability Correct answer.

Explanation

Acute mesenteric ischaemia from proximal superior mesenteric artery occlusion requires urgent revascularisation, usually by embolectomy or stenting, before or alongside resection. Bowel viability is reassessed after restoring flow, and infarcted segments are then resected.

Question 47Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

Three weeks after a Billroth II gastrectomy, a patient has postprandial epigastric pain that is relieved by an episode of bilious vomiting. What is the most likely diagnosis?

  1. Alkaline reflux gastritis
  2. Early dumping syndrome
  3. Efferent loop syndrome
  4. Afferent loop syndrome Correct answer.

Explanation

Afferent loop syndrome follows partial obstruction of the biliopancreatic limb after a Billroth II or Roux-en-Y reconstruction. Bile and pancreatic juice accumulate, causing postprandial pain that is relieved by bilious vomiting.

Question 48Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A patient with Crohn's disease has a high transsphincteric fistula and active proctitis. What is the most appropriate initial surgical management?

  1. Lay-open fistulotomy along the whole track
  2. Mucosal advancement flap repair
  3. Proctectomy with permanent end stoma
  4. Loose seton drainage with control of the Crohn's disease Correct answer.

Explanation

In perianal Crohn's fistula with active proctitis, a loose seton controls sepsis while preserving sphincter function, and medical therapy is used to heal the proctitis. Fistulotomy and advancement flaps have poor healing rates in active proctitis.

Question 49Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A 55-year-old has a 2 cm well-differentiated gastric antral adenocarcinoma confined to the mucosa on endoscopic ultrasound, with no ulceration, lymphovascular invasion or suspicious nodes. What is the most appropriate management?

  1. Total gastrectomy with Roux-en-Y reconstruction
  2. Subtotal gastrectomy with D2 lymphadenectomy
  3. Neoadjuvant chemotherapy followed by gastrectomy
  4. Endoscopic submucosal dissection Correct answer.

Explanation

Early gastric cancer that is well differentiated, 2 cm or less, intramucosal and without ulceration or lymphovascular invasion has a negligible risk of nodal metastasis. Endoscopic submucosal dissection is therefore curative in these favourable cases.

Question 50Gastrointestinal Surgery (oesophagus, stomach and duodenum, small bowel, appendix, colon, rectum and anus, abdominal wall and hernia, benign anorectal disease)

A 45-year-old man has haematemesis after several episodes of retching following an alcohol binge. Endoscopy shows a longitudinal mucosal tear at the gastro-oesophageal junction. Which statement about this lesion is most accurate?

  1. It most commonly arises in the gastric antrum
  2. It requires urgent surgical repair in most patients
  3. It involves full-thickness rupture of the oesophageal wall with mediastinitis
  4. It is a mucosal tear that usually stops bleeding spontaneously Correct answer.

Explanation

Mallory-Weiss tears are longitudinal mucosal lacerations at the gastro-oesophageal junction produced by a sudden rise in intragastric pressure against a closed glottis, typically after retching. Bleeding stops spontaneously in the large majority of patients, and endoscopic therapy is reserved for active or recurrent haemorrhage.