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SU28.5-9 | Upper Gastrointestinal Surgery — Practice Quiz
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A 34-year-old woman has a two-year history of dysphagia to BOTH solids and liquids from the outset, with nocturnal regurgitation of undigested food and stable weight. A barium swallow shows a smooth, tapering 'bird-beak' narrowing at the lower oesophagus with a dilated body above. Which investigation is diagnostic and what is the underlying defect?
Correct. Dysphagia to solids and liquids together with a bird-beak tapering is achalasia; manometry is diagnostic, showing failure of LOS relaxation and absent peristalsis from loss of myenteric (Auerbach's) plexus ganglion cells.
Achalasia: dysphagia to solids AND liquids from the start, bird-beak on barium, manometry diagnostic (non-relaxing LOS + aperistalsis). Contrast with mechanical/malignant dysphagia (solids first, progressive, weight loss).
Simultaneous solid-and-liquid dysphagia with a bird-beak appearance is achalasia; the diagnostic test is manometry (non-relaxing LOS, aperistalsis), not biopsy or pH study.
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A 62-year-old man with a long history of heartburn now reports progressive dysphagia, first to solids and then to liquids, with marked weight loss over three months. Endoscopy shows an ulcerated stricture in the LOWER third of the oesophagus, and biopsy confirms malignancy. Which malignancy and predisposing lesion is most likely?
Correct. Chronic acid reflux causes Barrett's metaplasia (columnar lining) in the lower oesophagus, which predisposes to adenocarcinoma — the typical lower-third oesophageal malignancy.
Lower oesophagus + GERD/Barrett's = adenocarcinoma. Upper/middle oesophagus + smoking/alcohol/corrosive/achalasia = squamous cell carcinoma.
Chronic GERD → Barrett's metaplasia → adenocarcinoma of the LOWER oesophagus. Squamous cell carcinoma typically affects the upper/middle thirds and is linked to smoking, alcohol and corrosive/achalasia strictures.
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A 55-year-old heavy smoker and drinker presents with progressive dysphagia and weight loss. Endoscopy shows a circumferential tumour in the MIDDLE third of the oesophagus. Which histological type is most likely?
Correct. Squamous cell carcinoma is the typical malignancy of the upper and middle thirds of the oesophagus and is strongly associated with smoking and alcohol.
Site predicts histology: upper/middle third → squamous cell carcinoma (smoking/alcohol); lower third → adenocarcinoma (Barrett's/GERD).
Upper/middle-third oesophageal cancer in a smoker/drinker is squamous cell carcinoma; adenocarcinoma characteristically affects the lower third (Barrett's-related).
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A 50-year-old man develops new, progressive dysphagia to solids with weight loss over two months. According to the principles of investigating dysphagia, what is the correct FIRST investigation?
Correct. New, progressive dysphagia in a patient over forty must be investigated by upper GI endoscopy with biopsy before a barium swallow, because it allows direct visualisation and tissue diagnosis of a possible malignancy.
New progressive dysphagia over forty → upper GI endoscopy + biopsy FIRST, before barium swallow. Endoscopy both visualises and biopsies.
Progressive dysphagia over forty needs upper GI endoscopy with biopsy first (to see and biopsy a cancer); barium swallow, CT staging and manometry follow as indicated, not before.
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A 3-week-old first-born boy has a two-week history of non-bilious, forceful (projectile) vomiting immediately after feeds; he remains hungry and is losing weight. A test feed reveals visible gastric peristalsis and a palpable, firm, olive-shaped mass in the right upper quadrant. Which metabolic disturbance do you expect, and what is the FIRST priority of management?
Correct. Loss of gastric HCl from projectile vomiting causes a hypochloraemic, hypokalaemic metabolic alkalosis; pyloric stenosis is a MEDICAL emergency first — resuscitate and correct electrolytes before the elective Ramstedt pyloromyotomy.
Infantile hypertrophic pyloric stenosis: non-bilious projectile vomiting, hungry baby, olive mass → hypochloraemic hypokalaemic metabolic alkalosis. Resuscitate FIRST, then Ramstedt pyloromyotomy.
Vomiting gastric acid produces hypochloraemic hypokalaemic metabolic alkalosis. The cardinal rule is resuscitation FIRST (fluids/electrolytes); Ramstedt pyloromyotomy follows once corrected — it is not a surgical emergency.
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A 48-year-old man with a long history of epigastric pain and a known duodenal ulcer presents with sudden severe epigastric pain that spreads across the abdomen, a board-rigid abdomen, and free gas under the diaphragm on an erect film. Which operative principle is used for the perforated duodenal ulcer?
Correct. A perforated duodenal ulcer is treated by closing the perforation with an omental (Graham) patch and lavaging the peritoneal cavity, alongside resuscitation, antibiotics and subsequent H. pylori eradication/acid suppression.
Perforated peptic (duodenal) ulcer → Graham omental patch + peritoneal lavage + resuscitation/antibiotics, then H. pylori eradication and acid suppression.
The standard operation for a perforated duodenal ulcer is omental (Graham) patch closure plus peritoneal lavage — not gastrectomy or pyloromyotomy; medical therapy alone does not control the perforation.
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A 60-year-old man has weeks of epigastric pain, early satiety and weight loss. Examination reveals a hard, irregular epigastric mass and an enlarged, firm left supraclavicular lymph node. Endoscopic biopsy of a gastric ulcer shows signet-ring cells. Which finding/eponym indicates spread, and what is the histological hallmark named here?
Correct. An enlarged left supraclavicular (Virchow's) node — the finding being Troisier's sign — indicates metastatic spread of gastric carcinoma; signet-ring cells are the hallmark of the diffuse type that can cause linitis plastica.
Gastric carcinoma: Virchow's node / Troisier's sign = supraclavicular spread; signet-ring cells → diffuse type → linitis plastica ('leather-bottle' stomach).
The left supraclavicular Virchow's node (Troisier's sign) signals metastatic gastric cancer; signet-ring cells characterise the diffuse adenocarcinoma (linitis plastica). The other eponyms relate to gallbladder/appendix/pancreatitis.
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When examining a patient with suspected gastric carcinoma, you are taught to 'finish the abdominal examination outside the abdomen'. Which set of sites must you specifically examine for evidence of spread?
Correct. Examine the left supraclavicular fossa (Virchow's node), the umbilicus (Sister Mary Joseph nodule), the rectum (rectal shelf / Blumer's shelf) and the pelvis in women (Krukenberg tumour) for transcoelomic and lymphatic spread of gastric cancer.
Gastric cancer spread is sought outside the abdomen: Virchow's node, Sister Mary Joseph umbilical nodule, rectal shelf on PR, and Krukenberg ovarian deposits in women.
Spread of gastric cancer is sought at the left supraclavicular fossa (Virchow), umbilicus (Sister Mary Joseph nodule), rectum (rectal shelf) and pelvis/ovaries in women (Krukenberg) — not the axillae, knees or thyroid.
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