MCQ – ANSWERS: INTESTINAL OBSTRUCTION

Clinical
Small Gut
1- What are the cardinal signs of obstruction syndrome?
A. Abdominal pain and cramping
B. Nausea, vomiting
C. Unable to pass stool or gas
D. Abdominal guarding.
E. Abdominal fullness, gaseous, distention

2. History and physical examination permit the diagnosis of intestinal obstruction in most cases. Which of the following are important for the clinical diagnosis of small bowel obstruction?
A. Crampy abdominal pain.
B. Fever.
C. Vomiting.
D. Abdominal distention.
E. Leukocyte count above 12,000.
F. Abdominal tenderness.

3. Which of the following statement(s) is/are true concerning the pathophysiology of small bowel obstruction?
A. Most of gas seen on plane abdominal radiographs is produced by gas forming microorganisms.
B. Elevation of luminal pressure contributes to fluid accumulation in the small bowel in closed loop but not open loop small bowel obstructions.
C. Intestinal blood flow initially increases to the bowel wall in early bowel obstruction.
D. In the face of obstruction, myoelectrical activity of the bowel is consistently increased.

4. The lamina propria between the intestinal epithelium and the muscularis mucosae contains:
A. Blood and lymph vessels.
B. Undifferentiated epithelial cells.
C. Nerve fibers.
D. Enterochromaffin cells.
E. Macrophages.
F. Connective tissue.

5. Regarding small bowel obstruction
A. In the United Kingdom is most often due to an obstructed hernia.
B. Causes colicky abdominal pain and vomiting.
C. Abdominal distension is seen in all patients.
D. All cases can be managed conservatively for the first 24 hours.
E. Rarely requires aggressive fluid resuscitation.

6. Regarding strangulated small intestine obstruction:
A. Pain syndrome occurs brutally.
B. Abdominal meteorism is central.
C. Vomiting are early and abundants.
D. Infectious syndrome is right away important
E. Douglass pouch is pain on rectal palpation.

7. A mechanism of strangulation in acute bowel obstruction is suspected when:
A. Continuous pain.
B. Sign Von Wahl.
C. Air-fluid noises.
D. Hiccups.

8. Occlusion in strangulation of the small intestine:
1: The pain syndrome begins abruptly.
2: The central abdominal bloating.
3: Vomiting is early and abundant.
4: The infectious syndrome is important from the outset.
5: The cul de sac (uterorectal or vesicorectal pouch) is painful at rectal examination.
A: 1-5-4 B:1-4-3 C: 1-2-3 D: 2-3-5 E :1-2-5

9. During the paralytic ileus, all signs those are common except one, which one?
A. Abdominal distension,
B. Iincreased-fluid noises on auscultation,
C. Abdominal pain discrete
D. Radiological small bowel distention and colon
E. Low fluid levels .

10. Extracellular dehydration:
A. Can be installed as a result of vomiting or biliary fistula.
B. Accompanied by dryness of mucous.
C. Its treatment involves the administration of saline.
D. Biologically accompanied the increase in the Ht and the rate of protein.
E. Accompanied by the skin pinch.

11. In acute intestinal obstruction by strangulation of the small intestine recent physical examination can establish that:
A - A central bloating.
B - Peristaltic waves.
C - An abdominal scar.
D - A contracture periumbilical.
E - Air-fluid noises on auscultation.

12. Before a bowel obstruction which (s) is (are) on (the) item (s) for a small bowel obstruction due to strangulation?
A - The gradual onset of pain.
B - The existence of an abdominal scar.
C - No matter the digital rectal examination.
D - The permanent nature of the pain.
E - The absence of fluid levels on radiographs of the abdomen without preparation.

13. For a mechanism of strangulation during acute intestinal obstruction is retained:
A - Existence of peristaltic waves.
B - Silence abdominal auscultation.
C - Early progressive.
D - Presence of an abdominal scar.
E – Pain with DRE.

14. Obstruction due to strangulation of small bowel clamp (frange, adhesion) is characterized by:
A - A sudden onset.
B - Severe pain.
C - Vomiting late.
D - Images with air-fluid folds haustraux on radiographs of the abdomen without preparation.
E - Images air-fluid level which shows the folding of the small intestine.

15. A mechanism of obstruction in acute bowel obstruction is suggested by:
A - Curl peristaltic.
B - Silence has abdominal auscultation.
C - Asymmetry of bloating.
D - Emptiness of the rectum to the touch.
E - Conservation of the general condition.

16. The small bowel obstruction by strangulation is characterized by:
A - Start brutal.
B - Important abdominal distension.
C - Strong intensity of abdominal colic.
D - Earliness vomiting.
E - Air-fluid level higher than wide.

17. A mechanism of strangulation in acute bowel obstruction is suggested by:
A - Constant pain.
B - Sign of Von Wahl.
C - Air-fluid sounds on auscultation.
D - Abdominal contracture.
E - Hiccups.

18. The location in the small intestine to acute intestinal obstruction by strangulation is suspected in:
A - Central bloat peri-umbilical.
B - Presence of peristaltic waves.
C - Asymmetrical arrangement of bloat.
D - Precocity and abundance vomiting.
E - Abdominal contracture.

19. In paralytic ileus, all the signs that are common but one. Which one?
A - Abdominal distension.
B - Increase in noise-fluid for the inspection.
C - Abdominal pain discreet.
D - Radiological small bowel distention and bowel.
E - Low fluid levels.

20. In the presence of an acute intestinal obstruction syndrome, all signs may be observed during a paralytic occlusion with the exception of one. Indicate which:
A - Important abdominal bloating.
B - No fever.
C - Retention of urine reflex.
D - Curl peristaltic. (Ondulations peristaltic).
E - Hiccups.

21. One definition is the following gallstone ileus. Which one?
A - A choledochal gravel gallstones. (empierrement)
B - A peritonitis by gallbladder perforation.
C - Inflammatory bowel obstruction in contact with acute cholecystitis.
D - A small bowel obstruction by migration of gallstones.
E - None of the above is correct.
Answer: D

22. For a mechanism of strangulation during an acute intestinal obstruction is retained:
A - Existence of peristaltic waves.
B - Silence abdominal auscultation.
C - Early progressive.
D - Presence of an abdominal scar.
E - Pain with digital rectal examination.

23. Concerning the adhesion volvulus of the small intestine:
A - The flange (s) may take (s) be congenital.
B - In case of single flange, it sits constantly at the foot of the vuvolus loop.
C - The direction of twist of the handle is either clockwise or counter-clockwise.
D - The expansion only affects intestinal bowel volvulus upstream of and respects the vuvolus loop.
E - The maximum anatomical lesions seat at the foot of the vuvolus loop.

24. A mechanism of obstruction in acute bowel obstruction is suggested by:
A - Curl peristaltic.
B - Silence has abdominal auscultation.
C - Asymmetry of bloating.
D - Emptiness of the rectum to the touch.
E - Conservation of the condition.

25. The small bowel obstruction due to strangulation is characterized by:
A - Sudden onset.
B - Abdominal distension important.
C - High intensity colicky abdominal.
D - Precocity vomiting.
E - Air-fluid level higher than wide.

26. On the occasion of an acute intestinal obstruction which of the following proposals, the one you remember?
A - Pneumoperitoneum.
B - Air-fluid level higher than wide.
C - Bulky abdominal distension.
D - Abdominal contracture.
E - None of these.

27. What are the signs accompanying occlusion by volvulus of the small intestine?
A - Sudden onset.
B – Bloat immobile.
C - Minor abdominal pain.
D - Auscultation Abdominal silent.
E - Early vomiting.

28. In acute intestinal obstruction due to strangulation of the small intestine recent physical exam may find:
A - A central bloating.
B - Peristaltic waves.
C - An abdominal scar.
D - A periumbilical contracture.
E - Air-fluid noises on auscultation.

29. In strangulation obstruction of the small intestine, bloating is:
A. Sudden onset.
B. Central.
C. Noise with air-fluid on auscultation.
D. Animated peristaltic waves.
E. Sound on percussion.

30. A bloat of obstruction in acute bowel obstruction is suspected when:
A. Peristaltic undulations.
B. Abdominal silence.
C. Asymmetry of bloat.
D. Conservation condition.

Large Gut

1. One of the following sign is characteristic of an occlusion of the sigmoid volvulus. Which?
A - Fever Early.
B - Bloat oblique.
C - Blood on rectal examination.
D - All of distension of the colon in the abdomen with preparation.
E - Liquid Levels colic. Colonic fluid level

2. Occlusion of the sigmoid colon cancer is characterized by:
A. Gradual onset.
B. Significant (important) abdominal bloating.
C. Intensive abdominal colic.
D. A large number of air fluid levels.
E. Air fluid levels higher than wide.

3. Bloat of the pelvic colon volvulus:
1. Has an asymmetrical layout.
2. Was tympanic to percussion.
3. Accompanied by peristaltic waves.
4. Accompanied by abdominal contraction.
5. Accompanied by removal of abdominal skin reflexes
A: 1-4 B: 2-3 C: 1-2 D: 3-5 E: 1-5

4. One of the following is characteristic of a sigmoid volvulus:
A. Fever early.
B. Bloat oblique.
C. Distension of the colon together with the ASP.
D. Colonic fluid level.

5. Occlusion of the sigmoid colon cancer is characterized by:
A- Beginning progressive.
B- Abdominal distension important.
C- Strong intensity of abdominal colic.
D- A large number of air-fluid level.
E- Air-fluid levels higher than wide.

6. The distension of the pelvic colon volvulus:
A - A an asymmetrical arrangement.
B - Is tympanic to percussion.
C - Comes with peristaltic waves.
D - Accompanied by abdominal contraction.
E - Comes with removal of abdominal cutaneous reflexes.

7. Among the various claims about the cecal volvulus include one (s) is (are) true (s):
A - There may be secondary to an absence of apposition of the cecum.
B - He was a frequent early clinical brutal.
C - Vomiting is often hemorrhagic.
D - The cessation of materials and gas net.
E - The pain is often intense.

8. The occlusion of the sigmoid colon cancer is characterized by:
A - Early progressive.
B - Abdominal distension important.
C - High intensity of abdominal colic.
D - A large number of air-fluid level.
E - The air-fluid level higher than wide.

9. The bloating of pelvic colon volvulus:
A - In an asymmetrical arrangement.
B - Is tympanic to percussion.
C - Comes with peristaltic waves.
D - is accompanied by abdominal contraction.
E - Comes with removal of abdominal cutaneous reflexes.

10. Among the various claims about the cecal volvulus include one (s) is (are) true (s):
A - It may be secondary to a lack of apposition of the cecum.
B - He was frequently a brutal early clinical.
C - Vomiting is often hemorrhagic.
D - The cessation of material and gas net.
E - The pain is often intense.

11. Koenig's syndrome is characterized:
A - Abundant steatorrhea.
B - In crises subocclusives resolve spontaneously.
C - A flush.
D - By recurrent gastrointestinal bleeding.
E - By fever joint pain with chronic diarrhea.

12. Indicate from the following, the (s) character (s) taken by the abdominal distension in cases of bowel obstruction when he realizes a sign of von Wahl:
A - Arranged in the frame.
B - Tympany to percussion.
C - Consistency elastic to the touch.
D - Presence of peristaltic waves.
E - Abdominal contracture.

13. Occlusion by neoplastic stenosis of the hinge rectosigmoid:
A. a mode is usually faster.
B. accompanied by vomiting early.
C. has a total silence on auscultation abdominal.
D. causes bloating in part (part in a flatulence).
E. may be preceded by rectal hemorrhage.

14. Of the following characters, which ones can not (usually) apply to the sigmoid volvulus?
A. Sudden onset.
B. Early vomiting.
C. Central bloat.
D. Many fluid levels.
E. Endoscopic treatment.

15. Indicate from the following, the (s) character (s) taken by the abdominal distension in cases of bowel obstruction when he realizes a sign of von Wahl:
A. Available in part.
B. Tympany to percussion.
C. Elastic consistency on palpation.
D. Presence of peristaltic waves.
E. Abdominal contraction.

16. In an occlusion of the left colon obstruction:
A. vomiting are early and abundant.
B. bloat is peripheric.
C. the peristaltic waves are numerous.
D. air-fluid sounds on auscultation are evident.
E. images radiological air-fluid are higher than wide.

Causes

1- Quote the 2 causes of obstruction small intestine by obstruction of the bowels:
A. Volvulus
B. Bilary ileus
C. Tumors blocking the intestines
D. Electrolyte imbalances.

2- Quote the 3 causes of intestinal obstruction by strangulation of the bowels:
A. Postoperative adhesions.
B. Obstruction intestine by mesenteric tumor.
C. Volvulus (twisted intestine).
D. Foreign bodies (ingested materials that obstruct the intestines).
E. Hernias (strangulated hernia).

3. Complete mechanical small bowel obstruction can cause dehydration by:
A. Interfering with oral intake of water.
B. Inducing vomiting.
C. Decreasing intestinal absorption of water.
D. Causing secretion of water into the intestinal lumen.
E. Causing edema of the intestinal wall.

4. 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.

5. In the patient described above, the following statement(s) is/are true concerning the possible etiology of bowel obstruction.
A. Simple obstruction secondary to an adhesion is most likely to resolve nonoperatively.
B. It is most likely that the patient’s obstruction is secondary to recurrent malignancy.
C. A history of colon cancer makes carcinomatosis the most likely diagnosis.
D. Lower abdominal procedures are more likely to result in obstructive adhesions than are upper abdominal procedures.

6. Which of the following statement(s) is/are true concerning the etiology of intestinal obstruction?
A. In the United States, peritoneal adhesions account for over half of the cases of small bowel obstruction.
B. A leading cause of bowel obstruction is early postoperative adhesions.
C. Bowel obstruction cannot occur with a Richter’s hernia.
D. Ninety percent of adult cases of intussusception are associated with a pathologic process, most commonly a tumor.

7. Which of the following statement(s) is/are true concerning Intestinal Obstruction?
A. Any impairment, arrest, or reversal of the normal flow of intestinal contents toward the anus.
B. Intestinal obstruction is a blockage of your small intestine or colon that prevents food and fluid from passing through.
C. Interruption in the passage of intestinal contents.
D. Intestinal obstruction is a partial or complete blockage of the bowel that results in the failure of the intestinal contents to pass through.
E. Bowel obstruction (or intestinal obstruction) is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion.

8. Most iron is stored in combination with?
A. Sulphate.
B. Ferritin.
C. Transferrin.
D. Ascorbic acid.

9. The following are true of colonic volvulus
A. Cecal volvulus is associated with malrotation.
B. Cecal volvulus is commonest in children.
C. In sigmoid volvulus the amount of torsion is most commonly 360 degrees.
D. In sigmoid volvulus the 'coffee-bean sign' is due to distinct midline crease corresponding to the mesenteric root in a distended loop.
E. Volvulus of the transverse colon accounts for about 10% of all colonic volvulus.

10. Among obstructions of newborn, one of the following aetiologies can complicate severe enterocolitis, indeed deadly necessary always emergency treatment what?
A. Hirschsprung’s disease.
B. Ileal atresia.
C. Meconial ileus.
D. Left little colon syndrome.

11. Certain intestinal obstructions can lead partial or complete ischemic necrosis of small gut, what?
A. Strangulated inguinal hernia.
B. Appendiceal peritonitis.
C. Intussusception.
D. Meconial ileus.
E. Duodenal atresia.
F. Hirschsprung’s disease.

12. Of the following characters, indicate that applying to gallstone ileus:
A - Is the result of the isolation of a calculation at the neck region cystic?
B - Its evolution is dominated by the risk of intrahepatic suppuration.
C - Is always associated with a vesicle large, tense, and palpable.
D - Is responsible for a small bowel obstruction.
E - The calculation is always pure, consisting of calcium bilirubinate.

13. Concerning volvulus flange of the small intestine (on adhesion)
A. The flange may be congenital.
B. In case of single flange, it sits constantly at the foot of the twist loop.
C. The meaning is twisting the handle is either clockwise or counterclockwise.
D. The expansion affects only the intestinal gut volvulus and upstream of the loop volvulus respects.
E. The maximum anatomical lesions seat at the foot of the twist loop.

14. Among the following which ones can be retained as a cause of intestinal obstruction by strangulation?
1. The occlusion of the sigmoid cancer.
2. The occlusion by volvulus flange.
3. The gallstone ileus.
4. The strangulated hernia.
5. The acute intussusception.
A: 1-4-5 B:1- 2-3 C: 1-2-4 D: 2-4-5 E :1-3-5

15. Hypokalemia:
A. Can cause paralytic ileus.
B. May cause muscle paralysis.
C. May cause cardiovascular events early on ECG.
D. Is often the result of renal and gastrointestinal losses?
E. Is never seen in drowning.

16 - Elements radiological evidence of organic obstruction stenosing cancer of the sigmoid:
A. Distension smooth, mainly gaseous bowel loops and colon
B. Images-fluid devices taller than wide
C. Large image hydroaeric of median lower abdominal
D. Thickening of the walls of small bowel with effacement of the valves connivent

17. A passenger presents severe abdominal pain by moving crisis amid ongoing pain, and vomiting with lost materials and gases. The review shows that you practice a distended abdomen without contracture. You think
A- Appendicitis.
B- Ruptured ectopic pregnancy.
C- Hepatic colic.
D- Intestinal obstruction.

18. Some intestinal obstructions are accompanied by a partial or total ischemic necrosis of the small intestine. Which?
A. Strangulated inguinal hernia.
B. Peritonitis.
C. Volvulus on common mesentery.
D. Intussusception.
E. Meconium ileus.
F. Hirschsprung's disease.
G. Duodenal atresia.
H. Occlusion flange.

19. A bite fever in intestinal obstruction can be indicative of the form:
A - Pelvic appendicitis.
B - Appendicitis mesoceliac.
C - Retro-caecal appendicitis.
D - The appendiceal abscess.
E – Appendicular peritonitis.

20. The gallstone ileus can be the result of fistula:
A - Cholecysto-colic.
B - Cholecysto-duodenal.
C - Cholecysto-choledochal.
D - choledocho-choledochal.
E - Hepatico gastric.

21. Among the conditions proposed as responsible for an inflammatory occlusion, the quote (s) is (are) true (s):
A - Gallstone ileus.
B - Renal colic.
C - Cholecystitis.
D - Sigmoiditis.
E - Peritonitis.

22. Among of the following causes of obstruction by strangulation proposed, what (s) is (are) one (s) is (are) true (s)?
A - Crohn's Disease.
B - Strangulated inguinal hernia.
C - Volvulus flange.
D – Biliary ileus.
E – Acute Intussusception.

23. A mechanism of obstruction in acute bowel obstruction is suggested by:
A - Curl peristaltic.
B - Silence has abdominal auscultation.
C - Asymmetry of bloating.
D - Emptiness of the rectum to the touch.
E - Conservation of the condition.

24. An occlusion febrile (bite fever) can be indicative of the form:
A - Pelvic appendicitis.
B - Meso-celiac appendicitis.
C - Retro-cecal appendicitis.
D - The appendiceal abscess.
E - The peritonitis.

25. The gallstone ileus may be due to a fistula:
A - Cholecysto-colic.
B - Cholecysto-duodenal.
C - Cholecysto-choledochal.
D - choledocho-choledochal.
E - Hepatico tube.

26. Among the conditions proposed as responsible for an inflammatory occlusion, the quote (s) is (are) true (s):
A - Gallstone ileus.
B - Renal colic.
C - Cholecystitis.
D - Sigmoiditis.
E - Peritonitis.

27. For the organic character of constipation, you hold:
A - Recent onset in a patient over 40 years.
B - General condition preserved.
C - Anemia associated.
D - Rectal bleeding.
E - Old and stable symptoms.

28. Among of the following causes of occlusion proposed by strangulation, what (s) is (are) one (s) is (are) true (s)?
A - Strangulated hernia.
B - Cancer of the colon.
C - Intestinal volvulus.
D - Intestinal infarction.
E - Bride scar.

29. Which of the following, the two most common causes of colonic obstruction organic outside the sigmoid cancer in an adult?
A - The sigmoid volvulus.
B - Ischemic colitis.
C - Ulcerative colitis.
D - The sigmoid diverticular.
E - The colo-colonic intussusception.

30. Hirschsprung's disease:
A. is a particular form of colon volvulus.
B. is an occlusion by stenosis of the small intestine.
C. is an occlusion by atresia in the colon.
D. is an occlusion by abnormal nerve plexus intraparietal.
E. is an occlusion by functional enzyme disorder.

31. Among of the following causes of occlusion proposed by strangulation, what (s) is (are) one (s) is (are) true (s)?
A. Crohn's disease.
B. Inguinal hernia.
C. Volvulus flange.
D. umbilical hernia.
E. Stenosis of the sigmoid colon cancer.

32. Among the neonatal low occlusions, one of the following causes may be complicated by enterocolitis extremely serious, even fatal, always requiring emergency treatment. Which?
A. Hirschsprung disease.
B. Ileal atresia.
C. Meconium ileus (cystic fibrosis).
D. Small left colon syndrome.

Investigations

1- The most helpful diagnostic radiographic procedure in small bowel obstruction is:
A. CT of the abdomen.
B. Contrast study of the intestine.
C. Supine and erect x-rays of the abdomen.
D. Ultrasonography of the abdomen.

2. Patients with established, complete, simple, distal small bowel obstruction usually have the following findings on plain and upright abdominal radiographs:
A. Distended small bowel identifiable by the valvulae connivances.
B. Multiple air-fluid levels.
C. Modest amount of gas in the pelvis.
D. Peripheral, rather than central, distribution of gas.
E. Prominent haustral markings.
F. Free air.

3. Which of the following statement(s) is/are true concerning laboratory tests which might be obtained in the patient discussed above?
A. The presence of a white blood cell count > 15,000 would be highly suggestive of a closed-loop obstruction.
B. Metabolic acidosis mandates emergency exploration.
C. An elevation of BUN would suggest underlying renal dysfunction.
D. There is no rapidly available test to distinguish tissue necrosis from simple bowel obstruction.

4. The patient discussed above was admitted to the hospital and after 24 hours remained distended with no evidence of resolution. Which of the following radiographic studies would be considered appropriate at this time?
A. Contrast enema.
B. Enteroclysis study with dilute barium.
C. CT scan with dilute barium oral contrast.
D. None of the above.

5. The most helpful diagnostic radiographic procedure in small bowel obstruction is:
A. CT of the abdomen.
B. Contrast study of the intestine.
C. Supine and erect x-rays of the abdomen.
D. Ultrasonography of the abdomen.

6. What is/are among the following radiological elements which reveal a biliary ileus?
A. Air under diaphragmatic.
B. Air-fluid level of small gut.
C. Aerobilia.
D. Enlargement parieto-colic groove.

7. What is/are among the following radiological elements which permit to diagnose a small gut obstruction on erect film (APF)?
A. Central air-fluid level.
B. Air-fluid level higher than larger.
C. Aerobilia.
D. Air under diaphragmatic.

8. On erect film in intestinal subobstruction patient reveals an isolated loop dilated with air-fluid level. What diagnosis can be evoked?
A. Colon volvulus.
B. Peritonitis.
C. Deep abscess.
D. Pancreatitis.
E. Cholecystitis.

9. Which is, among the following radiological features that allow you to diagnose small bowel obstruction on plain films of abdomen without preparation?
A. Image central air-fluid level.
B. Image air-fluid level wider than tall. (than higher)
C. Presence of dents and haustra thickened the walls of the distended loops.
D. Aerobilia.
E. Increasing clear subdiaphragmatic gas.

10. What is the review for asserting Hirschsprung's disease?
A. The barium enema.
B. Anorectal manometry.
C. Rectal biopsy.
D. The rise of a rectal probe.

11. What (s) is (are) among the following radiological signs, that (those) which translate (are) a gallstone ileus:
A - Crescent clear subdiaphragmatic gas.
B – Images fluid level of the small intestine.
C - Pneumobilie (pneumobilia).
D - Enlargement of the paracolic gutters.
E - Image parietography gaseous intestinal loops.

12. What (s) is (are) among the following radiological elements that (those) that will allow (s) to diagnose small bowel obstruction on plain films of abdomen without preparation?
A – Images central fluid level.
B - Images fluid level higher than wide.
C - Presence of dents and Haustrate thickened the walls of the distended loops.
D - Pneumobilia.
E - Crescent clear subdiaphragmatic gas.

13. What (s) is (are) among the following radiological elements that (those) which demonstrates occlusion of organic stenosis of the sigmoid colon cancer?
A - Abdomen smooth, mostly pop, small bowel and colon.
B - Images-fluid devices taller than wide.
C - Air in the rectum.
D - Thickening of the walls of small bowel loops with "erasing valves connivent".
E - Bulky image hydroaeric arched pelvic lower abdominal median.

14. What (s) is (are) among the following radiological elements that (those) that will allow to diagnose obstruction of the small intestine on image of abdomen urgent?
A – Central image fluid level.
B - Opacities gutters laterobladder "in ear dog".
C - Presence of dents and Haustrate thickened the walls of the distended loops.
D - Pneumobilia.
E - Crescent clear subdiaphragmatic gas.

15. A malignant tumor of the colon can give an obstruction:
A. By strangulation.
B. With early cessation of materials and gases.
C. Pictures with air-fluid devices.
D. Air-fluid with images wider than high.
E. Can provide a framework in bloating.

16. Regarding an occlusive syndrome, it is advisable to:
A. Do a rectal examination.
B. Feel the hernial orifices.
C. To perform an abdominal preparation.
D. To perform an enema with water-soluble.
E. Feed the patient.

17. An occlusion of the left colon obstruction:
A. Vomiting are early and abundant.
B. Bloat is peripheric.
C. The peristaltic waves are numerous.
D. Air-fluid sounds on auscultation are evident.
E. Image radiological air-fluid is higher than wide.

18. Obstruction by obstruction of the small intestine leads to:
A. A median abdominal distension.
B. Meteorism a lively peristaltic movement.
C. Stopping materials and gas early.
D. Many images air-fluid.
E. Air-fluid images taller than wide.


Complications

19. Which of the following statement (s) is/are true concerning postoperative ileus?
A. The use of intravenous patient-controlled analgesia has no effect on return of small bowel motor activity.
B. The presence of peritonitis at the time of the original operation delays the return of normal bowel function.
C. The routine use of metoclopramide will hasten the return of small intestinal motor activity.
D. Contrast radiographic studies have no role in distinguishing early postoperative bowel obstruction from normal ileus.

Treatment

1. A 75-year-old woman is hospitalized after a fall in which she has experienced a hip fracture. Several days after her surgical procedure, progressive painless abdominal distension is noted. Which of the following statement(s) is/are true concerning her diagnosis and management?
A. Colon distension with a cecal diameter in excess of 12 cm should indicate the need for urgent operation.
B. Endoscopic decompression may be attempted but seldom is successful.
C. After successful colonoscopic decompression, recurrence is unlikely.
D. A rectal tube as the primary treatment is generally not successful.

2. The initial management of this patient should consist of:
A. Fluid resuscitation with D5 half normal saline with 40 mEq of potassium chloride/liter
B. Placement of an indwelling urinary catheter.
C. Nasogastric decompression with a nasogastric tube.
D. Immediate surgery
E. The patient should be begun on broad spectrum antibiotics at the time of admission

3. An 82-year-old female nursing home resident is admitted with massive abdominal distension and constant abdominal pain with diffuse tenderness. Abdominal x-ray shows a massively distended loop of colon with a characteristic “bent inner tube” appearance. The management of this patient should include:
A. Urgent laparotomy because of the massive colon distension.
B. An attempt at endoscopic decompression with a flexible sigmoidoscope.
C. Elective laparotomy and sigmoid resection should follow if endoscopic decompression is successful.
D. If at urgent laparotomy resected bowel is present, colon resection with primary anastomosis is in order.


Intussusception

Clinical

1. Intussusception
A. Is most common in children from 6 to 12 years.
B. Presents with colicky abdominal pain, rectal bleeding and an abdominal mass.
C. 10% present with diarrhoea and vomiting suggestive of gastroenteritis.
D. If no shock or peritonitis hydrostatic reduction can be attempted.
E. A Meckel's diverticulum can induce an intussusception.

2. Regarding acute intussusception (AI), one of the following statements is true:
A – A.I. is a condition seen mainly between two and six.
B - The absence of rectal eliminates the diagnosis of A.I.
C - Intussusception can descend into the left colon.
D - A barium enema removes a normal A.I.
E - The standard radiological reduction of A.I. is the visualization of the cecum.

3. In case of intussusception in infants, a sign is virtually pathognomonic. Which?
A- Rectal bleeding
B- Paroxysmal abdominal pain
C- Emptiness of the right iliac fossa
D- Palpation of an intussusception
E- association pain, rectal bleeding

4. Regarding trans-valvular ileo-ileocolic intussusception: what are the true statements?
A- It was born on the colon
B- It is usually idiopathic
C- It is often resistant to radiation treatment
D- Appendix is driven in trans-valve with the flange
E- It can be caused by a Mekel diverticulum

5. Which of the following statement(s) is/are true concerning Intussusception?
A. A form of intestinal obstruction caused by the prolapse of a part of the intestine into the adjoining intestinal lumen.
B. Intussusception involves a telescoping of one portion of the intestine into another, which results in decreased blood supply of the involved segment.
C. Intussusception is the sliding of one part of the intestine into another.
D. Intussusception is a term derived from the Latin intus (within) and suscipere (to receive). One segment of the bowel (intussusceptum) invaginates into another (intussuscipiens) just distal to it, leading to obstruction. The bowel may simply telescope on itself (non-pathological lead point), or some pathology may be the focus of the invagination (pathological lead point).
E. Intussusception is defined as the telescoping of one segment of bowel into the immediately distal segment of bowel.

6. Claw sign seen in?
A. Intusseption.
B. Volvulus.
C. Adhesion.
D. Impacted feces

7. The acute intussusception:
A. Is observed mainly between 2 and 6 years
B. The absence of rectal bleeding diagnosis eliminates
C. A barium enema diagnosis eliminates normal
D. The strand of intussusception can descend into the left colon

8. Constipation is a symptom
A. Which is defined by a dry weight of stools> 22% of the total weight of these
B. Which can be enhanced by ingestion of magnesium salts
C. Can be improved by the continued use of its 15g / d

9. Regarding acute intussusception (AI), one of the following statements is true:
A - AI is a condition seen mainly between two and six.
B - The absence of rectal eliminates the diagnosis of AI.
C - intussusception can descend into the left colon .
D - A barium enema removes a normal AI.
E - The standard radiological reduction of AI is the visualization of the cecum.

Cause

10. Of the following etiological hypotheses, what is the one we should not use it as a possible cause of intussusception secondary?
A - Meckel's diverticulum,
B - Common mesentery.
C - Intestinal duplication cyst.
D - Lymphosarcoma,
E - Rheumatoid purpura.

11. Acute abdominal pain in children can be caused by:
A - An ovarian cyst in the little girl,
B - Meckel's diverticulum,
C - Testicular torsion in boys,
D - Bladder retention,
E - Pneumonia.

12. Cases of intussusception:
A. Nasopharyngeal infection
B. Meckel diverticulum
C. Intestinal lymphoma
D. Thrombocytopenic purpura
E. HSP

Investigation
13. What (s) image (s) radiological (s) can we see the enema of an infant who has an intussusception?
A - A picture sleeve sigmoid (en virole)
B - A gap in the cecum, (lacune)
C - An image of the Rosette splenic flexure.
D - A lobster claw image of the transverse colon,
E - A stack of plates aspect of the transverse colon,

14. How (s) review (s) may be appealed to explore first-line acute abdominal pain in children?
A - Small bowel transit,
B - Chest x-ray,
C - CT abdominal
D - Abdominopelvic ultrasound,
E – GI Barium.

15. The criteria for reduction of intussusception in the time course of barium enema are:
A - Image cockade
B - Frank fill the last intestinal loops,
C - Post-traumatic stenosis,
D - Visibility of the cecum in place,
E - No filling of the last intestinal loops.

16. Complete Rx of intussception indicates?
A. Free passage of barium in the small intestine.
B. Passage of faceus and flatus along with barium.
C. Improvement of clinical condition.
D. Claw sign.

17. To affirm the complete reduction by enema of intussusception valvulo-colic (caeco-colic), you must require:
A - A complete opacification of the right colon.
B - A complete opacification of the cecum.
C - A clouding of the appendix.
D - A frank and massive opacification of small bowel loops past.
E - One aspect curved inward toward the midline of the cecum and right colon.

Complication
18. All following injury or illness may be complicated by intussusception, except one:
A - Nasopharyngeal infection.
B - Meckel's diverticulum.
C - Intestinal lymphoma.
D - Thrombocytopenic purpura.
E - Purpura arthritis.


Biliary Ileus
1. What (s) is (are) among the following radiological signs, that (those) which reflect a gallstone ileus:
A - Ascending clear subdiaphragmatic gas.
B - Images-fluid of the small intestine.
C - Pneumobilie (pneumobilia).
D - Enlargement of the paracolic gutters.
E - Image parietography gaseous small bowel loops.

2. One definition is the following gallstone ileus. Which one?
A - A choledochal gravel gallstones. (empierrement)
B - A gallbladder perforation peritonitis.
C - Inflammatory bowel obstruction in contact with acute cholecystitis.
D - A small bowel obstruction by migration of gallstones.
E - None of the above is correct.

3. The gallstone ileus may be due to a fistula:
A - Cholecysto-colic.
B - Cholecysto-duodenal.
C - Choleysto-choledochal.
D - choledocho-choledochal.
E - Hepatico tube.

4. Indicate the exact proposal regarding gallstone ileus:
A. It comes with a pneumoperitoneum.
B. it is accompanied by a pneumobilia.
C. It produced an array of small bowel obstruction due to strangulation.
D. it is accompanied by jaundice.
E. it complicates an microlithiasis.

5. Indicate the exact proposal regarding gallstone ileus:
A. It comes with a pneumoperitoneum.
B. it is accompanied by a pneumobilia.
C. he produced a table of small bowel obstruction due to strangulation.
D. it is accompanied by jaundice.
E. it complicates an microlithiasis.


Clinical case

Clinical case A
A man aged 80 was hospitalized because of abdominal pain by moving crises, accompanied by a cessation of materials and gas and a feeling of nausea. In this patient, chronic constipation, trouble began two to three days before. Several similar attacks identified in the background had given spontaneously or after an enema. A review is an important abdominal distension, oblique and asymmetric. The patient is afebrile, the general condition is poor. The diagnosis of intestinal obstruction is discussed.

A1. The head of the colonic obstruction is suggested by:
A - Early to stop gas.
B - Bloating oblique and asymmetrical.
C - abdominal contracture.
D - Emptiness of the rectum to the touch.
E - Impairment of condition. (General state)

A2. You have made an x-ray of abdomen without preparation that confirms your clinical impression of pelvic colon volvulus. Indicate from the following (s) sign (s) radiological (s) compatible (s) with this diagnosis:
A - Anse dilated sole occupant most of the abdomen.
B - on multiple levels liquids hail.
C - Presence of a peritoneal effusion reaction.
D - Grand liquid level at the dilated loop.
E - Discharge of the liver shadow.


A3. The occurrence of pelvic colon volvulus is enhanced by:
A - Existence of dolichocôlon.
B - Presence of diverticula.
C - History of previous attacks of diverticulitis.
D - Existence of fibrous bands of the mesocolon.
E - Association of a tumor of the hinge rectosigmoid.

A4. In this patient, which of the following therapeutic measures do you recommend in an emergency?
A - Cleansing enema.
B - Untwisting by external manipulation.
C - Colonoscopy.
D - Sigmoid colostomy.
E - Sigmoid colectomy in an emergency.


Clinical case B
One patient of 78 years was hospitalized for intestinal obstruction. It has since morning arrest of materials and gas net and absolute, a meteorism important. There is a history of bowel dysfunction. The beginning, there are 3 or 4 days, was marked by vague abdominal pain colicky, a feeling of nausea. This period follows a sharp abdominal pain syndrome in early frankly, not very intense so far, because of widespread pain in the hypogastric predominant "abdomen." This is a permanent pain syndrome without paroxysmal crisis.
The patient reports a little vomiting at the beginning of pain syndrome and a simple and nausea without vomiting. The transit stop was early and absolute, for both materials and gases.
She is not shocked, there is no fever. The review shows a significant bloat, large and asymmetric in the inspection, there is no peristaltic waves; auscultation did not reveal noise-fluid. Palpation found a painless tummy, feeling rénitence, the abdomen is tympanitic on percussion, the hernial orifices are free. Digital rectal examination shows bulging of the anterior wall of the rectum, delivered by an elastic swelling, rectal mucosa was also normal.

B1. Signs of observation, which ones are compatible with the diagnosis of occlusion of the lower large intestine? (CM)
A. Early vomiting.
B. Sudden onset.
C. Early stopping materials and gas.
D. Some abdominal pain.
E. Meteorism important.

B2. The causes of occlusion of the large intestine, which is the one that is least likely? (CS)
A. Sigmoid.
B. Cancer of the sigmoid colon.
C. Volvulus of the pelvic colon.
D. Volvulus of the cecum.
E. Obstruction by gallstone ileus.


B3. Signs of observation, which ones are more in favor of an occlusion of the pelvic colon volvulus as an occlusion of the sigmoid colon cancer? (CM)
A. Sudden onset.
B. Absence of vomiting.
C. Stopping materials and gas early and brutal.
D. Meteorism asymmetrical.
E. Absence of peristalsis.

B4. The radiograph of abdomen without preparation, a sign is characteristic of the pelvic colon volvulus (CS)
A. Images fluid level central and peripheral.
B. Images fluid level peripheral.
C. Images fluid level wider than high.
D. Images multiple fluid levels.
E. Image fluid level large central arch.

B5. It is the diagnosis of pelvic colon volvulus. The following attitudes are acceptable, except one, which one? (CS)
A. Operate without any further examination.
B. Survey by repeated radiographs of the abdomen without preparation.
C. Soluble barium enema followed by surgery.
D. Endoscopy followed by surgery.
E. Rectal probe followed by surgery.



Answers MCQ
Clinical
Small Gut
1- ABCE
2. ABCDF
3. B, C
4. ACEF
5. B
6. ABC
7. A, B.
8. C: 1-2-3
9. E
10. B
11. ACE
12. B
13. BD
14. ABE
15. AC
16. ACD
17. AB
18. AD
19. B
20. D
21. D
22. BD
23. ACE
24. AC
25. ACD
26. E
27. ABDE
28. ACE
29. ABE
30. A

Large Gut
1. B
2. A, B, E.
3. B: 2-3
4. B
5. ABE
6. AB
7. BE
8. ABE
9. AB
10. BDE
11. B
12. BC
13. DE
14. BD
15. BC
16. BCDE

Causes
1- BC
2- ACE
3. ABCDE
4. B
5. A, D
6. AD
7. ABCDE
8. B
9. ACD
10. B
11. ACD
12. D
13. ACE
14. D: 2-4-5
15. E
16 - ABD
17. D
18. ACDEH
19. BE
20. B
21. BCDE
22. BC
23. AC
24. BE
25. B
26. BCDE
27. ACD
28. ACE
29. AD
30. D
31. ABCD
32. A

Investigations
1- C
2. AB
3. D
4. A, B, C,
5. C
6. BC
7. B
8. BDE
9. A
10. C
11. BC
12. A
13. ABD
14. A
15. BCDE
16. ABCD
17. BCDE
18. BD

Complications
19. B

Treatment
1. D
2. B, C
3. B, C

MCQs Intussusception

Clinical
1. B, C, D, E
2. C
3. D
4. C-E
5. ABCDE
6. A
7. D
8. A, C
9. C

Cause
10. B.
11. A B C D E
12. E

Investigation
13. B C D
14. B D.
15. B D.
16. BD
17. ABD

Complication
18. D
Biliary Ileus
1. C
2. D
3. B
4. B
5. B

Clinical case
Clinical case A
A1. ABD
A2. AD
A3. AD
A4. C

Clinical case B
B1. BCDE
B2. E
B3. ADE
B4. E
B5. B

BM41 Y4 IU MCQ- ANSWERS : ACUTE APPENDICITIS

MCQ

Clinical
1- What is the localization of appendix the most frequency?
A. Iliac
B. Pelvis
C. Mesocoeliac
D. Subhepatic

2- What is the triad clinical biologic of diagnosis of appendicitis?
A. Pain and Guarding Right Iliac Fossa
B. Abdominal distension.
C. Fever at 38 C
D. Leucocytes>10.000/mm3

3- What gestures regarding an acute appendicitis?
A. Abdominal palpation
B. Rectal palpation
C. Examination testes
D. Hernia orifice examination

4- What is the right proposition which accompany all attack acute appendicitis?
A. Pain right flank
B. Guarding exquisite
C. Pain of pouch
D. Infectious syndrome
E. Vomiting

5- What appendicular localization evokes a feverish obstruction?
A. Right iliac
B. Retrocaecal
C. Pelvis
D. Mesocoeliac

6- In infant, what’re the signs evocative of acute appendicitis?
A. Diarrhea.
B. Vomiting.
C. Insomnia.
D. Anorexia.
E. Abdominal pain.

7- Pain in the hypogastrium when internal rotation of the hip is :
A. The pointing sign.
B. The psoas sign.
C. The obturator sign.
D. Rovsing's sign.
E. Blumbert’s sign

8- Pain felt in the right iliac fossa when you press deeply in his left iliac fossa is:
A. The pointing sign.
B. The psoas sign.
C. The obturator sign.
D. Rovsing's sign.
E. Blumbert’s sign

9- Pressing the abdomen at Mc Burney's point and then rapidly released, the patient may increase in pain, is:
A. The pointing sign.
B. The psoas sign.
C. The obturator sign.
D. Rovsing's sign.
E. Blumbert’s sign.

10- Move the patient's legs the pain felt in the right iliac fossa on extension of the hip, and the right hip flexed for pain relief, is:
A. The pointing sign.
B. The psoas sign.
C. The obturator sign.
D. Rovsing's sign.
E. Blumbert’s sign.

11- The patient is then asked to point to where the pain began and to where it move,is:
A. The pointing sign.
B. The psoas sign.
C. The obturator sign.
D. Rovsing's sign.
E. Blumbert’s sign.

12. Which of the following is the least common position of appendix?
A. Retroileal.
B. Retroceacal.
C. Postileal.
D. Pelvic.
E. Subhepatic.

13- Clinical features likely in 23-year-old man with an acutely inflamed retrocaecal appendix include
A- Right iliac tenderness.
B- Temperature 37.5 C.
C- Anoerxia.
D- Back pain.
E- Macroscopic haematuria.

14- Regarding appendicitis
A. The risk of developing the illness is greatest in childhood
B. Mortality increases with age and is greatest in the elderly
C. 20% of appendices are extraperitoneal in a retrocaecal position
D. Faecoliths are present in 75-80% of resected specimens
E. Appendicitis is a possible diagnosis in the absence of abdominal tenderness

15. Which of the following is the least common position of appendix?
A. Retroileal
B. Retroceacal
C. Postileal
D. Pelvic
E. Subhepatic.

16- Concernant l’appendicite aiguë
A. L’appendicite mésocoeliaque peut simuler une salpingite aiguë
B. L’appendicite pelvienne peut être révélée par des signes urinaires.
C. Le toucher rectal est toujours douloureux
D. Il existe souvent une hyperleucocytose à PNN.

17- Regarding acute appendicitis
A. Mesocoeliac appendicitis can mimic an acute salpigitis.
B. Pelvic appendicitis can be revealed by urinary sign.
C. Rectal examination is always pain.
D. There is often polymorphonuclear neutrophil hyperleukocytosis.
Answer: BD

18- A ppendix shows the histology of the necrotic area, images of vascular thrombosis, an inflammatory infiltrate small. They are:
A. A normal appendix.
B. A catarrhal appendicitis.
C. A gangrenous appendix.
D. An appendiceal abscess.
E. A subacute endoappendicite.

19- With regard to eliciting tenderness on examination of patient with acute abdominal pain
A- Rebound tenderness can be assessed by finger percussion.
B- Tenderness associated with colonic disease is usually present in the midline suprapubically.
C- If tenderness is present without guarding, then peritonitis will not be present.
D- Tenderness on rectal examination is highly suggestive of a pelvic abscess.
E- Localised tenderness in the right iliac fossa is the most important single clinical sign of acute appendicitis.

20- A 79-year-old man has had abdominal pain for 4 days. An operation is performed, and a gangrenous appendix is removed. The stump is inverted. Why does acute appendicitis in elderly patients and in children have a worse prognosis?
A. The appendix is retrocecal.
B. The appendix is in the preileal position.
C. The appendix is in pelvic position.
D. The omentum and peritoneal cavity appear to be less efficient in localizing the disease in this age group.

21- A 17-year-old boy complains of pain in the lower abdomen (mainly on the right side). Symptoms commenced 12 hours before admission. He had noted anorexia in this period. Examination reveals tenderness in the right iliac fossa, which was maximal 1cm below Mc Burney’s point. In appendicitis, where does the pain frequently commence?
A. In the right iliac fossa and remains there.
B. In the back and moves to the right iliac fossa.
C. In the rectal region and moves to the right iliac fossa.
D. In the umbilical region and moves to the right iliac fossa.
E. In the right flank.

22- On examination, patients presenting with appendicitis typically show maximal tenderness over which of the following?
A. Inguinal region.
B. Immediately above the umbilicus.
C. At a point between the outer one-third and the inner two-third of a line between the umbilicus and the anterior superior iliac spine.
D. At a point between the outer two-thirds and the inner one-third of a line between the umbilicus and the anterior superior iliac spine.
E. At the midpoint of a line between the umbilicus and the anterior superior iliac spine.

23- A 79-year-old man has hade abdominal pain for 4 days. An operation is performed, an a gangrenous appendix is removed. The stump is inverted. Why does acute appendicitis in elderly patients and in children have a worse prognosis?
A. The appendix is retrocecal.
B. The appendix is perileal position.
C. The appendix is in the pelvic position.
D. The omentum and peritoneal cavity appear to be less efficient in localizing the disease of these age groups.
E. The appendix is longer in these age groups.

24- Acute appendicitis is most commonly associated with which of the following signs?
A. Temperature above 104؛ F.
B. Frequent loose stools.
C. Anorexia, abdominal pain, and right lower quadrant tenderness.
D. White blood cell count greater than 20,000 per cu.mm.

25. True statements regarding the pathophysiology of acute appendicitis include which of the following:
A. Fecaliths are responsible for the disease process in approximately 30% of adult patients.
B. Lymphoid hyperplasia is a rare cause of appendicitis in young patients.
C. Clostridium difficile is implicated as a pathogenic organism.
D. Carcinoid tumors account for approximately 5% of all cases of acute appendicitis.

26- A 12- year-old boy complains of pain in the lower abdomen (mainly on the right side). Symptoms commenced at 12 hours before admission. He had noted anorexia during this period. Examination revealed tenderness in the right iliac fossa, which was maximal 1 cm below McBurney’s point. In appendicitis, where does the pain frequently commence?
A. In the right iliac fossa and remains there.
B. In the back and move to the right iliac fossa.
C. In the rectal region and moves to the right iliac fossa.
D. In the umbilical region and then moves to the right iliac fossa.
E. In the right flank.

27- A 28-year-old man is admitted in emergency department complaining of pain in the umbilical region that moves to the right iliac fossa. Which is a corroborative sign of acute appendicitis?
A. Referred pain in the right side with pressure on the left (Rovsing’s sign).
B. Increased of pain with testicular elevation.
C. Relief pain in the lower abdomen with extent of thigh.
D. Relief pain in the lower abdomen with internal rotation of right thigh.
E. Hyperanesthesia in the right lower abdomen.

28. Among the different landforms (topographic) of appendicitis, one can find:
A - Retro-caecal.
B - Sub-liver.
C - Intra hernia.
D - Meso-celiac.
E - Pelvic.

29- The diagnosis of acute appendicitis is most difficult to establish in:
A. Persons aged 60 and older.
B. Women aged 18 to 35.
C. Infants younger than 1 year.
D. Pregnant women.

30. Regarding appendicitis
A. The risk of developing the illness is greatest in childhood.
B. Mortality increases with age and is greatest in the elderly.
C. 20% of appendices are extraperitoneal in a retrocaecal position.
D. Faecoliths are present in 75-80% of resected specimens.
E. Appendicitis is a possible diagnosis in the absence of abdominal tenderness.

31. Special populations of people that may have delayed diagnosis of acute appendicitis due to atypical presentation include:
A. Very young patients.
B. Elderly patients.
C. AIDS patients.
D. Pregnant patients.
E. All of the above.

32- On examination, patients presenting with appendicitis typically show maximal tenderness over which of the following?
A. Inguinal region.
B. Immediately above the umbilicus.
C. At a point between the outer one-third and inner two-third of a line between the umbilicus and the anterior superior iliac spine.
D. At a point between the outer two-third and inner one-third of a line between the umbilicus and the anterior superior iliac spine.
E. At the midpoint of a line between the umbilicus and the anterior superior iliac spine.

33. A patient presents with a subacute syndrome appendix. On abdominal examination, you can not find such clear physical signs that you expect, you're not sure, but the patient is obese and the review difficult. You remember from the following:
A - The lack of defense of the right iliac fossa cripple the diagnosis discussed.
B - The very furred tongue is a sign recognized guidance.
C - A normal number of white blood lymphocytosis but with a confirmed diagnosis.
D - In the absence of an emergency, a barium enema provides useful information to confirm the achievement appendix.
E - Low-grade fever of 38 ° C encouraged to prescribe rest and antibiotic treatment a few days.

34. In the case of acute appendicitis, pelvic position, the adolescent:
A - Bradycardia, when it exists, is a good sign of diagnostic orientation.
B - The pain may be epigastric early.
C - Nausea and vomiting are symptoms often found.
D - Coated tongue (furred tongue) is a good diagnostic feature.
E - Signs of local review are, in most cases, peri-umbilical.

35. Regarding an acute generalized peritonitis, we note for the appendicular origin (not ectopic)
A - A history of painful crisis in the right iliac fossa.
B - A digital rectal pain.
C - Existence of fever at the beginning.
D - The early signs in the right iliac fossa.
E - The existence of a defense of the right upper quadrant.

36. A patient presents suprapubic pain, urinary frequency and dysuria. The temperature is 38.2 °, leukocytosis is 12 000 with polynucleosis. On examination, there is a suprapubic pain with defense at this level. The right iliac fossa is smooth and painless. Digital rectal examination is painful on the right side. The urine is clear and the sediment normal. What is your diagnosis?
A - Cystitis.
B - Retro-cecal appendicitis.
C - Appendicitis pelvic.
D - Appendicitis mésocœliaque.
E - subhepatic appendicitis.

37. Acute appendicitis in a young adult, free of other pathology, may be by:
A - Intestinal obstruction.
B - An intermittent dysphagia.
C - Peritonitis.
D - Vomiting.
E - A Gram-sepsis.

38. Among the following statements about acute appendicitis include the usual position (s) is (are) true (s):
A - The onset of symptoms may be epigastric.
B - The diagnosis of acute appendicitis is clinic.
C - The leukocytosis is uncommon.
D - Digital rectal examination is always painful.
E - The defense of the right iliac fossa confirms the diagnosis.

39- Which of the following most often initiates the development of acute appendicitis?
A. A viral infection.
B. Acute gastroenteritis.
C. Obstruction of the appendiceal lumen.
D. A primary clostridial infection.

40. Among the physical signs following, indicate that (those) that can be found on clinical examination of a patient with intestinal dysfunction:
A - Swelling firm the right iliac fossa.
B - Pain on the right side face of the rectum.
C - Epigastric thickening.
D - Cordon painful downwards and inwards, at the side and the left iliac fossa.
E - Pain caused by the right iliac fossa.

41. The usual manifestations of appendicitis pelvic position include:
A - Acute retention of urine.
B - An abscess in the cul-de-sac.
C - A psoïtis.
D - A pain accurate in the digital rectal.
E - A pneumaturia.

42- Acute appendicitis is most commonly associated with which of the following signs?
A. Temperature above 104؛ F.
B. Frequent loose stools.
C. Anorexia, abdominal pain, and right lower quadrant tenderness.
D. White blood cell count greater than 20,000 per cu.mm.

43. Remember, one of the following clinical signs, those usually found in acute appendicitis in children aged 5 to 10 years:
A. Pain in the right iliac fossa.
B. Fever.
C. Nausea or vomiting.
D. Diarrhea.
E. Defense on palpation of the right iliac fossa.

44. Among the following statements about acute appendicitis in usual position, the quote (s) is (are) true (s):
A. The onset of symptoms may be epigastric.
B. Diagnosis of acute appendicitis is clinical.
C. Leukocytosis is uncommon.
D. DRE is always painful.
E. The defense of the right iliac fossa confirms the diagnosis.

45. A patient presents Suprapubic pain, urinary frequency and dysuria. The temperature is 38.2 C, leukocytosis is 12 000 with polynucleosis. On examination, there is a suprapubic pain with defense at this level. The right iliac fossa is smooth and painless. Digital rectal examination is painful on the right. The urine is clear. What is your diagnosis?
A. Cystitis.
B. Retrocaecal appendicitis.
C. Appendicitis pelvic.
D. Meso-celiac appendicitis.
E. Subhepatic appendicitis.

46. You are prompted to do an emergency 25 year old woman who complained for several hours, lower abdominal pain. Her temperature is 38.5 C and vomited twice. On examination, her stomach is flat without scarring: the pain is at maximum in the suprapubic region with a slight defense. On digital rectal examination, the cul-de-sac is painful on the right. What (s) diagnostic (s) can we talk?
A. Acute cholecystitis.
B. Right pelvic inflammatory disease.
C. Acute appendicitis.
D. Ulcerative colitis.
E. Attack of renal colic right.

47. Acute appendicitis in retro-caecal position includes:
A. Right flank pain.
B. An attitude in flexion of the thigh on the pelvis (psoïtis).
C. Urinary frequency.
D. Rectal pain.
E. Lleukocytosis with polymorphonuclear.

48. Among the different landforms of appendicitis, one can find:
A. Retrocaecal form.
B. Subhepatic form.
C. Intrahernial form.
D. Mesocœliac form.
E. Pelvic shape.

49- Regarding appendicitis
A. The risk of developing the illness is greatest in childhood
B. Mortality increases with age and is greatest in the elderly
C. 20% of appendices are extraperitoneal in a retrocaecal position
D. Faecoliths are present in 75-80% of resected specimens
E. Appendicitis is a possible diagnosis in the absence of abdominal tenderness

50- The diagnosis of acute appendicitis is most difficult to establish in:
A. Persons aged 60 and older.
B. Women aged 18 to 35.
C. Infants younger than 1 year.
D. Pregnant women.

51. The appendicular lump
A - Is a localized peritonitis.
B - is due to an agglutination of intestinal loops and omentum around the appendix .
C - is often favored by antibiotics.
D - resulting in mass of the right iliac fossa
E - Requires an emergency surgery.

52. Abscess cul-de-sac may:
A - To be due a pelvic appendix.
B - Give urinary frequency.
C - manifest as a febrile occlusion.
D - To be due a pyosalpynx.
E - Provide mucus made by the anus.

53. For the origin of appendicular peritonitis, you hold:
A - The early age.
B - The existence of a heartburn.
C - The absence of pneumoperitoneum.
D - Irradiation to the basic right thoracic pain.
E - The early signs in the RIF.

54. The plastron appendix (Appendicular lump):
A. is a localized peritonitis.
B. is due to an agglutination of intestinal loops and omentum around the appendix.
C. is often promoted by antibiotics.
D. reveals by a mass of the right iliac fossa.
E. requires emergency surgery.

55. Indicate the (the) proposal (s) exact (s) concerning the abscess cul-de-sac:
A. It may follow peritonitis.
B. It is accompanied by an oscillating fever.
C. Is the digital rectal examination, which often allows diagnosis?
D. Pelvic ultrasound can help in the diagnosis.
E. It may be accompanied by dysuria in men.

56. An appendix to his swollen distal part shows a destruction of the inner part of the wall with many polymorphonuclear altered in histology. What diagnosis should you of the following?
A. Appendix subacute.
B. Appendix bluetongue.
C. Appendiceal abscess.
D. Appendix chronic obliterans.
E. Gangrenous appendix.

57. Eight days after appendectomy, a patient complains of dysuria, urinary frequency, a slowing of transit who had taken the third postoperative day. Note the presence of mucus rectal temperature of 38.9 C, 20 000 white cells per mm3, with 90% neutrophils. What you evoke the first diagnosis?
A. Abscess of the wall.
B. Cecal fistula.
C. Hemoperitoneum.
D. Abscess cul-de-sac.
E. Abscess meso-celiac.


Etiology

1- In patient with an appendix abscess, which of the following organisms is least likely to be found in the abscess?
A- Bacteroides fragilis.
B- Bacteroides melanococcus.
C- Streptococcus faecalis.
D- Escherichia coli.
E- Staphylococcus aureus.

2. True statements regarding the pathophysiology of acute appendicitis include which of the following:
A. Fecaliths are responsible for the disease process in approximately 30% of adult patients.
B. Lymphoid hyperplasia is a rare cause of appendicitis in young patients.
C. Clostridium difficile is implicated as a pathogenic organism.
D. Carcinoid tumors account for approximately 5% of all cases of acute appendicitis.

3. Acute appendicitis is due to?
A. Fecoliths.
B. Worms of ileo caecal region.
C. Streptococcal infections.
D. Abuse of purgatives.
E. None.

4- Which of the following most often initiates the development of acute appendicitis?
A. A viral infection.
B. Acute gastroenteritis.
C. Obstruction of the appendiceal lumen.
D. A primary clostridial infection.

5. True statements regarding the pathophysiology of acute appendicitis include which of the following:
A. Fecaliths are responsible for the disease process in approximately 30% of adult patients.
B. Lymphoid hyperplasia is a rare cause of appendicitis in young patients.
C. Clostridium difficile is implicated as a pathogenic organism.
D. Carcinoid tumors account for approximately 5% of all cases of acute appendicitis.

6. Abscess cul-de-sac may:
A. be due to a pelvic appendix.
B. to urinary frequency.
C. manifest as a febrile occlusion.
D. be due to a pyosalpynx.
E. give mucus made by the anus.


Investigation

1- All are Ultrasonic features of Acute Appendicitis except?
A. A compressible blind ending tube.
B. Diameter of more than 7 mm.
C. Loss of submucosal echogenicity.

2- The best type of x-ray to locate free abdominal air is:
A. A posteroanterior view of the chest.
B. A flat and upright view of the abdomen.
C. Computed tomograph (CT) of the abdomen.
D. A lateral decubitus x-ray, right side up.

3. Regarding imaging in acute apendicitis:
A. US finding of a blind tubular structure 7 mm or more in diameter is characteristic.
B. On graded compression U/S the appendix is compressible.
C. Appendicolith seen on plain X-ray in 50 percent cases.
D. Localized ileus (on US) often seen in rif.
E. MR imaging is more accurate than US.

4- A primary appendiceal neoplasm underlying acute appendicitis would be suggested by which imaging finding?
A. A dilated appendix.
B. An appendiceal soft-tissue mass.
C. Inflammation surrounding the appendix.
D. Calcifications in the appendix.
E. Free air in the peritoneum.

5- What examination to different an acute appendicitis subhepatic with acute gallstone cholecystitis?
A. PFA
B. Abdominal sonography
C. Bilirubinemia
D. WBC counted
Answer: B

6- Which gynaecologic condition most commonly mimics appendicitis both clinically and on CT?
A. Uterine leiomyoma.
B. Endometriosis.
C. Hemorrhagic ovarian cyst.
D. Cervical carcinoma.
E. Adenomyosis.

7- Which CT finding helps differentiate acute appendicitis from Crohn’s disease?
A. Long-segment thickening of the terminal ileum.
B. Intraabdominal abscess formation.
C. Inflammatory stranding in right lower quadrant fat.
D. Enhancement of the cecal wall.
E. Free intraperitoneal air.

8- On CT of the abdomen in a woman with clinically suspected appendicitis, which diagnosis is suggested by a right lower quadrant lesion with a fat-fluid level?
A. Perforated peptic ulcer.
B. Ruptured ovarian dermoid.
C. Acute pancreatitis.
D. Ovarian torsion.
E. Ruptured ectopic pregnancy.

9- An enlarged appendix in the right lower quadrant of the abdomen can be simulated on CT by which condition?
A. Epiploic appendagitis.
B. Acute pyelonephritis.
C. Right-sided diverticulitis.
D. Pelvic inflammatory disease.
E. Mesenteric adenitis.

10- On CT of the pelvis in a postpartum woman, a dilated tubular structure extending caudad from the inferior vena cava into the pelvis most strongly suggests which diagnosis?
A. Pelvic inflammatory disease.
B. Ureteral obstruction.
C. Crohn's disease.
D. Typhlitis.
E. Ovarian vein thrombosis.

11- In a patient with suspected appendicitis, layered densities of fat and soft tissue inside the bowel lumen on CT of the abdomen suggest which diagnosis?
A. Intussusception.
B. Pseudomembranous colitis.
C. Appendix mucocele.
D. Cytomegalovirus colitis.
E. Meckel's diverticulum.

Differential diagnosis

1- Acute salpingitis occurs most often:
A. After menopause.
B. In patients with unilateral lower abdominal pain.
C. During the menstrual cycle.
D. In patients with cervical tenderness and vaginal discharge.

2- Most Common malignancy of appendix is?
A. Carcinoid Tumor.
B. Adenocarcinoma.
C. Squmaous Cell carcinoma.
D. Mixed Cellularity.

3- Which of the following statements about acute salpingitis are true?
A. The disease rarely occurs after menopause.
B. Gonococcal infection is most common.
C. There is minimal cervical tenderness to palpation.
D. Vaginal discharge occurs rarely.

4. Acute appendicitis in a young adult, free of other pathology, may be by:
A. Intestinal obstruction.
B. Intermittent dysphagia.
C. Peritonitis.
D. Vomiting.
E. Gram negative sepsis.

5. What examination to different an acute appendicitis subhepatic with acute gallstone cholecystitis?
A. PFA
B. Abdominal sonography
C. Bilirubinemia
D. WBC counted

6- What is not true as differentail diagnosis for appendicits in the elderly
A. Adenocarcinoma appendix
B. Diverticulitis
C. Pyelonephritis
D. Colitis

7- Regarding acute appendicitis
A. Mesocoeliac appendicitis can mimic an acute salpigitis.
B. Pelvic appendicitis can be revealed by urinary sign.
C. Rectal examination is always pain.
D. There is often polymorphonuclear neutrophil hyperleukocytosis.
Answer: BD

8. The diagnosis of acute appendicitis is most difficult to establish in:
A. Persons aged 60 and older.
B. Women aged 18 to 35.
C. Infants younger than 1 year.
D. Pregnant women.

9. Of adult patients presenting to the emergency room for evaluation of acute abdominal pain, which one of the following answers includes the most common diagnoses?
A. Urologic problems, cholelithiasis, pelvic inflammatory disease.
B. Mittelschmerz, appendicitis, ureterolithiasis.
C. Nonspecific abdominal pain, appendicitis, intestinal obstruction.
D. Appendicitis, pelvic inflammatory disease, perforated ulcer.

10- Which is the most likely explanation for right hydronephrosis and right hydroureter that occur in the setting of acute appendicitis with perforation and abscess formation?
A. Right ureteral obstruction caused by an intraluminal lesion.
B. Concurrent pyelonephritis involving the right kidney.
C. Underlying mucinous appendiceal tumor with direct engulfment of the ureter.
D. Extrinsic compression with periureteral inflammation.
E. Ureteral stone disease, because the incidence of appendicitis is significantly increased in the presence of renal stones.

11. You are prompted to do an emergency 25 year old woman who complained for several hours of lower abdominal pain. It was 38.5 degrees and she vomited twice. On examination, her stomach is flat without scarring: the pain is at maximum in the suprapubic region with a slight defense. On digital rectal examination, the cul-de-sac is painful on the right. What (s) diagnostic (s) can we talk?
A - Acute cholecystitis.
B - Acute Salpingitis right.
C - acute appendicitis.
D - Ulcerative Colitis.
E - Torsion of an ovarian cyst right.

12. Which of the following relating to the diagnosis of acute appendicitis, the statement (s) is (are) true (s):
A - Appendicitis mésocœliaque can simulate an acute salpingitis.
B - Pelvic Appendicitis can be revealed by urinary symptoms.
C - The defense of the right iliac fossa clinical signs is an essential.
D - Digital rectal examination is always painful.
E - There is often a leukocytosis with neutrophils in the blood count.

13- Which is the most likely explanation for right hydronephrosis and right hydroureter that occur in the setting of acute appendicitis with perforation and abscess formation?
A. Right ureteral obstruction caused by an intraluminal lesion.
B. Concurrent pyelonephritis involving the right kidney.
C. Underlying mucinous appendiceal tumor with direct engulfment of the ureter.
D. Extrinsic compression with periureteral inflammation.
E. Ureteral stone disease, because the incidence of appendicitis is significantly increased in the presence of renal stones.

14. True statements regarding appendiceal neoplasms include which of the following?
A. Carcinoid tumors of the appendix less than 1.5 cm are adequately treated by simple appendectomy.
B. Appendiceal carcinoma is associated with secondary tumors of the GI tract in up to 60% of patients.
C. Survival following right colectomy for a Dukes’ stage C appendiceal carcinoma is markedly better than that for a similarly staged colon cancer at 5 years.
D. Mucinous cystadenocarcinoma of the appendix is adequately treated by simple appendectomy, even in patients with rupture and mucinous ascites.
E. Up to 50% of patients with appendiceal carcinoma have metastatic disease, with the liver as the most common site of spread.


Complication

1- Quote the 3 late complications of acute appendicitis?
A. Adhesive intestinal obstruction.
B. Eventration.
C. Sterility.
D. Hemorrhage.
E. Faecal fistulae.

2- What are the 3 causes the most frequency of pain in RF in pregnancy women?
A. Acute appendicitis
B. Ectopic pregnancy
C. Right acute pyelonephritis
D. Adenopathy.
E. Twisting ovarian cyst

3- Acute appendicitis in pregnancy
A- Is very often fatal.
B- Is more common than in the non-pregnant state due to a reduction in cellular immunity.
C- Is easier to diagnose than in the non-pregnancy state.
D- Occurs with the same symptom and signs as in the non-pregnant woman.
E- Occurs, but the side of maximal tenderness is higher the later the condition occurs in pregnancy.

4. What is the mortality rate from acute appendicitis?
A. In the general population, it is 4/10.000.
B. After rupture, appendicitis is 4-5%.
C. For nonruptured appendicitis, it is 2%.
D. It is 80% if an abscess has formed.
E. It is increased in the past 40 years.

5- Which statement is true regarding recurrent appendicitis?
A. Less than 1% of patients who undergo appendectomy for appendicitis will have evidence of previous appendicitis.
B. CT findings of recurrent appendicitis are indistinguishable from those of acute appendicitis.
C. The recurrence rate after nonoperative percutaneous drainage for acute appendicitis is less than 5%.
D. Unrecognized malignancy is found in more than 5% of surgical specimens removed for appendicitis.
E. The recurrence rate after appendectomy is similar to the recurrence rate after nonoperative percutaneous drainage.

6. Appendicitis, without prejudice to its clinicopathological forms, operated by a Mac Burney incision, in a young adult free of any other disease, can be complicated:
A. A wound infection.
B. Evisceration
C. A hernia.
D. A cecal fistula.
E. A small bowel fistula.

7. Among the early complications (less than 6 days) that may follow an appendectomy, the name (s) is (are) true (s):
A - Occlusion flange.
B - Postoperative peritonitis.
C – Paralytic ileus.
D - Eventration on the scar.
E - Wound infection.

8- Most Common malignancy of appendix is?
A. Carcinoid Tumor
B. Adenocarcinoma
C. Squmaous Cell carcinoma
D. Mixed Cellularity

9- A 79-year-old man has hade abdominal pain for 4 days. An operation is performed, a gangrenous appendix is removed. The stump is inverted. Why does acute appendicitis in elderly patients and in children have a worse prognosis?
A. The appendix is retrocecal.
B. The appendix is perileal position.
C. The appendix is in the pelvic position.
D. The omentum and peritoneal cavity appear to be less efficient in localizing the disease of these age groups.
E. The appendix is longer in these age groups.

10. True statements regarding appendiceal neoplasms include which of the following?
A. Carcinoid tumors of the appendix less than 1.5 cm are adequately treated by simple appendectomy.
B. Appendiceal carcinoma is associated with secondary tumors of the GI tract in up to 60% of patients.
C. Survival following right colectomy for a Dukes’ stage C appendiceal carcinoma is markedly better than that for a similarly staged colon cancer at 5 years.
D. Mucinous cystadenocarcinoma of the appendix is adequately treated by simple appendectomy, even in patients with rupture and mucinous ascites.
E. Up to 50% of patients with appendiceal carcinoma have metastatic disease, with the liver as the most common site of spread.

11- A primary appendiceal neoplasm underlying acute appendicitis would be suggested by which imaging finding?
A. A dilated appendix.
B. An appendiceal soft-tissue mass.*
C. Inflammation surrounding the appendix.
D. Calcifications in the appendix.
E. Free air in the peritoneum.

12- Which statement is true regarding recurrent appendicitis?
A. Fewer than 1% of patients who undergo appendectomy for appendicitis will have evidence of previous appendicitis.
B. CT findings of recurrent appendicitis are indistinguishable from those of acute appendicitis.
C. The recurrence rate after nonoperative percutaneous drainage for acute appendicitis is less than 5%.
D. Unrecognized malignancy is found in more than 5% of surgical specimens removed for appendicitis.
E. The recurrence rate after appendectomy is similar to the recurrence rate after nonoperative percutaneous drainage.

13. What is the mortality rate from acute appendicitis?
A. In the general population, it is 4/10.000.
B. After rupture, appendicitis is 4-5%.*
C. For nonruptured appendicitis, it is 2%.
D. It is 80% if an abscess has formed.
E. It is increased in the past 40 years.

Treatment

1- What’s the treatment of acute appendicitis uncomplicated?
A. Surgical emergency.
B. Bacteriologic swab.
C. Appendicectomy.
D. Drainage.
E. Antibiotique, antalgique.

2- What’s the treatment of appendicitis complicated of abscess?
A. Surgical urgency.
B. Bacteriological sample.
C. Abscess drainage, AB, Antalgic.
D. Anatomopathological piece.
E. Appendicectomy at 2 month.

3- If a pregnant patient has an exploratory laparotomy for possible appendicitis and the appendix and other abdominal contents appear normal for the stage of gestation, what is the treatment of choice?
A- Close incision and observe.
B- Close incision and administer appropriate antibiotics and tocolytics,
C- Obtain peritoneal cytology and close incision.
D- Appendicectomy and incision closure.
E- Caesarean section if past 36 weeks gestation.

4- Once a diagnosis of acute appendicitis has been made and appendectomy decided upon, which of the following is/are true?
A. Prophylactic antibiotics should be administered.
B. Prophylactic antibitics are not necessary unless there is evidence of perforation.
C. If the appendix is not ruptured and not gangrenous, antibiotics may be discontinued after 24 hours.
D. Multiple antibiotics are in all cases preferable to a single agent.

5- Prospective studies have shown incidental appendectomy to be advantageous in which of the following patient groups?
A. Children undergoing staging laparotomy for malignancy who are then to enter chemotherapy.
B. HIV infected patients.
C. Patients over 50 years of age.
D. Patients with spinal cord injuries.
E. None of the above.

6. A patient is seen in the emergency room with reproducible right lower quadrant tenderness. The approximate incidence of finding a normal appendix on right lower quadrant exploration in similar nonselected patients is which of the following:
A. 5%.
B. 10%.
C. 20%.
D. 40%.

7. A 26-year old woman in her first trimester of pregnancy presents with a 2-day history of right lower quadrant pain and fever. Physical examination reveals a tender, palpable, right lower quadrant mass. There is no evidence of peritonitis or systemic sepsis. Laboratory evaluation is remarkable for mild leukocytosis, and abdominal ultrasound demonstrates an inflammatory mass but no evidence of abscess. As the surgeon on call, your recommendation would be:
A. Intravenous hydration, antibiotic prophylasis, and urgent appendectomy.
B. Intravenous hydration, antibiotics, bowel rest, and interval appendectomy in 4 to 6 weeks.
C. Intravenous hydration, antibiotics, and appendectomy if no improvement in 12 to 24 hours.
D. Intravenous hydration, antibiotics, and interval appendectomy when fever has subsided, leukocyte count has returned to normal, and the patient is pain free.
E. Emergent obstetrical consultation for evaluation and treatment of possible ectopic pregnancy.

8. Oschner sherren regime is used in the management of?
A. Appendicular mass.
B. Appendicular abscess.
C. Acute appendicitis.
D. Chronic appendicitis.

9- A 29-year- old woman presents to her physician’s office with pain in iliac fossa. Examination reveals tenderness in this region. Her last menstrual cycle was 2 weeks previously and finding on gynecologic examination and leukocyte count are normal. A provisional diagnosis of acute appendicitis is made. She should be informed that operations to treat this condition reveal acute appendicitis in what percentage of cases?
A. A small percentage of cases.
B. 50-89% of cases.
C. 90-99 % of cases.
D. More than 99% of cases.
E. No reliable statistics are avalaible.

10. Eight days after appendectomy, the patient complains of dysuria, urinary frequency, a slowing of transit which had resumed in the third postoperative day. We note the appearance of mucus rectal temperature is 38 ° 9C, count 20 000 counts GB/mm3 90% neutrophils. What you evoke diagnosis in the first place?
A - Abscess of the wall.
B - Cecal fistula.
C - Hemoperitoneum.
D - Douglas abscess.
E - Abscess meso-celiac.

11. Eight days after appendectomy, the patient complains of dysuria, urinary frequency, a slowing of transit who had taken the third postoperative day. We note the appearance of mucus rectal temperature is 38.9 ° C, counts 20,000 counts GB/mm3 90% neutrophils. What you evoke diagnosis in the first place?
A - Abscess wall.
B - Cecal fistula.
C - Hemoperitoneum.
D - Douglas abscess.
E - Abscess meso-celiac.


Case report: Appendicitis 1
A young 30 year old woman complains of dysuria, a pollakurie, a slowing of transit and abdominal tenderness, TR douloureux.On note a temperature at 39 ° C, NSF counts: 15000 GB/mm3 with 80% neutrophils

A1. What you evoke diagnosis first?
A- Cystitis.
B- Peptic ulcer.
C- Pelvic inflammatory disease.
D- Appendicular peritonitis.
E- Bowel volvulus.

A2. All the following clinical signs can be found in our patient except one which:
A- Stop materials and gases.
B- Vomiting early.
C- Cutaneous hyperesthesia.
D- Contracture generalized abdominal.
E- Audible bowel sounds.

A3. What is the therapeutic approach recommended:
A- Nasogastric tube, and surveillance.
B- Cleansing enema and surveillance.
C- Decompress the colon by a rectal probe.
D- Resuscitation and antibiotic therapy.
E- Electrolyte balance after laparotomy.


Acute appendicitis in pregnancy

1- Acute appendicitis in pregnancy
A- Is very often fatal.
B- Is more common than in the non-pregnant state due to a reduction in cellular immunity.
C- Is easier to diagnose than in the non-pregnancy state.
D- Occurs with the same symptom and signs as in the non-pregnant woman.
E- Occurs, but the side of maximal tenderness is higher the later the condition occurs in pregnancy.

2- If a pregnant patient has an exploratory laparotomy for possible appendicitis and the appendix and other abdominal contents appear normal for the stage of gestation, what is the treatment of choice?
A- Close incision and observe.
B- Close incision and administer appropriate antibiotics and tocolytics,
C- Obtain peritoneal cytology and close incision.
D- Appendicectomy and incision closure.
E- Caesarean section if past 36 weeks gestation.

3- Appendicitis in pregnancy is difficult to diagnose for all of the following reasons except
A- Anorexia, nausea and vomiting are common in pregnancy.
B- Due to uterine enlargement the site of the vermiform appendix is changed in pregnancy.
C- Leucocytosis is the rule in normal pregnancy.
D- There is immunological suppression in pregnancy, leading to the suppression of localising signs.
E- Other diseases during pregnancy are readily confused with appendicitis.

4- Appendicitis in pregnancy is difficult to diagnose for all of the following reasons except
A- Anorexia, nausea and vomiting are common in pregnancy.
B- Due to uterine enlargement the site of the vermiform appendix is changed in pregnancy.
C- Leucocytosis is the rule in normal pregnancy.
D- There is immunological suppression in pregnancy, leading to the suppression of localising signs.
E- Other diseases during pregnancy are readily confused with appendicitis.

5- What are the 3 causes the most frequency of pain in RF in pregnancy women?
A. Acute appendicitis
B. Ectopic pregnancy
B. Right acute pyelonephritis
D. Adenopathy.
E. Twisting ovarian cyst


Answers
Clinical
1- A
2- ACD
3- ABCD
4- D
5- D
6- ABCD
7- C
8- D
9- E
10- B
11- A
12. ABE
13- ABC
14- ABCDE
15. None or B
16- BD
17- BD
18- C
19- AE
20- D
21- D
22- C
23- D
24- C
25. A
26- D
27- A
28. ABCDE
29- C
30. All true
31. E
32- C
33. BD
34. BCD
35. ABCD
36. C
37. ACD
38. ABE
39- C
40. DE
41. D
42- C
43. ABCDE
44. ABE
45. C
46. BC
47. ABDE
48. ABCDE
49- All true: ABCDE
50- C
51. ABCD
52. ABD
53. ACE
54. ABCD
55. ABCDE
56. C
57. D

Etiology
1- E
2. A
3. AB
4- C
5. A
6. ABCDE

Investigation
1- ABC
2- D
3. ADE
4- B
5- B
6- C
7- A
8- B
9- D
10- E
11- A

Differential diagnosis
1- D
2- AB
3- AB
4. ACDE
5. B
6- A
7- BD
8. C
9. C
10- D
11. BCE
12. BCE
13- D
14. A

Complication
1- ABCE
2- ABCE
3- E
4. B
5- B
6. ABCD
7. BCDE
8- AB
9- D
10. A
11- B
12- B
13. B

Treatment
1- ABCE
2- ACE
3- C
4- AC
5- E
6. C
7. A
8. A.
9- C
10. D
11. D

Case report: Appendicitis 1
A1. D
A2. E
A3. E

Acute appendicitis in pregnancy

1- E
2- D
3- E
4- D
5- ABCE

Poème : Le dicton Cambodgien de la Connaissance

Oh! Tous les peuples, toutes les connaissances
Possède d’une gratitude, la vertu, et sage immenses.
Il faut les prendre tout le temps.
Ils ne sont pas lourds et sont légers.
Ils ne sont pas difficiles à garder et facile à cacher.
N’est pas comme l’or, l’argent et les trésors.
Les brigands, le voleur ne peuvent pas les voler.
Ils nous donnent des aliments dans le différent secteur.
Les termites, les cafards ne pouvaient pas grignoter et ronger
Les souris ne peuvent couper et trancher.
Nous les dépensons, mais ils ne perdrent pas.
En vérité, nous les dépensons tellement
Ils augmentent tellement trop
A partir de maintenant à la vie future et à la vie antérieure.

Why Japanese Udon Noodles named like this? And why Pampkin in Japan named Kabocha?

Why Japanese Udon Noodles named like this? And why Pampkin in Japan named Kabocha?

Why the Japanese forget Udon Noodles, Pampkin or Kabocha?

Udong was the seat of Cambodian kings from 1618 to 1866.
Phnom Udong, “Hill of the Victorious” from phnom “hill”. It was the capital between 1618 and 1866.
Udong is the former capital of Cambodia. The name Udong, often also spelled "Oudong", means "victorious". It was the former capital of Cambodia from 1618 to 1866, after the Khmers shifted from Angkor, and before the capital moved again, to Phnom Penh. It is a place that the Thais have plundered, the Americans have bombed and then finally the Khmer Rouge has blown up.
Japanese Udon Noodles
Udon are white and the thickest noodles Udon noodles are made by kneading wheat flour, salt, and water. Udon can be eaten hot or cold and can be cooked in many ways. You might have seen udon noodles in hot soup. Cold udon noodles are also popular in summer. Cold udon noodles are eaten by dipping into dipping sauce.
Khmer noodle (Num BonhChok)
Num Bonhchok - Rice vermicelli noodles with raw vegetables. There are two different soups that can accompany this dish, a green or red soup. The green soup is made of ground fish, lemon grass, and kroeung (Samlor Khmer). Prahok is used with a green soup. The red soup is made from tenderized chicken and a simple coconut curry (Samlor Kari).
Num BonhChok from Kampot province is different from Num BonhChok from other parts of Cambodia. Kampot inhabitants use distinctive ingredients to the thick noodle. Those are: tiny saltwater shrimp, bean sprout, coconut cream, peanut and fish sauce.

Pumpkin
It is generally believed that all squash originated in Mesoamerica, but may have been independently cultivated elsewhere, albeit later. The kabocha, however, was introduced to Japan by Portuguese sailors in 1541, which brought it with them from Cambodia. The Portuguese name for the pumpkin, Cambodia abóbora (カンボジャ・アボボラ), was shortened by the Japanese to kabocha. Certain regions of Japan use an alternate abbreviation, shortening the second half of the name instead to "bobora". Another name for kabocha is 南瓜 or 南京瓜 (Nanking melon), which suggest that the vegetable arrived in Japan by way of China (1).
In Cambodia, people plant pumpkin nearly everywhere. As one of the most popular crops in Cambodia, pumpkins are very versatile in their uses for cooking, from the fleshy shell, to the seeds, to even the flowers; most parts of the pumpkin are edible. The leaves, the male flowers of the pumpkin plant are consumed as a cooked vegetable or in soups (Samlor Korko, Samloor Proheu). The small pumpkins are steamed with custard inside and served as a dessert. Cambodia people made a little shredded of pumpkin flesh mixed with rice flour and wrapped with banana leave, are steamed and used as a cake. Pumpkin seeds, also known as pepitas, are small, flat, green, edible seeds.

When the delegation of Kingdom of Cambodia at Sangkum Reas Niyum in decade 1960s visited the Japan, they always prepared food from pumpkin and noodles for Cambodian delegates. The government personal of Japan said in front of delegation of Kingdom of Cambodia like this “We prepare the noodles and pumpkin for food for you because the Japanese brought them from Cambodia at the time of Udong, so the noodle the Japanese called Japanese Udon Noodles and the pumpkin named Kabocha from the word Kampuchea” (2).

References:
1. Wikipedia, the free encyclopedia.
2. Kampuchea journal at decade 1960.

LES FISTULES RECTO-VAGINALES RECTOVAGINAL FISTULAE

LES FISTULES RECTO-VAGINALES
RECTOVAGINAL FISTULAE
KOU KIM HEAK
Département de Chirurgie Viscérale, Digestive et Thoracique
Hopital Preah Kossamak

Résumé
Les FRV sont le plus souvent dues à une complication de la chirurgie proctologique et obstétrique. Trois types anatomiques sont distingués: FRV proprement dite, fistule ano-vaginale, fistule ano-périnéale. Il existe de nombreux procédés chirurgicaux pour traiter ces FRV. Trois procédés sont employés: abord transanal (Laird), transvaginal ou périnéal (Musset). Le traitement préventif repose sur la réalisation de délivrances vaginales moins traumatisantes, la réparation soigneuse des épisiotomies et une chirurgie proctologique rigoureuse. La réussite de l’intervention repose sur les bonnes expositions et dissection de la fistule, une suture sans tension de tissus bien vascularisés.

Abstract:
RVF are usually due to a complication of obstetrics and proctology surgery. Three anatomical types are distinguished: RVF itself, ano-vaginal fistula,and ano-perineal fistula. Numerous methods for the treatment of RVF have been described. Three methods are used: transanal (Laird), transvaginal or perineal (Musset). Preventive treatment is based on achieving less traumatic vaginal delivery, episiotomy repair careful and thorough proctology surgery. The success of the intervention is based on good shows and dissection of the fistula, a tension-free suture well vascularized tissue.

Introduction:
La fistule recto-vaginale (FRV) se définit comme une communication anormale s'établissant entre rectum et vagin au travers de la cloison recto-vaginale. Elle a pour conséquence l'issue du contenu rectal, gaz et/ou selles, dans le vagin et à la vulve [1]. La cloison recto-vaginale est une zone de faiblesse, aux structures conjonctives peu denses et souvent fragilisées par les traumatismes obstétricaux antérieurs et la ménopause [2].
Les fistules recto -vaginales (FRV) sont rares (5 % des fistules ano-rectales). Survenant au décours d'un accouchement ou à l'occasion d'une pathologie proctologique, elles créent un profond désarroi chez les patientes. Cette complication retarde en effet la reprise de la vie professionnelle, sociale et sexuelle, et nécessite souvent un traitement prolongé [3].

Observation:
Trois patientes que l’on a été admis dans le service de chirurgie digestive de l’hôpital Preah Kossamac.
1- Mme SV, femme Cambodgienne a consulté pour une plaie fistule recto- vaginale à la suite d’un traitement traditionnel d’une hémorroïde. Elle a hésité de récidive après l’opération dont elle a refusé l’opération.

2- Une vieille femme de 57 ans, a consulté le 12/11/2005 pour une plaie de déchirure ano- vaginale par séquelle d’un coup de lame à lame à raser sur l’hémorrhoïde traité par un guérisseur traditionnel. Malheureusement, la biopsie a montré qu’un carcinome et la malade a été refusée de l’AAP.

3- Mme ST provenant de Battambang, a présenté d’une double fistule ano-vaginale d’origine obstétricale. La patiente a été examinée en position gynécologique. L’index a été introduit dans le trajet fistuleux dont on a évalué les caractéristiques (doubles fistules ano-vaginales). Il est ici cliniquement manifestait qu'il existait une rupture sphinctérienne antérieure associée à la FRV. On a été faite la cure de fistule recto - vaginale selon la technique de Musset. Les suites opératoires étaient simples et la malade a sorti de l’hôpital le 7e jours postopératoire.

Discussion :
Certaines séries réduites et sporadiques font mention de succès avec l'emploi de procédés non chirurgicaux divers: colle biologique, cautérisation [4], voire drainage prolongé. Il existe de nombreux procédés chirurgicaux pour traiter ces FRV. Trois procédés sont employés: abord transanal (Laird), transvaginal ou périnéal (Musset). Pour la majorité des auteurs, la préparation colique avec nutrition parentérale est préférable à la colostomie de protection pour la réparation initiale de ce type de FRV. Le traitement préventif repose sur la réalisation de délivrances vaginales moins traumatisantes, la réparation soigneuse des épisiotomies et une chirurgie proctologique rigoureuse.

Cure de fistule recto-vaginale selon la technique de Musset [5]
La technique décrite par René Musset s'adresse aux fistules recto-vaginales de la moitié inférieure du vagin, qu'elles soient sus- ou trans-sphinctériennes. Classiquement réalisée en deux temps, elle peut, chez certaines patientes sélectionnées, être réalisée en un temps et sans colostomie.
Soins préopératoires
La préparation colique est impérative. Ainsi une irrigation colique complète 72 heures avant l'opération suivie d'un régime sans résidu strict, associée à une antibiothérapie prophylactique systématique. La vulve et le vagin sont également soigneusement préparés par un badigeonnage à la polyvidone iodée et une irrigation vaginale abondante.

Technique opératoire
Les différents temps opératoires, au nombre de 7, sont bien standardisés.
- Premier temps: périnéotomie médiane et mise à plat du trajet fistuleux
- Deuxième temps: exposition des lésions
- Troisième temps: reconstitution de la paroi recto-anale antérieure
- Quatrième temps: réfection sphinctérienne
- Cinquième temps : myorraphie des releveurs
- Sixième temps : colporraphie postérieure et fin de la myorraphie périnéale
- Septième temps : suture cutanée du corps périnéal

Soins postopératoires
Les soins postopératoires sont importants et la coopération de la patiente est nécessaire. Par confort, une sonde vésicale est maintenue pendant 3-4 jours. Une nutrition parentérale exclusive pour 8 jours. La toilette périnéale est faite matin et soir (irrigation à la polyvidone iodée) et le périnée soigneusement séché, au besoin avec un séchoir. Un premier toucher rectal est effectué à 48 heures par l'opérateur et il sera répété tous les jours ou tous les deux jours. Avant la sortie, on effectue un examen soigneux du périnée avec éventuellement ablation de fils. La patiente est revue chaque semaine jusqu'à cicatrisation complète.
Dans le travail de Kouadio et al. le traitement a consisté en majorité en une réparation périnéale en un temps dans 25 cas et en une technique de Musset modifiée par la confection d'une colostomie iliaque gauche temporaire dans 11 cas. Les résultats étaient de 73,38 % de succès en première intention et de 86,47 % de succès global [6].

La technique du lambeau muqueux rectal [7]
ou Lambeau rectal d’avancement [8]

La technique du lambeau muqueux a été décrite en 1948 aux États-Unis par Laird. Elle consiste à décaler la fermeture de la muqueuse et de la musculeuse rectale. La pression rectale applique de la muqueuse saine sur la suture de la musculeuse [7].
Le traitement des fistules anales dépend de nombreuses paramètres:
- du siège de l’orifice primaire (par rapport à la ligne pectinée);
- de la taille de l’orifice primaire (ponctiforme ou véritable ulcère creusant);
- de la hauteur du trajet fistuleux (par rapport au sphincter anal); - de l’état du rectum (sain, radique, inflammatoire...);
- du degré de suppuration (suppuration aigue, chronique ou absente);
- du degré de sclérose de l’atmosphère périanale (absente, modérée ou intense); - du degré de continence.
Les indications les plus habituelles du lambeau rectal d’avancement sont donc les fistules de la maladie de Crohn anorectale, les fistules iatrogènes et certaines fistules radiques [8].

Technique
L'intervention est réalisée en décubitus ventral, jambes écartées. Elle est facilitée par l'utilisation de l'écarteur anal à trois branches de Parks.
Elle consiste à disséquer un lambeau de muqueuse rectale en forme de U, préservant un apport vasculaire supérieur (Fig.1). L'extrémité distale du lambeau muqueux comportant l'orifice fistuleux est réséquée (Fig. 2). Les vaisseaux se situant dans la sous muqueuse, c'est un lambeau de muqueuse et de sous muqueuse qui est réalisé. Certains auteurs pour être plus sûrs de préserver la vascularisation, ajoutent quelques fibres musculaires [9] ou même la couche circulaire interne. Le trajet de la fistule est excisé. La musculeuse rectale est fermée alors que la paroi vaginale est laissée ouverte. Le lambeau muqueux est rabattu, puis suturé (Fig. 3). Auparavant, la musculeuse rectale peut être plicaturée de haut en bas. Une colostomie de protection n'est pas nécessaire. Le fait d'exciser le trajet et de laisser ouvert l'orifice vaginal, permettant l'évacuation d'éventuelles collections, est essentiel.
Ainsi, la technique du lambeau muqueux est simple et peu délabrante. Elle est effectuée par voie endo-anale. Elle respecte l'appareil sphinctérien, à l'inverse de la technique de Musset. Elle se fait en un seul temps et ne nécessite qu'une hospitalisation brève.
L'indication de cette technique est limitée aux fistules de diamètre inférieur à 2,5 cm, et respectant l'appareil sphinctérien. Si elle concerne une maladie de Crohn, l'intervention doit être faite en phase de rémission [7].


Lambeaux d'avancement transanal : le succès pour les fistules hautes est rapporté entre 50 et 80 % avec un taux de récidive élevé (50 %) après deux ans [10].

Conclusion
Les FRV sont les plus souvent dues à une complication de la chirurgie proctologique et obstétrique. La compréhension des principes nécessaires pour une bonne réparation de ces fistules et l’amélioration des techniques chirurgicales permet en règle générale un bon résultat. Le choix de la technique dépend de l’expérience du chirurgien et de l’évaluation précise des lésions. La réussite de l’intervention repose sur les bonnes expositions et dissection de la fistule, une suture sans tension de tissus bien vascularisés en plusieurs plans. L’interposition de lambeaux pour les fistules larges, complexes ou sur les tissus irradiés augmente le taux de succès.

Références :
1. Paul-Antoine LEHUR et al. Cliniques chirurgicales II du pôle digestif, CHU Nantes, 44093 Nantes Cedex. Hépato-Gastro. Vol. 7, n° 2, mars-avril 2000: 128-30
2. Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 1993;36 : 976-83.
3. Patrick ATIENZA Proctologie médico-chirurgicale, hôpital de Diaconesses, 18, rue du Sergent-Bauchat, 75571 Paris Cedex 12. Hépato - Gastro. Vol. 7, n° 2, mars-avril 2000: 135-6
4. Shafit A. Non-surgical repair of rectovaginal fistulae. Eur J Obstet Gynecol Reprob Biol 1996 ; 67:17-20.
5. Richard VILLET. Chirurgie viscérale et gynécologique, hôpital des Diaconesses, 18, rue du Sergent-Bauchat, 75571 Paris Cedex 12. Hépato - Gastro. Vol. 7, n° 2, mars-avril 2000: 130-2
6..GK KOUADIO, G. DOUMBIA, HT TURQUIN. Prise en charge des fistules recto-vaginales de l'adulte en milieu ivoirien. Médecine d'Afrique Noire Tome 51 - n°8/9 - Août/Septembre 2004 - pages 464-466.
7. Frank LAZORTHES et al. Les fistules recto-vaginales. Service de chirurgie digestive, hôpital Purpan, place du Docteur-Baylac, 31059 Toulouse Cedex. Hépato - Gastro. Vol. 7, n° 2, mars-avril 2000: 133-4.
8. J.-L. FAUCHERON, O. RISSE. Le lambeau rectal d’avancement. Service de Chirurgie Générale et Digestive, hôpital Albert Michallon-Grenoble. J Chir 2001 ; 138 :157-161.
9. Homsi R et al. Episiotomy: risks of dehiscence and rectovaginal fistula. Obstet Gynecol Surv. 1994; 49: 803-8.
10. JF. Contou Service d'Hépatogastroentérologie Hôpital Saint-Louis – Paris. Les fistules crohniennes ano-périnéales. Journée de Gastroentérologie EPU Paris VII - Paris - 05 janvier 2001.