MBBS Surgery Syllabus

Name the triple therapy regimen for Helicobacter pylori eradication.

A proton pump inhibitor plus two antibiotics, typically clarithromycin and amoxicillin (or metronidazole), given for 7-14 days.

What is the most common cause of massive lower GI bleeding from the colon in the elderly, and the most common site of diverticular disease?

Diverticulosis is a leading cause of massive lower GI bleeding. Diverticula are most common in the sigmoid colon, where intraluminal pressure is highest.

Differentiate the cancer association of ulcerative colitis from Crohn disease and one key histologic distinguishing feature.

Both increase colorectal cancer risk, but it is higher in extensive long-standing ulcerative colitis. UC: continuous mucosal inflammation from the rectum, crypt abscesses, no granulomas. Crohn: skip lesions, transmural inflammation, non-caseating granulomas, anywhere from mouth to anus.

What is the Goodsall rule for anal fistulae?

A fistula with an external opening posterior to the transverse anal line opens internally in the midline posteriorly via a curved tract; an opening anterior to the line tracks in a straight radial line to the corresponding internal opening.

What screening modality and interval is recommended for average-risk colorectal cancer screening, and the key tumor marker for surveillance?

Colonoscopy every 10 years starting at age 45-50 in average-risk adults (or alternatives like annual FIT). CEA (carcinoembryonic antigen) is used for postoperative surveillance, not screening.

State the components of Charcot's triad and Reynolds' pentad in cholangitis.

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

What is Murphy's sign and what does it indicate?

Inspiratory arrest during deep palpation of the right upper quadrant due to pain as the inflamed gallbladder descends onto the examining hand. It is positive in acute cholecystitis.

What are the three classic risk factors ('Fs') for gallstones and the most common stone type?

Classic risks: Female, Forty, Fat, Fertile (multiparity). The most common gallstones are mixed/cholesterol stones.

Define Courvoisier's law.

In the presence of painless jaundice, a palpable, non-tender gallbladder is unlikely to be due to gallstones (which cause a fibrotic, contracted gallbladder) and more likely due to an obstructing periampullary/pancreatic malignancy.

What is the Child-Pugh classification used for and which five parameters does it use?

It assesses prognosis and surgical risk in chronic liver disease/cirrhosis. Parameters: serum bilirubin, serum albumin, prothrombin time/INR, ascites, and hepatic encephalopathy.

What is the most common benign liver tumor and the typical management approach?

Hepatic (cavernous) hemangioma. Most are asymptomatic, found incidentally, and managed conservatively; resection is reserved for symptomatic, very large, or complicated lesions.

Which serum tumor marker is elevated in hepatocellular carcinoma and what is its main underlying risk factor?

Alpha-fetoprotein (AFP) is elevated in HCC. The main risk factor is cirrhosis, most commonly from chronic hepatitis B or C, alcohol, or aflatoxin exposure.

State the two scoring systems used to assess severity in acute pancreatitis.

Ranson's criteria (assessed at admission and 48 hours) and the APACHE II score (and the modified Glasgow/Imrie score) are used to grade severity and predict mortality in acute pancreatitis.

What are the two most common causes of acute pancreatitis, and which enzyme ratio aids diagnosis?

Gallstones and alcohol are the two most common causes. Diagnosis is supported by serum lipase or amylase elevated more than three times the upper limit of normal; lipase is more specific.

What is the classic clinical triad/presentation of pancreatic head adenocarcinoma?

Painless obstructive jaundice, weight loss, and a palpable non-tender gallbladder (Courvoisier sign). Tumor marker CA 19-9 is often elevated.

Outline the embryologic descent and most common ectopic site of thyroid tissue.

The thyroid develops from the foramen cecum at the tongue base and descends along the thyroglossal duct to its pretracheal position. The most common ectopic location is a lingual thyroid; a persistent duct causes a midline thyroglossal cyst that moves on tongue protrusion.

What is the most common type of thyroid carcinoma, and which type arises from parafollicular C cells?

Papillary carcinoma is the most common (best prognosis, spreads via lymphatics, 'Orphan Annie eye' nuclei and psammoma bodies). Medullary carcinoma arises from parafollicular C cells and secretes calcitonin (associated with MEN 2).

List the cardinal signs of thyroid storm and one trigger.

Hyperpyrexia, severe tachycardia/arrhythmia, agitation/delirium, and cardiovascular collapse. It is often triggered by surgery, infection, or trauma in an inadequately controlled hyperthyroid patient.

Which nerves are at risk during thyroidectomy and what is the effect of bilateral recurrent laryngeal nerve injury?

The recurrent laryngeal nerve (supplies most laryngeal muscles) and the external branch of the superior laryngeal nerve (cricothyroid). Bilateral recurrent laryngeal nerve injury can cause both cords to lie in adduction, producing airway obstruction/stridor requiring emergency airway management.

What biochemical picture characterizes primary hyperparathyroidism and the most common cause?

Elevated serum calcium with elevated (or inappropriately normal) parathyroid hormone and low/low-normal serum phosphate. The most common cause is a solitary parathyroid adenoma.

Recall the symptom mnemonic for hypercalcemia in hyperparathyroidism.

'Stones, bones, abdominal groans, and psychic moans': renal stones, bone pain/osteitis fibrosa cystica, abdominal pain/constipation/peptic ulcers, and neuropsychiatric disturbances (depression, confusion).

What is the classic ECG change and acute management priority of severe symptomatic hypercalcemia?

A shortened QT interval. Acute management priority is aggressive IV isotonic saline hydration to restore volume and promote calciuresis, with bisphosphonates and calcitonin for persistent hypercalcemia.

What is Conn syndrome and its classic biochemical findings?

Primary hyperaldosteronism (usually an adrenal adenoma) causing hypertension with hypokalemia, metabolic alkalosis, elevated aldosterone, and suppressed plasma renin activity (high aldosterone-to-renin ratio).

State the 'rule of 10s' for pheochromocytoma and the preoperative blockade sequence.

Roughly 10% are bilateral, 10% extra-adrenal, 10% malignant, 10% familial, 10% in children. Preoperatively, alpha-blockade (e.g., phenoxybenzamine) must precede beta-blockade to avoid an unopposed alpha-mediated hypertensive crisis.

What is the most common cause of Cushing syndrome overall, and of endogenous Cushing syndrome?

The most common cause overall is exogenous (iatrogenic) corticosteroid use. The most common endogenous cause is an ACTH-secreting pituitary adenoma (Cushing disease).

What is a fibroadenoma and why is it nicknamed the 'breast mouse'?

A benign tumor of breast lobular stroma and epithelium, most common in young women. It is firm, smooth, highly mobile under the examining fingers (hence 'breast mouse'), and typically requires no treatment unless large or growing.

Differentiate a breast fibroadenoma from a phyllodes tumor.

Both are fibroepithelial. A fibroadenoma is small, benign, and slow-growing in young women. A phyllodes tumor is larger, grows rapidly, occurs in older women, has hypercellular ('leaf-like') stroma, can be benign or malignant, and requires wide local excision due to recurrence risk.

What is the triple assessment for a breast lump?

Clinical examination, imaging (mammography and/or ultrasound), and pathology (fine-needle aspiration cytology or core biopsy). Combining all three maximizes diagnostic accuracy.

Which receptors are tested in breast cancer and what does triple-negative mean?

Estrogen receptor (ER), progesterone receptor (PR), and HER2/neu. Triple-negative breast cancer is negative for all three, lacks targeted hormonal/anti-HER2 options, and carries a worse prognosis.

What does peau d'orange skin change in the breast signify?

Dimpled, orange-peel-like skin caused by dermal lymphatic obstruction/edema by tumor, indicating locally advanced or inflammatory breast cancer.

In peripheral arterial disease, define the ankle-brachial pressure index (ABPI) and interpret a value of 0.5.

$\text{ABPI} = \dfrac{\text{ankle systolic pressure}}{\text{brachial systolic pressure}}$. Normal is $0.9\text{-}1.2$; $0.5$ indicates severe disease consistent with critical limb ischemia/rest pain. Values $> 1.2$ suggest non-compressible calcified vessels.

Recall the '6 P's' of acute limb ischemia.

Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Perishingly cold (Poikilothermia). Paresthesia and paralysis are late signs indicating threatened limb viability requiring urgent revascularization.

What threshold defines an abdominal aortic aneurysm and the usual size for elective repair?

An infrarenal aortic diameter $\geq 3\,\text{cm}$ defines an AAA. Elective repair is generally indicated at $\geq 5.5\,\text{cm}$, when expanding rapidly ($> 1\,\text{cm/year}$), or when symptomatic.

What is Virchow's triad for venous thrombosis?

Endothelial (vessel wall) injury, venous stasis, and hypercoagulability. These three factors predispose to deep vein thrombosis.

Explain the underlying cause of varicose veins and Trendelenburg test.

Varicose veins result from incompetent venous valves causing reflux and venous hypertension in superficial veins. The Trendelenburg test localizes the level of valvular incompetence (e.g., saphenofemoral junction) by occluding the vein after leg elevation and observing refill.

Compare arterial and venous leg ulcers in terms of typical site and characteristics.

Arterial ulcers: occur over pressure points/lateral malleolus or toes, are punched-out, painful, with absent pulses. Venous ulcers: occur over the medial malleolus (gaiter area), are shallow with sloping edges, associated with hemosiderin pigmentation, lipodermatosclerosis, and edema.

What is the order of preference for long-term vascular (hemodialysis) access, and the maturation time for an AV fistula?

Preference order: native arteriovenous fistula first, then synthetic AV graft, then tunneled central venous catheter last. An AV fistula typically needs about 6-8 weeks (often 6 weeks to 3 months) to mature before use.

What is a 'steal syndrome' complication of an arteriovenous fistula?

Distal limb ischemia caused by the fistula diverting ('stealing') arterial blood away from the distal extremity, presenting with a cold, pale, painful hand and reduced distal perfusion; severe cases may require fistula banding or ligation.