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MyPasTest: MRCS A Online - Jan Exam 201528. Surgical Specialities; General Surgery; Upper Gastrointestinal Surgery (52Qs)
01. Theme: Oesophageal diseases
A Gastro-oesophageal reflux disease (GORD)
B Post-cricoid web
C Hiatus hernia
D Peptic stricture of the oesophagus
E Achalasia
F Barrett's oesophagus Page
G Oesophageal stricture. 1600
For each of the following statements, select the most likely answer from the above list. Each option may
be used once, more than once, or not at all.
Scenario 1
Metaplastic change of squamous to columnar epithelium
A - Gastro-oesophageal reflux disease (GORD)« YOUR ANSWER
F - Barrett's oesophagus« CORRECT ANSWER.
Scenario 2
Shows the characteristic mega-oesophagus on barium swallow
B - Post-cricoid web« YOUR ANSWER
E - Achalasia« CORRECT ANSWER.
Scenario 3
Associated with iron deficiency anaemia
C - Hiatus hernia« YOUR ANSWER
B - Post-cricoid web« CORRECT ANSWER.
Scenario 4
Characterised by a weak lower oesophageal sphincter
D - Peptic stricture of the oesophagus« YOUR ANSWER
A - Gastro-oesophageal reflux disease (GORD)« CORRECT ANSWER.
Scenario 5
Manometry reveals high lower oesophageal sphincter pressure with failure to relax during swallowing
E - Achalasia« CORRECT ANSWER.
Achalasia is due to degeneration of the myenteric plexus causing dysphagia and often aspiration. A post-
cricoid web may predispose to carcinoma (usually squamous), as does achalasia and Barrett’s
oesophagus (adenocarcinoma). Hiatus hernia may have normal lower oesophageal sphincter pressures,
unless associated with gastro-oesophageal reflux disease (GORD).
02. Theme: Upper gastrointestinal (GI) bleeding
A Intravenous access, fluid resuscitation and cross-match
B Partial gastrectomy
C Duodenostomy and underrunning
D Gastrotomy and underrunning
E Balloon tamponade
F Oesophageal transection and devascularisation.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
28. Surgical Specialities; General Surgery; Upper Gastrointestinal Surgery (52Qs)
For each of the situations below, select the single most likely option from the list above. Each option may
be used once, more than once or not at all.
Scenario 1
A 32-year-old man presents with haematemesis preceded by episodes of vomiting. Endoscopy shows active
bleeding from a mucosal tear on the lesser curve of the cardia. The bleeding is recurrent and not controlled by
repeated endoscopic interventions. Page
A - Intravenous access, fluid resuscitation and cross-match« YOUR ANSWER 1601
D - Gastrotomy and underrunning « CORRECT ANSWER.
Ninety per cent of bleeding from Mallory–Weiss tears stops spontaneously and most cases of active
bleeding respond to endoscopic adrenaline (epinephrine) (1:10 000) injection. The use of balloon
tamponade may extend the mucosal laceration. In 3% of cases, surgery is required.
Scenario 2
A 41-year-old man presents to A&E with massive haematemesis. His heart rate is 110 beats/min and his blood
pressure (BP) is 90/55 mmHg. He is known to have a history of alcohol excess.
B - Partial gastrectomy« YOUR ANSWER
A - Intravenous access, fluid resuscitation and cross-match« CORRECT ANSWER.
The first priority when treating upper GI haemorrhage is prompt resuscitation before diagnostic studies.
Scenario 3
A 55-year-old man presents with haematemesis. He is tachycardic and his BP is 100/50 mmHg with ongoing
blood transfusion. An urgent endoscopy shows oozing haemorrhage from the posterior wall of the duodenum,
which is not controllable by endoscopic means.
C - Duodenostomy and underrunning « CORRECT ANSWER.
Bleeding from duodenal ulcers can involve the gastroduodenal artery or its branches. If there is minimal
scarring the duodenostomy may be closed longitudinally; otherwise, it may be closed vertically (similar to
a pyloroplasty).
Scenario 4
A 45-year-old man is admitted with haematemesis. He has a past history of alcoholic liver failure. His blood tests
show Hb 7.9 g/dl, platelets 86 ´ 10 9/litre and international normalised ratio (INR) 3.1. Urgent endoscopy shows
clots and oesophageal varices. He undergoes band ligation of the varices but has further massive haematemesis
leading to hypotension, tachycardia and confusion.
D - Gastrotomy and underrunning « YOUR ANSWER
E - Balloon tamponade« CORRECT ANSWER.
Continued bleeding after endoscopic intervention is an indication for balloon tamponade. A modified
Sengstaken–Blakemore (Minnesota) tube is a holding measure until a more definite treatment can be
instituted. Splanchnic vasoconstrictor drugs (eg terlipressin) can also be used before endoscopy.
Complications of balloon tamponade include aspiration pneumonia, mucosal ulceration and oesophageal
perforation.
03. Theme: Right iliac fossa pain (common causes)
A Acute appendicitis
B Caecal carcinoma
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
28. Surgical Specialities; General Surgery; Upper Gastrointestinal Surgery (52Qs)
C Crohn’s disease
D Diverticulitis
E Gastroenteritis
F Irritable bowel syndrome
G Mesenteric adenitis
H Non-specific abdominal pain
I Pelvic inflammatory disease Page
J Ruptured ectopic pregnancy 1602
K Torsion ovarian cyst
L Ureteric colic
M Urinary tract infection.
The following are descriptions of patients with common causes of right iliac fossa pain. Please select the
most appropriate diagnosis from the list. The items may be used once, more than once, or not at all.
Scenario 1
A 22-year-old man is seen in The Emergency Department with a 2-day history of right iliac fossa pain, anorexia,
vomiting and diarrhoea. On examination the patient is flushed and tachycardic (pulse 100/min). Abdominal
examination demonstrates the presence of tenderness and guarding in the right iliac fossa with no masses
palpable.
A - Acute appendicitis « CORRECT ANSWER.
A – Acute appendicitis:
The presence of acute right iliac fossa pain, coupled with anorexia, nausea/vomiting, diarrhoea or fever in
a septic, young male patient, should immediately raise the suspicion of acute appendicitis. Although
other causes of right iliac fossa pain and tenderness (e.g. Crohn's disease involving the terminal ileum)
exist, they do not present as commonly in the acute setting as acute appendicitis. Please note that in
female patients, the differential diagnosis must include utero-ovarian pathology (most importantly,
ectopic pregnancy).
Scenario 2
A 38-year-old woman is seen in the outpatients department with a 1-year history of right-sided abdominal pain that
is often relieved following defaecation. On direct questioning she describes a change in her bowel habit with
alternating diarrhoea and constipation along with recurrent abdominal distension. She has no loss in weight, or
rectal bleeding. On examination she appears well and her abdomen is soft with no obvious distension. Blood tests
and a supine abdominal radiograph are all normal.
B - Caecal carcinoma « YOUR ANSWER
F - Irritable bowel syndrome « CORRECT ANSWER.
F – Irritable bowel syndrome:
This ‘non-diagnosis’ is suggested by the long history and typical symptoms fulfilling the Rome criteria
that are based on the clustering of certain symptoms in population studies (now defined by Rome II
criteria). Clearly, irritable bowel syndrome should only be diagnosed when an organic cause for the
patient’s symptoms has been excluded. Patients are typically young or middle-aged women, as in this
case.
Scenario 3
A 26-year-old woman is seen in The Emergency Department with a history of increasingly severe right iliac fossa
pain, which made her faint. In addition, she complains of feeling weak, thirsty and has developed pain in her right
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
28. Surgical Specialities; General Surgery; Upper Gastrointestinal Surgery (52Qs)
shoulder. She describes no gynaecological symptoms. On examination she is pale, clammy and has a sinus
tachycardia of 115 bpm. Examination of her abdomen reveals diffuse tenderness, guarding and distension across
her lower abdomen.
C - Crohn’s disease « YOUR ANSWER
J - Ruptured ectopic pregnancy« CORRECT ANSWER.
J – Ruptured ectopic pregnancy: Page
‘Every woman of child-bearing age is pregnant until proven otherwise.’ The typical history is of abdominal 1603
pain associated with fainting or collapse. Symptoms and signs of shock are usually present and, in the
case of intraperitoneal rupture, diaphragmatic irritation gives referred pain to the shoulder. There may be
a history of a missed menstrual period, but symptoms of tubal pregnancy may occur before this occurs. It
is unusual for a tubal pregnancy to advance beyond 6–8 weeks without symptoms. There is usually a
degree of abdominal distension and sub-umbilical tenderness and guarding. A urinary or serum ß-human
chorionic gonadotrophin measurement aids in the diagnosis. Prompt treatment is important and includes
resuscitation followed by urgent laparoscopy or laparotomy depending on the availability of trained staff.
Scenario 4
A 23-year-old woman presents to The Emergency Department with a history of sudden onset severe right iliac
fossa pain 4 hours ago. She has tenderness and guarding localised to the right iliac fossa and suprapubic region.
Urine dipstick testing is unremarkable (including a negative urine pregnancy test).
D - Diverticulitis « YOUR ANSWER
K - Torsion ovarian cyst« CORRECT ANSWER.
K – Torsion ovarian cyst:
The history of sudden onset of pain without gastrointestinal disturbance suggests this diagnosis, which
is a common differential in young women. The diagnosis can usually be confirmed by pelvic or
transvaginal ultrasound examination, and commonly requires surgery. A similar presentation is seen with
haemorrhage into and rupture of an ovarian cyst.
It is easily possible to name at least 20 causes of right iliac fossa pain. The list given in this question
includes some of the more common ones. In general, like so much of medicine, it is more common to see
a common condition presenting atypically than a rare condition presenting typically, eg a urinary tract
infection while usually associated with suprapubic pain may also present with right iliac fossa pain. For a
complete list consider the contents of abdomen anatomically from front to back in the region of the right
iliac fossa.
Hence,
(1) anterior abdominal wall, eg rectus sheath haematoma
(2) peritoneal viscera: caecum, small intestine, appendix, right fallopian tube and ovary, bladder
(3) retroperitoneal structures: kidney, ureter, iliac artery (leaking aneurysm thereof), undescended
testis (torsion thereof), psoas muscle (abscess).
The two commonest final diagnoses are non-specific abdominal pain and appendicitis.
04. A 37-year-old female is urgently referred from her GP with symptoms of dysphagia, retrosternal
discomfort and regurgitation. On further questioning she admits to having lost weight. A Barium swallow
shows a dilated tapering oesophagus with a 'rat’s tail' appearance. What is the most likely diagnosis?
Select one answer only.
Achalasia« YOUR ANSWER (CORRECT ANSWER)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
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