Colorectal Surgery Flashcards
A 22 year old man has a long history of ulcerative colitis. His symptoms are well controlled with steroids. However, attempts at steroid weaning and use of steroid sparing drugs have repeatedly failed. He wishes to avoid a permanent stoma. Which of the following is the best operative option?
Pan proctolectomy and end ileostomy Abdomino perineal excision of the colon and rectum and end colostomy Abdomino perineal excision of the colon and rectum and construction of an ileo anal pouch Pan proctocolectomy and construction of an ileo anal pouch Sub total colectomy and construction of an ileo anal pouch
Pan proctocolectomy and construction of an ileo anal pouch
In patients with UC where medical management is not successful, surgical resection may offer a chance of cure. Those patients wishing to avoid a permanent stoma may be considered for an ileoanal pouch. However, this procedure is only offered in the elective setting.
A 56 year old man presents with episodes of pruritus ani and bright red rectal bleeding. On examination there is a mass in the ano rectal region and biopsies confirm squamous cell cancer. What is the most likely cause?
Anal cancer Rectal cancer Soft tissue sarcoma Retro-rectal cyst Pilonidal sinus disease
These are features of anal cancer. Anal cancers arise from the cutaneous epithelium and are therefore typically squamous cell. They are usually sensitive to chemoradiotherapy.
A 25 year old man complains of passing painless bright red blood rectally. It has been occurring over the past week and tends to occur post defecation. He also suffers from pruritus ani. The underlying cause is likely to be amenable by treatment from which of the following modalities?
Topical GTN Topical diltiazem Rubber band ligation Injection sclerotherapy Lateral internal sphincterotomy
Rubber band ligation
The history of one of the haemorrhoidal bleeding. The recent HUBLE trial showed equivalence of banding vs HALO for haemorrhoids. Rubber band ligation has a 30% failure rate but is generally easy and well tolerated. Painful PR bleeding is more suggestive of a fissure which is treated with nitrates or surgery.
A 74 year old gentleman presents with an obstructing carcinoma of the splenic flexure. Attempts at placement of a colonic stent have failed. Which of the operative options listed below offers the best solution to this problem?
Sub total colectomy Extended right hemicolectomy Standard right hemicolectomy Standard left hemicolectomy Transverse colectomy
The question always causes confusion and to understand it the information needs to be carefully read. Firstly, the tumour is definitely at the splenic flexure and the second point is that the operation is definitely an extended right hemicolectomy. A left hemicolectomy or even the older operation of a transverse colectomy could be considered if the patient was not obstructed. However, when obstruction is present, an extended right hemicolectomy (which involves an ileocolic anastomosis) is relatively safe even in the obstructed setting.
A 45 year old female is diagnosed as having a carcinoma of the caecum. She undergoes a CT scan which shows a tumour invading the muscularis propria with some regional lymphadenopathy. What is the most appropriate initial treatment?
Right hemicolectomy External beam radiotherapy Chemotherapy Combined long course chemo radiotherapy Referral for palliative care
Right sided colonic cancers should proceed straight to surgery. Radiotherapy to this area is poorly tolerated and almost never offered as first line treatment. The decision as to whether or not chemotherapy is given is dependent upon the final histology.
A 65 year old lady is admitted with large bowel obstruction. On investigation with CT, she is found to have a tumour of the mid rectum with no evidence of metastatic disease. What is the most appropriate course of action?
Formation of a loop colostomy Laparotomy and Hartmanns procedure Pan proctocolectomy and end ileostomy Low anterior resection and covering loop ileostomy Low anterior resection and end colostomy
Formation of a loop colostomy
This patient has presented with large bowel obstruction. However, in the case of rectal cancer, she is incompletely staged as ability to completely resect the lesion can only be determined with MRI scanning and this information is not provided. Even if the lesion were resectable, in the emergency setting, it is often safer to undertake a simple procedure such as a loop colostomy and then complete surgery at a later date. A low anterior resection and loop ileostomy in this situation would almost certainly leak (and for the reasons outlined above, may be incomplete).
A 78 year old lady from a nursing home is admitted with a 24 hour history of absolute constipation and abdominal pain. On examination, she has a distended abdomen with a soft mass in her left iliac fossa. An x-ray is performed which shows a large dilated loop of bowel in the left iliac fossa which contains a fluid level. What is the most likely diagnosis?
Caecal volvulus Sigmoid volvulus Incarcerated femoral hernia Diverticular stricture Malignant colonic stricture
Sigmoid volvulus may present with an asymmetrical mass in an elderly patient. It may contain a fluid level, visible on plain films. It’s very rare for femoral hernia to cause large bowel obstruction.
A 56 year old lady is investigated with a colonoscopy for a change in bowel habit. However, due to adhesions from a previous hysterectomy, she experiences pain and requests the procedure be terminated. The endoscopist feels that he reached the splenic flexure. What is the best course of action?
Discharge the patient Arrange an abdominal CT scan Arrange a CT colonoscopy Arrange a barium enema Arrange a gastrograffin enema
Failed colonoscopy should be managed with a CT colonoscopy in the first instance (more accurate than barium studies). If the procedure is needed for therapeutic intervention then GA colonoscopy may be needed.
A 73 year old lady presents with large bowel obstruction. On examination, she has a rectal cancer 6cm from the anal verge which has occluded the colonic lumen. An abdominal x-ray shows a caecal diameter of 7cm. Which of the management strategies outlined below is the most appropriate?
Construction of a loop ileostomy Construction of a loop colostomy Construction of a venting caecostomy Abdomino-perineal resection of the colon and rectum Low anterior resection and loop ileostomy
Bowel obstruction due to RECTAL cancer should be treated by loop colostomy.
Bowel obstruction due to obstructing left sided COLON cancer is usually treated by resection of the primary lesion and formation of colostomy.
A 21 year old man presents with a 5 week history of painful bright red bleeding that typically occurs post defecation and is noted on the toilet paper. External inspection of the anal canal shows a small skin tag a the six o’clock position. The patient declines internal palpation. What is the most likely underlying diagnosis?
Fissure in ano Fistula in ano Haemorrhoidal disease Solitary rectal ulcer Internal rectal prolapse
Painful bright red rectal bleeding is usually due to a fissure
The presence of pain and the sentinel tag suggests a posterior fissure in ano.
A 66 year old man is admitted as an emergency with torrential rectal bleeding. Following resuscitation, an upper GI endoscopy is undertaken and it is normal. However, he continues to bleed. What is the most appropriate course of action?
Arrange a CT angiogram Arrange a laparotomy and sub total colectomy Undertake a colonoscopy Perform a laparoscopy and on table colonoscopy Arrange a capsule endoscopy
Heavy lower GI bleeding should be investigated with an angiogram. It is best to avoid emergency surgery as the bleeding site is very difficult to find. Unlike upper GI endoscopy, colonoscopy in patients who are acutely bleeding is often difficult and seldom helpful. If it is to be done, a therapeutic scope with twin working channels is useful.
A 55 year old man is found to have an anal cancer. His staging investigations show no metastatic disease. What is the most appropriate treatment?
Radical abdominoperineal excision of the anus and rectum Radical chemoradiotherapy Excision proctectomy External beam irradiation alone Chemotherapy alone
Combined chemoradiotherapy is the standard treatment for anal cancer
A 62 year old man has previously undergone a left hemicolectomy for carcinoma of the descending colon. On follow up imaging he is found to have two deposits of metastatic disease located in the right lobe of his liver. What is the best treatment strategy?
Chemotherapy alone Chemotherapy followed by surgical resection Radiofrequency ablation Chemoradiotherapy Palliation
Chemotherapy followed by surgical resection
Liver metastasis from colorectal cancer are still potentially curable. Without resection, survival at 5 years is around 5%. With resection, this figure rises to around 20%. The best outcomes are seen where chemotherapy is given, followed by resection. Radiofrequency ablation is an option for those patients who lack the physiological reserve for surgery. However, there is longer term recurrence rates will all the non resectional strategies. There is no role for radiotherapy.
A 55 year old man presents with tenesmus and rectal bleeding. On examination he has a large bulky rectal cancer at 5cm with tethering to the prostate gland. Imaging shows no distant disease. What is the most appropriate initial treatment modality?
Abdomino-perineral resection of the colon and rectum Pelvic exenteration Abdomino-perineal excision of the colon and rectum with prostatectomy Long course chemoradiotherapy Short course radiotherapy
Rectal cancers with threatened resection margins are managed with radiotherapy and chemotherapy initially. This is not the case with colonic cancers which are usually primarily resected.
T4 rectal cancers are managed with long course chemoradiotherapy. A dramatic response is not uncommon. To embark on attempted resection at this stage is to court failure.
A 21 year old female presents with a 24 hour history of increasingly severe ano-rectal pain. On examination, she is febrile and the skin surrounding the anus looks normal. She did not tolerate an attempted digital rectal examination. What is the most likely diagnosis?
Fissure in ano Haemorrhoidal disease Proctalgia fugax Solitary rectal ulcer Intersphincteric abscess
Intersphincteric abscess
The presence of fever and severe pain makes an abscess more likely than a fissure. Although fissures may be painful they do not, in themselves, cause fever. The usual management for this condition is examination of the ano-rectum under general anaesthesia and drainage of the sepsis.
A 22 year old man presents with a 6 day history of passage of bloody diarrhoea with passage of mucous and slime. He is passing an average of 8 to 9 bowel movements per day. On digital rectal examination there is no discrete abnormality to feel, but there is some blood stained mucous on the glove. What is the most likely diagnosis?
Solitary rectal ulcer syndrome Ulcerative colitis Irritable bowel syndrome Rectal cancer Diverticulitis
Ulcerative colitis
The passage of bloody diarrhoea together with mucus and a short history makes this a likely first presentation of inflammatory bowel disease. A rectal malignancy in a 22 year old would be a very unlikely event. The history is too short to be consistent with solitary rectal ulcer.
A 70 year old female is admitted with a history of passing brown coloured urine and abdominal distension. Clinically she has features of large bowel obstruction with central abdominal tenderness. She is maximally tender in the left iliac fossa. There is no evidence of haemodynamic instability. What is the most appropriate investigation?
Cystogram Abdominal X-ray of the kidney, ureters and bladder Computerised tomogram of the abdomen and pelvis Flexible sigmoidoscopy Barium enema
Computerised tomogram of the abdomen and pelvis
This lady is most likely to have a colovesical fistula complicating diverticular disease of the sigmoid colon. In addition she may also have developed a diverticular stricture resulting in large bowel obstruction. A locally advanced tumour of the sigmoid colon may produce a similar clinical picture. The best investigation of this acute surgical patient is an abdominal CT scan, this will demonstrate the site of the disease and also supply regional information such as organ involvement and other local complications such as a pericolic abscess. A barium enema would require formal bowel preparation and this is contra indicated where large bowel obstruction is suspected. A flexible sigmoidoscopy is unlikely to be helpful and the air insufflated at the time of endoscopy may make the colonic distension worse. A cystogram would provide only very limited information.
A 24 year old man is identified as having a 5cm carcinoid tumour of the appendix. Imaging and diagnostic work up does not demonstrate any distant disease. What is the best course of action?
Appendicectomy Right hemicolectomy Resection of the caecal pole External beam radiotherapy Observation with imaging
Right hemicolectomy
Large carcinoid tumours should be formally resected. In many cases, they will be identified as an incidental finding. In such cases, it can be difficult to distinguish between carcinoid tumours and other appendiceal neoplasms
Which of the following statements in relation to fistula in ano is untrue?
High fistulae are safest treated with a seton insertion Low fistulae may be laid open They are typically probed with Lockhart Mummary probes When discovered during incision and drainage of peri anal abscess; should always be probed to locate the internal opening When complicating Crohns disease, may respond to infliximab
When discovered during incision and drainage of peri anal abscess; should always be probed to locate the internal opening
Probing fistulae during acute sepsis is associated with a high complication rate and should not be undertaken routinely.
upper gastro intestinal endoscopy which is normal. A small bowel contrast study shows a terminal ileal stricture. A colonoscopy was performed which was normal but the endoscopist was unable to intubate the terminal ileum. One week after the colonoscopy she is admitted with small bowel obstruction. Steroids are administered but despite this she fails to improve. What is the most appropriate treatment?
Administration of steroids at increased dose Right hemicolectomy Small bowel resection Sub total colectomy Pan proctocolectomy
Right hemicolectomy
Crohns disease commonly affects the terminal ileum and in this case the ileocaecal valve, this means some form of colonic resection will be needed in addition to the small bowel resection.
A 78 year old lady is admitted with a 3 hour history of passage of dark red blood per rectum. Prior to this event, she was otherwise well with no major medical co-morbidities. On examination, she has a mild tachycardia but other vital signs are normal, abdomen is soft and non tender. Digital rectal exam reveals dark blood but no other findings. What is the most likely underlying cause?
Diverticular disease Meckels diverticulum Jejunal diverticulosis Angiodysplasia of the colon Colonic cancer
Diverticular disease is the commonest cause of lower GI bleeding in adults.
A 75 year old man is admitted with large bowel obstruction and on investigation is found to have a significant sigmoid diverticular stricture as the underlying cause. What is the most appropriate treatment?
Colonoscopy and pneumatic dilatation of the stricture Laparotomy and Hartmanns procedure Colonoscopy and insertion of self expanding metallic stent Loop ileostomy Laparotomy, sigmoid colectomy and colorectal anastomosis
Laparotomy and Hartmanns procedure
Diverticular strictures have a high complication rate with stent insertion. Where patients present with large bowel obstruction, the best option is to resect the affected area. Given the fact that there is underlying colonic obstruction, a primary anastomosis would be unwise. Diverticular strictures should not be dilated.
A 19 year old male presents with bright red rectal bleeding that occurs post defecation onto the paper and into the pan. Apart from constipation his bowel habit is normal. Digital rectal examination is normal. What is the most likely cause?
Haemorrhoidal disease Fissure in ano Solitary rectal ulcer Rectal cancer Crohns disease
This is likely to be haemorrhoidal disease. A sigmoidoscopy should always be performed to exclude more sinister pathology.
What is the most likely explanation for a 63 year old male to complain of a painless blood stained mucous rectal discharge 6 months following a Hartmann’s procedure?
Pelvic abscess Crohns disease Dysplasia of the rectal stump Diversion proctitis Fissure in ano
Diversion proctitis
Once the bowel has been disconnected, a degree of inflammation is commonly seen in the quiescent bowel. This is typically referred to as diversion colitis. Dysplasia is not usually seen in this context as a Hartmanns procedure is not usually a treatment modality used for IBD (which is the main risk factor for dysplasia).
A 48 year old lady has previously undergone a sigmoid colectomy for carcinoma. On follow up imaging she is found to have a 3cm foci of metastatic disease in segment IV of the liver. What is the most appropriate course of action?
Palliative chemotherapy External beam radiotherapy Brachytherapy Surgical resection alone Chemotherapy followed by surgical resection
The treatment of colorectal liver metastasis is usually with chemotherapy followed by surgical resection. Where surgery is performed for liver metastasis with curative intent, the 5 year survival is 20%. Palliation would generally only be considered if the patient were frail or widespread disease found on imaging. Radiotherapy is not part of the treatment of liver metastasis.
A 19 year old man presents with diarrhoea and rectal bleeding that has been present for the past two weeks. In addition, he has noticed that he has had faecal incontinence at night. What is the most likely cause?
Viral gastroenteritis Inflammatory bowel disease Intersphincteric abscess Irritable bowel syndrome and haemorrhoids Irritable bowel syndrome and a fissure in ano
Nocturnal diarrhea and incontinence is a key feature in the history and is strongly suggestive of a diagnosis of IBD. More benign IBS presentations seldom have nocturnal events or a short history.
A 63 year old man presents with episodic rectal bleeding the blood tends to be dark in colour and may be mixed with stool. His bowel habit has been erratic since an abdominal aortic aneurysm repair 6 weeks previously. What is the most likely cause?
Ischaemic colitis Diverticulitis Angiodysplasia Cancer Ulcerative colitis
Ischaemic colitis
The inferior mesenteric artery may have been ligated and being an arteriopath collateral flow through the marginal may be imperfect.
What is the commonest type of fistula in ano?
Trans-sphincteric Supra levator Complex supra levator Intersphincteric Suprasphincteric
Intersphincteric fistulas are the commonest type and the external opening may be internal or external. These are the classical type of fistula and will have an internal opening near the anal verge and obey Goodsalls rule. Primary fistulotomy in this situation usually poses little risk to continence.
A 33 year old lady is admitted with recurrent discharging fistula in ano. She is also known to have ano rectal Crohns disease. On examination, she is found to have a low anal fistula with involvement of a very small amount of the external anal sphincter muscle. What is the most appropriate course of action?
Insertion of a loose seton Fistulotomy Core fistulectomy Core fistulectomy and advancement flap Insertion of a cutting seton
Fistula in ano in patients with Crohns disease should be managed with insertion of seton.
A 28 year old man is reviewed in the clinic. He has suffered from Crohns disease for many years, he has recently undergone a sub total colectomy. However, he has residual Crohns in his rectum and this is the cause of ongoing symptoms. Medical therapy is proving ineffective. What is the best course of action?
Abdomino perineal excision of the colon and rectum Proctectomy Hartmanns procedure Ileo-rectal anastomosis Formation of ileo-anal pouch
An abdomino-perineal excision of the colon and rectum is a cancer procedure and not appropriate in the context of inflammatory bowel disease. The only appropriate surgical option here is a proctectomy to remove the rectal stump and anal canal
A 75 year old lady is admitted with large bowel obstruction. She is previously well. She is investigated with an abdominal CT scan and this shows an obstructing carcinoma of the ascending colon. What is the best course of action?
Laparotomy, right hemicolectomy and ileo-colic anastomosis Laparotomy and ileo-colic bypass Laparotomy and loop ileostomy alone Insertion of self expanding metallic stent Laparotomy and sub total colectomy
Laparotomy, right hemicolectomy and ileo-colic anastomosis
Obstructing right sided cancers can be safely resected by right hemicolectomy. An abdominal CT scan will provide sufficient information to allow operative planning. Even if distant disease were present, immediate treatment is still warranted unless the patient is in the terminal phase of illness. In many cases, a primary anastomosis can be undertaken. Insertion of colonic stents for right sided obstructing lesions is not generally undertaken.
A 23 year old man is admitted to hospital with diarrhoea and severe abdominal pain. He was previously well and his illness has lasted 18 hours. What is the likely cause?
Laxative abuse Clostridium difficile infection Salmonella gastroenteritis infection Campylobacter jejuni infection Ulcerative colitis
Severe abdominal pain tends to favour Campylobacter infection.
A 25 year old male presents with altered bowel habit. He is known to have familial polyposis coli. A colonoscopy shows widespread polyps, with high grade dysplasia in a polyp removed from the rectum. What is the best course of action?
Undertake a pan proctocolectomy Undertake an abdomino perineal resection of the rectum and sigmoid colon Undertake a sub total colectomy Undertake a left hemicolectomy Perform sequential colonoscopic polypectomies until all polyps are resected
Since high grade dysplasia has been found in 1 polyp, the correct course of action is to remove the entire colon, rectum and anus. An ileo-anal pouch could be offered should the patient wish. None of the other procedures listed would be acceptable or safe under any circumstances.
What is the most likely diagnosis in a 17 year old man who presents with painful bright red ano- rectal bleeding that has been noticed to occur in past 2 weeks?
Fistula in ano Fissure in ano External haemorrhoids Internal haemorrhoids Ulcerative colitis
Painful rectal bleeding is typically seen with fissure in ano (most will be posterior). The initial history is often short (as in this case). A fistula is more likely to present with discharge than just blood. Haemorrhoidal disease bleeding is usually painless. Although thrombosed haemorrhoids may be painful, they typically occur in patients with a longer history.
A 53 year old man is due to undergo a right hemicolectomy for a caecal carcinoma. Which of the following would be usual practice prior to surgery?
Oral carbohydrate loading drink 2 hours pre operatively Mechanical bowel preparation with oral sodium picosulphate Mechanical bowel preparation with oral mannitol Total gut cleansing with oral antibiotics 3 days pre-operatively Iodine rectal washout pre-operatively
Of the options presented here, only the oral carbohydrate drink would be standard practice prior to a right sided colonic resection. Whilst some surgeons may administer phosphate enemas before surgery, total gut clearance confers no benefit for right sided resections and delays recovery. In contrast, the carbohydrate loading drink is part of enhanced recovery protocols.
You embark on a laparoscopic appendicectomy and find an appendix mass. There is no free fluid and the patient has no evidence of peritonitis. Which is the best option?
Convert to a midline laparotomy and perform a limited right hemicolectomy and end ileostomy Convert to midline laparotomy and perform and appendicectomy after taking down the adhesions Place a drain laparoscopically and administer parenteral antibiotics Send the patient for CT guided drainage Wrap omentum around the area and avoid drainage
Place a drain laparoscopically and administer parenteral antibiotics
Dissection of appendix masses can be associated with a considerable degree of morbidity, the gains of formally dissecting them over simple drainage and antibiotics are minimal.
A 23 year old male presents with bright red rectal bleeding that occurs post defecation onto the toilet paper. He has been suffering from severe pain associated with this. On external anal examination there is a skin tag located at the 6 O’clock position. Which of the treatments listed below is most likely to be helpful?
Topical GTN Rubber band ligation Injections of oily phenol Milligan Morgan haemorrhoidectomy Lords anal dilatation
Since the most likely diagnosis is a fissure, the correct treatment is topical nitrates. Haemorrhoidal treatments are not going to be helpful. Whilst a Lords anal dilation was the traditional treatment, there are few surgeons (and even fewer patients!) that would advocate a significant anal stretch these days as there are significant long term continence risks.
A 28 year old male presents with painful, bright red, rectal bleeding. On examination he is found to have a posteriorly sited, midline, fissure in ano. What is the most appropriate treatment?
Topical GTN paste Sub lingual GTN paste Anal stretch Advancement flap Tailored division of the external anal sphincter
Topical vasodilator therapy is the most commonly utilised treatment for fissure in ano. Surgical division of the internal anal sphincter is a reasonable treatment option in a young male. Division of the external sphincter will almost certainly result in incontinence and is not performed. Anal stretches were associated with a high rate of external sphincter injuries and have been discontinued for this reason.
During a colonoscopy, a patient is found to have a colonic cancer in the caecum and a 1cm polyp (which looks adenomatous) in the sigmoid colon. What is the correct management of the sigmoid polyp?
Undertake a snare polypectomy Leave in situ until the cancer has been resected Perform a hot biopsy Perform a cold biopsy Resect the sigmoid at the same time as the cancer resection
Leave in situ until the cancer has been resected
When a cancer has been identified during endoscopy, it is safest to avoid undertaking polyp interventions as there is a risk of seeding.
A 56 year old man is admitted with passage of a large volume of blood per rectum. On examination, he is tachycardic, his abdomen is soft, although he has marked dilated veins on his abdominal wall. Proctoscopy reveals large dilated veins with stigmata of recent haemorrhage. What is the most appropriate treatment?
IV terlipressin Excisional haemorrhoidectomy Injection sclerotherapy Proctectomy Rectal pack insertion
IV terlipressin
Rectal varices are a recognised complication of portal hypertension. In the first instance they can be managed with medical therapy to lower pressure in the portal venous system
A 43 year old male has been troubled with symptoms of post defecation bleeding for many years. On examination, he has large prolapsed haemorroids, colonoscopy shows no other disease. What is the best course of action?
Injection with 20% phenol Injection with 80% phenol Rubber band ligation Excisional haemorrhoidectomy Haemorrhoidal artery ligation
Excisional haemorrhoidectomy
Prolapsed haemorroids are best managed surgically if symptomatic.
A 78 year old lady is admitted with a lower GI bleed and on investigation with a CT angiogram is found to have bleeding sigmoid diverticular disease. She is otherwise well and apart from tachycardia, she is stable. What is the most appropriate course of action?
Laparotomy and Hartmanns procedure Laparotomy, sigmoid colectomy and colorectal anastomosis Colonoscopy and application of endoscopic clips to the area Conservative management with close observation Laparotomy and sub total colectomy
Most lower GI bleeds occur secondary to diverticular disease and will settle with conservative management. Attempts at endoscopic haemostasis are usually unsuccessful.
A 73 year old lady presents with constipation and no organic disease is identified on investigation. Which of the following types of laxatives works by direct bowel stimulation?
Magnesium sulphate Lactulose Potassium sodium tatrate Methylcellulose Senna
Senna contains glycosides. It passes unchanged into the colon where bacteria hydrolyse the glycosidic bond, releasing the anthracene derivatives. These stimulate the myenteric plexus.
A 32 year old man is diagnosed as having a carcinoma of the caecum. On questioning, his mother developed uterine cancer at the age of 39 and his maternal uncle died from colonic cancer aged 38. His older brother developed a colonic cancer with micro satellite instability aged 37. What is the most appropriate operative treatment?
Limited ileocaecal resection Right hemicolectomy Extended right hemicolectomy Panproctocolectomy Sub total colectomy
Panproctocolectomy
The likely diagnosis is one of a familial cancer syndrome and now that he has developed a colonic cancer the safest operative strategy is a total colectomy and end ileostomy.
A 53 year old man has a 1.5cm polyp identified and completely removed during a colonoscopy. Histology confirms a low grade adenoma. What is the correct follow up?
Discharge. Repeat endoscopy in 5 years. Repeat endoscopy in 3 years. Segmental resection of the affected area. Barium enema at 5 years.
Repeat endoscopy in 3 years.
It would be unsafe to discharge. Follow up with barium enemas for polyps is counter intuitive. In the UK NICE guidance (2011) this patient would only be classified as high risk if other adenomas were present, or the removal incomplete, in which case a repeat endoscopy at 1 year would be required. Otherwise the patient is at intermediate risk and repeat endoscopy at 3 years is warranted.
A 62 year old man is identified as having a rectal cancer. Following diagnostic work up no metastatic disease is identified. The tumour is 2cm from the anal verge. On MRI, lesion is T2, N0. Which of the following represents the correct course of action?
Proceed to abdomino-perineal excision of the colon and rectum (ELAPE) Undertake a low anterior resection and loop ileostomy Undertake a Hartmanns procedure Offer radical external beam radiotherapy followed by abdomino-perineal excision of the colon and rectum (ELAPE) Offer radical radiotherapy followed by low anterior resection and loop ileostomy
The tumour is too low for restorative surgery to be considered with an acceptable functional outcome. The tumour will therefore require an ELAPE style abdomino perineal resection. Since the lesion is T2 there is no prognostic benefit from adding radiotherapy which will confer additional morbidity.
A 67 year old man has had multiple episodes with fever and left iliac fossa pain. These have usually resolved with courses of intravenous antibiotics. He is admitted with a history of increasing constipation and abdominal distension. A contrast x-ray is performed which shows flow of contrast to the sigmoid colon, here the contrast flows through a long narrow segment of colon into dilated proximal bowel. What is the most likely cause?
Diverticular stricture Malignant stricture Ischaemic stricture Volvulus Crohns stricture
The long history of left iliac fossa pain and development of bowel obstruction suggests a diverticular stricture. These may contain a malignancy and most will require resection. Whilst colonic Crohns strictures can occur, they would be quite rare in this age group, with this history as an isolated finding.
A 24 year old woman presents with a long history of obstructed defecation and chronic constipation. She often strains to open her bowels for long periods and occasionally notices that she has passed a small amount of blood. On examination, she has an indurated area located anteriorly approximately 3cm proximal to the anal verge. What is the most likely diagnosis?
Haemorrhoids Rectal cancer Ulcerative colitis Solitary rectal ulcer syndrome Fissure in ano
Solitary rectal ulcers are associated with chronic constipation and straining. It will need to be biopsied to exclude malignancy (the histological appearances are characteristic). Diagnostic work up should include endoscopy and probably defecating proctogram and ano-rectal manometry studies.
A 34 year old man presents with symptoms attributable to a fistula in ano. He is examined in the lithotomy position and the external opening of the fistula is identified in the 7 o’clock position. At which of the following locations is the internal opening most likely to be identified?
7 o'clock 12 o'clock 9 o'clock 3 o'clock 6 o'clock
Goodsals rule:
Anterior fistulae will tend to have an internal opening opposite the external opening.
Posterior fistulae will tend to have a curved track that passes towards the midline.
According to Goodsalls rule the track of a posteriorly sited fistula will track to the posterior midline (i.e. 6 o’clock)
A 19 year old man presents with painful rectal bleeding and is found to have an anal fissure. Which of the following is least associated with this condition?
Leukaemia Syphilis Tuberculosis Sickle cell disease Crohn's disease
Sickle cell disease
Anal fissures are associated with:
Sexually transmitted diseases (syphilis, HIV)
Inflammatory bowel disease (Crohn’s up to 50%)
Leukaemia (25% of patients)
Tuberculosis
Previous anal surgery
A 53 year old man presents with a full thickness external rectal prolapse. Which of the following procedures would be the most suitable surgical option?
Rectopexy Delormes Altmeirs Thirsch tape Abdomino-perineal excision of the rectum
As this man is young and has full thickness prolapse a rectopexy is the most appropriate procedure. It will give the lowest recurrence rates.
A patient has an appendicectomy and a 1.2cm carcinoid tumour is identified in the tip of the appendix. What is the most appropriate management?
Watchful waiting Discharge Right hemicolectomy Limited ileocaecal resection Radioisotope scan
Individuals with small carcinoids can be discharged (<2cm and limited to the appendix). Larger tumours should have a radioisotope scan. Where the resection margin is positive or where the isotope scan suggests lymphatic metastasis a right hemicolectomy should be performed.
A 30 year old lady presents with painful bright red bleeding that occurs post defecation. Digital rectal examination is too uncomfortable for the patient, perineal inspection shows a prominent posterior skin tag. What is the best course of action?
Arrange for removal of the skin tag Arrange a haemorrhoidectomy Prescribe topical diltiazem Injection of 88% aqueous phenol Arrange a sphincterotomy
Prescribe topical diltiazem
The skin tag will be the sentinel pile of a posterior fissure and removal would be unwise. Fissures should be treated medically in the first instance.
A 31 year old male presents with recurrent episodes of knife like pain within his rectum. On examination, there is no abnormality to find on either proctoscopy or palpation. What is the most likely diagnosis?
Proctalgia fugax Fissure in ano Fistula in ano Anal cancer Intersphincteric abscess
Proctalgia fugax is a functional anorectal disorder characterized by severe, intermittent episodes of rectal pain that are self-limited. The diagnosis of proctalgia fugax requires exclusion of other causes of rectal or anal pain. Diagnostic work up should also include imaging (for example with MRI) to exclude occult pathology.
A 20 year old man is admitted with bloody diarrhoea. He has been passing 10 stools per day, Hb-8.0, albumin-20. Stool culture negative. Evidence of colitis on endoscopy. He has been on intravenous steroids for 5 days and has now developed megacolon. His haemoglobin is falling and inflammatory markers are static. What is the most appropriate course of action?
Double the steroid dose Undertake a loop ileostomy Undertake a sub total colectomy and end ileostomy Undertake a sub total colectomy and ileo-rectal anastomosis Undertake a pan proctocolectomy
Undertake a sub total colectomy and end ileostomy
This man requires a sub total colectomy. Conservative management has failed. Patients with ulcerative colitis should undergo colectomy if there is no significant improvement in 5-7 days after initiating medical therapy if they have a severe attack of the disease.
A 23 year old lady has suffered from diarrhoea for 8 months, she has also lost 2 Kg in weight. At colonoscopy, appearances of melanosis coli are identified and confirmed on biopsy. What is the most likely cause?
Ischaemic colitis Salmonella gastroenteritis infection Laxative abuse Irritable bowel syndrome Clostridium difficile infection
This may occur as a result of laxative abuse and consists of lipofuschin laden macrophages that appear brown.
A 73 year old lady is admitted with a brisk rectal bleed. She is otherwise well and the bleed settles. On examination, her abdomen is soft and non tender. Elective colonoscopy shows a small erythematous lesion in the right colon, but no other abnormality. What is the likely cause?
Diverticular bleed Angiodysplasia Colonic cancer Ischaemia Infective colitis
Angiodysplasia can be difficult to identify and treat. The colonoscopic stigmata are easily missed by poor bowel preparation.
A 55 year old man develops an acute colonic pseudo-obstruction following a laminectomy. Despite correction of his electrolytes and ongoing supportive care he fails to settle. Which of the drugs listed below may improve the situation?
Buscopan Neostigmine Metoclopramide Mebevrine Sodium picosulphate
Neostigmine affects the degradation of acetylcholine and will therefore stimulate both nicotinic and muscarinic receptors. It may produce symptomatic bradycardia and should therefore only be administered in a monitored environment. In colonic pseudo-obstruction it produces generalised colonic contractions and its onset is usually rapid.
An 83 year old man is admitted on the acute surgical take. His presenting symptom is of painless, profuse rectal bleeding of dark blood. His medical history comprises a previous TIA for which he takes clopidogrel and a statin. What is the most likely underlying cause?
Meckels diverticulum Colonic cancer Diverticular bleed Ischaemic colitis Diverticulitis
Diverticular bleed
The majority of patients with colonic bleeding will be found to have bleeding secondary to diverticular disease. Of note, inflammation (i.e. diverticulitis) is not seen in such cases. Around 70% will stop bleeding spontaneously. Anti platelet and anti coagulants are sometimes complicating factors and may make bleeding less likely to cease spontaneously. Ischaemic colitis often has more dominant colitis symptoms.
A 55 year old man is found to have a carcinoma of the sigmoid colon on screening colonoscopy. How should this be staged?
MRI of the abdomen and CT of the chest Liver MRI and Chest CT CT scanning of the chest, abdomen and pelvis alone MRI of the rectum and CT of the abdomen and chest Endoluminal USS and CT scanning of the abdomen
CT scanning of the chest, abdomen and pelvis alone
Colonic cancers are staged with CT scanning of the chest, abdomen and pelvis.
Which of the agents listed below is most likely to help a 22 year old lady with severe peri anal Crohns disease and multiple anal fistulae. The acute sepsis has been drained and setons are in place. She is already receiving standard non biological therapy.
Trastuzumab Bevacizumab Imatinib Cetuximab Infliximab
Infliximab is a popular choice in managing complex peri anal Crohns. It is absolutely vital that all sepsis is drained prior to starting therapy.
A 78 year old man has undergone a hemi-arthroplasty for a intracapsular hip fracture. Post operatively he develops electrolyte derangement and receives intravenous fluids. Over the next 24 hours he develops marked abdominal distension. On examination, he has a tense, tympanic abdomen which is not painful. A contrast enema shows flow of contrast through to the caecum and through the ileocaecal valve. What is the most likely cause?
Ogilvies syndrome Diverticular stricture Malignant stricture Volvulus Adhesive obstruction
Patients with electrolyte disturbance and previous surgery may develop colonic pseudo-obstruction (Ogilvies syndrome). The diagnosis is made using a contrast enema and treatment is usually directed at the underlying cause with colonic decompression if indicated.
A 68 year old man with ulcerative colitis is admitted with an exacerbation. You are called to see him because he is having brisk dark PR bleeding. He has been on intravenous hydrocortisone for 5 days. The gastroenterologists have done an OGD to exclude a duodenal ulcer, this was normal. What is the best course of action?
Sub total colectomy and end ileostomy Pan proctocolectomy and end ileostomy Colonoscopy CT angiogram Flexible sigmoidoscopy
Sub total colectomy and end ileostomy
Note that a pan proctocolectomy is not a suitable option in the emergency setting because there is increased morbidity from the pelvic dissection.
A 21 year old lady presents with a 6 month history of an offensive discharge from the anus. She is otherwise well, but is increasingly annoyed at the need to wear pads. On examination, she has a small epithelial defect in the 5 o’clock position, approximately 3cm from the anal verge. What is the most likely cause?
Fissure in ano Fistula in ano External haemorrhoid Squamous cell carcinoma of the anus Proctalgia fugax
Fistulas usually occur following previous ano-rectal sepsis. The discharge may be foul smelling and troublesome. Patients should be listed for examination under anaesthesia. Fistulas which are low and have little or no sphincter involvement are usually laid open.
A 77 year old man is admitted with large bowel obstruction and on investigation with an abdominal CT scan is found to have an obstructing cancer of the sigmoid colon. What is the most appropriate course of action?
Laparotomy, sigmoid colectomy and formation of end colostomy Laparotomy and loop colostomy Laparotomy and loop ileostomy Laparotomy, high anterior resection and colo-rectal anastomosis Palliation
Obstructing sigmoid cancers can be resected or stented. If stented, then the patient may need definitive surgery later. If resected, then a resection and end colostomy (Hartmann’s ) procedure is usually undertaken because of the risks of anastomotic leak in the setting of anastomosing obstructed colon to rectum.
A 19 year old female presents with colicky abdominal pain, bloating and alternating constipation/diarrhoea. Her grandmother died from colon cancer at the age of 87 years. A digital rectal examination and general physical examination are normal. What is the best course of action?
Measurement of faecal calprotectin Arrange a barium enema Undertake a colonoscopy Undertake a proctoscopy Undertake a rigid sigmoidoscopy
This patient fulfills the Rome criteria for irritable bowel syndrome. Examination is normal, therefore it’s likely that this patient will have IBS. However, its prudent to exclude IBD and since endoscopy is poorly tolerated in patients with IBS, measurement of faecal calprotectin is a reasonable alternative.
A 22 year old lady has a long history of severe perianal Crohns disease with multiple fistulae. She is keen to avoid a stoma. However, she has progressive disease and multiple episodes of rectal bleeding. A colonoscopy shows rectal disease only and a small bowel study shows no involvement with Crohns. What is the best operative strategy?
Abdomino perineal excision of the colon and rectum Proctectomy and end stoma Pan proctocolectomy and ileoanal pouch Loop colostomy alone Sub total colectomy
Proctectomy and end stoma
Crohns disease is a contra indication to having an ileo-anal pouch as its associated with very poor pouch function and significant complications.
Whilst the patient wishes to avoid a stoma, that’s inevitable here.
A 56 year old man presents with his first attack of diverticulitis. Which of these complications is least likely to ensue?
Formation of colonic strictures Malignant transformation Development of colovesical fistula Formation of a pericolic abscess Formation of a phlegmon
Diverticulitis may result in a number of complications. However, whilst malignant disease may coincide with diverticulitis it is not, in itself, a risk factor for colonic cancer.
A 60 year old lady is investigated for abdominal pain. A polyp is identified at the proximal descending colon, three small polyps are also noted in the sigmoid colon. The largest lesion is removed by snare polypectomy and the pathology report states that this polyp is a low grade dysplastic adenoma measuring 3cm in diameter. The remaining lesions are ablated using diathermy. What is the correct management?
Repeat endoscopy in 1 year No further endoscopic surveillance Repeat endoscopy in 5 years Segmental colonic resection Repeat endoscopy in 3 years
Repeat endoscopy in 1 year
She is at high risk of malignancy and should be closely followed up. Fulguration of polyps without histology is unhelpful.
A 34 year old lady presents to her general practitioner with peri anal discomfort. The general practitioner diagnoses pruritus ani, which of the following is least associated with the condition?
Hyperbilirubinaemia Anal fissure Leukaemia Syphilis Tuberculosis
Tuberculosis
Causes:
Systemic (DM, Hyperbilirubinaemia, aplastic anaemia)
Mechanical (diarrhoea, constipation, anal fissure)
Infections (STDs)
Dermatological
Drugs (quinidine, colchicine)
Topical agents
A previously well 21 year old man is admitted with 2 week history of diarrhoea and passage of blood and mucous rectally. He has previously undergone an ileocaecal resection in the past for an inflammatory bowel disorder and takes mesalazine. What is the most likely underlying cause?
Ulcerative colitis Diversion proctitis Crohns proctitis Diverticular associated bleed Irritable bowel syndrome
The history of a right sided resection is the patients young age are all strongly suggestive of an existing diagnosis of Crohns disease (segmental resections are not undertaken for UC). Since the bowel has remained in continuity, a diversion colitis is not possible.
A 28 year old male presents with a discharging sinus in his natal cleft. He is found to have a pilonidal sinus. Which statement is false?
Can occur in webs of fingers and the axilla After drainage pilonidal abscesses should not be primarily closed A rare complication is squamous cell carcinoma In a patient with an acute abscess the Bascoms procedure is the treatment of choice. Treatment involves excising or laying open the sinus tract.
In a patient with an acute abscess the Bascoms procedure is the treatment of choice.
Acute pilonidal abscesses should receive simple incision and drainage. Definitive treatments such as a Bascoms procedure should not be undertaken when acute sepsis is present.
A 23 year old lady presents with a posteriorly sited fissure in ano. Treatment with stool softeners and topical GTN has failed to improve matters. Which of the following would be the most appropriate next management step?
Lords procedure Injection of botulinum toxin Lateral internal sphincterotomy Endoanal advancement flap Surgical division of the external anal sphincter
The next most appropriate management option when GTN or other topical nitrates has failed is to consider botulinum toxin injection
