0 Not a true diaphragmatic opening


MCQ 146

 Q. Which of the following is not a true opening in diaphragm ?

a. Vena caval hiatus

b. Esophageal hiatus

c. Aortic hiatus

d. All are true apertures


ANSWER:
Answer : C - Aortic hiatus (T12 level)
Aortic hiatus is a gap in between diaphragm and body of T12 vertebra. It is not a true opening within the diaphragm and lies behind it.




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0 Open ring sign


MCQ 145

 Q. Open ring contrast enhancement (Open ring sign) is seen in ?

a. Demyelination

b. Cerebral abscess

c. Granuloma

d. Low grade glioma


ANSWER:
Answer : A - Demyelination.
The open ring is towards the grey matter. The enhancement towards the white matter represents the advancing front of demyelination.




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0 Boerhaave's syndrome vs Mallory–Weiss syndrome


Boerhaave's syndrome vs Mallory–Weiss syndrome



Boerhaave's syndrome

Mallory–Weiss syndrome

Site :  Lower thoracic oesophagus

Site: Vertical tear in cardia of stomach , may extend to distal oesophagus.

There is vertical perforation, and all gastric content goes into mediastinum.
No history of foreign body.

Mackler's triad may be seen :
  • Chest pain, 
  • vomiting and 
  • subcutaneous emphysema

Mucosa and submucosa are involved, NOT a complete perforation.
Presentation : Hematemesis (Not pain)

Reason : Vomiting / Retching against closed cricopharynx. i.e barotrauma

Reason : Vomiting , Increased LES (Lower esophageal sphincter)  pressure. –  can cause tear.

Sign : Air in mediastinum

Hamman’s Sign  (seen with any cause of pneumomediastinum.) – On auscultation , because of air around heart.

Investigation of Choice : Water soluble contrast study ( DO NOT USE BARIUM)

Diagnosis : Upper GI endoscopy.

Treatment : Immediate surgery
(via LEFT thoracotomy )

If >24-48 hrs – Let heal with secondary intention , do not suture , Just put a drain.

Treatment : Conservative (95 % cases)





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0 Esophageal ring





Site : Lower oesophagus.

 A-Ring = Lower esophageal muscular ring 
  • Mostly asymptomatic.
  • Symptoms if present : Dysphagia for both solids and liquids in absence of food impactions.
  • Situated few centimeters proximal to Schatzki's location (see below)


 B-Ring = Lower esophageal mucosal ring = Schatzki ring 
  • There is fibrous thickening in submucosa, it is symmetrical. Mucosa is normal histopathologically.
  • Most patients are asymptomatic.
  • Symptoms if present : Dysphagia, more for solids , and food impactions.
  • Has association with hiatus hernia
  • Seen in Lower oesophagus above diaphragm at Squamocolumner junction
  • Treatment : Balloon when needed.

DYSPHAGIA if present is NON-PROGRESSIVE



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0 Esophageal web


Esophageal web (acquired)

Site : Cricopharynx / Postcricoid.

Usually in association with Plummer–Vinson syndrome (PVS) = Paterson–Brown–Kelly syndrome = sideropenic dysphagia --which is a triad of
  • dysphagia , 
  • esophageal webs, and 
  • iron deficiency anemia.
Seen mostly in post-menopausal ladies.

Treatment : Iron supplementation, Balloon dilatation.



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0 Ligamentum teres hepatis


 Ligamentum teres hepatis 

  • Ligamentum teres hepatis is obliterated left umblical vein. (MCQ Point )
  • The umblical veins take oxygenated blood and join to the left and right branches of portal vein. (MCQ Point )
  • In embryo , normally , the right umblical vein completely disappears by about 8th week (intrauterine life) and only left umblical vein is present thereafter. ( can be remembered as "Left  is Left in body" ) (MCQ Point )
  • This left umbilical vein usually closes in <7days after birth, and forms round ligament of liver = ligamentum teres hepatis.
  • It results in the ligamentum teres joining to the left branch of the portal vein. (MCQ Point )




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0 Ligamentum teres hepatis (MCQ)


MCQ 143

Q. Ligamentum teres hepatis normally and usually joins to which of the following ?

a. Right branch of portal vein

b. Left branch of portal vein

c. Hepatic vein

d. IVC


ANSWER:
Answer : B - Left Portal Vein


  • Ligamentum teres hepatis is obliterated left umblical vein. (MCQ Point )
  • The umblical veins take oxygenated blood and join to the left and right branches of portal vein. (MCQ Point )
  • In embryo , normally , the right umblical vein completely disappears by about 8th week and only left umblical vein is present thereafter. ( can be remembered as "Left  is Left in body" ) (MCQ Point )
  • This left umbilical vein usually closes in <7days after birth, and forms round ligament of liver = ligamentum teres hepatis.
  • It results in the ligamentum teres joining to the left branch of the portal vein. (MCQ Point )




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0 Eosinophilia with Lung involvement


MCQ 142

 Q. Lungs are always involved in which of the following ?

a. Churg-strauss disease

b. Classic PAN

c. Both

d. None


ANSWER:
Answer : 
A - Churg-strauss disease = Allergic granulomatosis and angitis

  • Lungs are always involved
  • Occurs in patients with asthma
  • Blood eosinophilia seen

In Classic PAN -

  • may be associated with eosinophilia
  • Abnormality in lung is unusual but may be found.






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1 Tracheoesophageal fistula


   Tracheoesophageal fistula 




  • Male
  • Common with down's syndrome
  • Polyhydroamnios (in 50% cases)

Presentation :
  • 1st - Child drooling saliva
  • Aspiration and choking with breast feed

 Investigation of choice : Pass Nasogastric tube and take X-Ray image.


VACTERL Association :
  • V - Vertebral anomalies
  • A - Anal atresia
  • C - Cardiovascular anomalies (PDA , VSD , TOF)
  • TE - Tracheoesophageal fistula
  • R - Renal (Kidney) anomalies
  • L - Limb defects (Radial hypoplasia)

Treatment :
Surgery - RIGHT postero-lateral thoracotomy with ligation of fistula and end to end anastomosis.
If very sick child - Do feeding gastrostomy


Q. Why RIGHT postero-lateral approach ?
Ans : Because aorta is Left of oesophagus in upper and middle 1/3rd.




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0 Caval opening of diaphragm


MCQ 141

Q. Which of the following passes through caval opening of diaphragm ?

a. Right phrenic nerve

b. Left phrenic nerve

c. Azygous vein

d. Thoracic duct


ANSWER:
Answer : A - Right phrenic nerve. (Caval opening is at T8 level)

Left phrenic nerve directly pierces the diaphragm

Azygous and Thoracic duct accompany Aorta via opening at T12 level.

Oesophageal opening is at T10 level




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0 Hiatus hernia


 Hiatus hernia 



Investigation :
Barium meal ( IOC ) , in trendelenburg position

Treatment : 

Conservative - PPI for GERD

Surgery -

1. Fundoplication

  • Nissen's - 360 degree
  • Belsey - < 270 degree
  • Toupet - 180 degree

2. Hill's repair : Make angle of "His" acute by stitching lower oesophagus to median arcuate ligament.

3. Collis gastroplasty - Surgery for short oesophagus ( because of fibrosis )





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0 Gastroesophageal reflux disease (GERD)


Gastroesophageal reflux disease (GERD)

Normal pH range in Stomach is 1-4
Normal pH range in Oesophagus is 5-7
Thus regurgitation of acidic content is harmful to oesophagus.

Normal protective mechanisms :

  • LES (lower esophageal sphincter - pressure 20-25 mmHg)
  • Oesophageal motility

Minor protective mechanisms :
  • Mucosal folds
  • Angle of  "His"
  • RIGHT Crus of diaphragm


Presentation :

  • Heart burn
  • Water brash (if into mouth)


Investigations for GERD :
  1. 24 hr pH monnitoring (IOC)
  2. Manometry (Screening method of choice)
  3. Endoscopy and barium studies have also been used.
  4. Bernstein test (Obsolete)
Treatment : 
  • Medical - PPI (Proton pump inhibitors)
  • Surgery - Same as for hiatus hernia (i.e Fundoplication , Hill's repair)



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0 Intermittent dysphagia


MCQ 140

Q. Which of the following is not a cause of intermittent dysphagia ?

a. Zenker's diverticulum

b. Eosiniphilic oesophagitis

c. Diffuse esophageal spasm

d. Carcinoma oesophagus


ANSWER:
Answer : D - Carcinoma oesophagus






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0 Esophageal diverticulum


Esophageal diverticulum





 Zenker's Diverticulum : 

  • Male predominance , > 50 years
  • If enlarges then usually goes to left side.
  • MC presentation : Dysphagia (Intermittent)
  • Earliest presentation : Regurgitation (Also with Achlasia and GERD )



Note :
In Achlasia and Zenker - Old food regurgitates
In GERD - Fresh food regurgitates.

Sign : Swelling , changing size , gurgling sound - Boyce's Sign (Actual it is for laryngocele)

Investigation of choice : Barium swallow.

Treatment :
  1. Diverticulectomy + Cricopharyngomyotomy
  2. Botulinum toxin in cricopharynx (its temporary)
  3. Diverticulopexy
  4. Dohlman's procedure
  5. Medical : DOC - Calcium channel block - Nifedipine.


Causes of Intermittent Dysphagia :
  1. Zenker's diverticulum
  2. Eosinophilic esophagitis.
  3. Diffuse esophageal spasm





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0 Bosniak Renal Cyst Classification System


MCQ 139

Q. Bosniak Renal Cyst Classification System is based on ?

a. CT findings

b. Ultrasound findings

c. MRI findings

d. X-Ray findings


ANSWER:
Answer : A - CT findings 

Bosniak 1 - Simple cysts (No septations)
Bosniak 2 - Minimally complex cyst (thin single septation , no enhancement)
Bosniak 3 - Intermediate complex (multiple thick septations , mural nodules )
Bosniak 4 - Malignant mass with cystic component



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0 Medical One Liners 191 - 200


191. Lead pipe appearance of colon is seen in Ulcerative colitis.

192. Tomcat urine smell is associated to multiple carboxylase deficiency.

193. Caplan's syndrome is Rheumatoid arthritis (RA) + Pneumoconiosis.

194. Most common organism for UTI is E.Coli

195. Asymptomatic bacteriuria is only treated during pregnancy

196. Best urine sample for 8 month old girl is by SupraPubic catheterization (even a single colony is UTI with this sample)

197. IOC for VesicoUretric reflux is MCU (Micturating cystourethrography) = VCUG (Voiding cystourethrography )

198. Cranberry juice prevents UTI (because of its ant-adhesion property)

199. IOC for Posterior urethral valve -> MCU = VCUG

200. Pulmonary fibrosis in longstanding cases of Ankylosing spondylitis usually involves upper lobe.



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0 Egg shell lymph node calcification


MCQ 138

 Q. Egg shell lymph node calcification can be seen in ?

a. Sarcoidosis

b. Silicosis

c. Systemic sclerosis

d. All of the above


ANSWER:
Answer : D - All of the above.
Also can be seen in Treated Lymphoma





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0 Pulmonary fibrosis in Connective tissue disorders


MCQ 137

Q. Which of the following has highest incidence of pulmonary fibrosis amongst connective tissue disorders ?

a. Polyarteritis nodosa

b. Systemic sclerosis

c. Rheumatoid arthritis

d. SLE


ANSWER:
Answer: B - Systemic sclerosis




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0 Nephrotic Syndrome


Nephrotic Syndrome


  • Proteinuria (Albuminuria) > 40 mg/l2/hr (or > 2g /day )
  • Hypoproteinemia  < 2.5 g/dl
  • Hyperlipidemia (Serum cholesterol  > 200 mg/dl)

=> 85 % cases are Minimal change disease.
Electron microscopy shows effacement of foot process of podocytes.

=> In Adults Most common is Membranous glomerulonephritis (can have Renal vein thrombosis)

=> Mostly nephrotic syndrome is steroid sensitive, thus DOC - Prednisolone.

Clinical features :

  1. Oedema
  2. Hypovolemia
  3. Loss of Ig in urine - thus infections (Most common Spontaneous bacterial peritonitis - cause Pneumococcus ) (DOC - Cefotaxime)
  4. Loss of Protein C and S (thus risk of thrombosis)

Most common cause of steroid resistant nephrotic - FSGS

 Genetics : 
  • NPHS 1 - Nephrin ( Mutation causes FINNISH syndrome)
  • NPHS 2 - Podocin ( Mutation causes steroid resistant nephrotic syndrome)


DOC for steroid resistant nephrotic : 

  • Tacrolimus ( Its Calcineurin inhibitor )
  • Other Calcineurin inhibitor is Cyclosporin - Side effect Acne , Gingival hyperplasia

Both are nephrotoxic.

  • Rituximab (Monoclonal Antibody against CD 20)


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0 Chronic kidney disease


Chronic kidney disease (previously known as Chronic Renal Failure)

Most Common cause in < 5yr
  • Obstructive uropathy (eg: Posterior urethral valve in males)
  • Dysplasia/hypoplasia of kidney

Most Common cause in > 5yr 
  • Acquired ( Glomerulonephritis , HUS )

Complications :
  1. Azotemia
  2. Anaemia
  3. Acidosis
  4. Bony problems (Rickets , Renal Osteodystrophy)
  5. CVS problems (in Adults)
  6. Growth failure


If ESRD (end stage renal disease i.e GFR < 15 ml/min/1.73m2 ) then there will be need of dialysis or transplant (advised in child)



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0 Thoracic manifestations of rheumatoid disease


MCQ 136

Q. Most common thoracic manifestation of rheumatoid disease is ?

a. Rheumatoid pulmonary nodules

b. Pleural effusion

c. Fibrosing alveolitis

d. Bronchiolitis obliterans


ANSWER:
Answer : B - Pleural effusion.
Though rheumatoid disease can cause all the above options.




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0 Most common location of GIST


MCQ 135

Q. Most common location of GIST ?

a. Stomach
b. Duodenum
c. Jejunum
d. Ileum


ANSWER:
Answer : A - Stomach (70% cases)




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0 Calcified gastric carcinoma


MCQ 134

Q. Calcifications in gastric tumor are usually seen in ?

a. Hodgkin lymphoma
b. Non - Hodgkin lymphoma
c. Mucinous adenocarcinoma
d. Non-mucinous adenocarcinoma


ANSWER:
Ans : C , Calcified gastric carcinoma is rare and is usually mucinous adenocarcinoma.




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2 Odor ( Commonly asked in MCQs )




Odor

Condition

Fruity
  
Diabetic ketoacidosis.

Musty, mousy
  
Phenylketunuria

Yeast or malt

Oast-house syndrome = Smith-Strang diesease 

 Burned sugar smell to urine

Maple syrup urine disease 

Cheesy odor

 Isovaleric acidemia  


 Sweaty feet

  •  Glutaric acidemia type II = Multiple Acyl-CoA Dehydrogenase Deficiency (MADD)
  • Isovaleric acidemia (Also Cheesy)

Boiled cabbage

Hypermethioninemia / Tyrosinaemia  

Tomcat urine
  
Multiple carboxylase deficiency = 3-Methylcrotonylglycinuria

Fish odor

Trimethylaminuria  

Rotten egg odor

Cystinuria 





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