Colorectal

Question 1

What are the histological features seen in Crohns

Answer 1

Granulomas (non-caseating)

Question 2

What is the management of a patient with UC presenting with acute colitis

Answer 2

Medical mx= steroids for 5-7 days

Question 3

What is the management of a patient with UC and colitis who is not responding to steroids

Answer 3

Emergency: subtotal colectomy with end ileostomy and mucocutaneous fistula

Question 4

Management of crohns with ano rectal sepsis?

Answer 4

Very min resection if needed!!

Drain infection +/- seton to facilitate drainage

Question 5

T/F: all colonic adenomas are metaplastic

Answer 5

FALSE: colonic adenomas are DYSPLASTIC

Question 6

Why should colonic polyps not be resected in the presence of CRC during endoscopy

Answer 6

To avoid seeding

Question 7

T/F: all colonic adenomas >1cm have malignant potential

Answer 7

FALSE:

Colonic adenomas >2cm have malignant potential

Question 8

Patient presents with:
Painful PR bleeding on defecation
Skin tag present
Bright red blood

Diagnosis?

Answer 8

Fissure in ano

Question 9

Conditions associated with fissure in ano

Answer 9

Crohns
TB
internal rectal prolapse

Question 10

Management of obstruction due to diverticular stricture

Answer 10

Colonic resection

If malignant- stent

Question 11

Management of volvulus

Answer 11

Initial max: untwist- flexi sig

If ischaemic: surgical
If recurrent: resection

Question 12

Causes of LBO

Answer 12

Tumours
diverticular disease
volvulus

Question 13

Mx of right sided colonic tumour causing LBO

Answer 13

RESUSCITATE
right hemi +/- extend to transverse
ileocolic anastamosis

Question 14

Mx of left sided colonic tumour causing LBO

Answer 14

RESUSCITATE
left hemi + anastamosis

OR

Left hemi + end colostomy

OR

colonic stent

Question 15

Mx of rectosigmoid tumour causing LBO

Answer 15

resection + loop colostomy

distal sigmoid= high anterior resection

Question 16

What are the 4 types of fistulae

Answer 16

enterocutaneous
enterocolonic
enterovesical
enterovaginal

Question 17

Management of a high output fistula

Answer 17

octerotide + TPN

Question 18

Define Goodsall’s rule

Answer 18

For perianal fistulae:

if the outer opening of a fistula is anterior to the imaginary transverse line drawn across the perineum= the internal fistula opening (into the anal canal) is along the same radial path (fistula track is a straight line)

If the outer fistula opening is posterior to the imaginary transverse line= the fistula tract will follow a curved line and open at the posterior midline

Question 19

Indication for surgical mx of UC

Answer 19

Dysplastic lesions found
UC requiring maximal therapy
Prolonged courses of steroids

Question 20

In elective settings, what would be the surgical mx of UC

Answer 20

Panproctocolectomy + end colostomy/ ileoanal pouch

Question 21

In emergency settings, what would be the surgical mx of UC

Answer 21

subtotal colectomy + end ileostomy +/- mucous fistula (if rectum is very odematous)

in emergency settings rectum should not be resected

Question 22

Indications for surgical Mx of Crohns

Answer 22

Complications of crohns:
abscess, fistula, strictures

Question 23

What is the surgical management of crohns:

If stricture
if perianal fistulae
if perianal/ rectal crohns
if terminal ileal crohns

Answer 23

Resection should be minimized to prevent shot bowel syndrome

If stricture= stricturoplasty
if perianal fistulae= seton drainage
if perianal/ rectal crohns= protectomy
if terminal ileal crohns= limited ileal resection

Question 24

Commonest type of cancer in the:
anus
rectum
colon

Answer 24

Anus= SCC
rectum + colon= adenocarcinoma

Question 25

What is commonly associated with chronic straining and constipation

Answer 25

solitary rectal ulcer

Question 26

What is seen in histology of lesion associated with chronic straining and constipation

Answer 26

mucosal thickening collagen and fibrosis in the lamina propria

Question 27

What are the surgical management options for rectal prolapse and their associated complications

Answer 27

Delorme's = high recurrence rate Altemier's= anastamotic leak Rectopexy= constipation post-op

Question 28

Where are fissure in ano usually sited

Answer 28

posteriorly

Question 29

If fissure in ano present atypically what investigations should be carried out

Answer 29

Atypical= anteriorly sited/ multiple colonoscopy, EUA + biopsies *for ?Cancer/ IBD/ prolapse

Question 30

What are the different management options for fissure in ano

Answer 30

1- stool softeners 2- GTN/ diltiazem top 3- botox injection 4- surgical: men= laternal internal sphincterotomy women= manometry (caution with sphincterotomy as when combined with post-vaginal birth pelvic floor damage, can cause faecal incontinence)

Question 31

What is the commonest complication of ileostomy

Answer 31

dermatitis

Question 32

What is the earliest complication of ileostomy

Answer 32

necrosis

Question 33

Where are ileostomies usually sited

Answer 33

RIF (in the triangle between ASIS, pubic symphysis and umbilicus, 1/3 of the way b/w the umbilicus and ASIS)

Question 34

How much output would be considered high output for an ileostomy

Answer 34

normal 5-10ml/kg/24hr high >20ml/kg/24hrs

Question 35

initial mx of high output ileostomy

Answer 35

-loperamide + add gelatin to food to thicken

Question 36

management options for colonic pseudo-obstruction

Answer 36

Usually due to electrolyte imbalances 1- correct electrolytes + supportive care 2- decompress with rigid sigmoidoscope/ oral neostigmine *neostigmine can cause symptomatic bradycardia= give in monitored environment

Question 37

Complication of chronic pilonidal abscess

Question 38

Management of acute pilonidal abscess/ sinus

Answer 38

I&D

Question 39

Definitive mx of pilonidal abscess and when should this be done

Answer 39

Bascoms procedure- excising the pit and obliterating the cavity underneath Karydakis procedure- wide excision of the natal cleft so that the surface is recontoured once the wound is closed

Question 40

rectal cancer mx if: -T1/2/3, N0 -T4 -rectal Ca presenting with obstruction

Answer 40

-surgical resection -chemo-radiotherapy -defunctioning loop colostomy

Question 41

colon ca mx if: -any stage -high recurrence risk -presenting with obstruction

Answer 41

-surgical resection -resection + post-op chemo -resection/ stent

Question 42

Anal Ca mx: -1st line -2nd line

Answer 42

-chemoradiotherapy -salvage radical AP excision of anus and rectum (for NON-metastatic ca)

Question 43

What are the extra-intestinal manifestations of crohns

Answer 43

A PIE SAC Apthous ulcers pyoderma gangrenosum erythema nodosum sclerosing cholangitis arthritis clubbing

Question 44

What is the transition from polyp to cancer called

Answer 44

adenoma-carcinoma sequence-where oncogenes are activated and tumour suppressor genes are DE-activated to gradually form cancerous cells

Question 45

What are the genes involved in the transformation of a polyp to a carcinoma

Answer 45

APC c-myc bcl-2 K-RAS MCC DCC c-yes p53 deletions

Question 46

What are the extra-intestinal manifestations common to both crohn and UC

Answer 46

Arthritis PSC* uveitis* episcleritis** pyoderma gangrenosum erythema nodosum clubbing osteoporosis *more common in UC ** more common in crohns

Question 47

What is the most common extra-intestinal feature in both CD and UC

Answer 47

Arthritis