Alimentary tract questions and answers for surgical residents.

Alimentary

1. A 65-year-old woman undergoes a routine laparoscopic cholecystectomy for acute cholecystitis . She is discharged on postoperative day 1. Pathology shows she has gallbladder adenocarcinoma limited to the mucosa. Margins are negative for tumor. Which treatment course do you recommend to the patient? A. Reoperation with hepatic wedge resection of segments IVb and V B. Reoperation with hepatic wedge resection of segments IVb and V and lymphadenectomy C. Reoperation with hepatic wedge resection of segments IVb and V, lymphadenectomy, and chemotherapy D. Chemotherapy E. Observation

2. A 52-year-old woman undergoes an uneventful laparoscopic cholecystectomy for symptomatic cholelithiasis . The pathology report demonstrates chronic cholecystitis , cholesterolosis , and type III biliary intraepithelial neoplasm ( BilIN ) at the cystic duct margin. BilIN is associated with which of the following? A. Papillary carcinoma of the duodenum B. Cholangiocarcinoma C. Cholecystitis D. Intraductal papillary neoplasm of the bile duct E. Cholesterolosis

3. An otherwise healthy 55-year-old man underwent a successful R0 Whipple operation for a pancreatic adenocarcinoma. What adjuvant therapy is optimal? A. Gemcitabine plus fluorouracil B. 5-fluorouracil, oxaliplatin , and irinotecan C. Radiation alone D. Oxaliplatin alone E. Irinotecan plus cisplatin

4. A 60-year-old woman with a long-standing history of gastroesophageal reflux presents with weight loss and no other symptoms. CT scans shows a large gastric mass with adenopathy but no liver or distant metastases. Endoscopy and gastric biopsies reveal adenocarcinoma. The patient is taken to the operating room where laparoscopy reveals peritoneal carcinomatosis . To offer the patient the highest chance of overall survival, the surgeon should A. administer postoperative hyperthermic intraperitoneal chemotherapy. B. perform gastrectomy. C. treat with systemic chemotherapy. D. perform gastrectomy followed by chemotherapy. E. treat with radiation.

5. Anti-Programmed Cell Death Receptor-1 (PD-1) therapy A. is effective against microsatellite stable colon cancers B. is given orally. C. requires a specific tumor mutation D. should be discontinued if there is progression on CT scan after 1 cycle. E. is associated with autoimmune side effects.

6. A 67-year-old man presents with burning epigastric pain. Endoscopy reveals erythema, nodularity, and thickening of his distal gastric mucosa. Biopsy reveals mucosa-associated lymphatic tissue (MALT) lymphoma. CT scan suggests the tumor is limited to the antrum. What is the next step in the treatment of this tumor? A. Helicobacter pylori treatment B. Abdominal radiation C. Radiation with rituximab D. Antrectomy E. Subtotal gastrectomy

7. A 67-year-old man presents with burning epigastric pain. Endoscopy reveals erythema, nodularity, and thickening of his distal gastric mucosa. Biopsy reveals mucosa-associated lymphatic tissue (MALT) lymphoma. CT scan suggests the tumor is limited to the antrum. Which of the following statements is true regarding gastric MALT lymphoma? A. Radiotherapy is the preferred first-line option for patients with stage I and II MALT lymphoma. B. Eradication of H. pylori is indicated only for patients with stage I or II tumors. C. The depth of the lymphoma infiltration into the gastric wall predicts the response to H. pylori treatment. D. Eradication of H. pylori decreases the risk of gastric adenocarcinoma. E. Additional therapy is recommended even if there is no evidence of residual lymphoma after H. pylori treatment.

8. A 50-year-old man had an appendectomy 3 months ago. Pathology demonstrated a well-differentiated mucinous adenocarcinoma with negative margins. An omental nodule demonstrated similar pathology. A follow-up CT scan confirms additional omental nodules. What is the most appropriate treatment strategy? A. Neoadjuvant chemotherapy followed by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) B. Neoadjuvant radiation therapy C. Right hemicolectomy followed by postoperative chemotherapy D. Cytoreductive surgery and HIPEC E. Right hemicolectomy

9. A 66-year-old otherwise healthy woman with longstanding gastroesophageal reflux disease and known Barrett esophagus undergoes surveillance endoscopy. A 2.5- × 1-cm nodule is found on endoscopy (figure 1) and biopsy demonstrates invasive esophageal adenocarcinoma. A metastatic workup is negative. Endoscopic mucosal resection is performed, and the lesion is removed with negative deep and lateral margins; the tumor is in the submucosa (figure 2). Appropriate management is A. surveillance endoscopy. B. radiofrequency ablation of the Barrett. C. additional endoscopic mucosal resection. D. chemoradiation . E. esophagectomy .

10. Acanthosis nigricans affecting which of the following anatomic locations should heighten the suspicion for gastric or lung cancer? A. Scalp B. Palms C. Groin D. Posterior Neck E. Lower abdomen

11. A 71-year-old man presents to the emergency department with right upper quadrant pain. An MRI is obtained ( figure 1 ) that is diagnostic for hepatocellular carcinoma. His laboratory values are as follows: albumin = 4.0 g/ dL (3.5–5.2 g/ dL ), International normalized ratio = 1.3 (0.8 to 1.2), bilirubin (total) = 1.7 mg/ dL (0.2–1.9 mg/ dL ); platelet count 175,000/mm 3  (150,000–450,000/mm 3 ). Evaluation of this patient should include A. chest CT scan. B. PET scan. C. bone scan. D. hepatobiliary scan.

12. A 71-year-old man presents to the emergency department with right upper quadrant pain. An MRI is obtained ( figure 1 ) that is diagnostic for hepatocellular carcinoma. His laboratory values are as follows: albumin = 4.0 g/ dL (3.5–5.2 g/ dL ), International normalized ratio = 1.3 (0.8 to 1.2), bilirubin (total) = 1.7 mg/ dL (0.2–1.9 mg/ dL ); platelet count 175,000/mm 3  (150,000–450,000/mm 3 ). The chest CT scan is negative. The most appropriate next step is A. transarterial chemoembolization. B. liver resection. C. systemic chemotherapy. D. liver biopsy. E. Yttrium-90 microspheres.

13. A 35-year-old healthy woman presents with recurrent episodes of right upper quadrant abdominal pain. She has a large mass in segment 3 of the liver. Subsequent CT imaging demonstrates an 8-cm cavernous hemangioma in the left side of the liver, which has enlarged by 1 cm over a 3-month period (figure 1). She is taking birth control pills as her only medication. Which of the following is appropriate management of this lesion? A. Hepatic artery embolization B. Sorafenib C. Liver transplantation D. Resection of the hemangioma E. Imaging in 3 months after stopping birth control pills

14. Which of the following statements is true regarding colonoscopic surveillance for cancer in a patient with ulcerative colitis? A. The recommended timing of first surveillance from diagnosis is 5 years. B. The frequency should be every 10 years. C. The use of chromoendoscopy improves the detection rate of abnormal areas of mucosa compared with standard colonoscopy D. Patients with areas of flat high-grade dysplasia should undergo repeat surveillance in 6 months. E. A minimum of 16 samples should be obtained when random biopsy surveillance is used.

15. A 70-year-old man who worked as an insulator presents with abdominal distension and pain from ascites. He has extensive peritoneal carcinomatosis on CT scan. He remains in good performance status. What is the most appropriate initial therapeutic strategy for patients with epithelioid peritoneal mesothelioma? A. Serial paracentesis B. Gastrostomy tube C. Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy D. Systemic chemotherapy with cisplatin and pemetrexed E. Whole abdominal radiation

16. A 58-year-old man with no comorbidities presents with dysphagia. A partially obstructing esophageal squamous cell carcinoma at 29 to 33 cm from the incisors is identified. It is staged as T3N1 by endoscopic ultrasound. PET scan is negative for metastatic disease. Which strategy yields the best long-term survival? A. Carboplatin and paclitaxel concurrent with radiation B. Esophagectomy C. Trastuzumab followed by esophagectomy D. Radiation followed by esophagectomy E. Carboplatin and paclitaxel concurrent with radiation followed by esophagectomy

17. CD 20 EGFR VEGF TNF-alpha HER-2/ Neu A.Infliximab B.Bevacizumab C.Cetuximab D.Trastuzumab E.Rituximab

18. A. distal gastrectomy with D1 node dissection. B. distal gastrectomy with D2 node dissection including splenectomy. C. diagnostic laparoscopy with peritoneal washings. D. neoadjuvant radiation. E. endoscopic submucosal dissection followed by chemoradiation . A 60-year-old man presents with early satiety and weight loss of 9.1 kg over 3 months. On endoscopy, he is found to have an ulcerated tumor in the body of the stomach. Endoscopic ultrasound reveals a T3 N1 adenocarcinoma of the stomach (figure 1). Staging CT scan shows no distant disease. The optimal next step in the management of this patient is

19. A 60-year-old man with a 12-cm hepatocellular carcinoma and Child A cirrhosis is undergoing preoperative planning for a right hepatectomy . Based on imaging, his predicted remnant liver volume is estimated to be 25%. What is the most appropriate next step in management? A. Embolize the right portal vein B. Proceed with right hepatectomy C. Pursue nonoperative therapy D. Cryotherapy E. Proceed with liver transplantation

20. A 56-year old man with a history of a stage III right colon cancer (pT4N1M0) underwent a laparoscopic right colectomy and adjuvant chemotherapy. Eighteen months later, he develops a recurrence of the tumor in the right pericolic gutter and the omentum , discovered on surveillance. His recent colonoscopy was negative. CT scan of the thorax, abdomen, and pelvis does not reveal any other sites of metastatic disease. Which of the following is the most appropriate management? A. Resection of all recurrences B. Systemic fluorouracil (5 FU) and leucovorin for 6 months. C. Intraperitoneal mitomycin for 6 months D. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy E. Cytoreductive surgery followed by systemic 5 FU and leucovorin for 6 months

21. A 67-year-old, otherwise healthy man with history of gastroesophageal reflux disease presents with 20-pound weight loss and dysphagia. Upper endoscopy reveals esophagogastric junction mass, and biopsies show well-differentiated adenocarcinoma. Which of the following statements regarding esophagogastric junction cancers is true? A. The surgical approaches for Siewert type II and III cancers are similar. B. The transverse colon is the preferred conduit for reconstruction after resection. C. En bloc lymphadenectomy with more than 30 nodes is associated with improved survival after resection. D. Preoperative chemoradiotherapy or perioperative chemotherapy does not improve overall survival. E. Immunotherapy has no role in the treatment.

22. A 54-year-old woman diagnosed with ulcerative colitis 25 years ago is taking infliximab therapy. She feels well overall and denies abdominal pain, diarrhea, or hematochezia. She undergoes surveillance colonoscopy, which reveals active colitis throughout the colon and rectum. There is a large mass in the cecum; biopsies reveal adenocarcinoma. Workup is negative for metastatic disease. What is the most appropriate surgical management? A. Cecectomy B. Right hemicolectomy C. Subtotal colectomy with ileosigmoid anastomosis D. Total proctocolectomy with ileal pouch-anal anastomosis E. Total proctocolectomy with continent ileostomy

23. A 50-year-old man underwent pelvic exenteration with en bloc sacrectomy for recurrent rectal adenocarcinoma with sacral bone involvement. What is the best predictor of increased disease-free survival? A. Proximal level of sacrectomy B. Length of hospital stay C. R0 resection D. Intraoperative blood loss E. Duration of surgery

24. A 56-year-old man presents with complaints of early satiety, abdominal pain, and fatigue. A contrast-enhanced CT scan shows a gastric lesion measuring 2.6 cm in maximum dimension with no other abnormal abdominal findings Endoscopic ultrasound biopsy of the lesion confirms malignant tumor with greater than 5 mitoses/50 high-powered fields. CD117, DOG1, CD34, and c-kit are all expressed positive. Which of the following statements is true regarding treatment of this condition? A. Surgical therapy is the primary treatment. B. Surgical resection has a low 5-year recurrence-free survival rate. C. Laparoscopic resection is contraindicated D. Neoadjuvant chemotherapy is required. E. Extended tumor-free margins improve oncologic outcomes.

25. A 55-year-old man is diagnosed with midesophageal squamous cell carcinoma. Fiberoptic bronchoscopy reveals tumor penetration of the distal trachea just above the carina (figure 1). What is the best treatment plan? A. Definitive chemoradiation B. Neoadjuvant chemotherapy and radiation followed by esophagectomy C. Neoadjuvant chemotherapy followed by esophagectomy D. En bloc esophageal and carinal resection with reconstruction E. Esophageal bypass operation

26. On screening colonoscopy, a 60-year-old man is noted to have an 1.5 cm diameter rectal mass. It is located 10 cm from the anal verge. Biopsy results are consistent with carcinoid tumor. Subsequent endoscopic ultrasound confirms that the tumor is confined to the submucosa. What is the recommended management? A. Laser ablation B. Low anterior resection C. Observation D. Endoscopic resection E. Kraske procedure

27. Which of the following statements regarding patients with chronic radiation proctitis is true? A. They require more frequent rectal cancer screening. B. Treatment of mild radiation proctitis prevents future strictures. C. The first-line therapy is hyperbaric oxygen. D. Surgery is ultimately required in most patients. E. Endorectal sucralfate decreases symptoms.

28. A 55-year-old otherwise healthy woman presents with acute right lower quadrant pain. She undergoes appendectomy for presumed appendicitis. Final pathology demonstrates low-grade appendiceal mucinous neoplasm with negative margins. What is the best management strategy? . Observation B. Right hemicolectomy C. Cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (HIPEC) D. Neoadjuvant chemotherapy followed by HIPEC E. Adjuvant chemotherapy

29. Which of the following statements about hepatobiliary disorders associated with inflammatory bowel disease (IBD) is true? A. Forty percent of patients with primary sclerosing cholangitis have IBD. B. Hypercoagulability increases the incidence of acute portal vein thrombosis. C. Hepatitis C antiviral treatment accelerates the course of IBD. D. Patients with ulcerative colitis have a higher risk of developing cholelithiasis than do patients with Crohn disease. E. Nonalcoholic fatty liver disease (NAFLD) is more common in the IBD patients than in the general population.

30. Which of the following statements regarding pancreatic neuroendocrine tumors (PNETs) is true? A. Most PNETs are functional. B. The presence of a PNET indicates a previously unrecognized multiple endocrine neoplasia type 1 syndrome. C. Small asymptomatic PNETs are best followed with somatostatin scans. D. Evaluation of an asymptomatic patient should include chromogranin A and pancreatic polypeptide levels. E. Immunotherapy has replaced surgery as first-line therapy.

31. A 71-year-old man presents with a 6-month history of progressive weight loss, abdominal discomfort, and early satiety. Workup with abdominal CT scan, endoscopic ultrasound, and biopsy is consistent with pancreatic adenocarcinoma (figure 1). What is the optimal initial management of this patient? A. Pancreaticoduodenectomy B. Irreversible electroporation C. Radiation therapy D. Neoadjuvant chemoradiation E. Gastrojejunostomy

32. A 34-year-old woman who is 4 months postpartum presents with a 3- × 3-cm solid mass in her left rectus muscle. Core needle biopsy shows aggressive fibromatosis. What is the best next step in management? A. CT imaging of the chest B. Whole body PET-CT scan C. Tumor analysis for chromosomal translocation t(17;22) D. Obtaining family history of colonic polyposis E. Observation

33. A 56-year-old woman (figure 1) presents with a large liver and extensive peritoneal metastases. Initial treatment with a standard dose of imatinib shows no response. Tumor mutation analysis will most likely reveal A. Exon 11 KIT mutation. B. PDGFRA mutation, D842V. C. Exon 9 KIT mutation D. Activating mutation in BRAF. E. KRAS mutation.

34. RAS (KRAS, NRAS) mutation analysis in colorectal adenocarcinoma A. guides systemic treatment options in patients with metastases . B. determines benefit gained from radiation. C. is recommended for all stage I tumors. D. is performed on a blood sample. E. predicts response to 5-fluorouracil chemotherapy.

35. Which of the following statements regarding cirrhosis, portal hypertension, and hepatic venous portal gradient (HVPG) is true? A. An HVPG of 5 mm Hg is diagnostic of portal hypertension. B. Nonselective beta-blockers prevent variceal bleeding in patients with compensated cirrhosis. C. Nonselective beta-blockers with endoscopic variceal banding improve the patency of transjugular intrahepatic portosystemic shunt stents. D. Endoscopic screening for varices is unnecessary when liver stiffness is less than 20 kPa with a platelet count greater than 150,000/mm3 (14,000–44,000/mm3). E. Color Doppler examinations correlate well with changes in HVPG.

36. Which of the following statements regarding screening for hepatocellular carcinoma (HCC) in patients with chronic hepatitis C viral (HCV) infections is true? A. Surveillance should be performed in any patient with chronic HCV infection. B. The risk of hepatocellular carcinoma is directly related to the degree of fibrosis of the liver. C. Transabdominal hepatic ultrasound every 12 months is a recommended screening examination. D. Surveillance in HCV-infected patients with cirrhosis is unnecessary after successful virus eradication. E. Serum alpha-fetoprotein measurement is the recommended initial screening study.

37. Which of the following statements is true regarding pathologic molecular tests of metastatic colon cancer tumors in the liver and prognosis? A. Positive microsatellite instability (MSI) predicts tumor resistance to immune therapy. B. Tumor levels of vascular endothelial growth factor (VEGF) predict antitumor response to antibodies against VEGF receptor. C. The presence of epidermal growth factor receptor (EGFR) predicts a positive response to anti-EGFR monoclonal antibody therapy. D. A BRAF V600E gene mutation tumor confers a poor prognosis . E. Tumors with a k- ras oncogene mutation are sensitive to anti-EGFR monoclonal antibody therapy.

38. Right sided serrated polyps Phenotype Comments HNPCC – 3% of CRC and 10%< 50 y 1:300 estimated incidence Uterine endometrium, ovarian, GI, Urinary, Skin, Brian Left sided, best survival Classic Vogelstein, APC loss, KRAS activation, TP53 loss Any location Constitutive KRAS activation ( mutation), Ineffective EGFR 3% HER2 MSS Worst Survival EGFR resistant irrespective of KRAS status