AIIMS MAY 2013 : SALIVARY GLAND TUMOR : HOT SPOT

Q ] Which of the follwing show ” HOT SPOT ” in technitium scan ……

[a] Adenolymphoma

[b] Mucoepidermoid carcinoma

[c] Acinic cell tumor

[d] Adenoid cystic carcinma

NOTE : SOME IMPORTANT POINTS ABOUT SALIVARY GLAND TUMORS

[1] Most common tumor of salivary gland = PLEOMORPHIC ADENOMA [AIIMS 1998 , AI 2002]

[2] Most common benign tumor of salivary gland =PLEOMORPHIC ADENOMA

[3] Most common benign tumor of parotid gland = PLEOMORPHIC ADENOMA

[4] Most common malignant tumor of parotid gland = MUCOEPIDERMOID CARCINOMA

[5] Most common benign tumor of parotid gland in children = HEMANGIOMA [2nd MC = PLEOMORPHIC ADENOMA]

[6] Most common malignant tumor of salivary gland in adult/ child/ overall = MUCOEPIDERMOID CARCINOMA

[7] Most common radiation induced neoplasm in salivary gland = MUCOEPIDERMOID CARCINOMA

[8] Most common malignant tumor of small salivay gland = ADENOID CYSTIC CARCINOMA ( CYLINDROMA )

[9] Only salivary gland tumor which show ” HOT SPOT ” on tecnitium scan = WARTHINS TUMOR = ADENOLYMPHOMA = PAPILLARY CYSTADENOMA LYMPHOMATOSUM

[10] SUPERFICIAL PAROTIDECTOMY = (is also known as) = PATEYS OPERATION

[11] Tumor which almost exclusively occurs in Parotid = ACINIC CELL ADENOCARCINOMA [AI 2006]

[12] Most common site of pleomorphic adenoma = PAROTID GLAND [AI 2006]

[13] Head & neck tumor in which perineural invasion is most commonly seen = ADENOID CYSTIC CARCINOMA [AI 2005]

[14] WARTHINS = ADENOLYMPHOMA [AIIMS 2003 , 2005]

[15] TREATMENT OF CHOICE FOR

[A] PLEOMORPHIC ADENOMA = SUPERFICIAL PAROTIDECTOMY( PATEYS OPERATION) [AIIMS 98, 2001, AI 97 ,PGI 99]

[B] WARTHINS = SUPERFICIAL PAROTIDECTOMY [ AIIMS 2001 , AI 98]

[C] ADENOID CYSTIC = RADICAL PAROTIDECTOMY

[D] MUCOEPIDERMOID LOW GRADE = SUPERFICIAL /TOTAL PAROTIDECTOMY

[E] MUCOEPIDERMOID HIGH GRADE = RADICAL PAROTIDECTOMY

[16] Most common site of minory salivary gland tumor = oral cavity = HARD PALATE

SO ANS = [A]

Ref: CSDT PAGE 293 / 11 ed

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LIVER ANATOMY 10 Q

Q1 ]The COUINAD’S SEGMENTAL NOMENCLATURE is based on position of …[AI 2004]
  • Hepatic veins & Portal veins
  • Hepatic vein & biliary ducts
  • Portal vein & Biliary ducts
  • Portal vein & Hepatic artery
 Q2] A surgeon excises a portion of liver to the left of the attachment of falciform ligament .The segments that have been resected are…[AI 2008]
  • Segment I & IVa
  • Segment I & IVB
  • Segment II & III
  • Segment I & II

 Q3] Right hepatic vein drains all except…[AIIMS MAY 2009]
  • Segment V
  • Segment III
  • Segment VI
  • Segment VII

 Q4] The right lobe of liver consists of ..[AIIMS 2004]
  • V , VI , VII , VIII Segments
  • IV , V , VI , VII , VIII Segments
  • I , II, V , VI , VII
  • III , IV , V, VI

 Q5] Aprroximately what % of total blood supply comes from hepatic artery….

  • < 10%
  • 25%
  • 50%
  • 75%

 Q6] False about Hepatic Duct… [ AIIMS MAY 2009]

  • Left hepatic duct formed in umblical fissure
  • Caudate lobe is drained only by left hepatic duct
  • Right anterior hepatic duct formed by V & VIII Segments
  • Left hepatic duct crosses IV segment

Q7] Most common variant of normal anatomy of hepatic artery….

  • division into right and left hepatic artery after giving off gastroduodenal artery
  • division into right and left hepatic artery before giving off gastroduodenal artery
  • replaced right hepatic artery ie origin of right hepatic artery from superior mesentric artery
  • replaced left hepatic artery ie origin of right hepatic artery from superior mesentric artery

Q8 ] which of the following is arranged in correct order of % of total cardiac output received…
  • kidney > liver > skeltal muscle > brain
  • liver > kidney > skeltal muscle > brain
  • skeltal muscle > brain > kidney > liver
  • liver > skeltal muscle > brain > kidney

Q9] True about common bile duct all except…[AI 2000]

  • Opens 10 cm distal to pylorus
  • lies anterior to IVC
  • Portal vein lies posterior to it
  • usually opens into duodenum separate from the main pancreatic duct

Q 10] which of following is false ….
  • Right anterior hepatic duct is formed from segments V & VIII
  • Right posterior hepatic duct is formed from segments V & VIII
  • left anterior hepatic duct drains segment III , IV
  • left posterior hepatic duct drains segment II

ALTERNATIVELY U CAN ANSWER THESE Q IN QUIZZ FORMAT BY CHOOSING OPTIONS AT FOLLOWING LINK http://pguploads.polldaddy.com/s/liver-anatomy-10-q

Answers (Highlighted and star marked )

Q.1 The COUINAD’S SEGMENTAL NOMENCLATURE is based on position of …[AI 2004]
****Hepatic veins & Portal veins
Hepatic vein & biliary ducts
Portal vein & Biliary ducts
Portal vein & Hepatic artery
Q.2 A surgeon excises a portion of liver to the left of the attachment of falciform ligament .The segments that have been resected are…[AI 2008]
Segment I & IVa
Segment I & IVB
***Segment II & III
Segment I & II
Q.3 Right hepatic vein drains all except…[AIIMS MAY 2009]
Segment V
***Segment III
Segment VI
Segment VII
Q.4 The right lobe of liver consists of ..[AIIMS 2004]
***V , VI , VII , VIII Segments
IV , V , VI , VII , VIII Segments
I , II, V , VI , VII
III , IV , V, VI
Q.5 Aprroximately what % of total blood supply comes from hepatic artery….
< 10%
***25%
50%
75%
Q.6 False about Hepatic Duct… [ AIIMS MAY 2009]
Left hepatic duct formed in umblical fissure
***Caudate lobe is drained only by left hepatic duct
Right anterior hepatic duct formed by V & VIII Segments
Left hepatic duct crosses IV segment
Q.7 Most common variant of normal anatomy of hepatic artery….
Division into right and left hepatic artery after giving off gastroduodenal artery
Division into right and left hepatic artery before giving off gastroduodenal artery
***Replaced right hepatic artery ie origin of right hepatic artery from superior mesentric artery
Replaced left hepatic artery ie origin of right hepatic artery from superior mesentric artery
Q.8 whic of the following is arranged in correct order of % of total cardiac output received…
kidney > liver > skeltal muscle > brain
***liver > kidney > skeltal muscle > brain
skeltal muscle > brain > kidney > liver
liver > skeltal muscle > brain > kidney
Q.9 True about common bile duct all except…[AI 2000]
Opens 10 cm distal to pylorus
Lies anterior to IVC
Portal vein lies posterior to it
***Usually opens into duodenum separate from the main pancreatic duct
Q.10 which of following is false ….
Right anterior hepatic duct is formed from segments V & VIII
****Right posterior hepatic duct is formed from segments V & VIII
Left anterior hepatic duct drains segment III , IV
Left posterior hepatic duct drains segment II

ESOPHAGUS PART 2 : ACHALASIA TREATMENT AND OTHER MOTILITY DISORDERS

Q1] HELLERS OPERATION IS DONE FOR …[AIIMS NOV 93]

A] Achalasia cardia

B] Pyloric stenosis

C] Peptic ulcer

D] Ca Esophagus

ans =[a]

Q2] A young female presents with dysphagia for the past 2 years. she also complains of intermittent chest pain . Barium shallow shows dialation of esophagus with narrowing of the distal esophagus. the treatment of choice is ..[AIIMS MAY 2012]

A] Hellers cardiomyotomy

B] Esophagectomy

C] Coronary angiography

D] Proton pump inhibitor

ANS = [A] Hellers cardiomyotomy as the description fits the diagonosis of achalasia cardia [ see part 1 of this topic for diagonostic flochart] .Treatment of choice is laproscopic cardiomyotomy ( heller myotomy) { ref schwartz 9th ed page 859} .See the figure provided below

Image

so TOC of ACHALLASIA IS = HELLAR MYOTOMY [ SCHWARTZ 9ed page 859]

a/c to medscape = hellar myotomy + partial fundoplication is appropriate treatment[ as it decresses chances of reflux also ]

Q3] DIFFUSE ESOPHAGEAL SPASM IS BEST DIAGONOSED BY [AI 2008]

ANS = MANOMETRY [ see the figure provided below to understand manometric criterias for diagonosis of DES]

Q4] CORKSCREW ESOPHAGUS IS SEEN IN WHICH OF FOLLOWING CONDITIONS[ AI 2002]..

ANS = DIFFUSE ESOPHAGEAL SPASM [ see fig below]

Image

NOW LETS UNDERSTAND DIFFERENCE BETWEEN CORKSCREW AND NUTCRACKER ESOPHAGUS:

In nutcracker peristaltic sequence is normal and peristaltic amplitude and duration is increased in distal esophageal body[ see the figure below]

Image

Q5] MOST APPROPRIATE INITIAL TREATMENT OF NUTCRACKER ESOPHAGUS IS …

A] PPI

B] Calcium channel blocker

C] Nitroglycerin

D] Dialation

ans = [a] PPI . Treatment should be aimed at GERD as it is unclear that chest pain in nutcracker eso is due to acid reflux or intraluminal hypertension [ schwartz 9ed page852]

NOTE : ? IS HYPERTENSIVE LES ; Elevated LES pressure more than or equal to 26 mmHg with normal peristalsis in eso body and normal LES relaxation.

ESOPHAGUS : PART 1 ( LES , DYSPHAGIA AND ACHALASIA)

LOWER ESOPHAGEAL SPHINCTER = LES

The tone of LES is under neural control. Vagal endings by releasing acetylcholine cause contraction of LES and the vagal nerve endings on interneurons release NO and VIP which cause relaxation of LES. NOTE: in achalasia myenteric plexus is deficient at LES so release of NO and VIP is defective.

Q1] For normal functioning of LES all of the followig factors are important except….

a] length of intrabdominal esophagus

b] total length of LES

c] Width of diaphragmatic hiatus

d] resting tone in LES

ANS =[C] Width of diaphragmatic hiatus is not important ( see figure below)

Image

Image

Q2] Which of manometric finding is indicative of incompetent LES..?

A] resting LES tone< 25 mm hg

B] Total LES length < 2 cm

C] Intra-abdominal  length of LES < 3cm

D] Average LES pressure < 20 mm Hg

ANS =[B] TOTAL LES LENGTH < 2CM IS INDICATIVE OF INCOMPETENT LES

NOTE 1. Alpha adrenergic agents or Beta blockers , gastrin , motilin , bombesin , enkephalin and substance P   INCREASE LES tone.

NOTE 2. Cholecystokinin , estrogen , progesterone , glucagon , secretin and somatostatin DECREASE LES tone.

NOW LET US UNDERSTAND NORMAL MANOMETRY : Probes are applied at different locations within esophagus to record pressure hanges . Normally peristaltic wave travel down the esophagus and when the food bolus reaches LES then LES relaxes and allows the food to enter stomach. See the indicative manometric curve in figure below:

Image

Q] NON PROGRESSIVE CONTRACTION  OF ESOPHAGUS ARE… [AI 2009]

A] PRIMARY [B] SECONDARY  [C] TERTIARY  [D] QUATERNARY

ANS = [C] TERTIARY (see figure below)

Image

NOW LETS LEARN DIFFERENT CAUSES OF DYSPHAGIA THROUGH FLOW CHARTS:

Image

Image

Q3] INTERMITTENT DYSPHAGIA IS CAUSED BY …[PGI JUNE 2004]

A] Stricture

B] Achalasia cardia

C] Pharyngeal diverticulum

D] Diffuse esophageal spasm

ANS = [C] and [D] SEE FIGURE ABOVE

CAUSES OF INTERMITTENT DYSPHAGIA [A] Diffuse esophageal spasm [B] Zenkers diverticulum [C] Lower esophageal ring / schzatki ring.

Q4] Investigation of choice of dysphagia to solids only is .[PGI DEC 03 JUNE 00]

ANS = AS DYSPHAGIA TO SOLID signifies MECHANICAL OBSTRUCTION so investigation of choice in this case is = endoscopy.

NOTE: Barium is better for evaluation of motility disorder and zenkers diverticulum as compared to endoscopic evaluation. In case of motility disorders the diagonosis is confirmed by manometry so Investigation of choice is MANOMETRY.

ACHALASIA:

Q5] The initial pathological change that leads to clinical findings of achalasia is..

a] Increased reting LES tone

b] aperistalsis of esophageal body

c] hypertension of body of esophagus

d] failure of LES relaxation

ANS = [A] HYPERTENSIVE LES/ INCREASED LES RESTING TONE is primary pathology in ACHALASIA . it is bcoz of dysfunction of inhibitory neurons releasing NO and VIP so that acetylcholine releasing  excitatory vagal fibres take upper  hand.( see the figure below)

Image

Q6] IN ACHALASIA TRUE IS … [PGI JUNE 2000]

a] pressure at distal end increased with no peristalsis

b] low pressure at LES with no peristalsis

c] pressure > 50 mm Hg with peristalsis

d] pressure at distal end increased with normal relaxation

ANS = [A] PRESSURE AT DISTAL END INCREASED WITH NO PERISTALSIS.

NOTE : CHAGAS DISEASE = AMERICAN TRYPANOSOMIASIS IS CAUSED BY Trypanosoma cruzi and transmitted among mammalian hosts by hematophagus reduvid bugs. Symptomatic chronic disease = CARDIAC DISEASE { arrythmia (Mostly Right Bundle Branch Block) , dialated cardiomyopathy , throembolism} + MEGAESOPHAGUS( So chagas disease can lead to achalasia) + MEGACOLON.

NEXT : ESOPHAGUS  PART 2 ( ACHALASIA TREATMENT AND OTHER MOTILITY DISORDERS OF ESOPHAGUS)

References [1] ganong review of medical physiology 23ed pg 471

[2] schwartz `s principles of surgery  9ed page 812, 816 , 828, 851

[3] current diagonosis and treatment in gastroenterology 2nd ed page 288

[4] harrison 17 ed 1300 ,1847

LUMBAR TRIANGLE AND LUMBAR HERNIA

Q1] Which of the following statements is not true about lumbar hernia….

[a] Lumbar hernia is congenital in 20% cases and congenital lumbar hernia are usually bilateral.

[b] Herniation is more common through superior lumber triangle and more commonly occurs in left side as compared to right.

[c] Lumbar hernia tend to increase in size and should be repaired whenever found.

[d] Howship -Romberg sign is positive in lumbar hernias.

[e] In erect posture presence of reducible and often tympanitic mass in flank usually makes the diagonosis.

ANS [D] Howship -romberg sign : pain abdomen extends down the medial aspect of thigh with abduction, extension or internal rotation of thigh. This is most specific clinical finding of a OBTURATOR HERNIA

SEE THE FIGURE BELOW

Image

Ref CSDT pg no 794 / 11 ed.