SPEX Surgery 4 — Questions and Answers
Question 1: A 70-year-old patient develops sudden-onset severe abdominal pain, bloody diarrhea, and has atrial fibrillation. CT shows pneumatosis intestinalis and portal venous gas. What is the diagnosis?
- Ischemic colitis
- Acute mesenteric ischemia with bowel infarction (Correct answer)
- Diverticular hemorrhage
- Infectious colitis
Correct answer: Acute mesenteric ischemia with bowel infarction
Pneumatosis intestinalis and portal venous gas on CT in a patient with A-fib and acute abdominal pain indicate advanced acute mesenteric ischemia with intestinal infarction, requiring emergency surgery.
Question 2: Which type of shock is characterized by low SVR, high cardiac output, and warm extremities, and is commonly seen in early sepsis?
- Hypovolemic shock
- Cardiogenic shock
- Distributive (septic) shock (Correct answer)
- Obstructive shock
Correct answer: Distributive (septic) shock
Distributive/septic shock features vasodilation with low SVR, compensatory high CO, and warm extremities due to profound peripheral vasodilation from inflammatory mediators.
Question 3: A patient with end-stage renal disease on dialysis requires vascular access. Which is the preferred first-choice access for long-term hemodialysis?
- Tunneled central venous catheter
- Arteriovenous graft (AVG)
- Arteriovenous fistula (AVF) (Correct answer)
- PICC line
Correct answer: Arteriovenous fistula (AVF)
Arteriovenous fistula (AVF) is preferred per KDOQI guidelines due to its superior long-term patency, lower infection rate, and fewer complications compared to grafts or catheters.
Question 4: During an open inguinal hernia repair (Lichtenstein technique), which structure forms the floor of the inguinal canal that is reinforced with mesh?
- External oblique aponeurosis
- Internal oblique muscle
- Transversalis fascia (posterior wall) (Correct answer)
- Inguinal ligament
Correct answer: Transversalis fascia (posterior wall)
The Lichtenstein tension-free repair places mesh to reinforce the posterior wall of the inguinal canal (transversalis fascia), where direct hernias protrude through Hesselbach's triangle.
Question 5: Which antibiotic class is recommended for surgical prophylaxis in colorectal surgery to cover both aerobic gram-negative and anaerobic organisms?
- First-generation cephalosporin alone
- Aminoglycoside alone
- Cefazolin plus metronidazole or cefoxitin (Correct answer)
- Vancomycin alone
Correct answer: Cefazolin plus metronidazole or cefoxitin
Colorectal prophylaxis requires coverage of both gram-negative aerobes and anaerobes; cefazolin plus metronidazole, or cefoxitin alone, provides appropriate dual coverage.
Question 6: A 45-year-old woman has a 3 cm adrenal mass found incidentally. It is non-functioning and has imaging characteristics suggesting a lipid-rich adenoma. What is the recommended management?
- Immediate adrenalectomy
- Biopsy to confirm adenoma
- Repeat imaging in 6-12 months and reassess (Correct answer)
- No follow-up needed
Correct answer: Repeat imaging in 6-12 months and reassess
Non-functioning adrenal incidentalomas less than 4 cm with benign imaging features require follow-up CT at 6-12 months and annual hormonal assessment for 4 years per current guidelines.
Question 7: Which operation is indicated for a patient with Zollinger-Ellison syndrome (ZES) with a sporadic, localized gastrinoma identified on imaging?
- Total gastrectomy
- Surgical resection of the gastrinoma (Correct answer)
- Proton pump inhibitor therapy alone
- Whipple procedure for all cases
Correct answer: Surgical resection of the gastrinoma
Surgical resection of a sporadic, localized gastrinoma offers the only chance of cure in ZES and is recommended when there is no evidence of unresectable metastatic disease.
SPEX Surgery 4
A 70-year-old patient develops sudden-onset severe abdominal pain, bloody diarrhea, and has atrial fibrillation.
CT shows pneumatosis intestinalis and portal venous gas.
What is the diagnosis?