12 - surgery mcqs - 81 to 90

81. A varicocele

(a) Consists of aneurysmal dilatation of the testicular artery
(b) Is more common on the right
(c) May be associated with a left renal tumour
(d) May be associated with infertility
(e) Requires surgery in all cases

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only c and d are true . A varicocele consists of varicose dilatation of the veins draining the testis, principally the pampiniform plexus. The left testicular vein drains into the left renal vein and the right testicular vein drains directly into the inferior vena cava. As a result varicoceles are more common on the left. Particularly, in middle age or the elderly the appearance of varicocele may be due to an underlying renal tumour. Varicoceles may cause infertility but there is no evidence that surgery improves the sperm count or conception rate. Surgery is only required if the varicocele is symptomatic.

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82. In patients with a subarachnoid haemorrhage

(a) 70% of bleeds are due to Berry aneurysms
(b) Sub-hyloid haemorrhages may be seen on fundoscopy
(c) CT scanning has a sensitivity of approximately 90% if performed within the first 24 hours
(d) Lumbar puncture may show xanthochromia of the CSF
(e) The risk of rebleed is less than 5% within the first two weeks

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only e is false . Subarchnoid haemorrhage accounts for about 5% of cerebrovascular accidents. 70% of bleeds are due to Berry aneurysms and 10% due to arteriovenous malformations. The classic presentation is with a sudden onset of a severe headache. Photophobia with neurological symptoms and signs may also be present. Fundoscopy may show subhyloid haemorrhages. CT is the investigation of choice. It has a sensitivity of 90% if performed within the first 24 hours but this falls to 50% by 72 hours. The risk of rebleeding is 25% within 2 weeks and 60% within 6 months. The mortality associated with a reblled is over 60%.

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83. Regarding salivary gland stones

(a) 80% of stones occur within the parotid gland
(b) 80% of submandibular duct stones are radio-opaque
(c) Most parotid duct stones are radio-lucent
(d) The classic presentation is with pain and swelling occurring one hour after a meal
(e) If a stone is surgically removed the duct should be repaired

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only b and c are true . Most salivary calculi occur in the submandibular gland or duct and present with pain and swelling of the gland before or during a meal. Submandibular calculi are mostly radioopaque whereas parotid stones are often radiolucent. A stone detected on a plain x-ray will often confirms the diagnosis. It there is any doubt then a sialogram is a useful investigation. Stones can be treated by either removal of the stone from the duct and marsupialisation of the edges. Alternatively the gland can be excised.

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84. Sjogren's syndrome

(a) Is an autoimmune condition affecting the salivary and lacrimal glands
(b) Primary Sjogren's syndrome is associated with connective tissue disorders
(c) Over 30% of patients with Systemic Lupus Erythematosis develop the disorder
(d) The male to female ratio is over 10 : 1
(e) Sjogren' s syndrome is associated with an increased risk of a B-cell lymphoma

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b and d are false . Sjogren's syndrome is an autoimmune condition characterised by dry eyes (kerratoconjunctivitis sicca) and dry mouth (xerostomia). It has a strong female predisposition. Secondary Sjogren's syndrome is associated with various connective tissue disorders. 15% of patients with Rheumatoid Arthritis and over 30% of patients with SLE develop the disorder. The diagnosis can be confirmed by labial gland biopsy and treatment is largely symptomatic

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85. Regarding benign salivary gland adenomas

(a) Pleomorphic adenomas account for less than 10% of parotid gland tumours
(b) Pleomorphic adenomas can undergo malignant change
(c) Warthin's tumour is otherwise known as an adenolymphoma
(d) Adenolymphomas usually occur in elderly men
(e) Approximately 10% of adenolymphomas are bilateral

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only a is false . Over 75% of all salivary tumours occur in the parotid gland, the majority of which are benign. Pleomorphic adenomas are the commonest benign salivary tumour and account for 80% of parotid tumours. They can undergo malignant change and thus surgical excision is advised. This should by a formal superficial parotidectomy as incomplete excision can result in local recurrence. Adenolymphomas occur in the elderly with a male to female ratio of 4:1. They can be bilateral and almost never undergo malignant change.

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86. During surgical excision of the submandibular gland

(a) The skin incision should be placed 1 cm below the lower border of the mandible
(b) Both the facial artery and vein may need to be divided
(c) The lingual nerve should be identified and preserved
(d) The hypoglossal nerve should be divided
(e) The submandibular duct is ligated and divided as far forward as possible

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a and d are false . The skin incision for excision of the submandibular duct is placed at least 4 cm below the lower border of the mandible so as not to damage the marginal mandibular branch of the facial nerve that will be running in the upper skin flap. The gland will be seen deep to platysma wrapping around the poterior border of myelohyoid. The facial artery and vein have a variable course through or around the gland and either or both will need to be divided and ligated. Both the lingual and hypoglossal nerves should be seen and preserved.

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87. Regarding ulcerative colitis

(a) It usually arises in the caecum and spreads distally
(b) Chronic inflammatory polyps (pseudo-polyps) develop in approximately 20% of patients
(c) Approximately 15% of patients develop total colitis
(d) Systemic manifestations include a large joint polyarthropathy
(e) Overall, about 50% of patients will develop colonic cancer

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a and e are false . Ulcerative colitis is a non-specific inflammatory condition affecting the colonic mucosa and submucosa. It usually develops in the rectum and spreads proximally. Pseudoployps result from islands of spared mucosa surrounded by areas of colonic inflammation. Pyrexia, tachycardia, weight loss and hypoalbuminaemia are features of severe disease. Systemic manifestations include a polyarthropathy, pyoderma gangrenosum, iritis and sclerosing cholangitis. Overall, the risk of developing colonic carcinoma is approximately 3%.

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88. Carcinoma of the prostate

(a) Is the commonest malignancy in men over the age of 65 years
(b) Arises in the central zone of the prostate
(c) Bone is the commonest site of metastatic disease
(d) A serum prostate specific antigen concentration of more than 10 nmol/ml would support the diagnosis
(e) A serum prostate specific antigen concentration of more than 35 nmol/ml is highly suggestive of advanced disease

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only b is false . Carcinoma of the prostate is the commonest malignanct in men over the age of 65 years. It arises in the peripheral zone of the gland and as such localised disease can present as a nodule palpable on rectal examination. Clinical features include bladder outflow obstruction, pelvic pain, bone pain and renal failure.

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89. In patients with ascites the following conditions are due to an exudate

(a) Tuberculous peritonitis
(b) Nephrotic syndrome
(c) Congestive cardiac failure
(d) Peritoneal malignancy
(e) Constrictive pericarditis

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a and d are true . A transudate has a low protein concentration ( less than 25 g/l)and can result from a low serum protein concentration, high central venous pressure or portal hypertension. An exudate has a high protein concentration (greater than 25 g/l ). Tuberculous peritonitis, peritoneal malignancy, Budd-Chiari syndrome, pancreatic ascites, chylous ascites and Meigs syndrome are all due to an exudate.

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90. A Meckel's diverticulum

(a) Occurs in 10% of the population
(b) Will be found on the mesenteric border of the small intestine
(c) Consists of mucosa without a muscle coat
(d) Heterotopic gastric mucosa can ulcerate and cause a brisk gastrointestinal bleed
(e) A fibrous band between the apex and umbilicus can cause intestinal obstruction

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d and e are true . A Meckel's diverticulum is found in approximately 2% of the population approximately 60 cm (2 feet) from the ileocaecal valve. It is a remanent of the vitello-intestinal duct and is found on the antimesenteric border of the small intestine. It consists of all layers of the gut wall. Most are asymptomatic and if identified during surgery for other conditions can be left in-situ. Complications included gastro-intestinal haemorrhage, intussussception, small bowel obstruction, perforation and diverticulitis.

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