23 臨床懷疑PPU（perforated peptic ulcer）而plain abdomen X-ray並無顯示腹內free air，則最適當的處置為：

放N-G tube灌入air Barium meal study

Oral water soluble contrast medium study Endoscopic examination

Oral water soluble contrast medium study : DOES NOT CAUSE PERITONITIS

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25 下列關於膽囊癌之敘述，何者錯誤？

好發於女性

與膽結石相關性密切

多數病人發病時已屬晚期，無法手術治癒

因極易侵犯，預後不佳，故即使是第一期疾病，除切除膽囊外亦須切除部分肝臟並進行淋巴結廓清

因極易侵犯，預後不佳，故即使是第一期疾病，除切除膽囊外亦須切除部分肝臟並進行淋巴結廓清

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26 下列有關小腸憩室的敘述，何者錯誤？

Meckel’s憩室是偽性憩室，好發於終迴腸，核醫檢查是最佳的診斷工具

十二指腸憩室較好發於年長女性，2/3至3/4病例在十二指腸的壺腹周圍

手術適應症局限在有症狀或因發炎引起併發症患者

空腸憩室較多於迴腸憩室，是偽性憩室，若在剖腹探查中意外發現，不需要將其切除

Meckel’s憩室是偽性憩室，好發於終迴腸，核醫檢查是最佳的診斷工具

終迴腸 THAT IS WRONG

Meckel's diverticulum is located in the distal ileum, usually within about 60-100 cm (2 feet) of the ileocecal valve.

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27 下列何者不是intestinal type（Lauren classification）gastric carcinoma的特徵？

Younger age group較多Hematogenous spread常見

p53, p16 inactivation Environmental factor影響較大

ANS : Younger age group較多

Histologically, there are two major types of gastric adenocarcinoma (Lauren classification): intestinal type or diffuse type.

INTESTINAL

Intestinal typeadenocarcinoma tumor cells describe irregular tubular structures, harboring pluristratification, multiple lumens, reduced stroma ("back to back" aspect). Often, it associates intestinal metaplasia in neighboring mucosa. Depending on glandular architecture, cellular pleomorphism and mucosecretion, adenocarcinoma may present 3 degrees of differentiation: well, moderate and poorly differentiated.

Diffuse type adenocarcinoma (mucinous, colloid, linitis plastica, leather-bottle stomach) Tumor cells are discohesive and secrete mucus which is delivered in the interstitium producing large pools of mucus/colloid (optically "empty" spaces). It is poorly differentiated. If the mucus remains inside the tumor cell, it pushes the nucleus to the periphery- "signet-ring cell".

Adenocarcinomas tend to aggressively invade the gastric wall, infiltrating the muscularis mucosae, the submucosa, and thence the muscularis propria

The clinical stages of stomach cancer are:^[22][23]

• Stage 0. Limited to the inner lining of the stomach. Treatable by endoscopic mucosal resection when found very early (in routine screenings); otherwise bygastrectomy and lymphadenectomy without need for chemotherapy or radiation.
• Stage I. Penetration to the second or third layers of the stomach (Stage 1A) or to the second layer and nearby lymph nodes (Stage 1B). Stage 1A is treated by surgery, including removal of the omentum. Stage 1B may be treated with chemotherapy (5-fluorouracil) and radiation therapy.
• Stage II. Penetration to the second layer and more distant lymph nodes, or the third layer and only nearby lymph nodes, or all four layers but not the lymph nodes. Treated as for Stage I, sometimes with additional neoadjuvant chemotherapy.
• Stage III. Penetration to the third layer and more distant lymph nodes, or penetration to the fourth layer and either nearby tissues or nearby or more distant lymph nodes. Treated as for Stage II; a cure is still possible in some cases.
• Stage IV. Cancer has spread to nearby tissues and more distant lymph nodes, or has metastatized to other organs. A cure is very rarely possible at this stage. Some other techniques to prolong life or improve symptoms are used, including laser treatment, surgery, and/or stents to keep the digestive tract open, and chemotherapy by drugs such as 5-fluorouracil, cisplatin, epirubicin, etoposide, docetaxel, oxaliplatin, capecitabine, or irinotecan.