\\\\ What is the most important factor in endemic goiter?

\\\ stimulation of the thyroid gland by TSH; \\\ micro adenoma in the anterior pituitary; \\ dietary deficiency of iodine; \\\ high level of TRH in serum; \\\ high concentration of thyroid stimulation antibodies in serum. \\\\ The metabolic effects of the thyroid hormones are due to: \\\ T !T" bound to albumin; \\\ T !T" bound to thyro#ine binding globuline $T%&'; \\\ T !T" bound to thyro#ine binding prealbumine $T%()'; \\ unbound free T !T"; \\\ all ans*ers are correct. \\\\ +linical types of thyroto#icosis are all, e#cept \\\ diffuse to#ic goitre $&rave-s disease'; \\\ to#ic nodular goitre; \\ endemic goitre; \\\ to#ic nodule; \\\ hyperthyroidism due to rare causes. \\\\ The most significant signs of thyroto#icosis are all, e#cept \\\ goitre; \\\ e#ophthalmos; \\\ cardiac arrhythmia; \\ bradycardia; \\\ loss of *eight in spite of good appetite. \\\\ When an isotope scan before preoperative preparation is necessary? \\\ in patients *ith to#ic nodular goitre if total thyroidectomy is planed; \\ in patients *ith to#ic nodular goitre if total thyroidectomy is not planed; \\\ in patients *ith diffuse to#ic goitre if total thyroidectomy is planed; \\\ in patients *ith diffuse to#ic goitre if total thyroidectomy is not planed; \\\ in all cases. \\\\The e#tent of the resection of the thyroid gland not depends on: \\\ the si.e of the gland; \\\ the age of the patient; \\ the se# of patient; \\\ the e#perience of the surgeon; \\\ the need to minimi.e the ris/ of recurrent to#icity. \\\\ 0f a thyroto#ic patient has been inade1uately prepared for thyroidectomy, it occures: \\\ haemorrhage; \\\ recurrent laryngeal nerve paralysis; \\\ parathyroid insufficiency;

\\ thyroto#ic crisis; \\\ *ound infection. \\\\ Wich of the primary malignant tumors of the thyroid gland occures more fre1uently? \\ papillary carcinoma; \\\ follicular carcinoma \\\ anaplastic carcinoma; \\\ medulary carcinoma; \\\ malignant lymphoma. \\\\ %enign breast disorders are all, e#cept \\\ cyclical nodularity and mastalgia; \\\ fibroadenoma; \\\ galactocelle; \\ (aget2s disease; \\\ Tiet.e2s disease. \\\\ Which form of the breast cancer presents as a painful, s*ollen breast, *hich is *arm *ith cutaneous oedema: \\\ ductal carcinoma; \\\ lobular carcinoma; \\\ colloid carcinoma; \\\ medullary carcinoma; \\ inflammatory carcinoma. \\\\ Triple assessment of breast symptoms give confident diagnosis in \\\ 34!356 of cases; \\\ 74!756 of cases; Examination. A doctor or nurse asks about
your medical history and examines your breast. Imaging. Pictures of the inside of your breast are made using ultrasound, X-rays or a combination of both. Needle biopsy. A sample of your breast tissue is remo ed and sent to a laboratory for testing to find out !hether the lump is cancerous "malignant# or non-cancerous "benign#.

\\\ 84!856 of cases; \\ 54!556 of cases; \\\ 44!456 of cases; \\\\ Which form of the breast carcinoma presents as an ec.ema!li/e condition of the; nipple and areola *hich persists in spite of local treatment? \\\ lobular carcinoma; \\\ inflammatory carcinoma \\ (aget2s disease; \\\ medullary carcinoma; \\\ ductal carcinoma; \\\\ The second stage of breast cancer T9:;<= means:

\\ tumor si.e 9!4 cm, mobile a#illary metastases, no /no*n distant metastases; \\\ tumor si.e 9!4 cm, no nodal metastases, no /no*n distant metastases; \\\ tumor si.e >9cm, no nodal metastases, no /no*n distant metastases; \\\ tumor si.e ?4cm, mobile a#illary metastases, no /no*n distant metastases; \\\ tumor si.e ?4cm, fi#ed a#illary metastases, distant metastases;. \\\\ ) 4!year!old premenopausal *oman *hose mother had breast cancer comes into your office and has been told that she has fibrocystic breasts. @n e#amination she has multiple areas of thic/ening but no discrete mass. @f the follo*ing diagnostic tests, *hich should be performed? \\\ Re!e#amination in 3 months \\\ %ilateral breast ultrasound \\\ Thermography \\ %ilateral breast magnetic resonance imaging $<R0' *ith gadolinium \\\ Spot compression vie*s if an area of discrete asymmetry or concerning calcifications is seen \\\\ )"=!year!old la*yer comes into your office after seeing some information on the 0nternet relating to breast cancer. Which of the follo*ing factors has not sho*n to increase a *oman2s ris/ for breast cancer? \\ Smo/ing \\\ (revious history of benign breast biopsies \\\ )typia seen on pathology from previous breast biopsy \\\ Airst!degree relative *ith history of breast cancer \\\ 0ncreasing age \\\\ ) partially blind 34!year!old mother presents *ith a slight change in color of the

areola of her left breast. )n ec.ematous rash of the left areola has persisted for the last months. %iopsy of the nipple reveals (aget2s disease. 0n (aget2s disease of the nipple *hich of the follo*ing is TRBC? \\\ +arcinoma of the breast is rarely found. \\\ Surgical therapy often fails to cure (aget2s disease. \\ The diagnosis should be made by nipple biopsy *hen suspected. \\\ The underlying carcinoma *hen present is very large.

\\\ (aget2s disease of the bone is commonly encountered. \\\\ )4=!year!old patient has recently undergone a mastectomy for a 9.4!cm multicentric breast cancer *ith three positive a#illary lymph nodes $stage 00%'. ) metastatic survey is done, and is negative, and she receives adDuvant chemotherapy. The most common site for distant metastasis *ould be: \\\ %rain \\ %one \\\ Eung \\\ &astrointestinal tract \\\ Eiver \\\\ )"4!year!old premenopausal *oman undergoes a left breast lumpectomy for a ;.4! cm, lymph node positive, hormone sensitive invasive breast cancer. She receives chemotherapy, radiotherapy, and is on tamo#ifen. Recommended follo*!up after therapy should al*ays include: \\\ %lood tumor mar/ers dra*n every F3 months after treatment. \\\ Routine monitoring of liver function tests $EATs' every F3 months after treatment. \\\ Gearly bone scans. \\ Routine clinical e#amination every F3 months for the first 4 years after treatment as *ell as continued yearly mammography. \\\ Gearly breast <R0 *ith gadolinium. \\\\ Which is the most *idely used Hhormonal2 treatment in breast cancer? \\\ prednisolon; \\ tamo#ifen; $amoxifen is the usual endocrine "anti-estrogen# therapy for hormone receptorpositi e breast cancer in pre-menopausal !omen, and is also a standard in post-menopausal !omen althougharomatase inhibitors are also fre%uently used in that setting

\\\ cyclophosphamide; \\\ metotre#ate; \\\ 4!ftourouracil. \\\\ The commonest symptom of the gastro!oesophageal reflu# disease $&@RI' are: \\ heartburn and epigastric pain; \\\ odynophagia; \\\ dysphagia; \\\ angina!li/e chest pain; \\\ aphonia. \\\\ What operation *e usually use for treating &@RI? \\\ gastrostomy; \\\ subtotal oesophagectomy; \\ fundoplication by :issen; \\\ gastectomy; \\\ gastric resection by %ilroth 00. \\\\ +linical features of cancer of the oesophagus are:

\\\ dysphagia; \\\ *eight loss; \\\ dyspeptic symptoms; \\\ hoarseness; \\ all ans*ers are correct. \\\\ &astro!oesophageal reflu# follo*ing oesophagogastric resection may be limited or avoided by: \\\ subtotal oesophagectomy and gastric transposition high in the chest; \\\ resection of a generous portion of pro#imal stomach if an anastomosis is made to the lo*er oesophagus; \\\ Rou#!en!G reconstruction *ith a long ascending DeDunal limb $4=!3=cm'; \\\ interposition of DeDunum or colon; \\ all ans*ers are correct. \\\\ %arium radiology sho*ing a tapering stricture in the distal oesophagus, described as a bird2s bea/, is the sign of: \\\ gastro!oesophageal reflu# disease $&@RI'; \\ achalasia; \\\ oesophageal diverticula; \\\ cancer of the oesophagus; \\\ %arrett2s oesophagus. \\\\ Which is the commonest diverticulum affecting the region of the oesophagus? \\ Jen/er2s diverticulum; \\\ mid!oesophageal diverticula; \\\ epiphrenic divereticula, \\\ diffuse intramural pseudodiverticulosis; \\\ all ans*ers are incorrect. \\\\ Eeft gastric artery is a branch of: \\\ common hepatic artery; \\\ left hepatic artery; \\\ splenic artery, \\\ left gastroepiploic artery; \\ celiac a#is. \\\\ What is the Kgold standardL to investigate and image the stomach and duodenum? \\\ contrast radiology; \\ fle#ible endoscopy; \\\ ultrasonography; \\\ +T and <R0 \\\ laparoscopy. \\\\ +ommon sites of peptic ulcers are: \\\ grate curve of the stomach;

\\\ fundus of the stomach; \\ first part of the duodenum and the lesser curve of the stomach; \\\ stoma follo*ing gastric surgery; \\\ oesophagus. \\\\ The important factors in the development of peptic ulceration are all, e#cept \\\ helicobacter pylori; \\\ ingestion of :S)0Is; \\ ingestion of ((0s; \\\ stress factors; \\\ gastrinoma. \\\\ Which is the one of the classical features of untreated peptic ulceration: \\\ vomiting; \\\ alteration in *eight; \\ periodicity; \\\ chest pain; \\\ dysphagia. \\\\ <edical treatment of uncomplicated peptic ulcer aimed to reduce gastric acid secretion, using: \\\ :S)0Is, \\ H9!receptor antagonists; \\\ prednisolone; \\\ histamine; \\\ all ans*ers are incorrect. \\\\ <ar/edly high per cent of recurrent ulceration follo*ing duodenal ulcer operations occurs after: \\\ gastrectomy; \\ gastroenterostomy only; \\\ truncal vagotomy and drainage; \\\ selective vagotomy and drainage; \\\ highly selective vagotomy. \\\\ <ost common place of locali.ation of the upper gastrointestinal tract cancer, is: \\\ mid!oesophagus, \\ lo*er oesophagus and cardia, \\\ body of the stomach; \\\ antrum; \\\ pylorus. \\\\ Carly gastric cancer is defined as cancer: \\ limited to the mucosa and submucosa *ith or *ithout limph node involvement $T;, any :'; \\\ invades muscularis or subserosa *ith or *ithout limph node involvement$T9, any :';

\\\ invades mucosa, muscularis and serosa *ith or *ithout limph node involvement $T any :'; \\\ invades adDacent organs *ith or *ithout limph node involvement $T", any :'; \\\ all ans*ers are incorrect. \\\\ Which is radical operation for tumors distally placed in the stomach? \\\ gastrostomy; \\\ gastroenterostomy; \\\ truncal vagotomy and drainage; \\ subtotal gastrectomy; \\\ highly selective vagotomy *ith gastroenterostomy; \\\\The common site for primary gastrinoma $Jollinger!Cllison syndrome' is: \\\ cardia; \\\ body of the stomach; \\\ antrum; \\\ pylorus. \\ duodenum. \\\\ Se1uelae of peptic ulcer surgery are all, e#cept \\\ small stomach syndrome; \\\ bile vomiting; \\\ early and late dumping; \\\ gallstones; \\ Jollinger!Cllison syndrome. \\\\ What is this late dumping? \\ reactive hypoglycemia; \\\ reactive hyperglycemia; \\\ se1uestration of fluid from circulation into the gastrointestinal tract; \\\ hypernatremia; \\\ hypo/alemia. \\\\ Routinely tests of liver functions are all, e#cept \\\ al/aline phosphatase $)E('; \\\ aspartate transaminase $)ST'; \\\ gamma!glutamyl transpeptidase $&&T'; \\\ albumin; \\ glucose. \\\\ The current Kgold standardL for liver imaging is: \\\ ultrasound; \\ triple!phase spiral computerised tomography $+T'; \\\ magnetic resonance imaging $<R0'; \\\ endoscopic retrograde cholangiopancreatography $CR+('; \\\ angiography.

\\\\ (ortal hypertension may be presents in patients *ith: \\\ liver cirrhosis; \\\ e#trahepatic portal vein occlusion; \\\ intrahepatic veno!oclusive disease; \\\ occlusion of the main hepatic veins $%+S'; \\ in all cases. \\\\ The most common site for variceal bleeding is: \\\ upper part of oesophagus; \\\ mid!oesophagus; \\ lo*er oesophagus; \\\ antrum; \\\ duodenum. \\\\ When *e use an endos1opic techni1ue for management of bleeding varices: \\\ to insert %la/emore tube \\ to ma/e sclerotherapy; \\\ insertion of a transDugular intrahepatic portosystemic stent shunts $T0(SS'; \\\ to perform splenorenal shunts; \\\ in all this cases using of endoscopic techni1ue are necessary. \\\\ The different types of surgical shunts are all, e#cept \\\ side! to!side porto!caval anastomosis; \\\ end!to!side porto!caval anastomosis; \\\ meso!caval anastomosis; \\ meso!portal anastomosis; \\\ spleno!renal anastomosis; \\\\ %udd!+hiari syndrome is a: \\ thrombosis or obstruction of hepatic veins; \\\ thrombosis or obstruction of portal vein; \\\ thrombosis or obstruction of lienal vein; \\\ thrombosis or obstruction upper mesenteric vein; \\\ all this pathological conditions causes %udd!+hiari syndrome. \\\\ The congenital dilatation of the intrahepatic biliary tree *hich is often complicated by the presence of intrahepatic stone formation is: \\\ primary sclerosing cholangitis $(S+'; \\\ primary biliary cirrhosis $(%+'; \\ +aroli2s disease; \\\ simple cystic disease; \\\ polycystic liver disease. \\\\ (atients *ith clinical signs of an amoebic liver abscess *ill be treated empirically *ith:

\\\ penicillin; \\\ ceftria#one; \\\ prednisolone; \\ metronida.ole; \\\ combination of antibiotics and prednisolone. \\\\ )moebic liver abscess is cause by: \\\ Streptococcus; \\\ Cscherichia coli; \\\ (roteus vulgaris; \\ Cntamoeba histolytica; \\\ Mlebsiella. \\\\ The spleen has several functions, e#cept \\\ immune function; \\\ filter function, \\\ reservoir function; \\\ iron reutilisation; \\ drag and hormone metabolism. \\\\ Haematological investigations using during the haemolitic anaemias are all, e#cept \\\ the fragility test; \\\ the reticulocyte count; \\\ faecal urobilinogen; \\ fecal stercobilin. \\\ use of radioactive chromium. \\\\ )c1uired autoimmune haemolytic anemia may be due to: \\\ portal hypertension; \\\ Thalassemia; \\\ hereditary spherocytosis; \\\ sic/le cell disease; \\ a drug reaction. \\\\ The parts of common bile ducts are all, e#cept: \\\ the supraduodenal portion; \\ the e#traduodenal portion; \\\ the retroduodenal portion; \\\ the infraduodenal portion; \\\ intraduodenal portion. \\\\ Bsually, cystic artery is a branch of \\\ common hepatic artery; \\\ left hepatic artery; \\ right hepatic artery; \\\ left gastric artery;

\\\ gastroduodenal artery. \\\\ Which is the prime investigation for the patients presenting *ith Daundice? \\\ oral cholecystography; \\\ intravenous cholangiography; \\ ultrasonography; \\\ +T; \\\ CR+(; \\\\ +ausal factor of gallstone formation is: \\\ metabolic; \\\ infective; \\\ bile stasis; \\ all ans*ers is correct; \\\ all ans*ers is incorrect. \\\\ 0ndication for choledochotomy$ surgical incision of the common bile duct) is: \\\ palpable gall stones; \\\ there is a Daundice or history of Daundice; \\\ the common bile duct is dilaited; \\\ the liver function tests are abnormal; \\ all ans*ers are correct. \\\\ Which of the pancreas imaging investigations is less informative? \\\ ultrasonography; \\\ +T; \\\ <R0; \\ fle#ible endoscopy; \\\ CR+(. \\\\ The most fre1uent cause of chronic pancreatitis is: \\\ a duct obstruction; \\\ acute pancreatitis; \\\ acute cholecystitis; \\\ choledocholythiasis; \\ high alcohol consumption. \\\\ The prime investigation during chronic pancreatitis, is \\\ ultrasonography; \\ either an <R0 scan or a +T scan; \\\ CR+(; \\\ upper abdomen N!ray; \\\ pancreatic function tests. \\\\ Which type of the pancreas carcinoma is fre1uently occurs: \\ duct cell carcinoma;

\\\ giant cell carcinoma; \\\ adenos1uamous carcinoma; \\\ mucinous carcinoma; \\\ microadenocarcinoma. \\\\ The radical surgery *hen the carcinoma of the head of pancreas occurs, is: \\\ pancreatectomy; \\ pancreatoduodenal resection; \\\ hemipancreatectomy; \\\ choledochoDeDunostomy; \\\ choledochoduodenostomy. \\\\ The commonest endocrine tumors of the pancreas is: \\ insulinoma; \\\ gastrinoma; \\\ glucagonoma; \\\ somatostatinoma; \\\ *atery diarrhea hypo/alemia aclorhydria syndrome $WIH)'. \\\\ The characteristic signs of Hirschsprung2s disease is: \\\ nausea; \\\ dysphagia; \\ chronic constipation; \\\ diarrhea; \\\ regurgitation. \\\\ +orrect diagnosis of Hirschsprung2s disease depends on several investigations, e#cept \\\ colonoscopy; \\\ rectal biopsy; \\\ anorectal manometry; \\ angiography; \\\ radiography using *ater!soluble enema. \\\\ @ne stage operations performing for Hirschsprung2s disease treatment are all, e#cept \\ sigmoidostomy; \\\ coloanal anastomosis; \\\ Iuhamel operation; \\\ S*enson2s procedure; \\\ restorative proctocolectomy. \\\\ Which is the common place *here <ec/el2s diverticulum situated: \\\ duodenum; \\\ DeDunum; \\ ileum; \\\ ascending colon; \\\ cecum.

\\\\ Bsually <ec/el2s diverticulitis clinical features are same as: \\\ acute cholecystitis; \\ acute appendicitis; \\\ acute pancreatitis; \\\ acute dysentery; \\\ acute gastritis. \\\\ Aistula formation is one of the several complications of colon diverticulitis. Which type of fistula can2t occur? \\\ vesicocolic; \\\ vaginocolic; \\\ enterocolic; \\ oesophagocolic; \\\ colocutaneous. \\\\ The first symptom of ulcerative colitis is: \\\ pain; \\ *atery or bloody diarrhea; \\\ chronic constipation; \\\ vomiting; \\\ all ans*ers are correct. \\\\ Which is the commonest e#traintesrinal manifestation of ulcerative colitis: \\\ arthritis; \\\ erythema nodosum; \\\ eye problems; \\ sclerosing cholangitis; Primary sclerosing cholangitis is a progressive disease that leads to
liver damage and, eventually, liver failure. Liver transplant is the only known cure for primary sclerosing cholangitis, but transplant is typically reserved for people with severe liver damage.

\\\ bile duct cancer. \\\\ Which part of gastrointestinal tract can +rohn2s disease affect: \\\ mouth; \\\ oesophagus; \\\ small and large intestines; \\\ rectum; \\ any part of the gastrointestinal tract. \\\\ +arcinoma of the large intestine mostly occurs in: \\\ caecum; \\\ ascending colon; \\\ transverse colon; \\\ descending colon; \\ sigmoid colon. \\\\ Which is the palliative operation *hen the carcinoma of the large intestine occurs:

\\\ right hemicolectomy; \\\ e#cision of the transverse colon; \\\ left hemicolectomy; \\ colostomy; \\\ e#cision of the sigmoid colon. \\\\ +arcinoma of the left side of the colon usually present *ith: \\\ anemia; \\\ the presence of a mass in the ileocaecal fossa; \\\ sometimes discovered une#pectedly at operation for acute appendicitis; \\ increasing intestinal obstruction; \\\ all ans*ers are incorrect. \\\\ The superior rectal artery is the direct continuation of the: \\\ superior mesenteric artery; \\ inferior mesenteric artery; \\\ internal iliac artery; \\\ e#ternal iliac artery; \\\ internal pudendal artery. \\\\ The common sites for blood!born metastases of rectal carcinoma are: \\ liver; \\\ lungs; \\\ adrenals; \\\ pancreas; \\\ /idneys. \\\\ Carly symptoms of rectal cancer are all, e#cept \\\ bleeding per rectum; \\\ tenesmus; \\ pain, \\\ early morning diarrhea; \\\ sense of incomplete defecation. \\\\ +linical features of anal fissure are all, e#cept \\\ pain on defecation; \\\ bright red bleeding; \\\ mucos discharge; \\ diarrhea; \\\ constipation. \\\\ Symptoms of haemorrhoids are all, e#cept \\\ bright red painless bleeding; \\\ prolapse; \\\ pain only on prolapse; \\ *eight loss;

\\\ mucos discharge. \\\\ 0ndications for haemorrhoidectomy are all, e#cept \\ first!degree haemorrhoids; $First-degree haemorrhoids (grade

I): bleed but do not prolapse. Second-degree haemorrhoids (grade II): prolapse but reduce spontaneously. Third-degree haemorrhoids (grade III): prolapse but can be reduced manually Fourth degree haemorrhoids (grade IV): permanently prolapsed and cannot be reduced.)

\\\ failure of nonoperative treatment of second!degree haemorrhoids; \\\ third!degree haemorrhoids; \\\ fibrosed haemorrhoids; \\\ interoe#ternal haemorrhoids, *hen the e#ternal haemorrhoids is *ell defined. \\\\ The sac of hernia does not consisting of:

\\\ mouth; \\\ nec/; fundus; \\ ape#

\\\ body; \\\ .

\\\\ The contents of e#ternal hernias can not be: \\\ omenthum; \\ pancreas; \\\ small intestine; \\\ large intestine; \\\ ovary *ith or *ithout the corresponding fallopian tube. \\\\ The Eittre2s hernia is the content of the sac: \\\ appendi#; \\\ a portion of the circumfle#us of the intestine; \\\ a portion of the bladder; \\ a <ec/el2s diverti/ulum; \\\ fluids as part of ascitis.

\\\\ %oundaries of the inguinal canal are all, e#cept

\\\ e#ternal obli1ue aponeurosis; \\\ fascia transversalis; \\\ internal obli1ue and transversal muscles; \\ spermatic cord; \\\ inguinal ligament. \\\\ Which is the most common of all forms of hernia? \\\ direct inguinal hernia; &I' protrudes directly through the posterior !all of the inguinal
canal, medial to the inferior epigastric artery and deep inguinal ring

\\ indirect inguinal hernia;! the neck of the sac is situated at the deep inguinal ring, lateral to
the inferior epigastric artery. $he sac accompanies the spermatic cord along the inguinal canal to!ards the scrotum for a arying distance

\\\ femoral hernia; \\\ umbilical hernia; \\\ epigastric hernia. \\\\ When it is not necessary to open the inguinal canal during the herniotomy? \\\ in males; \\\ in females; \\ in infants; \\\ in elderly and old patients *ith cardiac failure; \\\ in patients *ho have a bad cough from chronic bronchitis. \\\\ The tension!free hernioplasty of inguinal hernia is the method of \\\ Shouldice; \\ Eichtenstein; \\\ Eoc/*ood; \\\ <cCvedy; \\\ Eothessen.

\\\\ What is the initial presentation of "= per cent of femoral hernia? !hen the trans ersalis
fascia !hich normally co ers the femoral ring is disrupted, so that a peritoneal sac and hernial contents pass through the femoral ring into the femoral canal.

\\\ reducibility; \\\ irreducibility; \\\ obstruction; \\ strangulation; \\\ inflammation. \\\\ When the conservative treatment of umbilical hernia is indicated: About one-third of
hernias close !ithin a month of birth, and they rarely persist beyond the age of ()* years, +epair is recommended for unusually large hernias or if the hernia is still present at school ag

\\ under the age of 9 years; \\\ at 9 years and old; \\\ in old patients; \\\ in females during the first trimester of gravidity. \\\ in all this cases. \\\\ Which from this techni1ues is no* the method of choice for all postoperative hernias, but smallest defects: \\\ simple apposition; \\\ comple# apposition by <ayo; \\\ comple# apposition by KMeelL; \\\ comple# apposition by da Silva; \\ plastic fiber mesh or net closures. \\\\ Aor the maDority of lung cancers account: \\ s1uamous cell carcinoma; \\\ adenocarcinoma; \\\ small cell carcinoma; \\\ alveolar cell carcinoma; \\\ all ans*ers are incorrect. \\\\ +ommon symptoms of lung cancers include all, e#cept: $horacic symptoms include
cough, haemoptysis, shortness of breath, chest pain "pleuritic or retrosternal#, hoarseness of oice "in ol ement of recurrent laryngeal ner e#, arm pain and !eakness "Pancoast,s syndromeapical tumour in ol ing brachial plexus#. Extra-thoracic symptoms include those of metastases "e.g. bone, central ner ous system, li er, adrenals# and those of non-metastatic paraneoplastic syndromes. $hese include the production of ectopic A.$', A&' and parathyroid hormone. /rist and ankle pain due to hypertrophic osteoarthropathy

\\\ persistent cough; \\\ *eight loss; \\\ dyspnoea; \\ myasthenia gravis;

\\\ nonspecific chest pain. \\\\ (ulmonary biopsy is ha.ardous under the follo*ing condition: Relative Contraindications to
Lung Biopsy

Abnormalities of lung function, Respiratory failure (including mechanical ventilation), Arterial and venous pulmonary hypertension, Coagulation abnormalities, The uncooperative patient

\\\ old patients *ith dyspnoea; \\ patients *ith pulmonary hypertension; \\\ patients *ith hamoptosis; \\\ patients *ith invasion of the mediastinum; \\\ in all cases pulmonary biopsy is ha.ardous; \\\\ +omplications of lung resection are all, e#cept: \\\ %leeding; \\\ respiratory infection; \\\ persistent air lea/; \\ bronchooesophageal fistula; \\\ bronchopleural fistula. \\\\ +ondition that still probably the most common predispose to pleural empyema formation is: \\ unresolved pneumonia; \\\ bronchoectasis; \\\ tuberculosis; \\\ fungal infection; \\\ lung abscess. \\\\The signs of thyroid deficiency are all, e#cept: \\\ cold e#tremities; \\\ dry s/in and hair; \\\ horse voice; \\ tachycardia; \\\ periorbital puffiness. \\\\ When the thyroid function tests sho* lo* T" and T levels *ith a high TSH, this pathological state is: \\\ euthyroid; \\\ thyroto#ic; \\ my#oedema; \\\ suppressive T therapy; \\\ to#ic nodule. \\\\ The treatmentof adult hypothyroidism usually is:

\\ conservative using oral thyro#ine; \\\ conservative using oral b!blo/ers; \\\ operative!subtotal thyroidectomy; \\\ operative!total thyroidectomy; \\\ all ans*ers are incorrect. \\\\ Which is not the feature of lo*er limb arterial stenosis: \\\ intermitten claudication; \\\ rest pain; \\\ ulceration and gangrene; \\ arterial pulsation increased; \\\ movement lost or diminished. \\\\ Se#ual impotence $Eeriche' presence *hen the site of obstruction located in: \\ aortoiliac part; \\\ iliac artery; \\\ femoral artery; \\\ popliteal artery; \\\ in all sites of obstruction. \\\\ The invasive method of investigation of arterial stenosis or occlusion is: \\\ doppler ultrasound blood flo* detection; \\\ duple# imaging; \\ arteriography; \\\ photopletismography; \\\ thermography. \\\\ +omplications of varicose of superficial vein are all, e#cept: \\\ venous ec.ema; \\\ venous complication; \\\ superficial thrombophlebitis; \\\ venous ulceration; \\ gangrene. \\\\ 0nvestigation of venous disease is more informative to tested the patency and competence of all lo*er limb veins: \\\ pletismography; \\\ doppler ultrasound; \\ duple# ultrasound imaging; $can c bld flo*' \\\ photopletismography; \\\ tourni1uet tests. \\\\ The treatment of varicose vein includes all, e#cept \\\ compression stoc/ings; \\\ inDection sclerotherapy; \\ transluminal angioplasty and stenting;

\\\ phlebectomy; \\\ saphenofemoral Dunction ligation. \\\\ The most common cause of leg ulceration in *estern countries is: \\ venous disease of the lo*er limb; \\\ peripherial arterial disease; \\\ diabetes; \\\ neuropathy; \\\ infective. \\\\ Aactor, that lead to venous thrombosis described by Oircho* is: \\\ high venous presuare; \\\ decreased cuagulability of the blood; \\ increased cuagulability of the blood; \\\ venous valves failure; \\\ all ans*ers are correct. \\\\ Ris/ factors for venous thromboembolism are all, e#cept: \\\ age; \\\ obesity; \\\ varicose vein; \\ physical activity; \\\ pregnancy. \\\\ +linical feature of deep vein thrombosis is: \\\ s*elling; \\\ pain; \\\ dilated superficial veins; \\\ calf tenderness; \\ all ans*ers are correct. \\\\ Treatment of deep vein thrombosis include: \\\ involves intravenous heparin, \\\ *arfarrin; an anticoagulant normally used in
thepre ention of thrombosis and thromboembolism, the formation of blood clots in the blood essels and their migration else!here in the body

\\\ inDection of lo*!molecular!*eight heparin; \\\ venous thrombectomy; \\ all mentioned methods. \\\\ ) 4!year!old professional dancer presents *ith a *ell!defined, tense, smooth mass in the upper outer 1uadrant of the left breast. She states that the mass becomes larger Dust before onset of her periods. )spiration yields a clear yello* fluid and the mass disappears. The most li/ely diagnosis is: \\\ Aibroadenoma is a cyst. \\ Aibrocystic disease of the breast. (B) %reast cysts are often *ell demarcated and
tend to get larger and contain nonbloody fluid,

*hich is usually acellular and cytology is rarely indicated. &alactoceles present in pregnant and nursing *omen are filled *ith mil/y fluid.

\\\ +arcinoma in a cyst. \\\ Eipoma. \\\ &alactocele. \\\\ )n ;8!year!old presents *ith a *ellcircumscribed 9!cm mass in her right breast. The mass is painless and has a rubbery consistency and discrete borders. 0t appears to move freely through the breast tissue. What is the li/eliest diagnosis? \\\ +arcinoma \\\ +yst \\ Aibroadenoma (C) Aibroadenomas are most often found in
teenage girls. They are firm in consistency, clearly defined , and very mobile. The typical feature on palpation is that they appear to move freely through the breast tissue $Kbreast mouseL'.

\\\ +ystosarcoma phyllodes \\\ 0ntramammary lymph node \\\\ &alactorrhea, a mil/y discharge from the nipple in nonpregnant *omen, is most li/ely to be associated *ith *hich of the follo*ing? \\\ Aibroadenoma \\\ Tubular adenoma \\ (ituitary adenoma \\\ Hyperparathyroidism \\\ %reast abscess \\\\ ) 3!year!old *oman complains of a !month history of bloody discharge from the nipple. )t e#amination, a small nodule is found, deep to the areola. +areful palpation of the nippleareolar comple# results in blood arrearing at the @2cloc/ position. <ammogram findings are normal. What is the li/eliest diagnosis? \\ 0ntraductal papilloma 0ntraductal papilloma is the most common
cause of bloody discharge from the nipple. The lesion is treated by e#cision and is benign in most cases. +ancer is present in 46 of cases. (reoperative ductography can be used to help locate the offending duct

\\\ %reast cyst \\\ 0ntraductal carcinoma \\\ +arcinoma in situ \\\ Aat necrosis

\\\\ ) "4!year!old man complains of burning epigastric pain that *a/es him up at night. The pain is relieved by eating or using over!thecounter antacids and H9 bloc/ers. Iiagnosis is best confirmed by *hich of the follo*ing? \\\ Brea breath test \\\ Serum gastrin levels \\\ %arium meal e#amination \\\ Bpper endoscopy \\ Bpper endoscopy and biopsy (E) Iuodenal ulcer is best diagnosed by upper
endoscopy and biopsy. Aindings of gastritis and the presence of H.pylori are indications to prescribe appropriate therapy. This typically includes a ((0 and t*o antibiotics $one regimen includes amo#icillin and clarithromycin'. )lthough the urea breath test is the most sensitive and specific test used to detect H. pyloriit is not readily available in all settings.

\\\\ Three months after recovery from an operation to treat peptic ulcer disease, a patient complains that she has difficulty eating a large meal. ) 55m Tc!labeled chic/en scintigraphy test confirms a mar/ed delay in gastric emptying.) delay in gastric emptying may be due to *hich of the follo*ing? \\\ Jollinger!Cllison syndrome $JCS' \\\ Steatorrhea \\\ <assive small!bo*el resection \\ (revious vagotomy \\\ Hiatal hernia \\\\ )3"!year!old supermar/et manager had an elective operation for duodenal ulcer disease. He has not returned to *or/ because he has diarrhea *ith more than 9= bo*el movements per day. <edication has been ineffective. The e#act details of his operation cannot be ascertained. What operation *as most li/ely performed? \\\ )ntrectomy and %illroth 0 anastomosis \\\ &astric surgery combined *ith choleystectomy \\ Truncal vagotomy (C) )lthough a milder type of diarrhea is not
uncommon after gastrectomy, fulminant diarrhea may be a problem after vagotomy $it is one of the many complications collectively referred to as post vagotomy syndromes'. The e#act mechanism is not /no*n. 0t occurs in ;F96 of patients follo*ing truncal

vagotomy and is less li/ely to be found after selective or highly selective vagotomy.

\\\ Highly selective vagotomy \\\ Selective vagotomy \\\\)"=!year!old man has had recurrent symptoms suggestive of peptic ulcer disease for " years. Cndoscopy reveals an ulcer located on the greater curvature of the stomach. ) mucosal biopsy reveals Helicobacter. pylori. What is TRBC about H. pylori? \\\ )ctive organisms can be discerned by serology. \\\ 0t is protective against gastric carcinoma. \\ 0t is associated *ith chronic gastritis. (C) H. pylori $previously called Campylobacter
pylori' is associated *ith chronic gastritis, duodenal ulcers, gastric ulcers, and gastric cancer. Serology can accurately detect H. pylori but remains positive for up to ; year post treatment. The urea breath test is highly sensitive $536' and specific $5"6'. 0n 9==4, %arry <arshall and P. Robbin Warren *on the :obel (ri.e in medicine for their *or/ on H. pylori and its role in gastritis and peptic ulcer disease.

\\\ 0t causes gastric ulcer but not duodenal ulcer. \\\ 0t can be detected by the urea breath test in >3=6 of cases. \\\\ )3 !year!old man under*ent gastric resection for severe peptic ulcer disease. He had complete relief of his symptoms but developed Kdumping syndrome.L This patient is most li/ely to complain of *hich of the follo*ing? \\\ &astric intussusception \\\ Repeated vomiting \\\ Severe diarrhea \\ Severe vasomotor symptoms after eating D) Iumping syndrome is a symptom comple#
ocurring after gastric surgery. 0t is characteri.ed by fatigue, abdominal distension, pain, and vasomotor symptoms caused by the rapid entry of

food into the small intestine. Tachycardia, s*eating, and feeling lightheaded after eating are symptoms patients may feel. There are t*o types of dumping syndrome, early and late.

\\\ 0ntestinal obstruction \\\\ )3"!year!old man *as evaluated for moderate protein deficiency. He under*ent a gastrectomy 9= years earlier. He is more li/ely to sho* *hich of the follo*ing? \\\ (orphyria \\\ Hemosiderosis \\\ )plastic anemia \\\ Hemolytic anemia \\ 0ron deficiency anemia (E) There is a varying degree of impairment in
carbohydrate, fat, protein, and mineral absorption after gastrectomy. These changes arsevere after a subtotal gastrectomy and gastrDeDunostomy $%illroth 00' $Aig. 4F7', in most patients these changes are mild. )n acid environment is necessary to release ferric ion frfood and ma/e it available for absorption in the small intestine.

\\\ ) 38!year!old *oman has been diagnosed *ith a benign ulcer on the greater curvature of her stomach, 4 cm pro#imal to the antrum. )fter months of standard medical therapy, she continues to have guaiac positive stool, anemia, and abdominal pain *ith failure of the ulcer to heal. %iopsies of the gastric ulcer have not identified a malignancy. The ne#t step in management is *hich of the follo*ing? \\\ Treatment of the anemia and repeat all studies in 3 *ee/s \\\ Cndoscopy and bipolar electrocautery or laser photocoagulation of the gastric ulcer \\\ )dmission of the patient for total parenteral nutrition $T(:', treatment of anemia, and endoscopic therapy \\ Surgical intervention, including partial gastric resection ) 0n general, vagotomy *ith a
gastric drainage procedure is less satisfactory in the treatment of primary gastric ulcer. Treatment of a gastric ulcer

may include partial gastrectomy *ith a gastroduodenal anastomosis $%illroth 0'. Oagotomy 0s not necessary because gastric ulcers are usually not associated *ith acid hypersecretion. )gastric ulcer that fails to heal despite medical therapy should be e#cised.

\\\ Surgical intervention, including total gastrectomy \\\\ ) 9!cm ulcer on the greater curvature of the stomach is diagnosed in a 7=!year!old *oman by a barium study. &astric analysis to ma#imal acid stimulation sho*s achlorhydria. What is the ne#t step in management? \\\ )ntacids, H9 bloc/ers, and repeat barium study in 3 to 8 *ee/s \\\ (roton pump inhibitor $((0' $e.g., omepra.ole' and repeat barium study in 3 to 8 *ee/s \\\ (rostoglandin C $misoprostol' and repeat barium study in 3 to 8 *ee/s \\ 0mmediate elective surgery \\\ Bpper endoscopy *ith multiple biopsies $at least 8 or 5' for the ulcer (E) The
distinction bet*een a benign and malignant ulcer can be difficult. The presence of achlorhydria rules out peptic ulceration. Cndoscopy is indicated so that biopsy can be performed.

\\\\ )44!year!old school bus driver *as diagnosed months ago *ith an antral ulcer. He *as treated for H. pylori and continues to ta/e a ((0. Repeat endoscopy demonstrates that the ulcer has not healed. What is the ne#t treatment option? \\\ Treatment *ith H9 bloc/ers \\\ Oagotomy alone *ithout additional surgery \\\ Cndoscopy and laser treatment of the ulcer \\ Iistal gastrectomy *ith gastroDeDunal anastomosis $Rou#2nG' (D) ) gastric ulcer that
does not respond to medical therapy re1uires surgical intervention. )n appropriate operation for an antral ulcer is an antrectomy *ith a gastroduodenal anastomosis $%illroth 0'. Oagotomy is not nearly as effective in preventing recurrences in gastric ulcers. 0t is important to reali.e that the management of gastric and duodenal ulcers is not identical because the etiologies are different.

Iuodenal ulcers are associated *ith acid hypersecretion *hile gastric ulcers are associated *ith impaired mucosal defense mechanisms. %oth are associated *ith H. pylori $duodenal ulcers 5=6 and gastric ulcers 746'. )gastric ulcer is much more li/ely to harbor a malignancy as compared to a duodenal ulcer. ) gastric ulcer should al*ays be biopsied. 0f a gastric ulcer fails to heal after appropriate med ical management, it should be e#cised.

\\\ Clevating the head of the bed *hen asleep \\\\ ) 39!year!old man presents *ith guaiac positive stool$detect the presence of fecal occult blood "012#!hich is blood in the feces that cannot be seen#. He is asymptomatic. Wor/up reveals a 9!cm ulcerated carcinoma on the antral lesser curvature. Tumor mar/ers are negative. ) +)T scan is negative for metastatic disease and lymphadenopathy liver function tests are normal. What is the correct treatment for this patient? \\\ +hemotherapy only \\\ Radiation therapy only \\\ +ombination chemotherapy and radiation therapy *ithout resection \\\ Total gastrectomy \\ Iistal gastrectomy *ith en bloc removal of lymph nodes E) The treatment of an antral
gastric cancer is distal subtotal gastrectomy *ith lymph node dissection $provided there is no metastatic disease'. Surgical resection is the only potential curative therapy. (ro#imal margins should be 4F3 cm. Total gastrectomy does not improve 4!year survival. (ostoperative chemoradiation may

increase 4!year survival $limited studies'

\\\\ ) 75!year!old retired opera singer presents *ith dysphagia, *hich has become progressively *orse during the last 4 years. He states that he is sometimes a*are of a lump on the left side of his nec/ and that he hears gurgling sounds during s*allo*ing. He sometimes regurgitates food during eating. What is the li/ely diagnosis? \\\ +arcinoma of the esophagus \\\ Aoreign body in the esophagus \\\ (lummer!Oinson $Melly!(atteson' syndrome \\ Jen/er2s $pharyngoesophageal' diverticulum ) Jen/er2s $pharyngoesophageal'

diverticulum is a mucosal outpouching through the triangular bare area bet*een the cricopharyngeus muscle and the inferior constrictor muscle of the pharyn# $Millian2s triangle'. <ost present on the left side of the nec/.

\\\ Scleroderma \\\\ ) symptomatic patient has a barium s*allo* that reveals a !cm Jen/er2s diverticulum. The ne#t step in management is? \\\ H9 bloc/ers \\\ )nticholinergic drugs \\\ Clemental diet \\\ %ougienage \\ Surgery $cricopharyngeal myotomy and diverticulectomy'

\\\\ ) "3!year!old man present *ith dysphagia of recent onset. His esophogram sho*s a lesion in the lo*er third of his esophagus. %iopsy of the lesion sho*s adenocarcinoma. His general medical condition is e#cellent, and his metastatic *or/up is negative. What should his management involve? \\\ +hemotherapy \\\ Radiation therapy \\\ 0nsertion of a stent to improve s*allo*ing \\ Surgical resection of the esophagus \\\ +ombination of chemotherapy and radiation therapy \\\\) "=!year!old *oman complains of heartburn located in the epigastic and retrosternal areas. She also has symptoms of regurgitation. Cndoscopy sho*s erythema of the esophagus consistent *ith reflu# esophagitis. The patient has tried conservative measures, including ((ls *ith no improvement in symptoms. Which of the follo*ing is TRBC? \\\ <anometry does not add any additional information. \\\ The 9"!hour pH test is no longer used. \\\ 0f endoscopy has been done, an esophagogram is unnecessary. \\ :issen fundoplication is the surgical treatment of choice. D) +onservative treatment of
&CRI includes lifestyle modifications $e.g., smo/ing cessation, decreased caffeine inta/e, avoidance of large meals before lying do*n, elevation of the head of the bed, and avoidance of constrictive clothing'. ((l2s are very effective if nonoperative management fails, surgical intervention should be considered. (reoperative evaluation includes manometry, 9"!hour pH test and esophagogram, in addition to endoscopy. <anometry evaluates the ECS resting pressure and effectiveness of peristalsis. The 9"!hour pH test is the gold standard for diagnosing and 1uantifying acid reflu#. Csophagogram sho*s the e#ternal

anatomy of the esophagus and pro#imal stomach, as *ell as demonstrating the presence of a hiatal hernia. :issen fundoplication is a 3= gastric *rap. 0t can be performed as an open or laparoscopic procedure. 0t is the most common operation performed for &CRI. (artial fundoplications $e.g., Thal, Ior, Toupet' are done if esophageal motility is poor.

\\\ Toupet fundoplication is 3= nic nerve. \\\\ ) patient has been diagnosed *ith achalasia. He refused surgery initially, preferring to try nonoperative therapy. He tried life style modification, calcium channel bloc/ers, botulin to#in inDection, and endoscopic pneumatic dilatation. :one of the treatments alleviated his symptoms. What are his surgical options? \\\ Csophagectomy \\\ Surgical esophagomyotomy pro#imal to the ECS \\ <odified Heller myotomy and partial fundoplication C) ) healthy patient *ith achalasia
*ho has failed nonoperative management should be considered for surgical intervention. (neumatic dilatation is first!line therapy. 0t causes disruption of the muscular layers of the ECS. ) balloon is placed endoscopically at the level of the ECS. Aluoroscopically is used to visuali.e the balloon as it is inflated to pressures no higher than ;= psi. 0f pneumatic dilatation fails, or if symptoms return after successful dilation, surgery should be considered. The procedure may

be done open or endoscopically. The operation involves a myotomy that divides the circular and longitudinal muscle fibers. 0t e#tends from the distal 3 cm of the esophagus, through the ECS, and the pro#imal gastric cardia. )partial fundoplication is usually included to prevent gastroesophageal reflu#.

\\\ Repeat pneumatic dilation using pressures of loops \\\ :issen fundoplication \\\\ )3=!year!old man *ith a long history of &CRI has *orsening symptoms. He has an upper endoscopy that sho*s esophagitis. )biopsy is ta/en that sho*s intestinal metaplasia. Which of the follo*ing is TRBC? \\\ %arrett2s esophagus is more common in *omen. \\\ 4=6 of patients *ith &CRI have %arrett2s esophagus. \\ High!grade dysplasia is an indication for prophylactic esophagectomy. (C) %arrett2s
esophagus is a metaplastic change found in ;=F;46 of &CRI patients. The normal s1uamous cells of the esophagus are transformed into columnar cells. 0t is more commonly seen in men. (atients *ith %arrett2s esophagus $*ithout dysplasia' re1uire lifelong
surveillance. (atients *ith severe dysplasia

have a "=F4=6 chance of developing adenocarcinoma of the esophagus. (rophylactic esophagectomy is recommended.

\\\ +ells typically found in the esophagus are columnar develop adenocarcinoma. \\\ ;==6 of patients *ith %arrett2s esophagus develop adenocarcinoma. \\\\ ) "=!year!old *oman presents *ith *eight loss, palpitations, and e#opthalmos. @n physical e#amination, the thyroid gland is diffusely enlarged. %lood tests reveal primary hyperthyroidism. Which one of the follo*ing is not the treatment of hyperthyroidism? \\\ +arbima.ole \\\ Eugols iodine

\\\ 0; ; \\\ Subtotal thyroidectomy \\ Steroids (E) Hyperthyroidism could be diffuse primary
hyperthyroidisms, &raves2 disease, or a to#ic nodular goiter. &raves2 disease is an autoimmune hyperthyroidism. The treatment consists of medical management *ith use of antithyroid drugs such as methima.ole, or ablation of the gland *ith radioactive 0 , or surgically *ith subtotal thyroidectomy. Aailure of medical management re1uires oblation procedures either *ith 0
; ; ; ;

or surgery. Eugols iodine is used in preparation to sur! gery. Steroids are not used in the treatment of hyperthyroidism. 0t may be used in the management of thyroid storm, a life threatening condition.

\\\\ Aollo*ing surgical resection of a large thyroid mass, a patient complains of persistent hoarseness and a *ea/ voice. What is the most li/ely cause of these symptoms? \\\ Traumatic intubation \\\ (rolonged intubation \\ 0nDury to the recurrent laryngeal nerve \\\ 0nDury to the superior laryngeal nerve \\\ Scar tissue e#tending to the vocal cords \\\\ ) 4!year!old man has /no*n ulcerative colitis. Which of the follo*ing is an indication for total proctocolectomy? \\\ @ccasional bouts of colic and diarrhea \\\ Sclerosing cholangitis \\ To#ic megacolon (C) To#ic megacolon is a fulminant e#acerbation
of ulcerative colitis, causing massive dilatation of the colon *ith perforation, fecal peritonitis, and death. Cmergency total colectomy is indicated.

\\\ )rthritides \\\ 0ron deficiency anemia \\\\ +omplications of diverticulitis include: \\\ +arcinoma of the colon \\\ C#traintestinal manifestations such as arthritis, iritis, and s/in rashes \\ Aistulisation to adDacent organs such as the bladder, *ith insueing colovesical fistula \\\ )rtheriovenous fistulae of the intestine

\\\ Sclerosing cholangitis \\\\ ) patients +T scan reveals diverticulitis confined to the sigmoid colon. There is no associated pericolic abscess. What is best course of treatment? \\ %o*el rest, nasogastric suction, 0O fluids, and broad spectrum antibiotics \\\ Brgent surgical resection \\\ Steroids \\\ Iiverting colostomy \\\ 0leostomy \\\\ ) !year!old *oman is noted to have a <ec/el2s diverticulum *hen she undergoes an emergency appendectomy. The diverticulum is appro#imately 3= cm from the ileocecal valve and measures 9F cm in length. What is the most common complication of <ec/el2s diverticulum among adults? \\\ %leeding \\\ (erforation \\ Iiverticulitis (C) 0ntestinal obstruction due to a <ec/el2s
diverticulum may result from a volvulus, band obstruction, or intussusception. )mong children, bleeding and inflammation are seen more fre1uently. <ec/el2s diverticulum is a remnant of the vitellointestinal duct.

\\\ Blceration \\\ +arcinoma \\\\ )35!year!old female is found to have an enterocutaneous fistula that arises from the pro#imal small intestine. Which of the follo*ing statements is TRBC concerning this fistula? \\\ 0f internal, it occurs mainly from iatrogenic causes. \\ 0t occurs more commonly after an anastomosis than spontaneously. (B) 0nternal small!
bo*el fistulas are caused almost e#clusively by small!bo*el disease or surrounding visceral disease involving the small bo*el. +rohn2s disease is the most common cause of internal small!bo*el fistulas, but neoplasia, lymphoma, and tuberculosis must be e#cluded. 0nternal fistula may be asymptomatic or cause serious malabsorption $pro#imal

to distal fistulas' or infection $enterovesical fistulas'.

\\\ 0f internal, it al*ays causes serious complications. \\\ 0f e#ternal, it closes spontaneously in ;=6 of cases. \\\ 0f e#ternal, it re1uires immediate closure in most cases. \\\\ ) "8!year!old *oman develops colon cancer. She is /no*n to have a long history of ulcerative colitis. 0n ulcerative colitis, *hich of the follo*ing is a characteristic of colon cancer? \\ @ccurs more fre1uently than in the rest of the population. (A) @ccurs more fre1uently
than in the rest of the population. The cumulative ris/ of developing cancer in patients *ith e#tensive ulcerative colitis is greater than in those *ith more locali.ed disease $"96 at 94 years'. +hildren are more li/ely to have e#tensive disease. +olon cancer occurs more fre1uently in the sigmoid and rectum in ulcerative colitis, but cancer is more li/ely to occur in patients *ho have universal disease. Synchronous carcinomas in patients *ithout ulcerative colitis occur in "6, compared to 946 in those *ith colitis. Eesions usually are flat, are fre1uently missed at e#amination, and have a *orse prognosis than sporadic colon cancers found in normal ris/ patients. )dults developing cancer under the age of "4 have a poorer

prognosis than those *ho develop it later.

\\\ 0s more li/ely to occur *hen the ulcerative disease is confined to the left colon. \\\ @ccurs e1ually in the right and left side. \\\ Has a synchronous carcinoma in "F46 of cases. \\\ Has an e#cellent prognosis because of physician a*areness \\\\ ) 3"!year!old train conductor is diagnosed as having carcinoma confined to the descending colon. %efore operation, *hat should be told? \\\ He *ill most li/ely re1uire a colostomy. \\\ He should have the cancer e#cised by cautery. \\ He should undergo left hemicolectomy. \\\ Radiotherapy is the treatment of choice. \\\ "=6 of colorectal cancer involves the colon. \\\\ )n 8 !year!old man is diagnosed on colonoscopy to have cancer of the colon. He refuses surgical intervention and after a !month follo*up period is admitted to the emergency department *ith large!bo*el obstruction. +arcinoma of the colon is most li/ely to obstruct if found in the \\\ +ecum \\\ )scending colon \\ Iescending colon The most common sites of obstruction are
descending colon (21%), sigmoid (17%), and splenic flexure (1 %

\\\ Rectum \\\ Transverse colon \\\\ ) 38!year!old dentist undergoes anterior resection $sigmoid resection' for cancer at the rectosigmoid Dunction. The tests performed before her surgery *ere colonscopy and biopsy. There *ere no other lesions detected *ith sigmoidoscopy or in the pathology specimen. Aollo*ing operation, she re1uires *hich of the follo*ing *ithin 9F months? \\\ Repeat rectal e#amination and sigmoidoscopy \\ +olonoscopy (B) Synchronous carcinoma and polyps, of all
types, occur at sites in the colon not included in an anterior or sigmoid resection. %oth synchronous carcinomas and benign polyps occur mainly at sites in the colon that *ould not be included in the definite resection for the primary carcinoma. Thus, it is important to try, *henever possible, to perform colonoscopy before colon resection to facilitate planning of the operation should a synchronous

lesion be detected. 0f this study is omitted, it is advisable to have a complete colonoscopy performed *ithin the first 9F months after resection.

\\\ +T scan of the abdomen \\\ )ngiography \\\ %one scan \\\\ )94!year!old man has recurrent, indolent fistula in ano$Anal fistula, or fistula-in-ano, is
an abnormal connection bet!een the epithelialised surface of the anal canal and "usually# the perianal skin.#. He also complains of *eight loss, recurrent attac/s of diarrhea *ith blood

mi#ed in the stool, and tenesmus. (roctoscopy revealed a healthy, normal!appearing rectum. What is the most li/ely diagnosis? \\ +rohn2s colitis \\\ Blcerative colitis \\\ )moebic colitis \\\ 0schemic colitis \\\ +olitis associated *ith ac1uired immunodeficiency syndrome $)0IS'
Difference Location Crohn's Disease Inflammation may occur any here along the digestive tract Inflammation may occur in patches Ulcerative Colitis Large intestine (colon) is typically the only affected site Inflammation is continuous throughout affected areas !ain is common in the lo er left part of the abdomen

Inflammation

Pain

!ain is commonly e"perienced in the lo er right abdomen

Appearance

Colon all may be thic#ened and may Colon all is thinner and sho s have a roc#y appearance continuous inflammation

$lcers along the digestive trac# are %ucus lining of large intestine may have deep and may e"tend into all layers of ulcers, but they do not e"tend beyond the bo el all the inner lining Bleeding Bleeding from the rectum during bo el movements is not common Bleeding from the rectum during bo el movements

\\\\ )79!year!old *oman presents *ith bright red rectal bleeding, not associated *ith abdominal pain, of 9!day duration. She had previous similar episodes but *as never hospitali.ed. C#amination reveals a pale but alert individual *ith no significant abdominal findings. Aindings on rectal e#amination are positive for bright red rectal

bleeding. Her vital signs are stable and her hemoglobin is 5.4 g. What is the most probable cause of her bleeding? \\\ Iiverticulitis of the colon \\\ +arcinoma of the sigmoid colon \\\ <ec/el2s diverticulitis \\\ )denomatous polyp of the colon \\ Iiverticulosis of the colon (E) The clinical picture of recurrent bright rectal
bleeding that is not associated !ith abdominal pain is characteristic of di"erticulosis of the colon. The bleeding in sigmoid carcinoma is often microscopic. #i"erticulitis of the colon !ould present !ith associated pain. $denomatous polyp may present !ith painless rectal bleeding, but the most common condition in this elderly age group is di"erticulosis of the colon.

\\\\ )44!year!old man has had previous hemicolectomy for a carcinoma of the right colon. )t this time, years after the primary resection, a +T scan sho*s a solitary lesion in the right lobe of the liver. What is the ne#t step in management? \\\ Easer cauteri.ation \\\ Radiotherapy \\\ Hepatic artery catheteri.ation and local chemotherapy \\\ Symptomatic treatment *ith analgesics, because the colon disease is no* stage 0O \\ C#ploratory laparotomy and resection of the tumor (E) %any patients !ho ha"e
metastasis to the li"er or lung ha"e resectable tumors. $reasonable disease&free inter"al has been reported after such resections, especially !ith carcinoma of the colon as the primary lesion.

\\\\ )n 8"!year!old man has had a reducible hernia in the right groin for ;7 years. @ne day before admission to the hospital, he complains of abdominal pain; because of the s*elling, the hernia has become irreducible. )t operation, part of the *all of the cecum is noted to form a portion of the hernia sac. What is the hernia? \\\ Spigelian hernia \\\ Iirect inguinal hernia \\\ Aemoral hernia \\\ Richter2s hernia \\ Sliding hernia (G) In this variety, the hernia does not have a
complete covering of peritoneum. It is called a sliding hernia. It is important that the surgeon does not attempt to remove peritoneum from

the circumference bowel wall where it does not exist, because the bowel will become devascularized.

\\\\ ) 9"!year!old college student recovers from about of severe pancreatitis. He has mild epigastric discomfort, sensation of bloating, and loss of appetite. C#amination reveals an epigastric fullness that on ultrasound is confirmed to be a pseudocyst. The s*elling increases in si.e over a !*ee/ period of observation. What should be the ne#t step in management? \\ (ercutaneous drainage of the cyst (A) 'seudocysts fre(uently are encountered on
ultrasound examination early after an acute attac) of pancreatitis. *n most cases, the pseudocyst resol"es, but if it enlarges, it may compress the stomach anteriorly. $n enlarging pseudocyst is an indication to attempt percutaneous drainage. *f percutaneous drainage is unsuccessful, internal drainage into the stomach should be performed at an appropriate inter"al to allo! the pseudocyst !all to mature (+ig. 7,-).

\\\ Eaparotomy and internal drainage of the cyst \\\ C#cision of pseudocyst \\\ Total pancreatectomy \\\ )dministration of pancreatic en.ymes \\\\) 37!year!old *oman is noted to have a gradual increase in the si.e of the abdomen. ) +T scan reveals a large pancreatic mass. The lesion *as e#cised; on pathology e#amination, it is sho*n to be a TRBC cyst. Which statement is correct regarding true cysts? \\\ They are commonly seen in alcoholic pancreatitis. \\\ They commonly occur after trauma. \\\ They are fre1uently malignant. \\\ They are associated commonly *ith choledochocele. \\ They have an epithelial lining. (E) True epithelial&lined cysts in the pancreas are
extremely rare. They should not be confused !ith the more common pseudocyst (no epithelial lining), benign cystadenoma, or malignant

cystadenoma of the pancreas. 'seudocysts are more common in men, but cystadenocarcinoma occurs more fre(uently in !omen.

\\\\ )48!year!old man *ith a =!year history of alcoholism and pancreatitis is admitted to the hospital *ith an elevated bilirubin level of 4 mgQdE, acholic stools, and an amylase level of 3==B. @bstructive Daundice in chronic pancreatitis usually results from *hich of the follo*ing? \\\ Sclerosing cholangitis \\ +%I compression caused by inflammation +ibrosis in the head of the pancreas as a result
of chronic inflammation may lead to compression of the ./#. *n pancreatitis, the narro!ing of the ./# is smooth on x&ray studies. There is no association !ith pancreatitis and sclerosing cholangitis. $lcoholic hepatitis is the most common cause of 0aundice, but it most fre(uently is not of an obstructi"e nature. 'seudocysts and carcinoma of the head of the pancreas are other recogni1ed causes of obstructi"e 0aundice in patients !ith chronic pancreatitis.

\\\ )lcoholic hepatitis \\\ %iliary dys/inesia \\\ Splenic vein thrombosis \\\\ )"=!year!old *oman *ith severe chronic pancreatitis is scheduled to undergo an operation, because other forms of treatment have failed. The ultrasound sho*s no

evidence of pseudocyst formation or cholelithiasis and endoscopic retrograde cholangiopancreatogram $CR+(' demonstrates dilated pancreatic ducts *ith multiple stricture formation. Which operation is suitable to treat this condition? \\ (ancreaticoDeDunostomy
(A) 0f the pancreatic duct is dilated and symptoms persist, a longitudinal pancreaticoDeDunostomy $(uesto*' is performed $Aig. 7F4'. 0n this operation, the pancreatic duct is slit open and anastomosed side!to!side to the cut end of the divided DeDunum *ith a Rou#!en!G anastomosis. Resection of the pancreas is reserved for patients *ithout a dilated duct $>3 mm'. 0n these cases, a distal pancreatectomy is performed *hen the disease primarily involves the body and tail of the pancreas; *hereas, a Whipple operation is performed *hen the disease is confined to the head.

\\\ &astroDeDunostomy \\\ +holecystectomy \\\ Splenectomy \\\ Subtotal pancreatectomy \\\\ ) =!year!old male is admitted *ith fre1uent episodes of hypoglycemia. %iochemical investigations confirmed an insulinoma. Eocali.ation studies *ere carried out. )+T scan and magnetic resonance imaging $<R0' of the abdomen failed to reveal a tumor in the pancreas. )n endoscopic ultrasound, ho*ever, locali.ed a 9!cm insulinoma in the tail of the pancreas. What should be the ne#t step in the management of this patient? \\\ Somatostatin receptor scintigraphy $SRS' to confirm the insulinoma \\\ C#ploratory laparotomy and total pancreatectomy \\\ Iistal pancreatectomy \\\ Whipple pancreaticoduodenectomy \\ Cnucleation of the tumor
(E) %ost insulinomas are small (22 cm), solitary, and benign. Therefore, simple enucleation is ade(uate. 3ess than 14% of cases are malignant and re(uire

resection in the form of either pancreaticoduodenectomy or distal pancreatectomy (depending upon the location of the tumor). Ten percent of insulinomas are associated !ith %56 * syndrome, and in these cases, the tumors are multiple. 'artial pancreatic resection may be re(uired for these patients. Total pancreatectomy is almost ne"er re(uired for the remo"al of insulinomas. 7omatostatin receptors are not al!ays present on insulinoma cells, and, therefore, 787 is less useful for locali1ation of this tumor.

\\\\ )33!year!old man *ith obstructive Daundice is found on CR+( to have periampullary carcinoma. He is other*ise in e#cellent physical shape and there is no evidence of metastasis. What is the most appropriate treatment? \\ Radical e#cision $Whipple procedure' *here possible
pancreaticoduodenectomy, the Whipple procedure involves removal of the "head" (wide part) of the pancreas next to the first part of the small intestine (duodenum). t also involves removal of the duodenum, a portion of the common bile duct, gallbladder, and sometimes part of the stomach. !fterwards, surgeons reconnect the remaining intestine, bile duct, and pancreas. "nly about #$% of pancreatic cancer patients are eligible for the Whipple procedure and other surgeries. &hese are usually patients whose tumors are confined to the head of the pancreas and haven't spread into any nearby ma(or blood vessels, the liver, lungs, or abdominal cavity.

A) +arcinoma of the head of the pancreas is treated *ith radical e#cision of the head of the pancreas along *ith the duodenum. +ontinuity of the biliary and &0 tract is established by performing hepaticoDeDunostomy, pancreaticoDeDunostomy, and gastroDeDunostomy $Aig. 7F3'. The

4!year survival rate is higher for periampullary carcinoma $ =6' than that for pancreatic head lesions $;=6'. <ost centers do not give irradiation routinely before or after surgery, because pancreatic cancers do not respond *ell to radiotherapy. Cndoscopically placed stents alone are used only in palliative circumstances in patients *ith limited life e#pectancy.

\\\ Eocal e#cision and radiotherapy \\\ C#ternal radiotherapy \\\ 0nternal radiation seeds via catheter \\\ Stent and chemotherapy \\\\ )7"!year!old man complains of epigastric discomfort. There is no Daundice evident, but an enlarged gallbladder is palpated. The bilirubin level is ; mgQdE, the al/aline phosphatase level is ";= B, and the hematocrit is 46. What is the most li/ely malignant tumor causing e#trahepatic obstructive Daundice? \\\ &allbladder \\\ +ommon hepatic duct \\\ +ystic duct \\\ (eriampullary area \\ Head of the pancreas (E) .ancer of the head of the pancreas is the
most common cause of obstructi"e 0aundice. *n cholangiocarcinoma of the common hepatic duct, the gallbladder !ill be empty and not distended. $nemia may occur as a result of bleeding into the duodenum in periampullary cancer, but this is relati"ely rare. .arcinoma of
the gallbladder results in 0aundice only after

the tumor in"ades the ad0acent biliary tree.

\\\\ ) 94!year!old female presents *ith episodes of bi.arre behavior, memory lapse, and unconsciousness. She also demonstrated previously episodes of e#treme hunger, s*eating, and tachycardia. Iuring one of these episodes, her blood sugar *as tested and *as found to be "= mgQdE.Which of the follo*ing *ould most appropriately indicate a diagnosis of insulinoma? \\\ Iemonstration of insulin antibodies in blood \\\ )bnormal glucagon level

\\\ +T of the pancreas sho*ing a mass \\ Hypoglycemia during a symptomatic episode *ith relief of symptoms by intravenous glucose
(D) The characteristic features of insulinomas include9 (a) hypoglycemic symptoms: (b) blood glucose 2 4 mg;d3 during the symptomatic episodes: and (c) relief of symptoms by intra"enous in0ection of glucose (<hipple=s triad). #iagnosis is confirmed by demonstration of fasting hypoglycemia in the presence of inappropriately ele"ated le"els of insulin in the blood. $ ratio of plasma insulin;glucose >4.? is diagnostic. .irculating le"els of .peptide are usually ele"ated in patients !ith insulinoma but not in patients !ith such other causes of hypoglycemia as tumors of mesenchymal origin and li"er tumors. 'atients !ho surreptitiously administer insulin de"elop insulin antibodies.

\\\ Iecreased circulating + peptide in the blood \\\\ )"4!year!old patient *ith chronic pancreatitis is suffering from malnutrition and *eight loss secondary to inade1uate pancreatic e#ocrine secretions. Which is TRBC regarding pancreatic secretions? \\\ Secretin releases fluid rich in en.ymes. \\ Secretin releases fluid rich mainly in electrolytes and bicarbonate.
(B) 7ecretin releases fluid rich mainly in electrolytes and bicarbonate. /oth cholecysto)inin and "agal stimulation result in fluid !ith a high content of en1ymes. $mong the pancreatic en1ymes, amylase and lipase are released in their acti"e forms: !hereas, the proteolytic en1ymes (trypsinogen, chymotrypsinogen) are secreted as inacti"e 1ymogens. Their acti"ation

occurs in the duodenum, !here the 1ymogens are exposed to entero)inase.

\\\ +holecysto/inin releases fluid, predominantly rich in electrolytes, andbicarbonate. \\\ )ll pancreatic en.ymes are secreted in an inactive form. \\\ The pancreas produces proteolytic en.ymes only. \\\\ )"8!year!old *oman presents *ith severe recurrent peptic ulcer located in the pro#imal DeDunum. Aive years previously she under*ent parathyroidectomy for hypercalcemia. Her brother *as previously diagnosed as having Jollinger!Cllison syndrome. To confirm the diagnosis of Jollinger! Cllison syndrome, blood should be tested for levels of *hich of the follo*ing? \\\ (arathyroid hormone \\\ Histamine \\\ (epsin \\ &astrin (D) Jollinger!Cllison syndrome is caused by
secretion of excessi"e amounts of gastrin by islet cells of the pancreas (gastrinoma). *t should al!ays be thought of in patients !ith peptic ulcer disease, !hose ulcers are se"ere, refractory to management, recurrent or located distally, beyond the first part of the duodenum. @astrin le"els in the blood are increased mar)edly and can be raised further by secretin in0ection (paradoxical response). The source of gastrin le"el in the blood may arise from hyperplasia, adenoma, or most commonly carcinoma of the islets. %ost gastrinomas are sporadic, but 2 % of patients ha"e a family history of multiple endocrine neoplasia.

\\\ Secretin \\\\ ) 4=!year!old patient develops severe peptic ulcer disease that recurs despite gastric resection and vagotomy operations. She no* presents *ith melena from a peptic ulcer located in the third part of the duodenum. To locali.e the gastrin!producing tumor, she should have *hich of the follo*ing? \\\ +T scan of the abdomen \\\ Bltrasound of the abdomen \\ SRS$somatostatin receptor scintigraphy' (C) %ecause most gastrinomas are small,
preoperative locali.ation of the tumor may be difficult. )nuclear scan may be performed using radiolabeled somatostatin $octreotide' analogue.

This binds *ith the somatostatin receptors present on the gastrin!producing cells *hich identifies the tumor. Cndoscopic $not transcutaneous' ultrasound is also useful in locali.ing these lesions in the pancreas and in the duodenum. The combined accuracy of SRS and endoscopic ultrasound in preoperative locali.ation of gastrinomas is 5 6.

\\\ <R0 of the abdomen \\\ %arium meal and follo* through \\\\ )37!year!old *oman is evaluated for obstructive Daundice. The cholangiographic findings indicate that she has a cancer of the lo*er end of the +%I. +linical e#amination *ould most li/ely reveal *hich of the follo*ing? \\ Cnlarged gallbladder (A) The gallbladder is enlarged $+ourvoisier2s
sign' in most cases of obstructive Daundice attributable to malignancy. 0n obstructive Daundice attributable to gallstones, the gallbladder is usually shrun/en, o*ing to the previous inflammatory condition affecting the gallbladder.

\\\ Shrun/en gallbladder \\\ Cnlarged pancreas \\\ Shrun/en pancreas \\\ (alpable tumor \\\\ )"8!year!old female travel agent presents *ith Daundice. Radiological findings confirm the presence of sclerosing cholangitis. She gives a long history of diarrhea for *hich she has received steroids on several occasions. She is li/ely to suffer from *hich of the follo*ing? \\\ (ernicious anemia \\ Blcerative colitis
(B) 7clerosing cholangitis is rare and occurs mainly in the third and fourth decades of life. Anli)e most autoimmune disorders, it affects men more commonly. *t may occur !ithout any other abnormal pathology or may be associated !ith ulcerati"e colitis or retroperitoneal fibrosis. The ./# is con"erted to a thic)ened cord

!hose lumen is almost completely obliterated. The prognosis is guarded, and the mean sur"i"al is only ,B years.

\\\ +eliac disease \\\ Eiver cirrhosis \\\ +rohn2s disease \\\\ ) "=!year!old man under*ent laparoscopic cholecystectomy 9 years earlier. He remains asymptomatic until ; *ee/ before admission, *hen he complains of RBR pain and Daundice. He develops a fever and has several rigor attac/s on the day of admission. )n ultrasound confirms the presence of gallstones in the distal +%I. The patient is given antibiotics. Which of the follo*ing should be underta/en as the ne#t step in therapy? \\\ Should be discharged home under observation \\\ Should be observed in the hospital \\\ Bndergo surgical e#ploration of the +%I \\ CR+( *ith sphincterotomy and stone removal
(D) The patient described has the features of .harcot=s triad&0aundice, abdominal pain, and rigors, !hich indicates the presence of ascending cholangitis in a patient !ith obstructi"e 0aundice. The patient should be treated !ith broad spectrum *C antibiotics and undergo 58.', sphincterotomy, and stone extraction. *f this fails, surgical exploration of the ./# !ill be re(uired.

\\\ )nticoagulants \\\\ 0n attempting to minimi.e complications during cholecystectomy, the surgeon defines the triangle of +alot during the operation. The boundaries of the triangle of +alot $modified' are the common hepatic duct medially, the cystic duct inferiorly, and the liver

superiorly. Which structure courses through this triangle ?

\\\ Eeft hepatic artery \\\ Right renal vein \\\ Right hepatic artery \\ +ystic artery \\\ Superior mesenteric vein \\\\ ) surgeon is removing the gallbladder of a 4!year!old obese man. @ne *ee/ previously the patient had recovered from obstructive Daundice and at operation, numerous small stones are present in the gallbladder. 0n addition to cholecystectomy, the surgeon should also perform *hich of the follo*ing? \\ 0ntraoperative cholangiogram
(A) *f there is a recent history of 0aundice, although the ./# is not dilated, intraoperati"e cholangiography must be performed to exclude ./# stones. Dther indications for intraoperati"e cholangiogram include a recent history of ascending cholangitis, dilated ./# on preoperati"e sonogram, or suspicion of a EmissingF stone in the gallbladder (i.e., as detected by ultrasound or other obser"ations). 5le"ated bilirubin and al)aline phosphatase are other indications that a ./# stone may be present.

\\\ Eiver biopsy \\\ :o further treatment \\\ Removal of the head of the pancreas

\\\ +%I e#ploration \\\\ ) "9!year!old man presents *ith recurrent RBR pain for 9 years. ) sonogram is negative for gallstones, and the +%I is normal. )n upper &0 endoscopy is also normal, and there is no peptic ulcer disease. %iliary dys/inesia is suspected, and the patient undergoes further evaluation. Which of the follo*ing *ill stimulate contraction of the gallbladder? \\ +holecysto/inin
(A) $ cholecysto)inin stimulated H*#$ scan should be performed. +ailure of the gallbladder to contract after stimulation by cholecysto)inin may suggest dys)inesia. This is an indication for cholecystectomy, e"en though stones are not demonstrated. 7ecretin is the duodenal hormone that stimulates exocrine pancreatic secretion. @astrin, released mainly from the antrum, increases gastric acid secretion that is high in bicarbonate and electrolytes.

\\\Oagal section \\\ Secretin \\\ Cpinephrine \\\ &astrin \\\\ )47!year!old previously healthy business e#ecutive presents *ith gradually increasing obstructive Daundice. )n ultrasound of the liver sho*s dilated intrahepatic ducts, but the +%I is normal. )n CR+( sho*s a filling defect at the level of the common hepatic duct. Cndoscopic brush biopsies are ta/en, and histology confirms cholangiocarcinoma. 0n discussing these findings, the surgeon should inform the patient that \\ This tumor affects men more commonly than *omen.
(A) Anli)e most biliary disease conditions, cholangiocarcinoma condition affects men more commonly than !omen. 'rimary sclerosing cholangitis, C. sinensis, and choledochal cysts may play an etiological role in some cases, but gallstones are not in"ol"ed in the pathogenesis of this tumor. 'atients present !ith obstructi"e 0aundice: pain, and !eight loss are less common. 'roximal tumors (Glats)in) are most common, and they re(uire excision of hepatic duct bifurcation and reconstruction !ith a 8oux&en&H limb

of 0e0unum. Tumors of the distal duct can be resected by performing a <hipple pancreatoduodenectomy. 'atients !ho are not operati"e candidates (those !ith ad"anced disease or those !ho cannot !ithstand a ma0or operation) should undergo palliati"e endoscopic stent placement to relie"e the obstruction.

\\\ The tumor is a result of gallstones. \\\ The tumor is best treated *ith a stent to relieve obstructive Daundice. \\\ Weight loss is common in this condition. \\\ The most common location of these tumors is at the ampulla of Oater. \\\\ )44!year!old *hite female undergoes a laparoscopic cholecystectomy for symptomatic cholelithiasis. The operation *ent *ell, and the patient *as discharged home. @ne *ee/ later, she comes to your office for a routine postoperative follo*!up. The final pathology report sho*s an incidental finding of a gallbladder carcinoma confined to the mucosa. 0n further advising the patient, you should inform her that \\\ She should undergo radiation therapy. \\\ She should undergo right hepatectomy to remove locally infiltrating disease. \\\ She should undergo regional lymphadenectomy. \\\ She re1uires systemic chemotherapy. \\ She does not re1uire any further therapy.
()) 7he does not re(uire any further therapy. *n instances !here gallbladder carcinoma is disco"ered incidentally during cholecystectomy and is sho!n to ha"e only in"aded the mucosa and submucosa it is classified as stage *. The &year sur"i"al for these patients is 144% and no further treatment is re(uired as for more ad"anced lesions, that is, those penetrating the muscular layer or !ith lymph node in"ol"ement (stages ** I ***). Here

there is a higher incidence of local and regional spread to the li"er and porta hepatis lymph nodes, respecti"ely. +or these patients an en bloc resection of segments - and of the li"er is performed along !ith dissection of celiac axis and porta hepatis lymph nodes. +or more ad"anced lesions (stage *C), the prognosis is "ery poor, and further resection is not indicated. @allbladder carcinoma responds poorly to radiotherapy or chemotherapy.

\\\\ 0n performing hepatic resection, a /no*ledge of the different lobes and segments of the liver is mandatory. The right and left lobes of the liver are separated by an imaginary plane $+antlie2s line' that passes bet*een the the inferior vena cava $0O+' and *hich of the follo*ing? \\\ (ortal vein \\\ Aalciform ligament \\\ Eeft margin of the 1uadrate lobe \\ &allbladder
(D) The hepatic artery, portal "ein, and hepatic bile duct are distributed e(ually bet!een both lobes of the li"er di"ided by .antlie=s line. This line passes bet!een the inferior "ena ca"a posteriorly and the gallbladder fossa anteroinferiorly. The falciform ligament does not di"ide the li"er into a right and left lobe: it di"ides the true left lobe into medial and lateral segments. The caudate and (uadrate lobes are part of the

left lobe, and, thus, .antlie=s line passes along their

right (and not left) margins.

\\\ Eeft margin of the caudate lobe \\\\ ) healthy 3"!year!old *oman had a cancer of the left colon resected " years previously. Iuring follo*!up, an increased carcinoembryonic antigen $+C)' level lead to a +T scan of the abdomen, *hich revealed t*o discrete lesions in the left lateral lobe of the liver. Eiver biopsy confirms that this is metastatic colon cancer. What is the most appropriate plan? \\\ 0nform the patient that there is no treatment, and that her e#pectation of life is limited. \\\ 0rradiation is recommended. \\\ Eocal cauteri.ation of the cancer is recommended. \\ Eiver resection is recommended.
(D) /efore performing the left hepatic lobectomy, any extrahepatic metastasis should be ruled out. *f lung, bone, adrenal, or s)in metastasis !ere present, then sub0ecting the patient to a ma0or operation !ould not be !arranted in most cases. %oreo"er, before proceeding !ith surgery,

it must be ascertained that control of the primary tumor has been achie"ed and that the patient=s physical condition !ill allo! such a ma0or operation. 7urgical excision of hepatic metastasis results in 2 %, &year sur"i"al. 'atients not treated by hepatic resection do not usually sur"i"e into the first year after clinical detection. .hemotherapy !ould be offered if resection !ere not indicated.

\\\ +hemotherapy is recommended. \\\\ )"5!year!old man *ith a history of cirrhosis is admitted *ith significant hematemesis. There is Daundice and clubbing of the fingers. His e#tremities are cold and clammy, and the systolic blood pressure drops to 8" mm Hg. The initial step in the management is to proceed *ith *hich of the follo*ing? \\\ Brgent endoscopy and sclerotherapy \\\ Sengsta/en!%la/emore tube \\ 0nfusion of intravenous crystalloids $resuscitation'
(C) $s in any patient !ith upper @* bleeding, the initial inter"ention follo!ing clinical e"aluation re(uires appropriate resuscitation. /lood transfusion may be re(uired. 3i"er functions must be assessed, and coagulopathy should be corrected !ith ++' or "itamin G in0ection. $fter resuscitation is completed, e"ery attempt should be made to perform an upper @* endoscopy as soon as possible. These patients may be bleeding from "arices, portal hypertensi"e gastropathy, peptic ulcer, or %allory&<eiss tear, and early endoscopy !ill pro"ide a higher diagnostic yield as to !hich lesion is actually bleeding.

\\\ 0ntravenous pitressin \\\ Surgery to stop bleeding \\\\ )"9!year!old *oman *ith a /no*n history of esophageal varices secondary to hepatitis and cirrhosis is admitted *ith severe hematemesis from esophageal varices. %leeding persists after pitressin therapy. What *ould the ne#t step in management involve? \\\ Cmergency portacaval shunt \\\ Cmergency lienorenal shunt \\\ 0nsertion of Sengsta/en!%la/emore tube \\\ Oagotomy \\ TransDugular intrahepatic portasystemic shunt $T0(S'
(E) T0(S refers to an implantable, e#pandable metal stent placed radiologically through the hepatic parenchyma to establish a tract bet*een the hepatic and portal vein. ) portal systemic shunt is, therefore, created, and the varices are decompressed. %ecause of the high incidence of complications $esophageal perforation, aspiration, air*ay obstruction' associated *ith the Sengsta/en!%la/emore tube, it is only used as a last ditch attempt to control e#sanguination. 0n ?4=6 of cases, bleeding recurs after the tube is deflated.

\\\\ ) 94!year!old *oman found a lump in her right breast on self!e#amination. She has no family history of breast cancer. The lump is freely mobile and *ell circumscribed. What is the best option to evaluate a breast mass in a young female? \\\ %iopsy \\\ <ammography \\\ Testing for breast cancer $/8.$' gene \\ Bltrasound \\\ Watchful *aiting \\\\ ) ;5!year!old *oman began breast!feeding for the first time. )t first, it *as difficult for her infant to feed. :o*, her breasts are red, *arm, and sore. She has continued to breast!feed, despite the pain; ho*ever, she has recently begun to use a breast pump instead of breastfeeding. She is begun on a course of oral antibiotics. What condition is this patient at ris/ of developing? \\ %reast abscess \\\ Aibrocystic disease \\\ 0nflammatory breast cancer \\\ (rolactinoma

\\\ Tuberculosis \\\\) ;!year!old *oman complains of a 3!month history of bloody diarrhea, abdominal pain, and intermittent fevers. She has a history of irritable bo*el syndrome but has had a *orsening of her symptoms during the above time period. Her past medical history is unremar/able. (hysical e#amination reveals abdominal distension. %o*el sounds are present in all 1uadrants. Rectal e#amination reveals multiple anal fissures. What is the most appropriate diagnostic testing for this patient? Irritable bo!el syndrome "I23# is a
disorder that leads to abdominal pain and cramping, changes in bo!el mo ements, and other symptoms. I23 is not the same as inflammatory bo!el disease "I2&#, !hich includes .rohn,s disease and ulcerati e colitis. In I23, the structure of the bo!el is not abnormal.

\\\ )noscopy \\ +olonoscopy \\\ Ale#ible sigmoidoscopy \\\ Rigid sigmoidoscopy \\\ :o further diagnostic testing is re1uired for this patient. \\\\ ) "=!year!old *oman undergoes repair of a right femoral hernia.Iuring the procedure, the femoral canal is dissected. The anatomic boundaries of the femoral canal include *hich of the follo*ing? \\ +ooper ligament \\\ 0nguinal ligament \\\ 0schial spine \\\ Eacunar ligament \\\ :erve $femoral' \\\\ ) "7!year!old *oman *ith a history of a left thyroid mass undergoes left thyroid lobectomy. (athology reveals a ;. !cm papillary carcinoma *ith no evidence of e#tracapsular e#tension. What is the most appropriate ne#t step in the treatment of this patient? \\\ C#ternal!beam radiotherapy \\\ <ultiagent chemotherapy \\\ Subtotal thyroidectomy \\\ Total thyroidectomy \\ Watchful *aiting *ith periodic follo*!up \\\\ ) 98!year!old *oman presents to her physician for evaluation of a lump in her right breast found on selfe#amination. She has a family history of breast cancer in that her mother died in her early "=s from this condition. The mother had a modified radical mastectomy follo*ed by chemotherapy. (hysical e#amination reveals a breast lump that is freely mobile and *ell circumscribed. There is no dimpling, asymmetry, or retractions. The lesion measures 9 cm. What is the ne#t step in the management of this patient? \\\ %iopsy of the lesion *ith sonographic guidance \\\ <ammography follo*ed by stereotactic +T scan \\\ Testing for /8.$ gene \\ Bltrasound of the breast and consideration for breast biopsy \\\ Watchful *aiting and follo*!up e#amination by primary care physician in ; year

\\\\ )3;!year!old man *ith a long history of heavy smo/ing sho*s on computed a#ial tomography $+)T' scanning a right upper lobe tumor and enlarged paratracheal nodes. The tumor has been diagnosed as malignant by bronchoscopy. Gour ne#t move should be: \\\ Csophagoscopy to rule out invasion of the esophagus. \\\ (roceed *ith lobectomy and paratracheal node dissection. \\\ %egin radiation of the tumor and paratracheal area. \\ (erform a mediastinoscopy for staging. \\\ Wait months and repeat +)T scan to evaluate further disease progression. \\\\ 0mmediately follo*ing a bout of pneumonia, a young *oman develops a large pleural effusion. ) chest tube is inserted and 3== mE of thin pus is obtained. )+)T scan sho*s incomplete drainage and multiple intrapleural loculations. <anagement of this empyema re1uires: \\\ 0nsertion of multiple chest tubes under +)T guidance to drain either most or all loculations. \\\ Treat the patient *ith antibiotics and continue single chest tube drainage. \\\ Treat patient *ith antibiotics and continue single chest tube drainage *aiting for a thic/ peel to develop and then proceed *ith open total lung decortication. \\ (roceed *ith thoracoscopy and intrapleural toilette. %rea/ the loculations and place drains. \\\ ) thorough open total lung decortication immediately. \\\\ ) "=!year!old *oman treated for many yearsfor gastroesophageal reflu# develops dysphagia and *eight loss. (revious esophagoscopy has revealed cellular atypia. )n esophagoscopy is about to be performed. What is it most li/ely to reveal? \\\ Eeiomyoma arising from the long esophageal muscular layer \\\ S1uamous cell carcinoma arising from esophageal mucosal lining \\ )denocarcinoma originated from islands of %arrett2s esophagus \\\ )denocarcinoma e#tending from the stomach \\\ ) large ulcer at the gastroesophageal Dunction \\\\ )young *oman has suffered severe achalasia of the lo*er most esophagus. )ttempted dilations have failed. The best treatment is: \\\ Eeft thoracotomy and e#tensive myotomy \\\ Resection of the gastoesophageal Dunction and reanastomosis \\\ Eeft thorcotomy, myotomy, and stomach *rap $fundoplication' \\ Eaparoscopic myotomy and partial fundoplication \\\ Transthoracic esophagogastrostomy $side!to!side' anastomosis to avoid disrupting the gastroesophageal sphincter \\\\ ) 3=!year!old male presents *ith an inguinal hernia of recent onset. Which of the follo*ing statements are TRBC? \\ The hernia is more li/ely to be direct than indirect. The indirect occur at any age,
from infancy to the elderly& In children or females the hernia is invariably indirect&

'irect herniae occur females)

ith increasing fre(uency in males as they age&(never occur in

\\\ (resents through the posterior *all of the inguinal canal, lateral to the deep inguinal ring. \\\ 0s covered anteriorly by the transversalis fascia. \\\ 0s more li/ely than a femoral hernia to strangulate. \\\ The sac is congenital. \\\\ )7=!year!old cigarette smo/er presents *ith a right inguinal mass that has enlarged and has caused discomfort in recent months. He complains of recent difficulty *ith micturition and nocturia. The s*elling, *hich does not e#tend to the scrotum, reduces *hen resting. What is the li/ely diagnosis? \\ Iirect inguinal hernia \\\ Strangulated indirect inguinal hernia \\\ Hydrocele \\\ )neurysm of the femoral artery \\\ +yst of the cord \\\\ )n other*ise healthy, 3=!year!old male has been advised to undergo surgical treatment for a left ingunial hernia. Which of the follo*ing are acceptable standards of surgical treatment? \\ Traditional surgical repair under general or local anesthesia \\\ Repair of the hernia and ipsilateral orchiectomy, in order to better assure closure of the inguinal canal and reduce the possibility of recurrence \\\ Eaparotomy to perform a retroperitoneal repair \\\ Surgical e#ploration of the contralateral groin to search for an occult hernia sac and to remove it before a hernia develops \\\ The patient should be advised to *ear a truss postoperatively, in order to reduce the incidence of recurrence \\\\ The follo*ing structures may be inDured during surgery to repair an inguinal hernia: \\ The ilioinguinal, genitofemoral, iliohypogastric, and lateral femoral cutaneous nerves \\\ The femoral nerve \\\ The popliteal nerve \\\ The nerve to the psoas maDor muscle \\\ The pudendal nerve \\\\ Which of the follo*ing structures *ould be encountered during repair of an inguinal hernia in a male? \\ Spermatic cord, cremaster muscle, transversalis fascia, deep epigastric vessels, conDoined tendon \\\ Round ligament \\\ @bturator nerve \\\ Symphysis pubis \\\ :erve to the adductor muscles of the thigh

\\\\ Which of the follo*ing structures *ould be encountered during repair of an inguinal hernia in a female? \\\Spermatic cord, cremaster muscle, transversalis fascia, deep epigastric vessels, conDoined tendon \\ Round ligament \\\ @bturator nerve \\\ Symphysis pubis \\\ :erve to the adductor muscles of the thigh \\\\ ) 7=!year!old, moderately obese, male presents *ith a large, midline incisional hernia. @ne year previously, he under*ent a colon resection for adenocarcinoma. +olonoscopy, metastasis *or/up and carcinoembryonic antigen $+C)' are normal. Which of the follo*ing statement is TRBC? \\ Repair *ith mesh can be performed laparoscopically. \\\ Strangulation is uncommon because the nec/ is narro*. \\\ Recurrence is common, even *ith the use of mesh of improved 1uality. \\\ Surgical repair is simple to perform under local anesthesia. \\\ (atients remain very uncomfortable, even *ith an ade1uate repair. \\\\ ) 43!year!old male has history of leg pain at rest. (atient also has history of severe coronary artery diseases. He cannot *al/ t*o flights of steps *ithout getting short of breath. He under*ent evaluation and *as noted to have complete aortoiliac occlusive disease. He needs surgery. Which one of the follo*ing options is acceptable? \\\ )ortobililiac bypass \\\ )ortobifemoral bypass \\\ )ortoiliac angioplasty and stent placement \\ )#illobifemoral bypass \\\ )#illoiliac \\\\ ) "=!year!old chronic smo/er presents *ith ulceration of the tip of the right second, third, and fourth toes. He gives a history of recurrent migratory superficial phlebitis of the feet occurring a fe* years ago. (hysical e#amination findings are remar/able for absent bilateral posterior tibial and dorsalis pedis pulses *ith palpable popliteal pulses. What is the single most important step in management? \\\ <ultiple toe amputations \\\ Eong!term anticoagulant therapy \\\ 0mmediate operative intervention \\\ )ngiography follo*ed by bypass surgery \\ +essation of smo/ing \\\\ )9;!year!old *oman is referred to your office because of multiple lo*er e#tremity varicose veins. She has large varicosities in the distribution of the long saphenous vein. What is the ne#t step in management? \\\ ) ligation and stripping operation \\\ Eigation of both the long and short saphenous system

\\\ Sclerotherapy \\ Iuple# evaluation along *ith clinical correlation as an essential initial step \\\ +ompression stoc/ings and anticoagulation therapy \\\\ )79!year!old retired ban/er complains of left leg intermittent claudication *hile playing golf. )n angiogram sho*s occlusion of the superficial femoral artery and reconstitution of the popliteal artery belo* the /nee. What is the treatment of choice? \\ ) vigorous e#ercise program \\\ Cndarterectomy of the superficial femoral artery \\\ Aemoropopliteal bypass *ith e#panded polytetrofluoroethylene $(TAC' graft \\\ 0n situ femoropopliteal bypass \\\ Aemoropopliteal bypass *ith reversed saphenous vein graft \\\\ )n elderly patient *ith ischemic rest pain is found to have combined aortoiliac and femoropopliteal occlusive disease. What is the treatment of choice? \\ )ortofemoral bypass \\\ Aemoropopliteal bypass \\\ )ortofemoral and femoropopliteal bypass \\\ Eumbar sympathectomy \\\ Oasodilator therapy \\\\)79!year!old man complains of bilateral thigh and buttoc/ claudication of several months duration. He *as told by his physician that the angiogram revealed findings indicating that he has Eeriche syndrome. What does this patient have? \\\ )bdominal aortic aneurysm \\ )ortoiliac occlusive disease \\ \0liac artery aneurysm \\\ Aemoropopliteal occlusive disease \\\ Tibial occlusive disease \\\\ ) middle!aged man complains of shortdistance claudication in the right thigh. The angiogram sho*s a right common iliac artery stenosis of 5=6 over a short segment. What is the treatment of choice? \\\ )ortofemoral bypass \\\ Eeft!to!right fermorofemoral bypass \\\ 0liofemoral bypass \\ (T) and stent placement$!ercutaneous Transluminal Angioplasty \\\ )#illofemoral bypass \\\\ ) 9"!year!old *oman on oral contraceptive pills develops an episode of deep vein thrombosis that is ade1uately treated *ith anticoagulation. She is at increased ris/ of developing *hich of the follo*ing? \\\ Recurrent foot infections \\ +laudication \\\ (ulmonary embolism \\ (ostphlebetic syndrome

\\\ Superficial varicose veins \\\\ )78!year!old *oman develops a liver abscess follo*ing stent drainage of Daundice. What is the preferred therapy? \\\ @ral administration of antibiotics \\\ )spiration of abscess \\\ +T!guided percutaneous drainage alone \\ )dministration of antibiotics and +T!guided percutaneous drainage \\\ Surgical drainage \\\\ )3"!year!old man is noted on +T scan to have a liver abscess. He is diagnosed as more li/ely to have a pyogenic than amebic liver abscess. Why? \\\ He emigrated from <e#ico. \\\ Paundice is absent. \\\ He has associated diarrhea. \\ He has a history of biliary tract disease. \\\ There is a rapid response to metronida.ole. \\\\ ) recently arrived 39!year!old emigrant from &reece complains of upper abdominal pain and fever. Bltrasound reveals a large liver cyst that, on serological testing, is sho*n to be hydatid disease. What should he undergo? \\\ +ortisone therapy \\\ (ercutaneous drainage \\\ Eaparotomy and open drainage \\\ Eaparotomy and needle aspiration \\ Eaparotomy and e#cision of cyst and perioperative albeda.ole $drug used for the
treatment of a ariety of parasitic !orm infestations#

\\\\ ) "9!year!old *oman presents *ith a !cm breast mass of !month duration. <ammography sho*s microcalcification and features suggestive of malignancy.The diagnosis is confirmed by *hich of the follo*ing? \\ :eedle biopsy \\\ @pen biopsy from the edge \\\ <ammography \\\ Eymph node biopsy \\\ Thermography \\\\ )9=!year!old man *ith a duodenal ulcer complains of pain *hen eating food as *ell as during the early hours of the morning. Iuring the cephalic phase of digestion, the stomach is stimulated by *hich of the follo*ing? $he cephalic phase of gastric
secretion occurs e en before food enters the stomach, especially !hile it is being eaten. It results from the sight, smell, thought, or taste of food, and the greater the appetite, the more intense is the stimulation.

\\\ @lfactory nerve \\\ Right glossopharyngeal nerve \\\ Sympathetic chain \\\ Eeft splanchnic nerve

\\ Oagus nerve \\\\ )34!year!old man presents *ith s1uamous cell carcinoma of the anus. He is in good health other *ise. <etastatic *or/up is negative. The treatment of choice for this cancer is: \\\ Radiation \\\ +hemotherapy \\ Radiation and +hemotherapy \\\ )bdomino!perineal resection \\\ Wide local e#cision \\\\ )74!year!old man is admitted *ith epigastric pain, anemia, and *eight loss. @n upper gastrointestinal endoscopy, a large ulcer is found in the distal antrum. The biopsy report sho*s adenocarcinoma of the stomach. +)T scan of the liver sho*s no metastasis. Gou *ould recommend: \\\ Whipple procedure $pancreaticoduodenectomy' \\\ Oagotomy and antrectomy \\ Subtotal gastrectomy \\\ Oagotomy and pyloroplasty *ith *edge resection of the ulcer \\\ Total gastrectomy \\\\ );9!year!old perpubertal female has a painless 9.4!cm firm mass in the left subareolar area upon e#amination in the clinic. The right side has no palpable masses. The patient2s mother is 1uite concerned. Gou recommend: \\\ C#cisional biopsy \\\ Bltrasound \\\ Aine needle aspiration \\\ 0ncisional biopsy \\ @bservation \\\\)"9!year!old *oman presents *ith a s*ollen, painful, erythematous left breast *hich does not repond to a ;= day course of o#acillin. Bltrasound reveals no abscess. The ne#t step in management should be: \\\ %egin a ;=!day course of vancomycin \\\ Wor/up the patient for an immunosuppressive disease \\\ 0ncise and drain the area \\ %iopsy the s/in and parenchyma of the breast \\\ %egin a 4!day course of prednisone in decreasing doses \\\\ ) =!year!old man is noted to be anemic, *ith clinical Daundice and a palpable spleen on abdominal e#am. Splenectomy is the only treatment for this patient2s automsomal dominant disorder. \\\ Thalassemia \\ Hereditary spherocytosis $3igns and symptoms include anemia, 4aundice, and an
enlarged spleen "splenomegaly#.

\\\ Sic/le cell disease \\\ 0diopathic autoimmune hemolytic anemia

\\\ Thrombotic thrombocytopenic purpura \\\\ ) 4=!year!old *oman under*ent *ide e#cision of a 9.4!cm infiltrating ductal carcinoma of the breast *ith a#illary lymph node dissection follo*ed by radiation and chemotherapy 9 years ago. The patient no* complains of RBR abdominal pain. ) +)T scan reveals t*o masses in the right lobe of the liver Select the most li/ely diagnosis for the patients belo* \\\ :onparasitic cyst \\\ )denoma \\\ Hemangioma \\\ Hepatocellular carcinoma \\ <etastatic carcinoma \\\ Iuring a routine e#amination of a =!year!old female actuary see/ing life insurance, she is found to have a ventricular septal defect $OSI'. She undergoes subse1uent studies including C+&, chest #!ray, echocardiography, and Ioppler ultrasound. What is the maDor determinant of operability in OSI? \\\ )ge of patient \\ (ulmonary vascular resistance \\\ Si.e of the OSI \\\ Eocation of the OSI \\\ (resence of cyanosis