PAPER I

CHOOSE THE BEST APPROPRIATE ANSWER:

1. Twenty years after subtotal thyroidectomy for hyperthyroidism during a
pregnancy, a 58-year-old woman has a diffuse toxic goiter. She had done
well, but has now developed recurrent hyperthyroidism. Thyroid scan
demonstrates a diffusely enlarged residual thyroid gland.
The definitive management at this time should be:
A. Completion thyroidectomy.
B. Angiography/embolization of blood supply to the residual gland .
C. Propranolol.
D. Radioactive iodine.
E. Propylthiouracil.

2. A62-year-old man had emergency laparotomy for blunt abdominal

trauma. Splenectomy was required and blunt pancreatic injury of the
tail of the pancreas was noted. An operative drain continues to yield 300
ml/day. Drain fluid analysis reveals an amylase level of 20,000 units/ml.
The best initial option for management of this patient would be:
A. Bowel rest, total parenteral nutrition, and somatostatin therapy.
B. Enteral feeding past the ligament of treitz.
C. Fibrin glue injection via drain.
D. Endoescopic retrograde cholangiopancreatogaphy (|ERCP) with
stent.placement .
E. Laparotomy for distal pancreatectomy.

3. A 38-year-old man has a painless, non tender mass in his left neck that
moves with swallowing. Fine-needle aspiration shows medullary
carcinoma. The right side appears normal.
The best course of action would be:
A. Left thyroid lobectomy.
B. Subtotal right lobectomy and left lobectomy.
C. Total thyriodectomy.
D. Total thyriodectomy with central neck dissection.
E. Total thyriodectomy with radical neck dissection.

4. An otherwise healthy, asymptomatic 59-year-old man has an infrarenal

abdominal aortic aneurysm. The aneurysm measures 4.9 cm in largest
transverse diameter The aneurysm is confined to the aorta, and the iliac
arteries are normal.
The most appropriate plan would be:
A. Transperitoneal repair with a tube graft.
B. Retroperitoneal repair with a tube graft.
C. Endovascular repair with a bifurcated graft.
D. Ultrasound study in 6 months.
E. Ultrasound study in 1 year.

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5. A 35-year-old otherwise healthy man has a 6-hour history of melena.
Nausea, and right upper quadrant pain. He had 1 episode of
hematemesis. He takes no medications and describes occasional alcohol
use. Four weeks previously, he was hospitalized for 3days after
sustaining rib factures and a grade 2 liver injury in a motorcycle
collision. Vital signs now show postural hypotension. His abdomen is non
distended, soft, and non tender. His sclera are slightly icteric.
After fluid resuscitation, the best diagnostic test would be:
A. Exploratory laparotomy.
B. Endoscopic gastrouodenoscopy.
C. Abdominal computed tomography (CT) scan.
D. Hepatic angiogram.
E. Tagged RBC scan.

6. A 24-year-old man undergoing laparotomy for symptomatic Crohn's

disease has 2-cm stricture of the mid-ileum without any evidence of
disease elsewhere in the gastroitestestinal tract.
The best surgical option for this lesion would be:
A. Resection with primary anastomosis.
B. Heineke-mikulicz strictureplasty with biopsy.
C. Mechanical dilation.
D. Isoperistaltic side-to-side strictureplasty.
E. Heineke-mikulicz strictureplasty.

7. Regarding prophylactic mastectomy for hereditary breast cancer

A. It reduces the risk of breast cancer by 90%.
B. It should attempt to preserve the nipple-areolar complex.
C. All the breast glandular tissue is removed.
D. It reduces mortality rates more in high-risk than moderate-risk women.
E. It should be offered to all women with diffuse ductal carcinoma in situ
(DCIS)

8. A 55-year-old man has a chronic draning sinus of the perineal region 1

year after undergoing abdominperineal resection of a low-lying rectal
carcinoma followed by localized radiation therapy. Biopsy is negative for
recurrent cancer. After the affected area is debrided, the next step
should be :
A. Healing by secondary intention.
B. Primary closure .
C. Skin grafting .
D. Coverage with a fasciocutaneous flap.
E. Coverage with a muscle flap.

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9. A 65-year old man arrives in the emergency department 24 hours after the
sudden onset of abdominal pain. The pain has remained constant, and he has
not had any previous obstructive pulmonary disease . He is afebrile, his pulse
is 90 and irregular, and his blood pressure is 130/68. He has mild diffuse
abdominal tenderness. An upper gastrointestinal study shows a perforated
ulcer with contained extravasation. Which of the following statement is NOT
true?
A. Exploratory laparotomy is required .
B. A nasogastric tube should be placed .
C. Helicobacter pylori may be implicated .
D. Broad –spectrum antibiotics should be administered .
E. Age is a consideration in determining his treatment plan.

10. A 26-year- old man sustains a stab would to the left neck. He arrives in the
emergency department with a moderate –sized hematoma just anterior to the
border of the sternocleidomastoid at the level of the cricoid cartilage. There is
a bruit present. He is awake and follows commands. Neurologic examination
is normal. He is intubated without difficulty for mild respiratory distress. The
next step in management should be :
A. Tracheostomy in the emergency department .
B. 4-vessel cerebral angiogram and possible endovascular treatment .
C. Operative exploration
D. Computed tomography of the neck .
E. Observation in the intensive care unit with serial examination and
hematocrit

11. Surgical correction of zenker’s diverticulem could include all of the

following EXCEPT :
A. Resection
B. Suspension
C. Cricopharyngeal myotomy .
D. Pneumatic dilation .
E. Internal pharygoesophagomyotomy.

12. A 66 years old patient develops severe retrosternal pain after dinner, three
days following a total hip replacement.
The pain, sharp in nature radiated to the interscapular region .He also has
nausea but no vomiting .He is a known hypertensive and chronic smoker .On
examination, he is found to be normotensive ,tachycardic with a pulse rate of
105/min and tachypnic .Few basal crackles are heard on chest auscultation
,on both sides. The radiograph of the chest is normal .Full blood count .Urea
and electrolytes, blood gases and cardiac enzymes performed within few
minutes of the onset of pain are all within normal limits .ECG taken 5
minutes after the onset of pain demonstrates tachycardia but no significant
ST elevation or T-inversion :
A. Pulmonary embolism is the most likely diagnosis.
B. This patient should have an urgent V/Q scan.
C. Highly flow oxygen and pain relief are essential.
D. High-dose anticoagulation should be commenced
E. Cardiac enzymes, arterial blood gases and ECG should be repeated after
24 hours .

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13. Twenty-five years after jejuna- ileal bypass ,a 57-years-old man has
renal calculi .The chemical composition of the stones is most likely:
A. Calcium oxalate
B. Cystine
C. Magnesium ammonium phosphate
D. Calcium phosphates
E. Uric acid

14. Tamoxifen is associated with an increased risk of all of the following

except:
A. Uterine adenocarcinoma
B. Cataracts
C. Uterine sarcoma
D. Pulmonary embolism
E. Ostoporosis

15. Which of the following statements about small cell lung cancer is not
true?
A. Surgical therapy is rarely indicated
B. The aeteology is unknown
C. Paraneoplastic endocrine syndrome are common.
D. Chemotherapeutic agents are effective.
E. Prophylactic radiation-therapy can reduce brain metastasis.

16. Regarding A 30-year-old female patient who presents with bleeding

per rectum is found at colonoscopy have colitis confined to the
transverse and descending colon .A biopsy is performed.
A. The inflammatory process is likely to be confined to the mucosa and
submucosa.
B. The inflammatory reaction is likely to be continuous.
C. Superficial as opposed to linear ulceration can be expected.
D. Non caseating granulomata can be expected in up to 50% of patients with
similar disease.
E. Micro abscesses within crypt are common.

17. The following statements about the repair of inguinal hernias are true
except:

A. The conjoined tendon is sutured to Cooper's ligament in the Bassini

hernia repair.
B. The McVay repair is a suitable option for the repair of femoral hernias.
C. The Shouldice repair involves a multilayer, imbricated repair of the floor
of the inguinal canal.
D. The Lichtenstein repair is accomplished by prosthetic mesh repair of the
inguinal canal floor in a tension-free manner.
E. The laparoscopic transabdominal preperitoneal (TAPP) and totally
extraperitoneal approach (TEPA) repairs are based on the preperitoneal
repairs of Cheattle, Henry, Nyhus, and Stoppa.

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18. The following statement(s) is/are true concerning umbilical hernias in
adults:

A. Most umbilical hernias in adults are the result of a congenital defect

carried into adulthood
B. A para umbilical hernia typically occurs in multiparous females
C. The presence of ascites is a contraindication to elective umbilical hernia
repair.
D. Incarceration is uncommon with umbilical hernias

19. Which of the following is most reliable for confirming the occurrence
of a significant esophageal caustic injury?

A. History of the event.

B. Physical examination of the patient.
C. Barium esophagraphy.
D. Endoscopy.

20. Meckel's diverticulum most commonly presents as:

A. Gastrointestinal bleeding.
B. Obstruction.
C. Diverticulitis.
D. Intermittent abdominal pain.

21. A 45-year-old man with a history of previous right hemicolectomy for

colon cancer presents with colicky abdominal pain which has become
constant over the last few hours. He has marked abdominal distension
and has had only minimal vomiting of a feculent material. His
abdomen is diffusely tender. Abdominal x-ray shows multiple air fluid
levels with dilatation of some loops to greater than 3 cm in diameter.
The most likely diagnosis is:

A. Proximal small bowel obstruction

B. Distal small bowel obstruction
C. Acute appendicitis
D. Closed-loop small bowel obstruction

22. The most common indication for surgery secondary to acute

Diverticulitis is:

A. Abscess.
B. Colonic obstruction.
C. Colovesical fistula.
D. Free perforation.
E. Hemorrhage.

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23. Useful methods for detection of splenic injury, in descending order of
sensitivity, are:

A. Diagnostic peritoneal lavage.

B. CT.
C. Ultrasonography.
D. Isotope scan.
E. Magnetic resonance imaging (MRI).

24. The most precise diagnostic screening procedure for differentiating

benign thyroid nodules from malignant ones is:

A. Thyroid ultrasonography.
B. Thyroid scintiscan.
C. Fine-needle-aspiration biopsy (FNAB).
D. Thyroid hormone suppression.

25. Which of the following breast lesions are noninvasive malignancies?

A. Intraductal carcinoma of the comedo type.

B. Tubular carcinoma and mucinous carcinoma.
C. Infiltrating ductal carcinoma and lobular carcinoma.
D. Medullary carcinoma, including atypical medullary lesions.

26. Which of the following does not describe intermittent claudication?

A. Is elicited by reproducible amount of exercise.

B. Abates promptly with rest.
C. Is often worse at night.
D. May be an indication for bypass surgery.

27. A 67-year-old man with acute popliteal arterial embolism has a

negative cardiac echo for source of the thrombus. The following is/are
true:

A. Most likely non-cardiac source is a thoracic aortic aneurysm

B. Embolism is more common from femoral than popliteal arterial
aneurysms
C. Emboli from popliteal aneurysms are often clinically silent
D. Embolism is rare from subclavian artery aneurysms

28. Renal adenocarcinomas:

A. Are of transitional cell origin.

B. Usually are associated with anemia.
C. Are difficult to diagnose.
D. Are extremely radiosensitive.
E. Frequently are signaled by gross hematuria.

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29. Lobular carcinoma in situ is treated by:
A. A simple mastectomy
B. Mastectomy and Axillary dissection
C. Follow up
D. Lumpectomy
E. Chemotherapy only

30. Regarding phyllodes tumor of the breast:

A. All should be treated by simple mastectomy
B. FNA is the best diagnostic option
C. Axillary lymph node dissection is part of treatment
D. Small phyllodes are excised with one cm free resection margin
E. None of the above

31. Sentinel lymph node biopsy:

A. Is used for node +ve breast cancer
B. Sensitivity is 70%
C. Should not be used in non palpable lymph nodes
D. All of the above
E. None of the above

32. Regarding thyroid lymphoma:

A. Represent 10% of thyroid malignancy
B. Are usually T cell lymphoma
C. There is a rule for radio active iodine ablation
D. Treatment is by Chemo radiation
E. None of the above

33. Reducing the complication after total thyroidectomy:

A. Recurrent laryngeal nerve should not be identified
B. Inferior approach is the best approach to identify RLN
C. Superior parathyroid gland is usually identified
D. Inferior parathyroid is not usually identified
E. All of the above

34. Small bowel fistula:

A. Type I occur in previously diseased bowel
B. If fistula tract is more than 2.5 cm the fistula is unlikely to close
C. Epithelisation of fistula tract help fistula closure
D. Duodenal stump fistula is unlikely to close
E. Jejunal fistula is likely to close

35. The commonest cause of acute mesenteric ischemia is:

A. Mesenteric artery thrombosis
B. Mesenteric artery embolism
C. Mesenteric venous thrombosis
D. Non occlusive mesenteric ischemia
E. Vasculitis syndromes

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36. Regarding liver abscess:
A. Pyogenic liver abscess is common in men between 20 -40 years.
B. Candida infection are responsible for 20% of cases
C. Amebic liver abscess often causes jaundice
D. Pyogenic liver abscess is usually caused by poly microbial organisms
E. All of the above

37. Barrett's esophagus:

A. Barrett's esophagus with severe dysplasia should be treated by anti reflux
surgery
B. Presence of columnar epithelium in esophagus without goblet cells is
barrett's.
C. Uncomplicated barrett's is best treated by Fundoplication
D. Short segment barrett's has no malignant transformation
E. All of the above

38. Regarding hiatus hernias:

A. In type one hernia the gastro esophageal junction is intra abdominal
B. Para esophageal type two hernia is common
C. Triad of inability to vomit,pain,and inability to pass N G tube is present in
strangulated paraesophageal hernias.
D. Type four hernias are mixed hernias
E. In presence of esophageal shortening the best surgical approach is trans
abdominal

39. Regarding polyps of the colon:

A. Adenomatous polyps are usually solitary.
B. Villous polyps are usually pedunculated.
C. Metaplastic polyps are not precancerous.
D. Villous polyps occur more proximal in colon.
E. Cancer risk is not related to size of polyp.

40. Mallory –Weiss syndrome:

A. Tear is usually below gastro-esophageal junction.
B. 50% will re bleed within 2-3 days.
C. Most tears are more than 5 cm in length.
D. Best treated by laparoscopic approach.
E. Bleeding is followed by severe abdominal pain.

41. Which statement is false regarding operative management of hepatic

injuries?
A. If initial control of bleeding cannot be obtained with packing, measures such as
the Pringle maneuver and mobilization of the liver with total vascular occlusion
can be performed.
B. The use of an atrial-caval shunt is difficult to perform and usually unnecessary.
C. Expanding hematomas should be incised and the bleeding vessels should be
directly ligated or cauterized.
D. Limited segmental debridement of devitalized tissue is safe but major resection
should be avoided given its mortality rate of 25—30% .

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 E. If the patient is suspected of having a retrohepatic caval injury and bleeding has
been controlled by packing, the packing should be left in the abdomen, the
patient returned to the ICU for resuscitation and plans should be made for
packing removal in 12 h.
42. Which of the following is true regarding pancreatic trauma and its
complications ?
A. Complications of pancreatic trauma include pancreatic pseudocyst,
abscess, hemorrhage, and fistula.
B. Asymptomatic pseudocysts may be managed conservatively, as
approximately 80% will spontaneously resolve .
C. Pseudocysts which do not spontaneously resolve can be managed with
percutaneous drainage, if ductal disruption is identified.
D. If a pancreatic fistula is secondary to a major ductal disruption it will not
respond to sphincterotomy and duct stenting via endoscopic
retrograde pancreatic
cholangiopancreatography (ERCP)
E. Overall mortality from pancreatic injuries is approximately 45%.
43. pathognomonic for Hodgkin’s lymphoma?
A. Mikulicz’s cells
B. Charcot-Leyden crystals
C. Birbeck granules
D. Reed-Sternberg cells
E. Physaliferous cells

44. Axillary lymph nodes are classified according to the relationship with
the:
A. Axillary vein
B. Pectoralis major muscle
C. Pectoralis minor muscle
D. Latissimus dorsi muscle
E. Serratus anterior muscle

45. Breast cellulitis found in a lactating patient:

A. Is best treated with incision and drainage in the operating room
B. Is reason for the infant to stop breast-feeding
C. That develops into an abscess is diagnosed by fever, leukocytosis, and a
fluctuant mass .
D. Is treated by antibiotics, warm packs, and emptying the breast
E. Involves multiple organisms

46. A 65-year-old female presents with a large (5 cm) mass in her right
breast with overlying ulceration of the skin. She is noted to have
several enlarged, mobile axillary lymph nodes on examination. She is
subjected to a core biopsy which confirms the impression of invasive
ductal carcinoma of the breast. Her manage ment should begin with:
A. Mastectomy
B. Sentinel lymph node biopsy
C. Systemic chemo or hormonal therapy
D. Radiation therapy
E. Alternative therapy.

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47. Which of the following is false regarding lobular carcinoma in situ?
A. It is a marker for increased risk of breast cancer.
B. Mirror image breast biopsy is indicated ductal in origin.
C. Subsequent invasive cancer is more often.
D. Treatment is close observation versus bilateral prophylactic mastectomy.
E. Prognosis is solely related to the development of subsequent cancer

48. A 56-year-old female is found to have symptoms of hypothyroidism

with a painless, enlarged, firm, rub bery thyroid gland. FNA shows
diffuse infiltration of the gland with lymphocytes and plasma cells.
Which of the following best describes her condifion?
A. Hashimoto’s thyroiditis.
B. acute suppurative thyroiditis.
C. Riedel’s thyroiditis.
D. painless thyroiditis.
E. subacute de Quervain thyroiditis.

49. Where does the arterial supply to the superior and inferior parathyroids
originate from?
A. Superior thyroid artery.
B. inferior thyroid artery.
C. External carotid artery.
D. Internal carotid artery.
E. Common carotid artery.

50. A 22-year-old lady with hypertension refractory to medical

management is referred to you after a CT scan was obtained that
demonstrates a 3 cm mass in the right adrenal gland. The initial
diagnostic test of choice is
A. Measurement of catecholamines, metanephrines, and vanillyhnandelic
acid in a 24-h urine collection.
B. MRI.
C. Measurement of catecholamines and metanephrines in a morning. serum
sample.
D. High-dose dexamethasone suppression test.

51. Peroperative and operative management of pheochro mocytoma

all except which one of the following?
A. Use of a long-acting alpha-adrenergic antagonist preoperatively.
B. Laparoscopic removal is not acceptable because of the need to adequately
explore both adrenal glands .
C. Ligation of the adrenal vein(s) before the adrenal arteryies .
D. Surgical debulking is indicated even if the pheochromocytoma is deemed
unresectable on exploration.

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52. The chromosome carrying the gene associated with MEN 1 is:
A. Chromosome 14
B. Chromosome 13
C. Chromosome 12
D. Chromosome 11
E. Chromosome 10

53. MEN-associated gastrinomas are most frequently found in what anatomic

location?
A. Head of the pancreas
B. Tail of the pancreas
C. Gastric antrum
D. Duodenum
E. Jejunum

54. Cholecystokinin :
A. relaxes the sphincter of Oddi .
B. inhibits gastric acid secretion
C. inhibits gallbladder contractions
D. causes mesenteric vasodilation
E. inhibits pancreatic exocrine secretions

55. For the surgical treatment of gastroesophageal reflux disease (GERD), which
of the following treatment- condition pairs is most likely to fail?
A. Nissen fundoplication for scieroderma.
B. Toupet fundoplication for peptic stricture.
C. Belsey Mark IV fundoplication for lowamplitude peristalsis.
D. Collis gastroplasty with Nissen fundoplication for short esophagus.
E. E Dor fundoplication for achalasia.

56. A 44-year-old female with achalasia is treated with oral nitrates but
experiences significant side effects and is switched to calcium antagonists.
There is mild improvement in symptoms during the first several months
but she now complains of regurgitation and weight loss. What surgical
option(s) should be con sidered in this patient?
A. Fundoplication.
B. Laparoscopic esophagomyotomy.
C. Esophagectomy.
D. Myotomy and fundoplication.

57. Approximately 24 h after an uneventful transhiatal esophagectomy with a

cervical esophagogastric anastomosis for esophageal carcinoma, the patient
develops respiratory distress requiring emergent intubation. The post
intubation chest radiograph shows an infiltrate in the right middle lobe.
What is the likely etiology of this complication?

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 A. Phrenic nerve injury.
B. Tracheal laceration.
C. Gastric outlet obstruction.
D. Esophagogastric anastomotic leak.
E. Recurrent laryngeal nerve injury.
58. Which of the following tests are used to guide management of GERD?
A. Endoscopy
B. Gastric scintigraphy
C. Manometry
D. Esophageal pH monitor
E. All of the above

59. Which of the following statements regarding gastric adenocarcinoma

is true?
A. Premalignant conditions include infection with H. pylon, hyperplastic gastric
polyps, chronic gastrititis, and chronic alcohol abuse.
B. Mortality associated with total gastrectomy for gastric cancer is less than
10%.
C. Patients with metastatic gastric cancer are better served by surgical bypass
because endoscopic techniques are not effective at relieving obstructive
symptoms.
D. Japanese endoscopic screening programs have not been shown to improve
survival for patients with gastric cancer.

60. Which of the following medical regimens against H. pylon is least likely
to eradicate the organism?
A. Omeprazole, clarithromycin, and metronidazole for 14 days.
B. Bismuth, omeprazole, metronidazole, and tetracycline for 14 days.
C. Ranitidine bismuth citrate, amoxicillin, and clarithromycin for 14 days.
D. Lansoprazole and amoxicillin for 14 days.

61. The most common presentation of Meckel’s diverticulum in an adult is:

A. GI bleed
B. intussuception
C. Littre’s hernia
D. diverticulitis

62. Superior mesenteric artery (SMA) syndrome is not associated with

which of the following?
A. Scoliosis
B. Placement of a body cast
C. Anorexia nervosa
D. Abdominal aortic aneurysm
E. Rapid weight gain

63. Intraabdominal adhesions following abdominal surgery have been

associated with all of the following Except:
A. Small bowel obstruction.
B. Infertility.
C. Chronic pelvic pain.

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 D. Intestinal malabsorption.
E. Increased risk for enterotomy on subsequent laparotomy.

64. H. pylori produces hypersecretion of gastric acid in patients who develop H.

pylon-related duodenal ulcers. What is a proposed mechanism for
development of increased gastric acid secretion by this bacterium?
A. Attenuation of somatostatin release from antral D cells.
B. Direct stimulation of gastrin receptor on parietal cells.
C. Direct stimulation of proton pump on parietal cells.
D. Blockage of somatostatin receptors on parietal cells.
E. Bacterial enzymatic degradation of local prostaglandins.

65. Which of the following statements regarding colonic diverticulosis is true?

A. Diverticula are primarily located in the transverse colon.
B. The rectum is virtually never the site of diverticula .
C. The pathogenesis of diverticulosis has been associated with
hyperactive colonic motility and high fecal volume.
D. No identifiable etiology for diverticulosis has been described at the
cellular level.
E. In a patient undergoing sigmoid colon resection for apparent
isofated sigmoid divertiathtis, he recurrence rate for diverticulitis
approaches 90%.

66. Which of the following regarding inflammatory bowel disease is true?

A. Bloody diarrhea is more common in Crohii’s disease than ulcerative colitis.
B. Associated extraintestinal disease is less common in ulcerative colitis than in
Crohn’s disease.
C. Crobn’s disease frequently involves the entire colon.
D. Crohn’s is more commonly associated with primary sclerosing cholangitis
than is ulcerative colitis.
E. Surgical intervention for ulcerative colitis is limited to management of
complications of the primary disease process.

67. Regarding acute colonic pseudoobstruction (Ogilvie’s syndrome), each of the

following is correct Except:
A. This condition is defined as the radiographic appearance of a large bowel
obstruction without mechanical etiology.
B. The best pharmacologic treatment is neostigmine, which leads to rapid
decompression in a significant number of adults after a single infusion.
C. Ogilvie’s syndrome is associated with a number of neurologic disorders,
including Alzheimer’s and Parkinson’s disease and elderly dementia.
D. Most cases of this disease are idiopathic in etiology.
E. The proximal and transverse portions of the colon tend to be more
involved than the left or sigmoid colon.
68. Regarding volvulus of the sigmoid colon, each of the following is true
Except:
A. Likely results from redundant sigmoid colon with an elongated narrow
mesocolon.
B. Eighty to ninety percent of colonic volvulus cases in the United States involve
the sigmoid colon.

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 C. There appears to be a congenital predisposition sigmoid volvulus.
D. Diagnostic x-ray for sigmoid volvulus shows a dilated loop of colon which points
toward the right upper quadrant.
E. Diagnostic barium enema for sigmoid volvulus shows a“bird’s beak”
deformity.
69. According to the tumor, node, metastasis (TNM) staging for colon
cancer, which of the following is true?
A. All perforated colon cancers are considered T4.
B. N2 refers to involvement of greater than one regional lymph node.
C. T5 grade involves direct carcinoma invasion into adjacent solid organs.
D. MX indicates metastatic disease involvement of more than one
additional organ system (e.g., liver, lung, brain.).
E. Five-year survival for stage I colon cancer is approximately 75%.

70. A 73-year-old male presents to your emergency department

complaining of a large amount of bright red blood per rectum. He is
moderately tachycardic, but otherwise is hemodynamically stable.
Which of the following statements regarding the management of this
patient is false?
A. Anoscopy followed by proctoscopy should be performed to exclude localized
anorectal disease as the cause of hemorrhage.
B. Before surgical intervention is considered, he must undergo
esophagogastroduodenoscopy(EGD).
C. He should undergo colonoscopy if clinically stable.
D. A positive tagged RBC scan should prompt segmental surgical
resection.
E. None of the above

71. Principles of surgical treatment of anal fistula should include all of

the following Except:
A. After identification of external and internal fistula openings, the tract
should be incised unless excessive overlying muscle is present.
B. The granulation tissue exposed in the fistula tract should be treated with
gentle curettage.
C. If a large portion of external sphincter is involved, sphincter reconstruction,
seton division, or endorectal flap advancement should be considered.
D. Treatment of horseshoe fistula-in-ano should include complete resection of
the entire fistula tract regardless of the extent of soft tissue
involvement.
E. The deep postanal space must be entered, curetted, and irrigated if the
fistula is transphincteric.

72. Anorectal manometry can be used in the evaluation of fecal

incontinence. All of the following statements regarding anal
manometry are correct Except: U

A. It is an objective method used to assess anal muscular tone, rectal

compliance, and anorectal sensation.
B. Anorectal manometry can be used to verify the integrity of the rectoanal
inhibitory reflex.

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 C. There is only one universally accepted method for obtaining and
analyzing data for quality assurance.
D. Manometry can identify and document sphincter function before
operative intervention that might require optimal continence.
E. Slow waves, ultraslow waves, and intermediate waves are examples of
waveforms that might be encountered.
73. Regarding staging in rectal cancer, all of the following statements are
correct Except:
U

A. Stage I rectal cancer has 80—90% 5-year survival rate.

B. In stage II rectal cancer, the primary tumor has extended either through
the muscularis propria or into the pericolic fat with possible local
extension into other organs.
C. Metastatic nodal involvement in stage III rectal cancer is
classified as either Ni or N2, describing the number of nodes
positive for metastatic cancer in the pericolic or perirectal position.
D. Stage IV rectal cancer is limited to a T4 lesion with any local lymph node
involvement and distant metastasis.
E. Stage II rectal carcinoma has a 62—76% 5-year survival rate.

74. Melanoma of the anal canal can be discovered incidentally in

hemorrhoid specimens, all of the following statements are
correct Except:
U

A. The anal canal is the most common site of the development malignant
melanoma of the alimentary tract.
B. 0.2% of all melanomas occur in the anal canal.
C. All melanoma-in-ani are characteristically pigmented.
D. Although abdominoperineal resection has traditionally been the surgical
procedure of choice for melanoma of the anal canal, wide local excision
is gaining acceptance.
E. Supplemental therapy with chemotherapy, radiotherapy, and
immunotherapy has been of no consistent benefit for survival.

75. Retroperitoneal fibrosis:

A. Is considered idiopathic in about one-third of all cases
B. Has been associated with hydralazine, ergotamine, methyldopa, and
alpha-blocking agents.
C. Is excluded if only one ureter appears to be involved.
D. Can be treated surgically with ureteral transposition, renal
autotransplantation, or omental encasement
E. Cannot be accurately diagnosed with intravenous pyelography.

76. The peritoneum :

A. Can absorb isotonic fluids such as saline at a rate of approximately
90—100 cc/h.
B. Contains a mesothelial lining that secretes fluid to lubricate the peritoneal
surfaces, and normally 200—300 cc of free intraperitoneal fluid is
present in an adult.
C. Can reabsorb approximately 90% of the red blood cells in the peritoneal
cavity intact via fenestrated lymphatic channels in the undersurface of the
diaphragm.

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 D. Air can normally be present in the peritoneum after laparotomy for 7—8
days.
E. Chylous ascites predisposes to intraperitoneal infection.

77. Mesenteric cysts:

A. Are usually filled with lymph.
B. Are only embryonic or traumatic in origin.
C. Are rarely palpable on physical examination.
D. Usually present as nontender, asymptomatic abdominal mass.
E. Have a characteristic lateral mobility on physical examinatio.

78. Which of the following is true concerning the location of spigelian

hernias?
A. It is more likely to occur below the semicircular line of Douglas because
the aponeurotic fibers of the internal and external oblique muscles are
parallel below the umbilicus.
B. They occur just medial to the semilunar line.
C. Spigelian hernias may occur inferior to the epigastric vessels.
D. A and B.
E. B and C.

79. During a laparoscopic cholecystectomy performed on a healthy young

man, a 1-cm cavernous hemangioma is noticed on the surface of the left
lobe of the liver. The most appropriate treatment for this lesion at this
lime is:
A. Biopsy and frozen section analysis.
B. Observation.
C. Resection
D. Laparoscopic fulguration.
E. Postoperative embolization.

80. Regarding cholesterol gall stones pathogenesis, all are true Except:
A. Changes in the equilibrium between the amount of cholesterol and bile
saturation capacity play a major role in stone formation.
B. Decrease gallbladder motility results in less amount of bile available for
cholesterol solubilization, predisposing to crystal formation.
C. The formation of cholesterol stones is the result of specific alterations,
congenital or acquired, in the hepatic metabolism.
D. Mucin production in the gallbladder is known to be a pronucleating
factor that predispose the stone formation.

81. What is the most sensitive test for the diagnosis of biliary dyskinesia?
A. Abdominal CT scan.
B. ERCP.
C. Cholecystokinin-Tc-HIDA scan.
D. Abdominal US.
E. Magnetic resonance cholangiopancreatography (MRCP).

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82. What is the appropriate treatment for cholangiocarcinoma of the
hepatic bifurcation?
A. Right hepatic lobectomy.
B. Left hepatic lobectomy.
C. Pancreaticoduodenectomy (Whipple).
D. Bile duct resection and hepaticojejunostomy + partial hepatectomy.
E. Radiation therapy + bile duct stenting.
83. The most common gallbladder tumor:
A. Adenocarcinoma.
B. Papillary carcinoma.
C. Mucinous carcinoma.
D. Squamous cell carcinoma.
E. Oat cell carcinoma.

84. After an uneventful laparoscopic cholecystectomy in a 55-year-old

male, the pathology review demonestrates a gallbladder carcinoma
invading, but not penetrating the muscularis layer. What is the most
appropriate next step in the management of this patient?
A. No more treatment needed.
B. En-bloc resection of gallbladder bed including segments four to five of the
liver. and regional lymph nodes.
C. Postoperative chemotheraphy.
D. Biliary stent placement to prevent future hiliary obstruction.
E. Biliary-enteric bypass.

85. A 67-year-old male presents to your office with painless jaundice.

Courvoisier's sign is present. An abdominal ultrasound (US) is
performed, followed by an abdominal computed tomography (CT)
scan. You suspect that there is a neoplasm in the head of the pancreas.
Which of the following CT scan findings does not rule out
resectability?
A. Encasement of the superior mesenteric artery (SMA) or celiac axis
B. Dilated intra- and extrahepatic biliary ducts, with an engorged
gallbladder.
C. The confluence of the superior mesenteric vein (SMV and portal vein is
not patent.
D. Evidence of extrapancreatic disease.
E. Absence of a fat plane between the tumor and the SMA.

86. Which of the following is true with regard to palliative strategies for
unresectable pancreatic cancer?
A. Pancreatic adenocarcinoma is an asymptomatic disease.
B. Celiac axis neurolysis is effective in 90% of patients over the short term.
C. Gastric outlet obstruction (GOO) in the presence of unresectable disease
is best treated by gastrojejunostomy.
D. Presence of biliary obstruction is best treated with biliary-enteric
anastomosis.
E. Prophylactic gastrojejunal anastomosis is widely recommended.

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87. Splenectomy is of proven benefit in the management of the following
autoimmune conditions Except:
A. Felty’s syndrome.
B. Immune thrombocytopenic purpura (ITP).
C. Cold-agglutinin syndrome (1gM autoimmune hemolytic anemia).
D. Warm-agglutinin syndrome (IgG autoimmune hemolytic anemia).
E. Systemic lupus erythematosus.
88. Splenectomy may increase long-term risk of each of the
following Except:
A. Hypercoagulability.
B. Secondary atherosclerotic events.
C. Pneumococcal sepsis.
D. Pulmonary hypertension.
E. Pancreatitis.

89. A 45-year-old woman with Hodgkin’s lymphoma is referred to you by

her oncologist for staging laparotomy. You open the abdomen through
a standard midline incision. Gross visual inspection of the abdominal
cavity is unremarkable for any discrete lesions. You perform core
needle biopsies of each lobe of the liver and then a wedge biopsy of the
free edge of the left lateral segment. Frozen section is positive for
lymphoma. What is the appropriate next step?
A. Close the abdomen and terminate the operation.
B. Splenectomy.
C. Lymph node sampling.
D. Oophoropexy.
E. Lymphangiography.

90. A patient with a history of atrial fibrillation presents with a 6-h history
of acute right lower extremity pain. On examination, the lower
extremity is cool to the touch and the patient has pain on attempts to
move his foot. The femoral pulse is palpable but pulses are absent, as
are Doppler signals below this level. The next step in management
should be:
A. Immediate embolectomy.
B. Arteriogram.
C. Anticoagulation and observation.
D. Amputation.
E. Femoral-femoral bypass.

91. Regarding thoracic outlet syndrome (TOS):

A. It maybe present with arterial, venous, or neurologic symptoms.
B. Arterial TOS is the most common form of the syndrome.
C. Thrombotic occlusion of the subclavian artery is the most common
presentation of arterial TOS.
D. Resection of the middle scalene muscle is curative.
E. Thrombolysis is contraindicated in venous TOS.

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92. Which of the following is true regarding aortic aneurysm?
A. The aorta is considered aneurysmal when its size is twice that of the
normal proximal aorta.
B. Women are generally affected more frequently than men.
C. Aneurysm walls contain increased levels of collagen and elastin.
D. The most common presentation of Abdominal Aortic Aneurysm is back
pain.
E. The risk of rupture increases with increasing size of the aneurysm.
93. Regarding the appropriate surgical resection margin for melanoma ,
all are true Except:
A. Melanoma in situ on the trunk—0.5 cm margin.
B. 0.8 mm thick melanoma on the extremity—1.0 cm margin.
C. 2 mm thick melanoma on the trunk—2.0 cm margin.
D. 2 mm thick melanoma inferior to the lateral canthus 1.0cm.
E. All of the above are appropriate.

94. A 3-week-old, first-born male baby develops, non- bilious

vomiting, Which of these findings establishes the diagnosis?
A. Ultrasonographic pyloric muscle thickness of 2.5 mm.
B. Ultrasonographic pyloric:antrum ratio greater than 1.5 cm.
C. Ultrasonographic pyloric diameter of 1.0 cm or less.
D. An UGI series showing a classic “double bubble” sign.
E. Palpable pyloric mass (olive) midline of the abdomen.

95. The mechanism of action of local anesthetics is best described as:

A. Binding of the catior fv o the local anesthetic molecule to extracellular
local anesthetic receptors.
B. Binding of the neutral (basic) form of the local anesthetic molecule to
cytoplasmic receptors.
C. Binding of the cationic form of the local anesthetic molecule to
transmembrane sodium receptors in the inactivated-closed state.
D. Binding of the neutral (basic) form of the local anesthetic molecule to
transmembrane sodium channels in the activated-open state.
E. Binding of the local anesthetic molecule to transmembrane potassium
channels.

96. A patient receives a spinal anesthetic at the T5 level, all are true Except:
A. Urinary retention.
B. Dilated and relaxed small bowel.
C. Decreased venous return.
D. Bradycardia.
E. Decreased ability to cough.

97. The injury severity score (ISS) is determined based on which of the
following?
A. The sum of the squares from the three highest abbreviated injury scale
(AIS) scores.
B. The sum of the three highest AIS scores.
C. The sum of all nine sections from the AIS.
D. The sum of the scores from all six body regions used in the ISS.
E. The sum of the squares from all nine sections of the AIS.
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98. What is the blood supply for a pedicled transverse rectus abdominus
muscle (TRAM) flap?
A. Superior epigastric artery.
B. Inferior epigastric artery.
C. Rectus abdominis perforators.
D. Internal iliac artery.
E. Intercostal artery.
99. Which of the following is required for addressing any pressure sore?
A. Antibiotics.
B. Pressure reduction.
C. Hyperbaric oxygen.
D. Flap coverage.

100. Regarding familial adenomatous polyposis (FAP) :

A. Inherited in an autosomal-dominant manner, this genetic defect is of

variable penetrance, some patients having only a few polyps whereas
others develop thousands.
B. The phenotypic expression of the disease depends mostly on the
genotype.
C. Appropriate surgical therapy includes total abdominal colectomy with
ileorectal anastomosis and ileoanal pull-through with rectal
mucosectomy.
D. Panproctocolectomy with ileostomy is not appropriate therapy for this
disease.
E. Pharmacologic management of this disease may be appropriate in some
instances.

Good Luck

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