FMGE Surgery Syllabus

What is the modified Johnson classification of gastric ulcers (Type I-V)?

Type I: lesser curve at incisura (most common, normal acid); Type II: gastric body + duodenal ulcer (high acid); Type III: prepyloric (high acid); Type IV: high on lesser curve near GE junction; Type V: NSAID-induced, anywhere.

What triad defines Zollinger-Ellison syndrome and what test confirms it?

Gastrinoma causing gastric acid hypersecretion, severe/refractory or multiple peptic ulcers, and diarrhea. Confirmed by elevated fasting serum gastrin and a positive secretin stimulation test (paradoxical rise in gastrin).

What is a Krukenberg tumor and its origin?

A metastasis to the ovary (typically bilateral) of signet-ring cell adenocarcinoma, most often from a primary gastric (or other GI) carcinoma.

What is the most common location of colorectal cancer and the classic presentation by side?

Rectosigmoid region is the most common site. Right-sided cancers present with occult bleeding, iron-deficiency anemia, and a mass; left-sided cancers present with obstruction, change in bowel habits, and hematochezia.

In acute diverticulitis, what is the Hinchey classification used for and what does Stage III mean?

It classifies perforated diverticulitis severity. Stage I: pericolic abscess; II: pelvic/distant abscess; III: purulent peritonitis; IV: feculent peritonitis. Stage III-IV typically require surgery (Hartmann's procedure).

Differentiate the typical features of ulcerative colitis from Crohn's disease.

UC: continuous mucosal inflammation from the rectum proximally, limited to colon, crypt abscesses, increased cancer risk, cured by colectomy. Crohn's: transmural skip lesions anywhere mouth-to-anus, granulomas, fistulae/strictures, terminal ileum common, not cured by surgery.

What are Charcot's triad and Reynolds' pentad in cholangitis?

Charcot's triad: right upper quadrant pain, fever, jaundice (acute cholangitis). Reynolds' pentad adds hypotension and altered mental status (suppurative cholangitis).

What is Courvoisier's law?

A palpable, non-tender, enlarged gallbladder in a jaundiced patient is unlikely due to gallstones and suggests malignant obstruction of the common bile duct (e.g., pancreatic head cancer).

What is the imaging gold standard for acute cholecystitis and a classic positive sign?

Ultrasound is first-line (gallstones, wall thickening >3 mm, pericholecystic fluid, sonographic Murphy's sign); HIDA scan is most sensitive/specific, showing non-visualization of the gallbladder.

What is the most common type of gallstone, and which type associates with hemolysis?

Cholesterol stones are most common (associated with the 4 F's: female, forty, fat, fertile). Black pigment stones (calcium bilirubinate) associate with chronic hemolysis; brown pigment stones associate with biliary infection/stasis.

What is the most common benign liver tumor and the imaging contraindication associated with it?

Cavernous hemangioma is the most common benign liver tumor; percutaneous biopsy is contraindicated due to hemorrhage risk. Diagnosis is by characteristic peripheral nodular enhancement with centripetal fill-in on contrast imaging.

Which serum tumor marker is elevated in hepatocellular carcinoma, and what is its most common risk factor worldwide?

Alpha-fetoprotein (AFP) is elevated in HCC. Chronic hepatitis B (and cirrhosis from any cause, including hepatitis C) is the leading risk factor worldwide.

What is the classic appearance and treatment of a hepatic amebic abscess?

Single right-lobe abscess with "anchovy paste" (reddish-brown) contents caused by Entamoeba histolytica; treated medically with metronidazole, drainage only if no response or large/at risk of rupture.

State Ranson's criteria categories and what they predict in acute pancreatitis.

They predict mortality/severity. On admission: age >55, WBC >16,000, glucose >200, AST >250, LDH >350. At 48 hours: Hct drop >10%, BUN rise >5, Ca <8, PaO2 <60, base deficit >4, fluid sequestration >6 L. ≥3 criteria indicates severe pancreatitis.

What is the most common cause of acute pancreatitis and the most common cause of chronic pancreatitis?

Gallstones are the most common cause of acute pancreatitis; chronic alcohol use is the most common cause of chronic pancreatitis.

What is Whipple's triad for insulinoma?

Symptoms of hypoglycemia, documented low plasma glucose (<50 mg/dL) at the time of symptoms, and relief of symptoms with glucose administration.

What is the Whipple procedure (pancreaticoduodenectomy) and its main indication?

Resection of the pancreatic head, duodenum, gallbladder, common bile duct, and part of the stomach with reconstruction; the standard curative operation for resectable pancreatic head (periampullary) cancer.

What is the most common type of thyroid cancer, its spread pattern, and key histology?

Papillary thyroid carcinoma (most common, best prognosis); spreads via lymphatics; histology shows Orphan Annie eye nuclei and psammoma bodies.

Which thyroid cancer arises from parafollicular C cells, secretes calcitonin, and is associated with MEN 2?

Medullary thyroid carcinoma — produces calcitonin, may show amyloid stroma, and is associated with MEN 2A and 2B (RET proto-oncogene mutation).

What nerve is at risk during thyroidectomy and what is the consequence of bilateral injury?

The recurrent laryngeal nerve; unilateral injury causes hoarseness, while bilateral injury can cause airway obstruction (stridor) requiring emergency tracheostomy.

What biochemical pattern confirms primary hyperparathyroidism, and what is the most common cause?

Elevated PTH with elevated serum calcium and low phosphate; most commonly caused by a single parathyroid adenoma. Classic mnemonic: "stones, bones, abdominal groans, and psychiatric moans."

What localization study is used before minimally invasive parathyroidectomy?

Technetium-99m sestamibi scan (often with neck ultrasound) to localize the hyperfunctioning parathyroid adenoma.

What is the classic biochemical and clinical triad of pheochromocytoma?

Episodic headache, palpitations (tachycardia), and sweating with paroxysmal hypertension; diagnosed by elevated plasma/urine metanephrines. The "rule of 10s" applies (10% bilateral, malignant, extra-adrenal, familial).

What is the critical preoperative preparation for pheochromocytoma resection and why?

Alpha-blockade first (e.g., phenoxybenzamine) for 7-14 days, then beta-blockade only after adequate alpha-blockade — to prevent unopposed alpha stimulation causing hypertensive crisis.

Differentiate Conn syndrome and Cushing syndrome by their primary adrenal hormone and key electrolyte/clinical findings.

Conn (primary hyperaldosteronism): excess aldosterone → hypertension, hypokalemia, metabolic alkalosis. Cushing: excess cortisol → central obesity, striae, hyperglycemia, hypertension, easy bruising.

What is the most common benign breast tumor in young women and its classic features?

Fibroadenoma — a firm, smooth, well-circumscribed, mobile ("breast mouse") painless lump, most common in women under 30; benign with no significant cancer risk.

Differentiate a fibroadenoma from a phyllodes tumor.

Fibroadenoma is small, benign, and stable. Phyllodes tumor is larger, fast-growing, can be benign or malignant, has a leaf-like stromal pattern, and requires wide local excision due to recurrence/malignant potential.

What are the receptor subtypes of breast cancer and which carries the worst prognosis?

Subtypes: Luminal A (ER+/PR+, HER2−, best prognosis), Luminal B, HER2-enriched, and Triple-negative (ER−/PR−/HER2−), which has the worst prognosis and no targeted hormonal/HER2 therapy.

What is the most common histologic type of invasive breast cancer and which type is classically bilateral/multifocal?

Invasive ductal carcinoma (no special type) is the most common (~75%); invasive lobular carcinoma is more often bilateral and multifocal and characteristically shows single-file cell infiltration.

What is the ankle-brachial index (ABI), and what value indicates significant peripheral arterial disease versus critical limb ischemia?

ABI = highest ankle systolic pressure / highest brachial systolic pressure. Normal 0.9-1.3; <0.9 indicates PAD; <0.4 indicates critical limb ischemia (rest pain/tissue loss). >1.3 suggests non-compressible calcified vessels.

List the "6 Ps" of acute limb ischemia.

Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia (perishingly cold). Paralysis and paresthesia indicate advanced ischemia requiring emergency revascularization.

What is the most common site and presentation of an abdominal aortic aneurysm, and the threshold for elective repair?

Most are infrarenal; often asymptomatic and found as a pulsatile abdominal mass. Elective repair is indicated at ≥5.5 cm, rapid expansion (>0.5 cm/6 months), or symptoms. Rupture presents with the triad of pain, hypotension, and pulsatile mass.

What clinical scoring/findings differentiate deep venous thrombosis risk, and what is the diagnostic first-line imaging?

Wells score stratifies DVT probability; duplex (compression) ultrasound is the first-line diagnostic test. D-dimer is useful to rule out DVT in low-probability patients.

What is the gold standard treatment for varicose veins with saphenofemoral incompetence and the underlying pathology?

Incompetent venous valves cause venous reflux and dilation; endovenous ablation (laser/radiofrequency) or saphenous vein stripping/ligation is the standard treatment. The Trendelenburg test localizes the level of valvular incompetence.

What is the preferred long-term vascular access for chronic hemodialysis and why?

An autogenous arteriovenous fistula (e.g., radiocephalic/Brescia-Cimino), because it has the lowest infection and thrombosis rates and best long-term patency compared with grafts or catheters.

State the components of the primary survey (ABCDE) in trauma management.

A: Airway with cervical spine protection; B: Breathing/ventilation; C: Circulation with hemorrhage control; D: Disability (neurologic status/GCS); E: Exposure/Environment (undress, prevent hypothermia).

How is the Glasgow Coma Scale scored and what total indicates severe head injury?

GCS = Eye opening (4) + Verbal response (5) + Motor response (6), range 3-15. Severe head injury is GCS ≤8 (also the threshold for intubation); moderate 9-12; mild 13-15.

What is the classic presentation and immediate treatment of a tension pneumothorax?

Hypotension, distended neck veins, tracheal deviation away from the affected side, and absent breath sounds with hyperresonance. Immediate needle decompression (2nd intercostal space, midclavicular line) followed by chest tube — diagnosis is clinical, not radiographic.

Differentiate epidural from subdural hematoma on CT and mechanism.

Epidural: biconvex (lens-shaped) hematoma not crossing suture lines, from middle meningeal artery injury, with a classic lucid interval. Subdural: crescent-shaped, crosses suture lines, from torn bridging veins, common in elderly/alcoholics.

What does the Cushing reflex (triad) indicate in head trauma?

Hypertension (widened pulse pressure), bradycardia, and irregular respirations — a sign of raised intracranial pressure and impending brain herniation, requiring urgent intervention.

What is the FAST exam and which four areas does it assess in abdominal trauma?

Focused Assessment with Sonography for Trauma detects free intraperitoneal/pericardial fluid at: hepatorenal recess (Morison's pouch), splenorenal recess, pelvis (pouch of Douglas), and pericardium (subxiphoid).

Which solid abdominal organ is most commonly injured in blunt abdominal trauma, and what determines operative versus non-operative management?

The spleen is most commonly injured in blunt trauma. Hemodynamic stability determines management: stable patients can be managed non-operatively with observation/embolization; unstable patients require exploratory laparotomy.

What is the Salter-Harris classification used for, and what does Type II (the most common) involve?

It classifies pediatric physeal (growth plate) fractures. Type I: through physis; Type II (most common): through physis and metaphysis; Type III: physis and epiphysis; Type IV: across metaphysis, physis, and epiphysis; Type V: crush injury of physis. (Mnemonic SALTR.)

What are the signs and the emergency management of compartment syndrome after a fracture?

Pain out of proportion to injury, especially on passive stretch, plus the 5 Ps (paresthesia, pallor, pulselessness late, paralysis, pressure/tense compartment). Diagnosed by compartment pressure (>30 mmHg or within 30 mmHg of diastolic); treated by emergency fasciotomy.

Which hip fracture type risks avascular necrosis of the femoral head and why?

Intracapsular (femoral neck) fractures, because they can disrupt the medial femoral circumflex artery supplying the femoral head; displaced neck fractures in elderly are often treated with arthroplasty rather than fixation.

What are the two main types of total hip replacement fixation and a leading long-term complication of joint replacement?

Cemented (polymethylmethacrylate) and uncemented (press-fit/osseointegration) fixation. Aseptic loosening is a leading long-term cause of revision; periprosthetic infection and dislocation are other key complications.

What is cauda equina syndrome and why is it a surgical emergency?

Compression of the lumbosacral nerve roots (commonly by a large central disc herniation) causing saddle anesthesia, bilateral leg weakness/sciatica, and bowel/bladder dysfunction (urinary retention). It requires emergency surgical decompression to prevent permanent deficits.

Differentiate spinal stenosis (neurogenic claudication) from vascular claudication.

Neurogenic claudication: leg pain relieved by leaning forward/sitting (flexion) and worsened by standing/walking, with normal pulses. Vascular claudication: pain reliably reproduced by a fixed walking distance, relieved by rest (standing), with diminished pulses.

What is the most common composition of kidney stones and the classic presentation of renal colic?

Calcium oxalate stones are most common (~75%). Renal colic presents with acute, severe, colicky flank pain radiating to the groin, with hematuria; non-contrast CT (KUB) is the diagnostic gold standard.

What stone size threshold favors spontaneous passage versus intervention, and what are common interventions?

Stones <5 mm usually pass spontaneously; stones >10 mm rarely pass and need intervention. Options include extracorporeal shock wave lithotripsy (ESWL), ureteroscopy with laser, and percutaneous nephrolithotomy (for large/staghorn stones).

What is the classic triad of renal cell carcinoma and its most common histologic subtype?

Flank pain, hematuria, and a palpable abdominal mass (the full triad is now uncommon, seen in <10%). Clear cell carcinoma is the most common subtype; RCC characteristically invades the renal vein/IVC and may cause a left-sided varicocele.

Name three paraneoplastic syndromes associated with renal cell carcinoma.

Polycythemia (erythropoietin), hypercalcemia (PTH-related peptide), and hypertension (renin); Stauffer syndrome (non-metastatic hepatic dysfunction) is also classic.

What is ureteropelvic junction (UPJ) obstruction, its most common cause, and how is function assessed?

Obstruction of urine flow from the renal pelvis to the ureter, most commonly congenital (intrinsic narrowing or a crossing lower-pole vessel). Diuretic renography (MAG-3 scan) assesses differential function and degree of obstruction; pyeloplasty is the standard repair.

What is the most common cause of iatrogenic ureteral strictures, and which imaging best defines the stricture?

Iatrogenic injury during pelvic/abdominal surgery (especially gynecologic) is the most common cause; retrograde or antegrade pyelography (or CT urography) best defines stricture location and length, guiding stenting versus reconstruction.

What is the most common cause of neonatal intestinal obstruction with bilious vomiting, and what is the dreaded surgical emergency to exclude?

Bilious vomiting in a neonate is malrotation with midgut volvulus until proven otherwise — a surgical emergency due to risk of midgut ischemia. Upper GI contrast study (showing abnormal duodenojejunal junction position) is diagnostic; Ladd's procedure is the treatment.

Differentiate the typical bowel-gas findings of duodenal atresia from jejunoileal atresia on X-ray.

Duodenal atresia: "double-bubble" sign (gas in stomach and proximal duodenum, no distal gas), associated with Down syndrome. Jejunoileal atresia: multiple dilated bowel loops with air-fluid levels, usually due to in-utero vascular accident.

What is the classic presentation and treatment of hypertrophic pyloric stenosis?

Non-bilious projectile vomiting in a 3-6 week-old (more common in firstborn males), a palpable "olive" mass, and hypochloremic hypokalemic metabolic alkalosis. Ultrasound confirms (pylorus thickness >3-4 mm, length >15-17 mm); treatment is Ramstedt pyloromyotomy after fluid/electrolyte correction.

What is the most common cause of intestinal obstruction in infants 3 months to 2 years, and the classic findings?

Intussusception (usually ileocolic, idiopathic at this age). Classic triad: intermittent colicky abdominal pain (drawing up legs), "currant jelly" stools, and a sausage-shaped abdominal mass; air/contrast enema is both diagnostic and therapeutic (reduction).

How is Hirschsprung disease diagnosed and what is the underlying pathology?

Congenital absence of ganglion cells (aganglionosis) in the distal colon causing functional obstruction and failure to pass meconium within 48 hours. Rectal suction biopsy is the gold standard (absent ganglion cells, hypertrophied nerve fibers); contrast enema shows a transition zone.