SMT NHL Municipal Medical College - 3rd MBBS General Surgery

First Internal Examination - Model Answers

SECTION 1

Q-1 (10 Marks) - RECOMMENDED ANSWER: Acute Appendicitis

OPTION A: Gangrene - Definition, Clinical Features and Management of Diabetic Foot

• Dry gangrene: Ischemic necrosis without infection; the part becomes dry, shrunken, black, and mummified. There is a well-defined line of demarcation. Common in arteriosclerosis.
• Wet gangrene: Necrosis combined with bacterial putrefaction; the part is swollen, edematous, and foul-smelling. Line of demarcation is absent. More dangerous due to toxemia.
• Gas gangrene: Due to Clostridium perfringens; there is gas in the tissues (crepitus), rapid spread, and severe toxemia.
• Diabetic gangrene: Mixed type - both ischemic and infective components; usually begins in toes/foot.

1. Peripheral neuropathy - sensory loss leads to unnoticed injuries; motor neuropathy causes foot deformity; autonomic neuropathy causes dry skin and fissuring
2. Peripheral vascular disease - ischemia reduces healing and increases susceptibility to infection
3. Impaired immunity - hyperglycemia reduces neutrophil function

• Neuropathic ulcer: Painless, punched-out, on pressure areas (metatarsal heads, heel); warm foot, good pulses, diminished sensation
• Ischemic ulcer: Painful, at tips of toes; cold, pulseless foot
• Charcot's joint: Destruction of joints due to neuropathy
• Gangrene: Begins in toes; can be dry (ischemic) or wet (infected)
• Signs of infection: cellulitis, lymphangitis, crepitus (gas-forming organisms), foul-smelling discharge
• Wagner Grading (important for exams):
  • Grade 0: No open lesion; high-risk foot
  • Grade 1: Superficial ulcer
  • Grade 2: Deep ulcer to tendon/capsule/bone
  • Grade 3: Deep ulcer with osteitis/abscess
  • Grade 4: Forefoot gangrene
  • Grade 5: Whole foot gangrene

• Control blood sugar (target HbA1c <7%)
• Treat hypertension and dyslipidemia
• Stop smoking
• Patient education: daily foot inspection, proper footwear

• Antibiotics: broad-spectrum (covering Gram-positive, Gram-negative, and anaerobes) - e.g., amoxicillin-clavulanate, metronidazole ± ciprofloxacin
• Wound debridement and dressings
• Offloading: total contact cast, special footwear

• Debridement of necrotic tissue
• Drainage of deep space abscess
• Revascularization: angioplasty or bypass grafting for ischemic component
• Amputation: digit amputation → ray amputation → transmetatarsal → below-knee → above-knee (as last resort)

OPTION B: Acute Appendicitis - Aetiology, Clinical Features and Management (10 marks)

• Increased intraluminal pressure
• Venous engorgement → bacterial invasion → transmural inflammation → gangrene → perforation

• Faecolith (hardened stool) - most common in adults
• Lymphoid hyperplasia - most common in children (following infection)
• Pinworms, Ascaris
• Carcinoid tumor of appendix
• Adhesions
• Barium impaction

• Pain: Begins as central/periumbilical colicky pain (visceral), shifts to right iliac fossa (RIF) within 6-12 hours (somatic, due to peritoneal involvement) - called Kocher's phenomenon
• Anorexia (almost always present; if absent, diagnosis is doubtful)
• Nausea and vomiting (after onset of pain - important: pain before vomiting)
• Low-grade fever (38°C)
• Constipation (occasionally diarrhea in pelvic appendix)

• Tenderness at McBurney's point (junction of medial two-thirds and lateral one-third of a line from umbilicus to ASIS)
• Rebound tenderness (Blumberg's sign)
• Rovsing's sign: Pressure in LIF causes pain in RIF (due to peritoneal irritation)
• Psoas sign: Pain on extending the right hip (retrocaecal appendix)
• Obturator sign: Pain on internal rotation of flexed right hip (pelvic appendix)
• Guarding and rigidity in RIF
• Alvarado score: score 5-6 suggestive, 7-8 probable, 9-10 almost certain

• CBC: Leucocytosis (>10,000/mm³) with neutrophilia
• Urinalysis: To exclude UTI/renal calculus
• X-ray abdomen: Faecolith (5%), loss of psoas shadow
• Ultrasound abdomen: Non-compressible appendix >6mm diameter, periappendiceal fat stranding (first-line in females to rule out gynecological causes)
• CT scan abdomen: Gold standard; most sensitive and specific; used when diagnosis uncertain

• IV fluids, keep nil by mouth
• IV antibiotics: cefuroxime + metronidazole (or co-amoxiclav)
• Analgesia (does not mask signs)
• Monitoring

• Appendicectomy - open or laparoscopic
• Laparoscopic appendicectomy: Preferred - less pain, shorter hospital stay, better visualization, lower wound infection rate, especially in obese patients and females
• Open appendicectomy: Grid-iron (McBurney's) incision or Lanz incision in RIF

• Wound infection (most common)
• Ileus
• Pelvic/residual abscess
• Faecal fistula

• Appendix mass (Phlegmon): Conservative management (Ochsner-Sherren regimen) with antibiotics + IV fluids. Interval appendicectomy after 6-8 weeks.
• Appendix abscess: Percutaneous drainage under USG, then interval appendicectomy.
• Generalised peritonitis: Emergency laparotomy, appendicectomy, peritoneal lavage

Q-2 (12 Marks total) - Breast Lump in a 60-year-old Female

(a) Clinical Diagnosis and Investigation (6 marks)

• Age 60 (post-menopausal) - peak incidence for breast cancer
• Hard (stony hard = malignant), painless lump in upper outer quadrant (most common site, 50% of breast cancers)
• Progressive increase over 6 months
• Change in nipple contour - suggests nipple retraction due to fibrosis/tethering of Cooper's ligaments

• Skin changes: peau d'orange, dimpling, fixity to skin
• Nipple: retraction, discharge, Paget's disease
• Fixity to pectoralis major
• Axillary lymph nodes: enlarged, hard, matted
• Supraclavicular nodes

1. Clinical examination (already done)
2. Radiological:
   • Mammography: Shows irregular spiculate mass, microcalcifications (malignant), skin thickening (gold standard screening + diagnostic tool in postmenopausal women)
   • Ultrasound breast: Distinguishes solid from cystic; irregular hypoechoic mass with posterior shadowing in carcinoma; also assesses axilla
   • MRI breast: Used for lobular carcinoma (not clearly seen on mammography), chest wall involvement, contralateral breast screening
3. Histopathological:
   • FNAC (Fine Needle Aspiration Cytology): Quick, cheap, gives cytological diagnosis (C1-C5 grading)
   • Core needle biopsy (Tru-cut): Preferred - gives histological diagnosis, allows ER/PR/HER2 receptor testing - essential for treatment planning
   • Excision biopsy if needed

• X-ray chest: Lung metastasis
• Bone scan (isotope): Bone metastases (most common site)
• Liver ultrasound/CT scan: Liver metastases
• CBC, LFT, ALP, calcium
• CT chest/abdomen/pelvis: Full staging

• ER (Estrogen Receptor) - positive in 70%: guides hormonal therapy
• PR (Progesterone Receptor) - guides hormonal therapy
• HER2/neu: Positive in 20-25%; guides trastuzumab therapy
• Ki-67: Proliferative index

(b) Treatment (6 marks)

1. Breast-conserving surgery (BCS) / Lumpectomy/Wide local excision:
   • Removal of tumor with clear margins + radiotherapy
   • Suitable if: single tumor <4cm, favorable tumor:breast ratio, no skin/chest wall involvement, no contraindication to radiotherapy
   • Equivalent survival to mastectomy
2. Modified Radical Mastectomy (MRM) - Patey's operation:
   • Removal of entire breast + skin + nipple-areola complex + axillary lymph node clearance (levels I, II, III)
   • Pectoralis major preserved
   • Standard surgery for most cases
3. Sentinel Lymph Node Biopsy (SLNB):
   • If axilla clinically negative, SLNB done first; if negative, no full axillary clearance needed (reduces morbidity)

• Radiotherapy: After BCS (mandatory), after mastectomy in high-risk cases (large tumor, >4 nodes positive)
• Chemotherapy: Anthracycline-based (AC: Adriamycin + Cyclophosphamide) ± taxanes (Paclitaxel); used in node-positive, triple-negative, HER2-positive disease
• Hormonal therapy:
  • Tamoxifen (ER+): Pre/perimenopausal women; 5-10 years; blocks estrogen receptors
  • Aromatase inhibitors (Anastrozole, Letrozole): ER+, post-menopausal women; superior to tamoxifen post-menopause; inhibits peripheral estrogen synthesis
• Targeted therapy: Trastuzumab (Herceptin) for HER2-positive disease (monoclonal antibody against HER2 receptor)
• Neoadjuvant chemotherapy: Given before surgery to downstage tumor, convert inoperable to operable, or allow breast conservation

• MRM or BCS + SLNB/axillary clearance
• Adjuvant radiotherapy (if BCS)
• Aromatase inhibitor for 5-10 years
• Chemotherapy if high-risk features (node positive, high grade, large tumor)
• Trastuzumab if HER2+

Q-3 (18 marks) - Short Notes (Any 3; 6 marks each)

(a) Management of Hypovolemic Shock (6 marks)

1. Airway with cervical spine control
2. Breathing and ventilation - supplemental O2 (100% O2 by non-rebreather mask)
3. Circulation:
   • Two large-bore peripheral IV cannulae (14/16G) in antecubital fossae
   • Initial bolus: Warmed crystalloid solution (Normal saline or Hartmann's) - 1-2 litres in adults
   • Blood transfusion: Packed Red Blood Cells (pRBCs); crossmatch blood; if no time, O-negative blood
   • Damage Control Resuscitation: 1:1:1 ratio of pRBCs : FFP : Platelets for massive hemorrhage
   • Permissive hypotension (target SBP 80-90 mmHg) in penetrating trauma until surgical hemorrhage control
   • Stop the bleeding: direct pressure, tourniquets, surgical intervention
4. Disability: GCS, pupils
5. Exposure: Full examination

• Pulse, BP, respiratory rate, urine output (target >0.5 mL/kg/hr in adults via urinary catheter)
• Central venous pressure (CVP)
• SpO2, ECG monitoring
• Blood: CBC, coagulation profile, ABG, lactate (marker of tissue perfusion), electrolytes, blood glucose

• Identify and control source of hemorrhage (surgery, endoscopy, interventional radiology)
• Treat underlying cause
• ICU monitoring

• Lactate clearance
• Base deficit correction
• Normal urine output
• Normalization of vital signs

(b) Basal Cell Carcinoma (BCC) (6 marks)

• Ultraviolet radiation (most important - UVB especially)
• Fair skin, blue eyes, red/blonde hair (Fitzpatrick skin types I-II)
• Chronic arsenic exposure
• Ionizing radiation
• Immunosuppression
• Xeroderma pigmentosum
• Basal cell nevus syndrome (Gorlin's syndrome - multiple BCCs)

1. Nodular BCC: Most common (60%); pearly, translucent papule with rolled edges and surface telangiectasia; central ulceration later ("rodent ulcer")
2. Superficial BCC: Flat, red, scaly plaque; occurs on trunk
3. Morpheaform/Sclerosing BCC: Scar-like, ill-defined; most aggressive; high recurrence
4. Pigmented BCC: Dark brown; may resemble melanoma

• Site: Face (90%) - nose, inner canthus, nasolabial fold, periorbital area ("H-zone" - high risk)
• Lesion: Pearly nodule with rolled, everted edges and central ulceration
• Surface telangiectasia
• Slow growing, locally destructive
• Rarely metastasizes (<0.1%)

• Derived from pluripotent basal cells
• Histology: Palisading arrangement of nuclei at periphery of tumor lobules, retraction artefact

1. Surgical excision with 4mm margins (standard) - first choice for most BCCs
2. Mohs micrographic surgery: For high-risk sites (H-zone), recurrent, morpheaform BCCs; highest cure rate (99%)
3. Radiotherapy: Elderly patients, large/inoperable lesions, areas where surgery would cause cosmetic morbidity
4. Curettage and electrodessication: For superficial BCCs; not for morpheaform type
5. Cryotherapy: For superficial, small BCCs
6. Topical agents: 5-Fluorouracil cream, Imiquimod (for superficial BCC)
7. Photodynamic therapy (PDT): For superficial BCCs
8. Vismodegib (Hedgehog pathway inhibitor): For advanced/metastatic BCC; blocks Smoothened protein in Hedgehog signaling pathway (mutated in BCC)

(c) Factors Affecting Wound Healing (6 marks)

1. Infection: Most important local factor; prolongs inflammatory phase, produces collagenase; Streptococcus pyogenes especially bad
2. Blood supply: Ischemia impairs healing (PVD, radiation, tight sutures); good vascular supply essential
3. Wound environment:
   • Moist environment promotes re-epithelialization
   • Dead space and hematoma: bacteria culture medium, prevent apposition
4. Radiation: Damages microvessels; impairs fibroblast proliferation; causes radiation endarteritis
5. Foreign body: Suture material, debris prolongs inflammation
6. Tension and mobility: High-tension wounds (over joints) heal poorly; immobilization helps
7. Wound type: Incised wounds heal better than contused/lacerated wounds
8. Denervation: Neuropathic wounds (diabetic foot) heal poorly

1. Nutrition:
   • Protein deficiency: Reduces fibroblast proliferation and collagen synthesis
   • Vitamin C (ascorbic acid) deficiency: Essential for hydroxylation of proline/lysine in collagen; deficiency causes scurvy (poor wound healing, dehiscence)
   • Zinc deficiency: Required for DNA synthesis, cell proliferation
   • Vitamin A: Promotes epithelialization; counteracts steroid effect on healing
2. Diabetes mellitus:
   • Impaired leukocyte function (phagocytosis, chemotaxis)
   • Microangiopathy (reduced blood supply)
   • Neuropathy
   • Hyperglycemia inhibits fibroblast function
3. Steroids/immunosuppressants:
   • Inhibit inflammation, fibroblast proliferation, collagen synthesis
   • Stabilize lysosomal membranes (reduce inflammatory mediators)
   • Vitamin A can reverse this effect
4. Age: Elderly patients heal slower (reduced collagen synthesis, reduced growth factors, comorbidities)
5. Anemia and hypoxia: Oxygen is required for collagen synthesis (hydroxylation reactions); anemia impairs this
6. Jaundice/Liver disease: Reduced protein synthesis, bile salts impair wound healing
7. Uremia/Renal failure: Toxic metabolites impair fibroblast function
8. Chemotherapy/Radiotherapy: Impair cell proliferation
9. Obesity: Poor vascularity of adipose tissue, high wound tension, comorbidities

• Keloid: Scar extends beyond wound margins; type III collagen; does not regress
• Hypertrophic scar: Scar within wound margins; regresses; type III collagen excess
• Wound dehiscence: Usually 5-10 days post-op; associated with hypoproteinemia, infection
• Incisional hernia: Late complication

(d) Metabolic Acidosis (6 marks)

• M - Methanol
• U - Uremia (renal failure)
• D - DKA (Diabetic Ketoacidosis)
• P - Propylene glycol / Paraldehyde
• I - Isoniazid, Iron
• L - Lactic acidosis (most common in surgery - shock, hypoxia)
• E - Ethylene glycol
• S - Salicylates

• Diarrhea (loss of HCO3-)
• Ureterosigmoidostomy / Renal tubular acidosis
• Hyperalimentation
• Acetazolamide
• Massive NaCl infusion

• Kussmaul breathing: Deep, rapid, sighing respirations (compensatory)
• Weakness, fatigue, lethargy
• Nausea, vomiting, abdominal pain (in DKA)
• Flushed skin (vasodilation)
• Hypotension (decreased myocardial contractility)
• Confusion, coma (severe)
• Arrhythmias

1. Treat the underlying cause (most important):
   • Lactic acidosis: Restore perfusion (fluids, oxygen, vasopressors), treat sepsis
   • DKA: Insulin, fluids, potassium
   • Renal failure: Dialysis
2. Sodium bicarbonate (NaHCO3): IV sodium bicarbonate only when pH <7.1 or HCO3- <10; controversy exists; overuse causes paradoxical CSF acidosis, tetany, fluid overload
   • Dose: HCO3- deficit = 0.3 × body weight (kg) × (desired HCO3- - actual HCO3-)
   • Give half the calculated deficit initially
3. Respiratory support if respiratory failure
4. Monitor: Serial ABGs, electrolytes (potassium rises in acidosis - watch for hyperkalemia), ECG

Q-4 (10 Marks) - 2-3 Sentences (Any 5; 2 marks each)

(a) Tension Pneumothorax

(b) Collar-Stud Abscess

(c) Saint's Triad

(d) Typhoid Ulcer

(e) Zollinger-Ellison Syndrome

(f) Risus Sardonicus

SECTION 2

Q-5 (10 Marks) - RECOMMENDED ANSWER: Anal Canal Anatomy + Internal Haemorrhoids

Anatomy of Anal Canal (4 marks)

• Upper end: Anorectal ring (puborectalis + top of internal sphincter) at level of dentate/pectinate line + 1.5 cm above (surgical anal canal extends from anorectal ring to anal verge)
• Lower end: Anal verge (junction with perianal skin)

• Internal Anal Sphincter (IAS): Smooth muscle; continuation of circular muscle of rectum; involuntary; supplied by sympathetic (contract) and parasympathetic (relax); maintains resting tone (85% of resting pressure)
• External Anal Sphincter (EAS): Striated muscle; voluntary; supplied by inferior rectal nerve (S2,3) and perineal branch of S4; 3 parts: subcutaneous, superficial, deep

Management of Internal Haemorrhoids (6 marks)

• 1st degree: Bleeding only; do not prolapse
• 2nd degree: Prolapse on defecation but reduce spontaneously
• 3rd degree: Prolapse and require manual reduction
• 4th degree: Permanently prolapsed and irreducible (may be strangulated)

• High-fibre diet, increased fluid intake
• Avoid straining at stool
• Stool softeners (lactulose, ispaghula husk)
• Sitz baths (warm water soaks)

1. Injection sclerotherapy (1st degree): 5% phenol in almond oil injected into submucosa above dentate line; causes fibrosis; no anesthesia needed; painless
2. Rubber band ligation (most effective non-operative - 2nd and 3rd degree): A rubber band is applied at the base of the haemorrhoid above the dentate line; causes ischemic necrosis and fibrosis; highly effective

• Open haemorrhoidectomy (Milligan-Morgan): Excision of three primary haemorrhoids with skin bridges preserved; wounds left open
• Closed haemorrhoidectomy (Ferguson): Wounds closed with absorbable sutures; faster healing

1. Stapled haemorrhoidopexy (PPHH/PPH - Procedure for Prolapse and Haemorrhoids): Circular stapler removes a ring of mucosa and submucosa above the dentate line; repositions prolapsed haemorrhoids; less pain than conventional haemorrhoidectomy; higher recurrence rate
2. HALO (Haemorrhoidal Artery Ligation Operation) / THD: Doppler-guided ligation of terminal branches of superior rectal artery; minimal pain, suitable for 2nd-3rd degree

• Early: Hemorrhage (reactionary or secondary), urinary retention (most common), pain
• Late: Anal stenosis, fecal incontinence (if sphincter damaged), anal fissure

OPTION B: Portal Hypertension (10 marks)

• Portal vein thrombosis (most common cause in children)
• Splenic vein thrombosis
• Increased portal blood flow (AV fistula)

• Pre-sinusoidal: Schistosomiasis, primary biliary cholangitis, sarcoidosis
• Sinusoidal: Liver cirrhosis (most common overall) - alcohol, viral hepatitis, NAFLD, Wilson's disease
• Post-sinusoidal: Veno-occlusive disease (sinusoidal obstruction syndrome)

• Budd-Chiari syndrome (hepatic vein thrombosis)
• IVC obstruction
• Right heart failure, constrictive pericarditis

• Oesophageal and gastric varices: Haematemesis (massive, life-threatening upper GI bleed) - most dangerous complication
• Caput medusae: Dilated veins around umbilicus
• Haemorrhoids (internal)
• Splenomegaly → hypersplenism (anaemia, thrombocytopenia, leukopenia)
• Ascites: Due to portal hypertension + hypoalbuminaemia + sodium retention
• Hepatic encephalopathy: Ammonia bypasses liver via collaterals
• Jaundice (underlying liver disease)
• Spider naevi, palmar erythema, leukonychia (liver disease signs)

• LFT, coagulation studies, albumin, CBC
• Ultrasound abdomen with Doppler: Portal vein diameter >13mm, reversed portal flow, splenomegaly, ascites
• Upper GI endoscopy (OGD): Gold standard for varices - assess grade and red sign (active bleeding risk)
• CT angiography: Portal vein anatomy
• Liver biopsy: Underlying cause
• Hepatic venous pressure gradient (HVPG): >10 = severe portal hypertension

1. ABC: Airway protection, IV access, blood transfusion (target Hb 7-8 g/dL - avoid over-transfusion)
2. Vasoactive drugs: Terlipressin (vasopressin analogue) or Octreotide (somatostatin analogue) - reduces splanchnic blood flow; start immediately, continue 5 days
3. Antibiotics: Ceftriaxone - reduces bacterial infection (a major trigger of variceal bleeding) and improves survival
4. Emergency Endoscopy (within 12 hours):
   • Band ligation (EVL) - treatment of choice
   • Sclerotherapy (if ligation not possible)
5. Balloon tamponade (Sengstaken-Blakemore tube): Temporary measure when endoscopy fails; bridge to TIPS
6. TIPS (Transjugular Intrahepatic Portosystemic Shunt): Used when endoscopic and pharmacological therapy fails; shunts blood from portal to hepatic vein; can precipitate encephalopathy

• Primary prophylaxis (before first bleed): Non-selective beta-blockers (Propranolol/Nadolol/Carvedilol) + EVL for high-risk varices
• Secondary prophylaxis (after first bleed): Beta-blockers + EVL (both); TIPS in Child-Pugh A/B who fail endoscopic therapy

Q-6 (12 Marks) - Gallstone Case

(a) Clinical Diagnosis and Causes of Symptoms (4 marks)

• Also has: Cholelithiasis (gallstones in gallbladder)
• The triad of Right upper quadrant pain + Fever + Jaundice = Charcot's Triad = Acute cholangitis
• Dilated CBD on USG confirms common bile duct obstruction (choledocholithiasis)
• Reynolds' Pentad (Charcot's triad + hypotension + confusion) = severe/suppurative cholangitis

1. RUQ Pain: Distension of gallbladder and biliary colic caused by stones obstructing the cystic duct or CBD; hepatic capsule stretch; biliary spasm
2. Fever: Stasis of bile in CBD → secondary bacterial infection (ascending cholangitis); most common organisms: E. coli (most common), Klebsiella, Enterococcus, Bacteroides
3. Jaundice: Stone impacted in CBD → obstruction to bile outflow → obstructive (post-hepatic) jaundice → conjugated bilirubin accumulates → dark urine (bilirubinuria), pale stools (no bile in stool), pruritus

(b) Investigations (4 marks)

• CBC: Leukocytosis (neutrophilia) - infection
• LFTs: Elevated bilirubin (conjugated/direct), elevated ALP and GGT (cholestatic pattern), mildly elevated AST/ALT
• Coagulation profile (PT/INR): Obstructive jaundice causes Vitamin K deficiency (fat-soluble) → coagulopathy; must correct before surgery
• Blood cultures: x2 before antibiotics (in febrile patient)
• Amylase/Lipase: To rule out gallstone pancreatitis
• Blood urea, creatinine, electrolytes: Baseline before intervention
• Blood glucose

• USG abdomen (already done): Shows stones in GB, dilated CBD (>8mm); may not always see CBD stone directly (CBD stone seen in only 50% on USG)
• MRCP (Magnetic Resonance Cholangiopancreatography): Non-invasive, gold standard for CBD stones; shows entire biliary anatomy
• ERCP (Endoscopic Retrograde Cholangiopancreatography): Both diagnostic AND therapeutic; CBD stone can be removed by sphincterotomy + stone extraction; preferred over surgery for CBD stones in most cases
• CT abdomen: If diagnosis uncertain, assess complications (perforation, pancreatitis, abscess)
• EUS (Endoscopic Ultrasound): Highly sensitive for CBD stones; used when MRCP unavailable

(c) Treatment Options (4 marks)

1. Nil by mouth, IV fluids (resuscitation)
2. IV antibiotics: Piperacillin-tazobactam or Cefuroxime + Metronidazole (cover Gram-negative and anaerobes)
3. Analgesia: Diclofenac (preferred; reduces Oddi spasm), Pethidine (avoid Morphine - increases sphincter of Oddi tone)
4. Vitamin K injection (for coagulopathy from obstructive jaundice)
5. Monitoring (vitals, urine output)

1. ERCP + Sphincterotomy + CBD stone extraction (EST): - Treatment of choice
   • Endoscope passed to duodenum, sphincterotomy of sphincter of Oddi, stone removed by balloon or Dormia basket
   • For large stones: mechanical lithotripsy, electrohydraulic lithotripsy
   • If stone cannot be removed: plastic stent placed for decompression
2. Percutaneous Transhepatic Cholangiography (PTC) + drainage: If ERCP fails or not available; external biliary drainage
3. Surgical CBD exploration: Open or laparoscopic; used if ERCP fails; CBD opened (choledochotomy), stones removed, T-tube placed for decompression and drainage

1. Laparoscopic Cholecystectomy: Definitive treatment; usually done 4-6 weeks after acute episode resolves (after ERCP)
   • Can be done at same sitting as ERCP (intra-operative cholangiogram during laparoscopic cholecystectomy)
   • Laparoscopic common bile duct exploration (LCBDE) may be performed simultaneously

• Cholangitis → sepsis → multi-organ failure
• Acute pancreatitis
• Secondary biliary cirrhosis (chronic obstruction)
• Gallbladder empyema, perforation, Mirizzi syndrome

Q-7 (18 Marks) - Short Notes (Any 3; 6 marks each)

(a) Thyroid Storm (6 marks)

• Surgery (especially thyroid surgery - most classic)
• Radioiodine therapy (early phase)
• Infection/Sepsis (most common precipitant overall)
• Trauma
• DKA, MI, pulmonary embolism
• Pregnancy/childbirth
• Abrupt withdrawal of antithyroid drugs
• Iodinated contrast dye

• Fever: Very high (>39-40°C); diaphoresis (sweating)
• Cardiovascular: Tachycardia (out of proportion to fever; >150 bpm), atrial fibrillation, hypertension, high-output cardiac failure
• CNS: Agitation, delirium, psychosis, stupor, coma
• GI: Nausea, vomiting, diarrhea, jaundice (hepatic involvement)
• Signs of underlying hyperthyroidism: goiter, exophthalmos, pretibial myxedema

• Free T3, Free T4: Markedly elevated
• TSH: Undetectable
• Blood glucose, electrolytes, LFTs, CBC
• ECG (AF)

1. Supportive Care (ICU):
   • O2, IV access, continuous monitoring
   • Cool the patient: cooling blankets, paracetamol (NOT aspirin - displaces T4 from TBG)
   • IV fluids: Correct dehydration and electrolyte imbalances (dextrose-saline with potassium)
2. Block Thyroid Hormone Synthesis:
   • Propylthiouracil (PTU) - preferred over carbimazole in thyroid storm: 600 mg loading dose, then 200-250 mg every 4 hours orally/NG; PTU also blocks peripheral conversion of T4 to T3
3. Block Thyroid Hormone Release:
   • Lugol's iodine (potassium iodide): Give 1-2 hours AFTER PTU (prevents iodine being used as substrate for new hormone synthesis - Wolff-Chaikoff effect); 8 drops every 6 hours
4. Block Peripheral Effects:
   • Propranolol (IV/oral): Blocks adrenergic effects (tachycardia, tremor); also blocks T4→T3 conversion; 1-5 mg IV slowly (monitor BP), then oral 40-80 mg 6-hourly
   • Esmolol infusion if IV preferred
5. Steroids:
   • Hydrocortisone 100 mg IV every 8 hours (or Dexamethasone): Blocks T4→T3 conversion, treats possible relative adrenal insufficiency, addresses autoimmune component
6. Treat Precipitating Cause: Antibiotics if infection, etc.
7. Definitive Treatment: After stabilization - radioiodine ablation or thyroidectomy to prevent recurrence

(b) Achalasia Cardia (6 marks)

• Idiopathic (most cases): Autoimmune destruction of inhibitory neurons (nitric oxide and VIP-containing inhibitory myenteric plexus neurons of Auerbach's plexus) in the esophageal wall
• Chagas disease (Trypanosoma cruzi): Destroys myenteric plexus; common in South America; secondary/pseudo-achalasia
• Oesophageal cancer (secondary achalasia - must always exclude)

• Absence/reduction of ganglion cells in myenteric (Auerbach's) plexus
• Predominant loss of inhibitory neurons (VIP and NO neurons responsible for LES relaxation)
• Result: LES hypertension (LES resting pressure >40 mmHg, normal 10-40) + failure to relax on swallowing + absent peristalsis

• Dysphagia: To both solids and liquids simultaneously (unlike carcinoma where solids first then liquids); progressive
• Regurgitation: Of undigested food (not acid; no heartburn typically); aspiration pneumonitis risk
• Chest pain/discomfort (especially early)
• Weight loss (late)
• Heartburn (less common - paradoxical; ineffective clearance of any acid reflux)

1. Barium swallow (oesophagram): Classic findings: dilated oesophagus with smooth, tapering "bird's beak" or "rat's tail" appearance at the gastro-oesophageal junction; absence of gastric air bubble
2. Upper GI endoscopy (OGD): Must do to exclude carcinoma at cardia ("secondary achalasia"); shows dilated oesophagus with food residue; LES closed but opens with gentle pressure ("pop")
3. Oesophageal manometry (gold standard): Shows: absent peristalsis (hallmark), elevated LES resting pressure, incomplete LES relaxation on swallowing; Chicago Classification (Type I, II, III based on pressurization pattern)
4. CT chest: If carcinoma suspected

1. Medical (temporary, for poor surgical candidates):
   • Calcium channel blockers (Nifedipine) or nitrates (sublingual GTN): Reduce LES pressure; poor efficacy
   • Phosphodiesterase inhibitors (Sildenafil)
2. Botulinum toxin (Botox) injection: Endoscopic injection into LES; blocks acetylcholine release; temporary (6-12 months); for elderly/poor surgical risk patients; repeat injections needed
3. Pneumatic (balloon) dilatation:
   • Endoscopic balloon dilation of LES; highly effective (85% initial response)
   • Risk of perforation (2-5%)
   • Multiple sessions may be needed
4. Surgical Heller's cardiomyotomy (Laparoscopic - gold standard for definitive treatment):
   • Division of circular muscle fibers of LES (myotomy) 6 cm on esophagus + 2 cm onto stomach
   • Always combined with partial fundoplication (Dor - anterior, or Toupet - posterior) to prevent post-operative GERD
   • Long-term success >90%
5. POEM (Per-Oral Endoscopic Myotomy):
   • Newer endoscopic technique; incision-free; creates submucosal tunnel from esophagus to stomach and cuts the LES muscles endoscopically
   • Excellent results; comparable to surgical Heller; risk of post-POEM GERD (no fundoplication done)

• Aspiration pneumonia
• Oesophageal carcinoma (increased risk - squamous cell carcinoma due to stasis and chronic inflammation)
• Mega-oesophagus

(c) Intussusception (6 marks)

• Ileocolic: Most common (85-90%) - terminal ileum into caecum/ascending colon; common in infants
• Ileo-ileal, colo-colic (rare)
• Retrograde intussusception: Distal into proximal (rare)

• Idiopathic (>90%): Lymphoid hyperplasia at ileocaecal junction following viral infection (adenovirus); enlarged Peyer's patches act as lead point
• Meckel's diverticulum (most common pathological lead point in children)

• Polyp, carcinoma (most common), lipoma, Meckel's diverticulum
• Lymphoma, intramural hematoma (HSP)

1. Colicky abdominal pain: Paroxysmal, severe; child draws up legs and screams; episodes with symptom-free intervals
2. Red currant jelly stool: Blood and mucus per rectum; occurs due to venous congestion → mucosal ischemia → blood mixed with mucus; occurs late (6-12 hours)
3. Sausage-shaped mass: Palpable in right hypochondrium or right iliac fossa, mobile, with empty right iliac fossa (Dance's sign)

• Vomiting (initially reflex, later bilious due to obstruction)
• Pallor, lethargy, shock (late)
• Rectal examination: May show blood on gloved finger; occasionally intussusceptum palpable

• X-ray abdomen: Target sign, small bowel obstruction pattern, absence of gas in RIF
• Ultrasound abdomen (investigation of choice for diagnosis): Pathognomonic findings: "target sign" or "doughnut sign" on transverse view (concentric rings); "pseudokidney sign" on longitudinal view
• Barium/air enema: Both diagnostic AND therapeutic in pediatric ileocolic intussusception
• CT scan: For adults (identify lead point)

1. Resuscitation: IV fluids, NGT decompression, IV antibiotics
2. Non-operative reduction:
   • Air (pneumatic) enema reduction (preferred) - under fluoroscopy/ultrasound guidance; 80-90% successful
   • Hydrostatic (saline/barium) enema
   • Contraindications: Peritonitis, perforation, shock, prolonged duration (>48h), recurrence
3. Surgical reduction: If non-operative fails or contraindicated
   • Laparoscopic or open; manual "milking" of intussusceptum
   • Bowel resection if ischemia/necrosis

(d) Sigmoid Volvulus (6 marks)

• Long sigmoid colon with narrow mesenteric attachment (anatomical predisposition)
• Chronic constipation/megacolon
• High-residue diet
• Psychiatric patients on anticholinergic medications (institutionalized patients)
• Chagas disease
• Hirschsprung's disease
• Previous volvulus (recurrence common)
• Neuropsychiatric patients, elderly

• Sudden onset colicky abdominal pain with distension
• Gross abdominal distension (the most prominent feature)
• Absolute constipation (no flatus or stool)
• Vomiting (late)
• High tympanic note on percussion
• Asymmetric distension (due to distended sigmoid loop)
• Rectal examination: empty rectum

• X-ray abdomen (AXR): Classic findings:
  • "Coffee bean" or "inverted U" sign: Massively dilated sigmoid loop pointing to right upper quadrant (ahaustral, "bent inner tube")
  • "Northern exposure sign" (apex above T10)
  • Loss of rectal gas
  • "Bird of prey" sign on barium enema
• CT scan: Most accurate; shows whirl sign (mesenteric twisting), transition point, assess bowel viability
• Barium/water-soluble enema: "Bird's beak" or "ace of spades" deformity at the site of twist

1. Resuscitation: IV fluids, NGT, urinary catheter, IV antibiotics
2. Endoscopic detorsion (first-line):
   • Flexible sigmoidoscopy + rectal tube decompression: Instrument passed into rectum through the twist; bowel decompressed; flatus tube left in situ for 24-48 hours
   • Success rate: 70-85%
   • Recurrence rate without surgery: 50-90%
3. Elective sigmoid colectomy: After successful detorsion; definitive treatment to prevent recurrence; done after bowel preparation; Hartmann's procedure or primary anastomosis

• Emergency laparotomy: Sigmoid colectomy
• Hartmann's procedure: Resection of sigmoid colon + end colostomy + oversewing of rectal stump (safe option in emergency, avoids anastomosis in contaminated field)
• Reversal of Hartmann's procedure later (colostomy closure)

Q-8 (10 Marks) - 2-3 Sentences (Any 5; 2 marks each)

(a) Goodsall's Law

(b) Strangulated Inguinal Hernia

(c) Signs of Acute Inflammation

(d) Venous Ulcer

(e) Hypersplenism

(f) Split Thickness Skin Grafting (STSG)

Note for the student: Section 1 carries 50 marks (Q1=10, Q2=12, Q3=18, Q4=10). Section 2 carries 50 marks (Q5=10, Q6=12, Q7=18, Q8=10). All answers above are calibrated to the marks indicated. For 6-mark short notes, aim for ~1 page; for 2-mark answers, stick to 3-4 lines maximum in the actual exam.