Dr:AYAZ

College of International Education of

Jinzhou Medical University 2015-2016
Surgery (1)

Mid_term paper (A)With three pages.

Dr:Ayaz kh

MCQ correct Answers

1. D

2.
3.
4.
5.
6.
7.

C
B
C
A
C
D

8. D
9. A
10.B
11.B
12.B
13.C
14.A

15.B
16.A
17.D
18.C
19.C
20.A

Terms explanations (3 points each question, total 15

points)

1. Foster-Kennedy syndrome
2.Lucid interval
3.Cushing response
4.Thyroid hot nodule
5.Hernia

Answers
1.Foster- Kennedy syndrome :
sphenoid ridge meningioma can lead
to atrophy of optic disk on the same
side and papilledema on the opposite
side.

2.impact injuries ----- lucid interval

Loss of consciousness

Lucid period

Unconsciousness
hematomas

time of impact

recover from concussion

brain stem compressed by

expanding epidural

3.Cushing response:
hypertension and bradycardia usually
indicates the presence of intracranial
hypertension.( BP HR always seen
in the TBI)
hypotension and tachycardia mean
hypovolemia

4.Thyroid Hot nodule

Nodules take up more of the isotope
than normal thyroid tissue does, it
means nodules produce excess
thyroid hormone ,it indicates
hyperfunctioning thyroid nodules.

5.Hernia
A hernia is the protrusion of an organ
through its containing wall
Composition of a hernia
1. The sac
2. The covering of the sac
3. The content of the sac

Short Answers Question(10 points each , total 30

points )

1.Plese write down the

etiology of intracranial tumor
and quote at least 3 kinds of
brain tumor?

Etiology
oncogenes
loss of tumor
suppressor gene

primary brain tumor

genetic physical
biological

chemical

Classification

Tumors of neuroglial cells

Astrocytomas
Oligodendrogliomas
Ependymomas
Medulloblastomas
Glioblastoma multiforme

Non-glial cell tumors

Meningiomas
Pituitary tumors
Nerve sheath neoplasms
Craniopharyngiomas
Metastatic tumors

Congenital tumors
Epidermoid tumors
Dermoid tumors

2.List the treatment of breast

cancer
Surgery
is the oldest form of treatment for cancer.
Surgery offers the greatest chance for cure for many
types of cancer.

Radiation therapy
uses high-energy particles or waves,
such as x-rays or gamma rays, to
destroy or damage cancer cells and may
be recommended for the treatment of
some types of breast cancer.

Hormone Therapy
is treatment with hormones, drugs that
interfere with hormone production or
hormone action, or surgical removal of
hormone-producing glands to kill cancer
cells or slow their growth .
may be recommended for the treatment
of some types of breast cancer.

3.Clinical manifestations of Thyroid

Crisis
cause: unsatisfactory
preoperative preparation
clinical findings:

fever 39

rapid and weak

pulse(>120/min),

dysphoria, delirium
even coma, vomiting,
diarrhea

Treatments:
1. sedation, ice pack cooling, fluid
replacement, oxygen,
2. iodides (IV),
reduce the release of thyroid
hormones
3. hydrocortisone
4. propranolol (IV),
counteract the effect of thyroid
hormone
5. propylthiouracil ( PTU).
block production of thyroid
hormones.
blocks the conversion of T4 to T3

Answer of Long Question

1.where does the center of pupillary
light reflex locate?
ans:
Afferent N
Efferent N
Localized

midbrain
Optic Nerve

Oculomotor Nerve

 2.If Physical examination:

Right side
Left side
Direct reflex
_
+
Indirect reflex
+
_
What structure (and which side)may be dama
Right side:
Optic
Nerve

3.If physical examination

Right side
Direct reflex
+
Indirect reflex
+

Left side
_
_

What structure (and which side )may be

damage ?
Right side :
Oculomotor Never

Important slides for MCQ

Liver

MCQ
1. Anatomical division of liver into
right and left and divided by falciform
ligament

2. Functional division of liver into

right and left and divided by the
middle of gall bladder fossa and the
right edge of inferior vena cava.
3. Blood supply:
75% from portal vein(50%)
25% from hepatic artery(50%)

v.Imp mcq

Hepatic Vein . Pass b/w 7,8 +6,5 segments

e Hepatic Vein ..Pass b/w 1,4 segments

Hepatic Vein pass b/w 4+2,3 segments

Liver injury scale:

MCQ+short question
1.subcapsular,non-expanding,
10%
2. subcapsular,non-expanding, 1050%
3. subcapsular, expanding, 50%
4.parenchymal ruptured with
bleeding
5.parenchymal ruptured 50%
6.hapatic avulsion

Non Operative Situations

Mcq v.imp
Sometimes we use
gauzes(unabsorbable) to maintain
pressure and tamponade the
bleeding.
Great majority of liver trauma need
only drainage.
30%-need suture ligation of hepatic
vessels
10%-need debride of devitalized
tissues

Three main cellular types of primary liver carcinoma

V.V.V imp

1.Hepatocellular carcinoma-hepatoma
2.Cholangiocellular carcinomacholangioma
3.Mixed form-hepatocholangioma

According to the size of lump:

v.v.v.v imp
1.Microhepatoma
2.Lesser hepatoma
3.Greater hepatoma
4.Macrohepatoma

70%of patients have tumor metastasis when they first

be diagnosed as hepatoma.(MCQ)

Tumormarkers.
AFP presents only in fetal circulation,which
is in high concentration in the serum of
primary hepatic carcinoma.(CEA) Imp.mcq
Once hepatomegaly and a filling lesion
detect in the liver are found,it must be
considered whether the liver harbors a
primary carcinoma or metastasis.

Primary liver cancer Complications (v.v.v imp

short q)
Intraabdominal hemorrhage
-spontaneous bleeding of tumor
Portal hypertension
-tamponade of portal vein
Budd-Cha syndrome
-obstruction of hepatic vein or thrombus
formation in IVC
Jaundice
-due to compress of bile duct
Death
-liver failure

Metastatic neoplasm of liver(MCQ)

Metastatic tumor:primary
hepatoma=20:1

The tumor spreads to the liver via

the systemic circulation,portal vein
or lymphatics

Benign tumor and cyst of liver(MCQ)

Hemangiomas(lobe-symptom)
Women:men=6:1
Greater than 4cm in diameter may
cause abdominal pain or a palpable
mass.
Symptomatic terminal polycyst need
liver transplantation

Pancreas diseases
imp mcq and short q
Definition: (exocrine function)
The external secretion of pancreas
consists of a clear,alkaline solution
contain digestive enzyme.
(endocrine function)
Secretion of insulin and glycogen are
endocrinal function.
Site: body and tail

Pancrease digests itself?

Imp short q
NO
Three mechanisms prevent autodigestion of
the pancreas by its proteolytic enzymes
the enzymes are stored in acinar cells as
zymogen grandules,where they are seperated
from other cell proteins
the enzymes are secreted in an inactive form
inhibitors of proteolytic enzymes are present
in pancreatic juice and pancreatic tissue

Pancreatitis (V.imp q)
Etiology
(Height Phobia Temperature Fever
Drugs )easy way to remember. H. PHOBIA T
FD
1. Hypercalcemia
2. protein deficiency
postoperative
3. Hypercalcemia
pancreatitis
4. Obstructive
5. biliary disease

6. -idiopathic
7. trauma or
8. -familial
9. -drug induced

MCQ
Alcohol stimulates pancreatic
secretion and induces spasm in the
sphincter of Oddi.
(V.V.V IMP MCQ )
biliary disease-stone-jam
-alcoholism-spasm of oddi-jam
-hypercalcemia-calculous-jam
-trauma/postoperative-edematous-jam
hyperlipidemia-interfere the amylase

According to grade of pancreatitis,the complications may be:(MCQ)

--dehydration
--tachycardia
--hypotension
--shock
--MODS

In 1-2% hemorrhagic pancreatitis,bluish

discolouration is present in periumbilical area (MCQ)

(Cullen's sign)

Acute pancreatitis (V.V IMP

Q)
Treatment
Gastric suction
--fasting
--nasogastric tube(NG Tube)
Criteria of oral feeding:
fluid replacement
--albumin
--great volume intravenous fluid
--blood transfusion

Antibiotics
-Very useful
Severe pancreatitis---antibiotics can
penetrate into pancreatic tissue to
eradicate bacteria
calcium and magnesium
In severe pancreatitis,serum calcium is
decreased,hypocalcemia may induce
cardiac dysrhythmia.

.
Oxygen
Hypoxemia severe enough to require
therapy develops in about 30% of
pancreatitis.
other drugs
Like H2 receptor blockers and
glucagon,they

Portal Hypertension
(MCQ+Short q)
(upper alimentary tract bleeding)
The common diseases are as followed:
1 perforation of gastric ulcer
2 severe gastritis
3 hemobilia
4 gastric tumor
5 portal hypertension

Portal hypertension (v.v imp q)

Etiology
The basic lesion is increase resistance
to portal flow.
Causes
-prehepatic
-hepatic Cirrhosis-85% of
hypertension
-posthepatic.

Imp for MCQ

1

1.prehepa
tic
2.Hepati
c

3Posthepatic

IMP MCQ
Prehepatic---congenital stenosis or
compression by adjecent tumor
Posthepatic--- BUD-cha syndrome or
constrictive pericarditis
Hepatic portal hypertension is also
divided into 3 categories as:
Presinus--always due to
schistosomiasis(S)
Sinu-and postsinus---always due to
cirrhosis.

Portal Hypertension Pathophysiology

(V.I.Q)
Portal hypertension result from
increased volume of portal flow or
increased resisitance to flow.
Normal pressure of portal vein is
about13-24cm H2O(7-11mmHg)
(mcq)
Average value is 18 cm H2O
(mcq)

The causes of increased resistance in this disease are:

distortion of hepatic veins by

regenerative nodules;
fibrosis of the hepatic veins and
perisinusoidal areas.

Venous system
(MCQ)

When portal pressure reaches

40cmH2O the pressure will not
increase because of the greater
portal flow to collaterals,
and then to systemic system.

The four collaterals(IMP.Q)

in cirrhosis---collaterals blood flows make
esophageal and gastric varices.
through parumbilical vein to the
abdominal wall
through retroperitoneal plexus pathway to
inferior vena cava
from superior rectal veins into middle and
inferior hemorrhoid veins then flow into
internal iliac vein,then to inferior vena cana

The four
collateral
s

1
2
4
3

Clinical experience
(V.V.IMP Q+MCQ)
Isolated thrombosis of splenic vein
causes localized splenic venous
hypertension,
blood returns to main portal system
through short and posterior gastric
veins.
Then gastric varices are often present
without esophageal varices.

MCQ

Of all the collaterals,bleeding mostly

happened in the junction of
gastroesophagus.
A-Compared with adjacent area,the
depth of vein in this area is more
superficial.

This is the nearest region to the stem of PV,so it

is most vulnerable to become varix(MCQ)

Types of portosystemic shunts:

(V.V.IMP.Q)
total shunt:
(2)Mesocaval shunt
(3)selective shunt
Choice of shunt:
Distal splenorenal shunt is the first choice for
elective portal decompression; (MCQ)
If ascites is present or anatomy is
unfavorable,we choose end-side portocaval
(MCQ)

MCQ

extensive sclerotherapy can thicken

the esophagus,which does not lend
itself to stapled transection.

Treatments:D E T D O
T(V.V.V.IMP.Q)
D-drugs
E-endoscopy
T-tamponade
D-decompression
O-devascularizaion operation
T-liver transplantation

Disease of the Biliary Tract(MCQ)

The common hepatic duct

Diameter : 0.4-0.6 cm

Common bile duct

Diameter: 0.6-0.8cm

Whats bile(Q+MCQ)
Complex lipid-rich micellar
solution
Iso-osmotic with plasma
Volume of hepatic bile
=500-600CC/day
Composition of Bile:
90% (Bile salts, lecithin,
cholesterol)
10% (Bilirubin + fatty acid +
inorganic salts)

Classification of stones(MCQ)
1. Cholesterol stones

Hard, layed on cross-section

2. Pigment stones

black or black brown

3. Mixed stones

radio-opaque

Predisposing factors(IMP Q)
1. Cirrhosis
2. bile stasis
3. chronic hemolysis
4. increased concentration of
unconjugated bilirubin in the
bile(MCQ)
5. Bacteria

MCQ
Size
2-5 mm in diameter

Color
black or black brown

Composition
Calcium bilirubinate, complex bilirubin polymers

Acute
cholecystitis(IMP.Q)
Etiology
Obstruction of cyst duct :
80% by an impacted gallstone

Torsion or stenosis of cyst duct

Ascarid
Bacterial inflammation
Trauma
Chemical stimulus

Treatment (IMP Q)

Intravenous fluid
Correct Dehydration and electrolyte balance
Nasogastric tube should be inserted
Parenteral antibiotics
Penicillin, cefazolin, clindamycin
Cholecystectomy
Whether the diagnosis is established
The general health of the patient as modified by coexistent disease
Signs of local complications of acute cholecystitis.
In 30% cases, ancillary disease is control
About 10% patients require emergency treatment
Become complicated or is about to
Suppurative progression
Poor condition need decompression treatment

Chronic Cholecystitis (IMP.Q)

Treatment
A. Medical treatment
Avoidance of offending food
Dissolution:
Ursodiol reduces the cholesterol saturation of bile by
inhibiting cholesterol secretion

Lithotripsy and dissolution

Many drawbacks

B. Surgical treatment

Cholecystectomy
Laparoscopic cholecystectomy(LC)

Laparoscopic cholecystectomy(LC)

Important cases

Liver
A patient was brought by ambulance,and the
accompanied doctor said there was a car
accident,the car hit the victims belly.The
patient has no wounds all over the body
surface,the most uncomfortable situation is
abdominal pain.Also the patient has a pale face.
The relative said the patient had no experienced
of hematemesis
The BP was 90/60mmHg,HR was 124t/m

What is wrong with the patient?

-shock
-blunt abdominal trauma
The most vulnerable organs to the car
crash are as followed:
1.small intestine
2.liver
3.spleen
4.kidneys
5.duodenum

physical examinations
-mild abdominal distention
-no palpable mass
-tenderness and rebound tenderness of
right subcostal area,local muscle is
relax;left region is negative
-percussion pain of liver region
-shifting dullness is negative
-bowel sound is 3t/m

Blood Tests:
WBC:5.6*109/L.HB:108g/L.RBC:2.8*1012
/L.
PLT:230*109/L
ALT:45U/L,AST:46iu/L
Hepatic subcapsular Ultrasound:
hemorrhage
-mild effusion around liver
-intact spleen and kidneys

Hemoglobin and RBC

Referential values

male

RBC

HB

4.0
5.5 1012/L

120
160g/L

femal
3.5 5.0
110 150g/L
e
1012/L
Anemia: RBC, Hb and HCT less than the lower limit of
normal range adjusted for age and sex.

Normal platelet count is 100 000 300

000/uL.

Normal range:

ALT: 5 - 40 U/L
AST: 8 - 40 U/L
ALT/AST 1

Abdominal X-ray
No free gas under diaphragm

The diagnoses are :

Shock
Blunt abdominal injury
Traumatic damage of liver

Hepatic trauma (mcq)

Accroding to the mechanisms
-penetrating
-blunt

The principal surgical goals :(v.v.v.imp q.)

-stop bleeding
-debridement of the devitalized tissues.
Bile leakage is also a dangerous
complication;
acute abdominal pain-infective shock-fatal
treatment: always need surgery(position
of leakage)

Primary liver cancer (case)

Most arise in person over age 50,but a few
are found in children ,mainly under 2 years
of age.
Eatiologic factor:(imp q)
Chronic hepatic B and C viral infection,but whether
it has any direct oncogenic effect is unknown.
Cirrhosis :
It is associated with an increased risk of
hepatocellular carcinoma

Clinical findings
1 symptoms and signs
-right upper quadrant abdominal pain
-referred pain of right shoulder.
-weight loss
-Icterus-1/3of cases(mcq)
-hepatomegaly or a mass is palpable in
many cases(advanced disease)

laboratory findings
icterus (mcq)
1/3 of cases,the serum bilirubin is
elevated-(tumor compresses the bile
duct)
-AFP(mcq)
AFP is increased for most cases
-tumor markers
CEA,CA19-9(mcq)

Differential diagnoses

- weight loss
-weakness
-abdominal pain
confused with other abdominal
carcinoma.

Treatment(v.v.v.imp.q)

1 partial hepatectomy
2 liver transplantation
3 ethanol injection
4 radiofrequency ablation
5 arterial chemoembolization

Pancreas diseases(case)
a patient walked slowly into the
emergency department with his
friends help,the main complain was
severe abdominal and lumbar pain.
The friend said the patient had
vomited a lot of gastric fluid with bile
inside for several times,and the
patient could not stand still.
The BP was 138/78mmHg,HR was
106t/m.

What is wrong with the patient?

-abdominal pain
The common diseases are as followed:
1 perforation of gastric ulcer
2 acute cholecystitis/cholangitis
3 acute pancreatitis
4 ileus
5 mesenteric infarction

Past history
abuse of alcohol for a long time
-just finish a meal of BBQ
- no gastritis or gastroduodenal
ulcer(no endoscopy experience)

physical examinations
abdominal distention
-tenderness for the left subcostal and
periumbilical regions
- icterus(sclera and skin)
-no palpable hepatomagely or
splenomagely
-bowel sound is decreased - 2t/m

Blood Tests:
WBC:12.3*109/L.HB:134g/L.PLT:186*10
9
/L
ALT:34U/L.AST:46iu/L
ALB:38g/L
Serum amylase 12333iu/L
Urine amylase 324iu/L

Ultrasound:
Enlargement of pancrease, ascites
around pancrease, small intestinal
distension,mild enlargement of gall
bladder

Abdominal X-ray
No free gas under diaphragm

The diagnoses are :

Acute pancreatitis
Chronic cholecystitis

Portal Hypertension(case)
a patient rushed into the emergency
department with his family,the
clothes were soaked in blood,and the
bloody stain still around the
mouth.The patient has a pale face.
The relative said the patient had
vomited a lot of blood.
The BP was 90/60mmHg,HR was
120p/m

What is wrong with the patient?

-shock
-Hematemesis
(upper alimentary tract bleeding)
The common diseases are as followed:
1 perforation of gastric ulcer
2 severe gastritis
3 hemobilia
4 gastric tumor
5 portal hypertension

Past history
-B-viral hepatitis
-no gastritis or gastroduodenal
ulcer(no endoscopy experience)
-Melena for one or twice months ago

physical examinations
abdominal distention(mild-moderate)
-no tenderness or rebound tenderness
-no icterus(sclera and skin)
-no palpable hepatomegaly

Blood Tests:
WBC:2.6*109/L.HB:102g/L.PLT:86*109/L
ALT:65U/L
AST:46iu/L
Ultrasound:
Cirrhosis.diameter of PV is 1.4cm
Splenomegaly and mild ascites

Abdominal X-ray
No free gas under diaphragm

The diagnoses are :

Cirrhosis
Potal hypertension
dx)
Splenomegaly
Ascites
UATB

(most imp

Important Questions

Epidural Hemorrhage

Subdural Hemorrhage

Subarachnoid Hemorrhage

Case

Subdural hematoma most commonly

caused by what type of traumatic
brain injury ?

Ans: acceleration-deceleration
injury
Example

Common type of Shock (v.imp. Q)

only names enough

2.Septic Shock

Anaphylactic Shock

Neurogenic Shock

Cardiogenic Shock