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BSSEE practice questions

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Question 1General Surgery Principles and Perioperative Care

A patient is scheduled for elective surgery. Which fasting interval before induction of anesthesia is currently recommended for clear liquids in a healthy adult?

  1. 4 hours
  2. 6 hours
  3. 8 hours
  4. 2 hours Correct answer.

Explanation

Standard preoperative fasting guidance permits clear liquids up to two hours before anesthesia because gastric emptying of clear fluids is rapid. Longer intervals apply to breast milk and light meals, but clear liquids need only a short fast to reduce aspiration risk while improving patient comfort.

Question 2General Surgery Principles and Perioperative Care

Which wound classification applies to an operation entering the biliary tract under controlled conditions without unusual spillage?

  1. Contaminated
  2. Clean
  3. Dirty
  4. Clean-contaminated Correct answer.

Explanation

Clean-contaminated wounds are created when a controlled entry into a hollow viscus occurs without significant spillage of luminal contents. Elective biliary, gastrointestinal, and genitourinary procedures without gross contamination fall into this category. This classification predicts infectious risk and guides prophylactic antibiotic decisions.

Question 3General Surgery Principles and Perioperative Care

Which agent is the preferred reversal for a patient with residual neuromuscular blockade from rocuronium when rapid reversal is required?

  1. Flumazenil
  2. Naloxone
  3. Neostigmine
  4. Sugammadex Correct answer.

Explanation

Sugammadex is a selective relaxant binding agent that encapsulates rocuronium and vecuronium, producing rapid reversal even from deep blockade. Neostigmine works indirectly by inhibiting acetylcholinesterase and is unreliable when blockade is profound. Flumazenil and naloxone reverse entirely different drug classes.

Question 4General Surgery Principles and Perioperative Care

Which finding best indicates that a patient has adequate volume status before induction of anesthesia?

  1. A resting heart rate of 110 beats per minute
  2. A urine output of 0.5 mL/kg/h or more Correct answer.
  3. A systolic pressure that falls by 20 mmHg on standing
  4. Clear breath sounds bilaterally

Explanation

Urine output of at least 0.5 mL/kg/h suggests adequate renal perfusion and is a practical bedside marker of volume status. Tachycardia and orthostatic hypotension point toward hypovolemia, and clear breath sounds do not quantify circulating volume. Combining output with perfusion signs gives the most reliable assessment.

Question 5General Surgery Principles and Perioperative Care

Which suture material is most appropriate when permanent tensile strength is required in a fascial closure?

  1. Polypropylene Correct answer.
  2. Chromic catgut
  3. Polyglactin 910
  4. Silk

Explanation

Polypropylene is a nonabsorbable monofilament that retains tensile strength indefinitely and is commonly used for fascial closure when permanent support is desired. Absorbable sutures lose strength over weeks, and silk is a braided nonabsorbable material associated with higher infection risk. The choice should match the healing time of the tissue.

Question 6General Surgery Principles and Perioperative Care

Which monitor provides the earliest reliable detection of hypoxemia during procedural sedation?

  1. Pulse oximetry
  2. Electrocardiography
  3. Noninvasive blood pressure
  4. Capnography Correct answer.

Explanation

Capnography detects apnea and hypoventilation within seconds by measuring exhaled carbon dioxide, often before oxygen saturation falls. Pulse oximetry lags because of the oxygen reserve in the lungs and peripheral circulation time. Blood pressure and electrocardiography detect other problems but not early respiratory depression.

Question 7General Surgery Principles and Perioperative Care

Which vitamin deficiency most strongly predisposes a patient to poor wound healing and dehiscence?

  1. Vitamin C Correct answer.
  2. Vitamin K
  3. Vitamin B12
  4. Folate

Explanation

Vitamin C is a required cofactor for hydroxylation of proline and lysine during collagen synthesis, so deficiency impairs wound strength. Vitamin K and folate affect coagulation and erythropoiesis rather than collagen cross-linking. Vitamin B12 deficiency causes megaloblastic anemia and neuropathy but is not a primary cause of wound failure.

Question 8General Surgery Principles and Perioperative Care

Which finding in the immediate postoperative period most suggests hypovolemic shock rather than sepsis?

  1. Oliguria with cool extremities and tachycardia Correct answer.
  2. Bounding pulses with warm flushed skin
  3. Bradycardia with hypertension
  4. Fever with rigors and leukocytosis

Explanation

Hypovolemic shock produces decreased cardiac output with compensatory tachycardia, cool clammy extremities, and reduced urine output. Septic shock often presents with warm flushed skin and bounding pulses during the early hyperdynamic phase. Fever and leukocytosis favor infection, while bradycardia with hypertension suggests raised intracranial pressure or pain.

Question 9General Surgery Principles and Perioperative Care

A patient undergoes a long operation and develops a firm swollen calf with pain on passive dorsiflexion. What is the most appropriate initial diagnostic step?

  1. Bedside compression ultrasonography of the leg Correct answer.
  2. Contrast venography
  3. Immediate open thrombectomy
  4. D-dimer testing

Explanation

Compression ultrasonography is the first-line noninvasive test for suspected deep vein thrombosis and has high sensitivity for proximal clots. D-dimer is useful mainly to exclude thrombosis in low-risk patients but is often elevated after surgery. Contrast venography is invasive and reserved for equivocal cases.

Question 10General Surgery Principles and Perioperative Care

Which perioperative measure most effectively reduces the risk of surgical site infection in colorectal surgery?

  1. Administering prophylactic antibiotics within 60 minutes before incision Correct answer.
  2. Continuing antibiotics for seven days postoperatively
  3. Routine postoperative wound irrigation with hydrogen peroxide
  4. Shaving the surgical site the night before with a razor

Explanation

Timing prophylaxis so that tissue levels peak at incision reduces contamination at the moment of greatest risk. Prolonged postoperative antibiotics do not improve outcomes and promote resistance, while razor shaving the night before increases microtrauma and infection risk. Hydrogen peroxide irrigation is not evidence-based for infection prevention.

Question 11General Surgery Principles and Perioperative Care

Which patient is at highest risk of aspiration pneumonitis during induction of anesthesia?

  1. A fasting outpatient undergoing knee arthroscopy
  2. A patient scheduled for cataract surgery under topical anesthesia
  3. A patient with well-controlled hypertension
  4. A patient with a full stomach and small bowel obstruction Correct answer.

Explanation

Delayed gastric emptying with a distended stomach increases the volume and acidity of regurgitated material, raising aspiration risk. Fasting outpatients and patients under topical anesthesia have intact protective reflexes and low risk. Well-controlled hypertension does not impair airway protection.

Question 12General Surgery Principles and Perioperative Care

A patient on chronic prednisone therapy is undergoing major abdominal surgery. Which perioperative strategy is most appropriate?

  1. Provide supplemental stress-dose corticosteroids Correct answer.
  2. Abruptly discontinue the steroid on the morning of surgery
  3. Withhold all fluids until the patient can eat
  4. Delay surgery until the adrenal axis recovers

Explanation

Chronic glucocorticoid use suppresses the hypothalamic-pituitary-adrenal axis, and major surgery increases cortisol demand, so stress-dose supplementation prevents adrenal crisis. Abrupt withdrawal risks hypotension and shock, and delaying surgery indefinitely is unnecessary. Maintenance fluids are continued as clinically indicated.

Question 13General Surgery Principles and Perioperative Care

Which fluid is most appropriate for initial resuscitation of a young adult with acute massive hemorrhage before blood products are available?

  1. 0.9% sodium chloride in large volumes
  2. Hypertonic saline
  3. 5% dextrose in water
  4. Balanced crystalloid solution Correct answer.

Explanation

Balanced isotonic crystalloids approximate plasma composition and avoid the hyperchloremic acidosis seen with large-volume normal saline. Dextrose solutions provide free water and do not expand the intravascular space effectively. Hypertonic saline is reserved for specific indications such as raised intracranial pressure.

Question 14General Surgery Principles and Perioperative Care

Which statement about the acute pain service and multimodal analgesia after major surgery is most accurate?

  1. Scheduled acetaminophen and regional blocks reduce opioid requirements Correct answer.
  2. Patient-controlled analgesia eliminates the need for respiratory monitoring
  3. Nonsteroidal anti-inflammatory drugs are contraindicated in all postoperative patients
  4. Opioids should be the sole analgesic modality to simplify monitoring

Explanation

Multimodal analgesia combines agents and techniques with different mechanisms, allowing lower opioid doses and fewer opioid-related adverse effects. Regional blocks and scheduled acetaminophen are core components, while patient-controlled analgesia still requires monitoring for respiratory depression. Nonsteroidal anti-inflammatory drugs are avoided only in specific situations such as renal impairment or bleeding risk.

Question 15General Surgery Principles and Perioperative Care

A patient develops fever, tachycardia, and wound erythema on postoperative day four after a clean-contaminated operation. Which action is most appropriate?

  1. Reassure the patient that postoperative fever is always benign
  2. Open the wound and obtain cultures before starting antibiotics Correct answer.
  3. Start broad-spectrum antibiotics without further evaluation
  4. Obtain blood cultures and observe for 48 hours

Explanation

A wound infection with systemic signs requires source control, which means opening the incision to drain the collection and sending fluid for culture. Antibiotics alone are insufficient when an undrained collection exists, and observation delays necessary treatment. Cultures guide subsequent therapy.

Question 16General Surgery Principles and Perioperative Care

Which factor most increases the risk of postoperative nausea and vomiting in a nonsmoking woman undergoing laparoscopic surgery?

  1. Intraoperative use of dexamethasone
  2. Regional anesthesia instead of general anesthesia
  3. Use of total intravenous anesthesia with propofol
  4. A history of motion sickness Correct answer.

Explanation

Female sex, nonsmoking status, and a history of motion sickness or prior postoperative nausea and vomiting are established patient risk factors. Propofol-based total intravenous anesthesia and dexamethasone are preventive strategies that lower risk. Regional anesthesia generally reduces the risk compared with general anesthesia.

Question 17General Surgery Principles and Perioperative Care

Which preoperative cardiac evaluation is indicated before elective surgery in an asymptomatic patient who can climb two flights of stairs without symptoms?

  1. Exercise stress testing for all patients
  2. Echocardiography for every patient over 50 years
  3. Routine coronary angiography
  4. No further cardiac testing beyond clinical assessment Correct answer.

Explanation

Good functional capacity without symptoms indicates low perioperative cardiac risk, and routine stress testing or angiography is not indicated. Testing is reserved for patients with poor or unknown functional capacity and risk factors that would change management. Clinical assessment remains the foundation of preoperative evaluation.

Question 18General Surgery Principles and Perioperative Care

A patient with cirrhosis and ascites requires elective hernia repair. Which preoperative consideration most influences perioperative risk?

  1. The choice of surgical drain
  2. The presence of ascites and Child-Pugh class Correct answer.
  3. The patient's blood type
  4. The type of suture used for skin closure

Explanation

In cirrhosis, the presence of ascites and the Child-Pugh or MELD score strongly predict postoperative decompensation, infection, and mortality. Ascites increases wound leakage and hernia recurrence and should be optimized before elective surgery. Suture choice, blood type, and drain selection have little effect on overall risk.

Question 19General Surgery Principles and Perioperative Care

Which change in a postoperative patient best meets the criteria for systemic inflammatory response syndrome?

  1. Temperature 36.0 C, heart rate 60, respiratory rate 12, white cells 5
  2. Temperature 37.0 C, heart rate 70, respiratory rate 14, white cells 6
  3. Temperature 38.5 C, heart rate 96, respiratory rate 24, white cells 14 Correct answer.
  4. Temperature 37.5 C, heart rate 80, respiratory rate 16, white cells 9

Explanation

Systemic inflammatory response syndrome requires at least two of fever or hypothermia, tachycardia, tachypnea, and abnormal white cell count. A temperature above 38 C, heart rate above 90, respiratory rate above 20, and leukocytosis satisfy several criteria. The other sets fall within normal ranges.

Question 20General Surgery Principles and Perioperative Care

A patient is scheduled for surgery and takes warfarin for atrial fibrillation. Which perioperative plan is most appropriate when the bleeding risk of the procedure is high?

  1. Stop warfarin and give vitamin K to reverse immediately
  2. Switch to aspirin without interruption
  3. Stop warfarin and bridge with low-molecular-weight heparin Correct answer.
  4. Continue warfarin at full dose through surgery

Explanation

For high bleeding-risk procedures, warfarin is stopped several days before surgery and bridging with low-molecular-weight heparin maintains anticoagulation in patients with high thromboembolic risk. Continuing full-dose warfarin causes major bleeding, and routine vitamin K reversal is reserved for urgent situations. Aspirin does not substitute for anticoagulation in atrial fibrillation.

Question 21General Surgery Principles and Perioperative Care

A patient develops oliguria and rising creatinine on the second postoperative day after aortic surgery. Which mechanism most likely explains the renal injury?

  1. Acute interstitial nephritis from suture material
  2. Prerenal azotemia from hypovolemia and ischemia-reperfusion injury Correct answer.
  3. Postrenal obstruction from a urinary catheter
  4. Chronic glomerulonephritis unrelated to surgery

Explanation

Aortic surgery may involve aortic cross-clamping, ischemia-reperfusion, and periods of hypovolemia or hypotension that reduce renal perfusion and cause acute tubular injury. Prerenal and ischemic tubular injury are the dominant mechanisms in this setting. Suture material does not cause interstitial nephritis, and a functioning catheter argues against obstruction.

Question 22General Surgery Principles and Perioperative Care

Which acid-base disturbance is most characteristic of prolonged vomiting with loss of gastric hydrochloric acid?

  1. Metabolic alkalosis with hypochloremia and hypokalemia Correct answer.
  2. Metabolic acidosis with a high anion gap
  3. Respiratory acidosis with hypercapnia
  4. Metabolic acidosis with hyperkalemia

Explanation

Loss of gastric hydrogen and chloride ions produces a hypochloremic metabolic alkalosis, and volume depletion drives renal potassium wasting with hypokalemia. The urine becomes paradoxically acidic as the kidney prioritizes sodium conservation. High anion gap acidosis and hyperkalemia are seen with other processes such as renal failure.

Question 23General Surgery Principles and Perioperative Care

A patient with a history of malignant hyperthermia requires general anesthesia. Which approach is safest?

  1. Premedicate with dantrolene and proceed with halothane
  2. Use succinylcholine with volatile agents and monitor temperature
  3. Use sevoflurane at low concentration without monitoring
  4. Avoid triggering agents and use a clean anesthesia machine with total intravenous anesthesia Correct answer.

Explanation

Malignant hyperthermia is triggered by volatile anesthetics and depolarizing relaxants, so a trigger-free technique using total intravenous anesthesia with propofol and a nondepolarizing relaxant is preferred. Preparing a machine free of residual volatile agent reduces exposure. Dantrolene is the treatment for an episode rather than a routine premedication for trigger avoidance.

Question 24General Surgery Principles and Perioperative Care

A patient becomes hypotensive and tachycardic after a central line placement during surgery, with tracheal deviation and absent breath sounds on one side. Which step should be taken first?

  1. Obtain a chest radiograph to confirm the diagnosis
  2. Needle decompression of the affected hemithorax Correct answer.
  3. Start broad-spectrum antibiotics
  4. Administer a fluid bolus and observe

Explanation

Tension pneumothorax is a clinical diagnosis requiring immediate needle decompression, followed by tube thoracostomy, without waiting for imaging. Delay for radiography or observation can lead to cardiovascular collapse. Antibiotics and fluid boluses do not address the mechanical obstruction to venous return.

Question 25General Surgery Principles and Perioperative Care

A patient with severe acute pancreatitis and infected necrosis deteriorates despite antibiotics. Which principle best guides surgical management?

  1. Perform total pancreatectomy as the first procedure
  2. Delay intervention when feasible and use a step-up approach starting with drainage Correct answer.
  3. Immediate open necrosectomy within 24 hours of admission
  4. Avoid all drainage procedures in infected necrosis

Explanation

A step-up approach beginning with percutaneous or endoscopic drainage and reserving necrosectomy for failure delays surgery until collections are organized and reduces morbidity and mortality. Immediate open necrosectomy carries high physiologic stress and complication rates. Total pancreatectomy is not a standard treatment for infected necrosis.

Question 26General Surgery Principles and Perioperative Care

Which hemodynamic parameter is the most direct bedside indicator of adequate volume status after major surgery?

  1. Serum lactate measured once on arrival in recovery
  2. Central venous pressure trend over twelve hours
  3. Response of stroke volume to a passive leg raise Correct answer.
  4. Urine specific gravity from a single specimen

Explanation

A passive leg raise transiently shifts pooled venous blood into the thorax, and a rise in stroke volume or cardiac output indicates that the heart is operating on the steep portion of its Frank-Starling curve and will respond to volume. It is dynamic and reversible, so it predicts fluid responsiveness better than static pressures. Single measurements of lactate or urine specific gravity describe a moment in time and cannot establish whether additional volume will help.

Question 27General Surgery Principles and Perioperative Care

Which perioperative intervention most reliably prevents atelectasis and pulmonary complications after elective open upper abdominal surgery?

  1. Incentive spirometry combined with early mobilization and adequate analgesia Correct answer.
  2. Routine postoperative nasogastric decompression until flatus
  3. Routine prophylactic antibiotics continued for five days
  4. Bed rest with oxygen by nasal cannula for the first two days

Explanation

Lung expansion maneuvers such as incentive spirometry, together with early ambulation and pain control that permits deep breathing and coughing, reduce postoperative atelectasis and pneumonia. These measures address the underlying mechanisms of reduced tidal volume, splinting, and retained secretions. Prolonged antibiotics, bed rest, and routine decompression do not improve respiratory mechanics and carry their own harms.

Question 28General Surgery Principles and Perioperative Care

A 62-year-old man with Child-Pugh class B cirrhosis and a small umbilical hernia presents with recurrent incarceration. Which factor most strongly determines his perioperative mortality risk?

  1. The length of the planned skin incision
  2. The diameter of the hernia defect on examination
  3. The presence of ascites and its medical control Correct answer.
  4. The type of mesh material selected for repair

Explanation

In cirrhosis, the presence of ascites is a dominant driver of perioperative morbidity and mortality because it worsens wound healing, predisposes to leakage and infection, and contributes to hepatic decompensation. Optimizing ascites control and nutritional and metabolic status before elective repair improves outcomes. Defect size, mesh choice, and incision length are secondary technical considerations.

Question 29General Surgery Principles and Perioperative Care

A patient with a body mass index of 46 kg/m2 is undergoing laparoscopic cholecystectomy. Which perioperative strategy best reduces the risk of postoperative pulmonary complications?

  1. Using lung-protective ventilation with recruitment and early ambulation Correct answer.
  2. Extubating in the supine position without head-up positioning
  3. Restricting opioid analgesia to the point of moderate pain
  4. Placing a routine abdominal drain to reduce diaphragmatic splinting

Explanation

In obese patients, intraoperative lung-protective ventilation with appropriate positive end-expiratory pressure and recruitment maneuvers, combined with early mobilization and adequate analgesia, limits atelectasis and improves oxygenation. Opioid-sparing multimodal analgesia supports deep breathing. Positioning and drains do not substitute for these measures.

Question 30General Surgery Principles and Perioperative Care

A 70-year-old woman with chronic kidney disease (baseline creatinine 2.1 mg/dL) is undergoing elective hemicolectomy. Which perioperative plan best balances her risks of acute kidney injury and volume overload?

  1. Liberal crystalloid at 15 mL/kg/h throughout the case with routine furosemide
  2. Goal-directed fluid therapy guided by stroke volume variation with avoidance of nephrotoxins Correct answer.
  3. Fixed low-dose dopamine infusion to preserve renal perfusion
  4. Withholding all intravenous fluid until urine output falls below 0.3 mL/kg/h

Explanation

In chronic kidney disease, goal-directed fluid administration avoids both hypovolemia and overload, and avoiding nephrotoxic agents such as NSAIDs and aminoglycosides preserves residual function. Dynamic indices of fluid responsiveness help titrate therapy in patients whose kidneys cannot readily excrete a sodium and water load. High-volume fluid, dopamine, and deliberate fluid restriction until oliguria develops all increase harm.

Question 31Gastrointestinal Surgery

A 45-year-old man presents with epigastric pain, fever, and jaundice. Imaging shows a stone in the common bile duct. What is the most appropriate initial management for choledocholithiasis with cholangitis?

  1. Percutaneous transhepatic cholangiography
  2. Immediate open common bile duct exploration
  3. Oral ursodeoxycholic acid therapy
  4. Endoscopic retrograde cholangiopancreatography with sphincterotomy Correct answer.

Explanation

Acute cholangitis from choledocholithiasis is best managed initially by endoscopic biliary drainage, typically ERCP with sphincterotomy and stone extraction, combined with antibiotics and resuscitation. Surgery is reserved for failure of endoscopic therapy or specific anatomic situations.

Question 32Gastrointestinal Surgery

Which organism is most commonly associated with gastric adenocarcinoma and mucosa-associated lymphoid tissue lymphoma?

  1. Campylobacter jejuni
  2. Clostridium difficile
  3. Helicobacter pylori Correct answer.
  4. Escherichia coli

Explanation

Helicobacter pylori is a class I carcinogen and is strongly linked to both distal gastric adenocarcinoma and gastric MALT lymphoma. Eradication can induce regression of early MALT lymphoma.

Question 33Gastrointestinal Surgery

A 30-year-old man has a tender right inguinal swelling that reduces spontaneously when lying down. What is the most likely diagnosis?

  1. Indirect inguinal hernia Correct answer.
  2. Femoral hernia
  3. Hydrocele
  4. Strangulated hernia

Explanation

A reducible, tender inguinal swelling in a young man is most consistent with an indirect inguinal hernia, which passes through the deep inguinal ring. Femoral hernias occur below the inguinal ligament and are more common in older women.

Question 34Gastrointestinal Surgery

What is the most common cause of acute pancreatitis worldwide?

  1. Alcohol
  2. Hypertriglyceridemia
  3. Trauma
  4. Gallstones Correct answer.

Explanation

Gallstones and alcohol are the two leading causes of acute pancreatitis, with gallstones being the most common overall in most populations. Hypertriglyceridemia and trauma are less frequent causes.

Question 35Gastrointestinal Surgery

A patient presents with a painful anal fissure located in the posterior midline. What is the most likely underlying mechanism?

  1. Infection with herpes simplex virus
  2. Ischemia from internal anal sphincter spasm Correct answer.
  3. Anal carcinoma
  4. Crohn disease

Explanation

Most primary anal fissures occur in the posterior midline and are thought to result from trauma and ischemia related to internal anal sphincter hypertonia. Lateral or multiple fissures raise suspicion for secondary causes such as Crohn disease, infection, or malignancy.

Question 36Gastrointestinal Surgery

Which finding best supports a diagnosis of acute appendicitis on physical examination?

  1. Pain relief with hip flexion
  2. Hyperactive bowel sounds with diarrhea
  3. Rebound tenderness at McBurney point Correct answer.
  4. Diffuse abdominal tenderness

Explanation

Localized tenderness with rebound at McBurney point reflects parietal peritoneal irritation over the inflamed appendix. Diffuse tenderness or diarrhea suggests alternative diagnoses such as gastroenteritis.

Question 37Gastrointestinal Surgery

A 60-year-old woman has painless jaundice and a palpable gallbladder. Which diagnosis should be suspected?

  1. Periampullary malignancy Correct answer.
  2. Acute cholecystitis
  3. Choledochal cyst
  4. Gallstone ileus

Explanation

Painless jaundice with a palpable, distended gallbladder (Courvoisier sign) suggests malignant obstruction of the distal common bile duct, such as pancreatic head or periampullary cancer. Gallstones usually cause a fibrotic, non-distensible gallbladder.

Question 38Gastrointestinal Surgery

Which of the following is the most appropriate first-line treatment for an uncomplicated bleeding internal hemorrhoid that has failed conservative therapy?

  1. Lateral internal sphincterotomy
  2. Hemorrhoidectomy
  3. Rubber band ligation Correct answer.
  4. Fistulotomy

Explanation

Rubber band ligation is an effective office-based treatment for grade II and III internal hemorrhoids that do not respond to dietary and lifestyle measures. Surgical hemorrhoidectomy is reserved for higher-grade or refractory disease.

Question 39Gastrointestinal Surgery

A 55-year-old man has a 3 cm ulcerated lesion in the distal rectum. What is the most appropriate staging investigation before treatment planning?

  1. Barium enema
  2. Endoscopic ultrasound and pelvic MRI Correct answer.
  3. Serum CEA alone
  4. Colonoscopy alone

Explanation

Local staging of rectal cancer relies on endoscopic ultrasound for early lesions and pelvic MRI for depth of invasion and nodal status. Cross-sectional imaging guides neoadjuvant therapy decisions.

Question 40Gastrointestinal Surgery

A patient with cirrhosis presents with hematemesis from esophageal varices. Which medication is used to reduce portal pressure acutely?

  1. Propranolol
  2. Vitamin K
  3. Octreotide Correct answer.
  4. Pantoprazole

Explanation

Octreotide, a somatostatin analog, reduces splanchnic blood flow and portal pressure acutely in variceal hemorrhage. Non-selective beta blockers such as propranolol are used for prophylaxis, not the acute bleed.

Question 41Gastrointestinal Surgery

Which feature most strongly suggests a malignant gastric ulcer rather than a benign one?

  1. Presence of Helicobacter pylori
  2. Smooth, regular margins with radiating folds
  3. Rapid healing with proton pump inhibitors
  4. Heaped, irregular edges with a nodular base Correct answer.

Explanation

Malignant gastric ulcers typically show heaped, irregular, nodular margins with an uneven base and fail to heal with medical therapy. Benign ulcers have smooth, punched-out margins with radiating folds.

Question 42Gastrointestinal Surgery

A 40-year-old woman has a 2 cm thyroid nodule and a family history of medullary thyroid carcinoma. Which test is most specific for this tumor?

  1. Anti-thyroglobulin antibodies
  2. TSH level
  3. Serum calcitonin Correct answer.
  4. Serum thyroglobulin

Explanation

Medullary thyroid carcinoma arises from parafollicular C cells and secretes calcitonin, making serum calcitonin a specific marker. Thyroglobulin is used to monitor differentiated thyroid cancer, not medullary carcinoma.

Question 43Gastrointestinal Surgery

A patient develops fever, tachycardia, and abdominal pain 5 days after a right hemicolectomy. CT shows a fluid collection near the anastomosis. What is the most appropriate next step?

  1. Observation alone
  2. Immediate reoperation with anastomotic takedown
  3. Oral antibiotics as an outpatient
  4. Percutaneous drainage of the collection with antibiotics Correct answer.

Explanation

A postoperative intra-abdominal abscess without generalized peritonitis is best managed by image-guided percutaneous drainage combined with antibiotics. Surgery is reserved for anastomotic dehiscence with peritonitis or failed drainage.

Question 44Gastrointestinal Surgery

Which finding is most characteristic of acute mesenteric ischemia on CT angiography?

  1. Pneumatosis intestinalis with portal venous gas Correct answer.
  2. Contrast enhancement of the bowel wall
  3. Fat stranding confined to the right lower quadrant
  4. Dilated fluid-filled colon with haustra

Explanation

Advanced acute mesenteric ischemia shows bowel wall ischemia with pneumatosis intestinalis and portal venous gas. CT angiography demonstrating an arterial or venous occlusion is diagnostic.

Question 45Gastrointestinal Surgery

A 65-year-old man has a 4 cm abdominal aortic aneurysm. What is the recommended management?

  1. No follow-up required
  2. Ultrasound surveillance every 6-12 months Correct answer.
  3. Immediate open repair
  4. Endovascular repair now

Explanation

Aneurysms between 4.0 and 5.4 cm are managed with regular surveillance imaging, typically every 6 to 12 months, along with risk factor modification. Repair is generally considered when the diameter reaches 5.5 cm or grows rapidly.

Question 46Gastrointestinal Surgery

Which is the most common cause of small bowel obstruction in adults with no prior abdominal surgery?

  1. Hernia
  2. Malignancy Correct answer.
  3. Crohn stricture
  4. Adhesions

Explanation

In patients without prior surgery, malignancy is the leading cause of small bowel obstruction, whereas adhesions predominate in those with previous abdominal operations. Hernias and inflammatory strictures are less common.

Question 47Gastrointestinal Surgery

A 25-year-old man has a fistula-in-ano with a tract passing through the internal and external sphincters. What is the best initial surgical approach?

  1. Lateral internal sphincterotomy
  2. Seton placement Correct answer.
  3. Proctocolectomy
  4. Fistulotomy with sphincter division

Explanation

A transsphincteric fistula involving significant sphincter muscle is best initially managed with a draining seton to allow drainage and reduce the risk of incontinence before definitive repair. Fistulotomy risks incontinence when substantial sphincter is involved.

Question 48Gastrointestinal Surgery

A patient with a gastric outlet obstruction from peptic ulcer disease has persistent vomiting. Which metabolic abnormality is most likely?

  1. Metabolic alkalosis with hypokalemia Correct answer.
  2. High anion gap acidosis
  3. Metabolic acidosis with hyperkalemia
  4. Respiratory alkalosis

Explanation

Persistent vomiting of gastric contents loses hydrogen and chloride, causing a hypochloremic metabolic alkalosis with paradoxical aciduria and hypokalemia. Volume depletion and potassium loss contribute to the alkalosis.

Question 49Gastrointestinal Surgery

Which is the most appropriate treatment for a symptomatic gallstone in a patient with sickle cell disease and recurrent crises?

  1. ERCP with sphincterotomy
  2. Observation until symptoms persist
  3. Oral bile acid dissolution
  4. Elective laparoscopic cholecystectomy Correct answer.

Explanation

Symptomatic cholelithiasis in sickle cell disease warrants elective cholecystectomy to prevent recurrent biliary complications and crises. Surgery is ideally performed during a stable period with hematologic optimization.

Question 50Gastrointestinal Surgery

A 70-year-old man has painless hematuria and a right-sided colon mass. Which syndrome should be considered?

  1. Gardner syndrome
  2. Familial adenomatous polyposis
  3. Peutz-Jeghers syndrome
  4. Lynch syndrome Correct answer.

Explanation

Lynch syndrome (hereditary nonpolyposis colorectal cancer) is associated with right-sided colon cancer and extraintestinal malignancies including urothelial and endometrial cancers. It results from mismatch repair gene mutations.