Colorectal Surgery

Question 1

A 55 year old man undergoes a colonoscopy and a colonic polyp is identified. It has a lobular appearance and is located on a stalk in the sigmoid colon. Which of the processes below best accounts for this finding?

Apoptosis
Metaplasia
Dysplasia
Calcification
Degeneration

Answer 1

C- Dysplasia
Most colonic polyps described above are adenomas. These may have associated dysplasia. The more high grade the dysplasia the greater the level of clinical concern.

Question 2

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

Answer 2

Haemorrhoidal disease
Uncomplicated grade 1 or 2 haemorrhoids are usually impalpable

This is likely to be haemorrhoidal disease. A sigmoidoscopy should always be performed to exclude more sinister pathology.

Question 3

Which of the following hepatobiliary disorders are most classically associated with ulcerative colitis?

Gallstones
Primary sclerosing cholangitis
Bile duct stones
Liver hamartomas
Hepatocellular carcinoma

Answer 3

Primary sclerosing cholangitis

Primary sclerosing cholangitis is an idiopathic inflammation of the bile ducts. It may result in episodes of cholestasis and cholangitis and ultimately result in the need for liver transplantation. It carries a 10% risk of malignant transformation. Crohns disease is associated with gallstones due to impaired entero-hepatic circulation. Apart from PSC, ulcerative colitis does not increase the risk of other liver lesions.

Question 4

A 75 year old lady is admitted with a 12 hour history of absolute constipation, vomiting and colicky abdominal pain. On examination, her abdomen is distended and she has right sided tenderness. Imaging demonstrates an obstructing hepatic flexure tumour with a caecal diameter of 11cm. What is the best course of action?

Undertake an immediate laparotomy
Commence resuscitation with intravenous fluids and then undertake a laparotomy 2-4 hours later
Administer antibiotics and intravenous fluids and schedule surgery for the following day
Arrange a colonoscopy
Administer oral sodium picosulphate

Answer 4

Commence resuscitation with intravenous fluids and then undertake a laparotomy 2-4 hours later

The sun should not rise and set on unrelieved large bowel obstruction! This patient has a competent ileocaecal valve. As a result lack of surgery would result in caecal perforation leading to faecal peritonitis with and associated high mortality rate.

Question 5

A 43 year old woman undergoes a sigmoid colectomy for carcinoma. The histology report shows pT3, pN1, systemic staging is M0. She is otherwise well. What is the most appropriate course of action?

Active surveillance with CT scans at 6 and 12 months and monthly CEA measurement
Referral for chemotherapy
Radiotherapy to the resection site
Active surveillance with colonoscopy at 12 months and CT scan at 6 months and 3 monthly CEA measurement
Discharge

Answer 5

Referral for chemotherapy

Chemotherapy for colonic cancer is offered when patients have nodal disease.

Diagnose with CRC
- Colonoscopy/ Ct colonography

Question 6

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

Answer 6

Radical chemoradiotherapy

Combined chemoradiotherapy is the standard treatment for anal cancer

Question 7

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

Answer 7

Rectopexy

As this man is relatively young and has full thickness prolapse a rectopexy is the most appropriate procedure. It will give the lowest recurrence rates.

Question 8

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

Answer 8

Sigmoid volvulus

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.

Question 9

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 Mummery 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

Answer 9

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.

Question 10

A 34 year old male presents with painful rectal bleeding and a fissure in ano is suspected. On examination he has an epithelial defect at the mucocutaenous junction that is located anteriorly. Approximately what proportion of patients with fissure in ano will present with this pattern of disease?

90%
10%
50%
25%
100%

Answer 10

10%

Only a minority of patients with fissure in ano will have an anteriorly sited fissure. They are particularly rare in males and an anterior fissure in a man should prompt a search for an underlying cause.

Question 11

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

Answer 11

Chemotherapy followed by surgical resection

Liver metastasis from colorectal cancer are still potentially curable.

Radiofrequency ablation is an option for those patients who lack the physiological reserve for surgery. However, there is a higher longer term recurrence rates with all the non resectional strategies. There is no role for radiotherapy.

Question 12

A 23 year old man presents with diarrhoea and passage of mucous. He is suspected of having ulcerative colitis. Which of the following is least likely to be associated with this condition?

Superficial mucosal inflammation in the colon
Significant risk of dysplasia in long standing disease
Episodes of large bowel obstruction during acute attacks
Haemorrhage
Disease sparing the anal canal

Answer 12

Episodes of large bowel obstruction during acute attacks

Large bowel obstruction is not a feature of UC, patients may develop megacolon. However, this is a different entity both diagnostically and clinically. Ulcerative colitis does not affect the anal canal and the anal transitional zone. Inflammation is superficial. Dysplasia can occur in 2% overall, but increases significantly if disease has been present over 20 years duration. Granulomas are features of crohn’s disease.

Other features:
Disease maximal in the rectum and may spread proximally
Contact bleeding
Longstanding UC crypt atrophy and metaplasia/dysplasia

Question 13

What is the main risk factor for the development of anal cancer?

Smoking
Ano-receptive intercourse
Immunosuppression
Infection with Epstein Barr virus
Infection with Human Papilloma virus

Answer 13

Infection with Human Papilloma virus

Anal cancer is strongly associated with HPV 16 infection

Question 14

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

Answer 14

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.

Question 15

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

Answer 15

Formation of a loop colostomy

Avoid emergency resections in large bowel obstruction due to rectal cancer

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).

Question 16

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

Answer 16

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.

Question 17

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

Answer 17

Angiodysplasia
Angiodysplasia can be difficult to identify and treat. The colonoscopic stigmata are easily missed by poor bowel preparation.

Question 18

A 24 year old man presents with a 10 day history of right sided abdominal pain. Prior to this he was well. On examination, he has a low grade fever and a mass palpable in the right iliac fossa. The rest of his abdomen is soft. An abdominal USS demonstrates matted bowel loops surrounding a thickened appendix. What is the best course of action?

Arrange a laparotomy and right hemicolectomy
Perform a laparoscopic appendicectomy
Perform an open appendicectomy
Manage conservatively with antibiotics
Arrange a colonoscopy

Answer 18

Manage conservatively with antibiotics

This man is likely to have an appendix mass. There is no history suggestive of inflammatory bowel disease. These are usually managed without surgery, especially in the absence of peritoneal signs. Broad spectrum antibiotics are required. In the past an interval appendicectomy was performed. This is rare now and in most cases the process resolves with fibrosis of the appendix.

Administration of metronidazole reduce wound infection rate

Question 19

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

Answer 19

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).

Question 20

A 59 year old man presents with recurrent episodes of urinary sepsis. In his history he mentions that he has suffered from recurrent attacks of left iliac fossa pain over the past few months. He has also notices bubbles in his urine. He undergoes a CT scan which shows a large inflammatory mass in the left iliac fossa. No other abnormality is detected. The most likely diagnosis is:

Ulcerative colitis
Crohns disease
Mesenteric ischaemia
Diverticular disease
Rectal cancer

Answer 20

Diverticular disease
is one of the commonest causes of colovesical fistula

Recurrent attacks of diverticulitis may cause the development of local abscesses which may erode into the bladder resulting in urinary sepsis and pneumaturia. This would be an unusual presentation from Crohns disease and rectal cancer would be more distally sited and generally evidence of extra colonic disease would be present if the case were malignant and this advanced.

Question 21

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

Answer 21

Topical GTN paste

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.

Question 22

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

Answer 22

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.

Question 23

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

Answer 23

Fistula in ano

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.

Question 24

A 39 year old man has suffered from terminal ileal Crohns disease for the past 20 years. Which condition is he least likely to develop?

Gallstones
Malabsorption
Pyoderma gangrenosum
Amyloidosis
Feltys syndrome

Answer 24

Feltys syndrome

Feltys syndrome:
Rheumatoid disease
Splenomegaly
Neutropenia

Feltys syndrome is associated with rheumatoid disease. Individuals with long standing Crohns disease are at risk of gallstones because of impairment of the enterohepatic recycling of bile salts. Formation of entero-enteric fistulation may produce malabsorption. Amyloidosis may complicate chronic inflammatory states.

Question 25

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 ```

Answer 25

Solitary rectal ulcer syndrome 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.

Question 26

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 ```

Answer 26

Injection of botulinum toxin The next most appropriate management option when GTN or other topical nitrates has failed is to consider botulinum toxin injection. In males a lateral internal sphincterotomy would be an acceptable alternative. In a female who has yet to conceive this may predispose to delayed increased risk of sphincter dysfunction. Division of the external sphincter will result in faecal incontinence and is not a justified treatment for fissure.

Question 27

A 19 year old lady has a long standing history of diarrhoea and weight loss. She is investigated with an 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 ```

Answer 27

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. It is likely that this lady has terminal ileal disease. Although first presentation of Crohns disease is usually managed with IV steroids, these have been trialed here and failed. A resection will remove the stricturing disease. If proximal small bowel disease has not been excluded pre-operatively then this must be evaluated during surgery to exclude other small bowel strictures. Note that since the endoscopist could not enter the terminal ileum, the ICV is also involved and this means some form of right sided colonic resection is needed. It is not appropriate to simply excise the valve and small bowel and then proceed to an ileocolic anastomosis at the site of the old ICV.

Question 28

Which of the following is not an extraintestinal feature of Crohns disease? ``` Iritis Clubbing Aphthous ulcers Erythema multiforme Pyoderma gangrenosum ```

Answer 28

Pyoderma gangrenosum Extraintestinal manifestation of inflammatory bowel disease: A PIE SAC ``` Aphthous ulcers Pyoderma gangrenosum Iritis Erythema nodosum Sclerosing cholangitis Arthritis Clubbing ```

Question 29

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 proctocolectomy 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

Answer 29

Pan proctocolectomy and construction of an ileo anal pouch Don't confuse AP resection and proctectomy. The former is a cancer related procedure. 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.

Question 30

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

Answer 30

Proceed to abdomino-perineal excision of the colon and rectum (ELAPE) 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.

Question 31

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 ```

Answer 31

Ischaemic colitis The inferior mesenteric artery may have been ligated and being an arteriopath collateral flow through the marginal may be imperfect.

Question 32

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 ```

Answer 32

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.

Question 33

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

Answer 33

Leave in situ until the cancer has been resected Dysplasia and cancer are not the same disease. All colonic adenomas are dysplastic. Adenomas greater than 2cm may harbor foci of malignancy within them. However, many have dysplastic cells only. These do not require segmental resection. When a cancer has been identified during endoscopy, it is safest to avoid undertaking polyp interventions as there is a risk of seeding. In summary, do NOT remove polyps until after the cancer has been resected.

Question 34

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

Answer 34

Construction of a loop colostomy 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. This patient should be defunctioned, definitive surgery should wait until staging is completed. A loop ileostomy will not satisfactorily decompress an acutely obstructed colon. Low rectal cancers that are obstructed should not usually be primarily resected. The obstructed colon that would be used for anastomosis would carry a high risk of anastomotic dehiscence. In addition, as this is an emergency presentation, staging may not be completed, an attempted resection may therefore compromise the circumferential resection margin, with an associated risk of local recurrence.

Question 35

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

Answer 35

Laparotomy, sigmoid colectomy and formation of end colostomy 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.

Question 36

Which of the following is seen more commonly with Crohns disease rather than ulcerative colitis? ``` Mucosal islands at endoscopy Goblet cell depletion on biopsy Fat wrapping of the terminal ileum Attenuated symptoms in smokers Toxic megacolon ```

Answer 36

Fat wrapping of the terminal ileum Crohns disease is worse in smokers and smoking is an independent risk factor for disease recurrence following resection. Fat wrapping of the terminal ileum is commonly seen in patients with ileal disease (the commonest disease site). The mesenteric fat in patients with IBD is often dense, hard and prone to considerable haemorrhage during surgery. At endoscopy, the mucosa in patients with Crohns disease is said to resemble cobblestones, mucosal islands (pseudopolyps) are seen in ulcerative colitis.

Question 37

A 24 year old male was admitted with bloody diarrhea, cramping abdominal pain and weight loss. Colonoscopy revealed a friable, diffusely red mucosa involving the rectum and sigmoid colon. The mucosa was normal proximal to this. The disease progressed with time to involve most of the entire colon, but not the ileum. Many years later, a colonic biopsy shows high grade epithelial dysplasia. What is the most likely initial diagnosis? ``` Colonic tuberculosis Collagenous colitis Ulcerative colitis Crohns disease Ischaemic colitis ```

Answer 37

Ulcerative colitis Ulcerative colitis spreads in a progressive distal to proximal manner. Over time a dysplastic transformation is recognised. Such endoscopic findings mandate a minimum of close endoscopic surveillance and if they occur in association with a colonic mass then usually a pancproctocolectomy.

Question 38

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 ```

Answer 38

Extended right hemicolectomy Standard right hemicolectomy involves colonic division to the right of the middle colic vessels Extended right hemicolectomy involves division of the middle colic vessels and usually resection of the splenic flexure as well. 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.

Question 39

A 78 year old man has undergone a hemi-arthroplasty for an 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 ```

Answer 39

Ogilvies syndrome 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.

Question 40

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 ```

Answer 40

Crohns proctitis The history of a right sided resection and 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.

Question 41

A 56 year old man undergoes a difficult splenectomy and is left with a pancreatic fistula. There are ongoing problems with very high fistula output. Which of the following agents may be administered to reduce the fistula output? ``` Metoclopramide Erthyromycin Octreotide Loperamide Omeprazole ```

Answer 41

Octreotide Octreotide is a useful agent in reducing the output from pancreatic fistulae. Prokinetic agents will increase fistula output and should be avoided.

Question 42

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.

Answer 42

In a patient with an acute abscess the Bascoms procedure is the treatment of choice. When performing incision and drainage for pilonidal abscess try to avoid making the incision in the midline of the natal cleft. 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.

Question 43

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 ```

Answer 43

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. TIPSS may be considered. Whilst band ligation is an option, attempting to inject these in same way as haemorroids would carry a high risk of precipitating further haemorrhage.

Question 44

A 45 year old man develops a colocutaneous fistula following reversal of a loop colostomy fashioned for the defunctioning of an anterior resection. Pre-operative gastrograffin enema showed no distal obstruction or anastomotic stricture. What is the best course of action? Make the patient nil by mouth and commence total parenteral nutrition Provide local wound care and await spontaneous resolution Undertake a laparotomy and resect the fistula Construct a loop ileostomy Re-construct the loop colostomy

Answer 44

Provide local wound care and await Fistulas are more likely to heal in the absence of distal luminal obstruction Colocutaneous fistulae may occur as a result of anastomotic leakage following loop colostomy reversal. In the absence of abdominal signs a laparotomy is not necessarily required. Signs of wound sepsis may require antibiotics. Because there is not any distal obstruction (note normal pre-operative gastrograffin enema) these fistulae will usually close spontaneously.

Question 45

A 53 year old man has a 1cm polyp identified and completely removed during a colonoscopy. Histology confirms a low grade adenoma. What is the correct follow up? Suggest participation in bowel cancer screening but no further routine endoscopy Repeat endoscopy in 5 years. Repeat endoscopy in 3 years. Segmental resection of the affected area. Barium enema at 5 years.

Answer 45

Suggest participation in bowel cancer screening but no further routine endoscopy In the UK, the guidance has now changed and patients like this are managed expectantly with suggestion that they participate in bowel cancer screening programmes.

Question 46

You are the specialist trainee asked to review a 39 year old man post gastrectomy for bleeding duodenal ulcers. He is hypotensive and tachycardic. His drain has increased output, contains pus and has bubbles. There is excoriated skin around the drain site. What is the explanation for this presentation? ``` Distal enterocutaneous fistula Superficial wound infection Proximal enterocutaneous fistula Entero-enteric fistula Colocutaneous fistula ```

Answer 46

Proximal enterocutaneous fistula Suspect an enterocutaneous fistula if there is excessive drainage and bubbles. Pus may confuse surgeons, leading them to make a diagnosis of wound infection. If there is any uncertainty, methylene blue can be given. If methylene blue is found in the drain, this confirms a fistula.

Question 47

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 ```

Answer 47

Excisional haemorrhoidectomy Prolapsed haemorroids are best managed surgically if symptomatic. Note that phenol injections are usually only used for minor internal haemorroids. Where phenol is used, low concentration phenol in oil is the correct agent, the 80% phenolic solution above is used to ablate the nail bed in toe nail surgery! Either way, phenol does not work for haemorrhoidal disease in general.

Question 48

You embark on a laparoscopic appendicectomy and find an inflammatory appendix mass. There is no free fluid and the patient has no evidence of peritonitis. What is the best course of action? 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

Answer 48

Place a drain laparoscopically and administer parenteral antibiotics Attempt conservative management for appendix mass without peritonitis. 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.

Question 49

A 33 year old lady presented with jaundice secondary to common bile duct stones. A cholecystectomy and common bile duct exploration is performed and the bile duct closed over a T tube. Six weeks post operatively a T tube cholangiogram is performed and shows no residual stones. The T tube is removed and five hours after removal a small amount of bile is noted to be draining from the T tube site. What is the best course of action? ``` Await spontaneous resolution Arrange an MRCP Arrange an ERCP Return to theatre for CBD exploration Re-insert the T tube ```

Answer 49

Await spontaneous resolution When the bile duct is closed over a T Tube the latex in the T tube encourages tract fibrosis. This actually encourages a fistula to develop. The result is that when the tube is removed any bile which leaks will usually drain through the tract. Provided that there are no residual stones in the duct the fistula will slowly close. Persistent high volume drainage may be managed with ERCP and sphincterotomy.

Question 50

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

Answer 50

Undertake a sub total colectomy and end ileostomy Pan proctocolectomy should not be performed in acute unwell patients Loop ileostomy is not conventional management of UC 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. To undertake a pan proctocolectomy in an acutely unwell patient is very high risk and most unwise. Management of the rectum is generally left until the patient is more stable.

Question 51

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 ```

Answer 51

Chemotherapy followed by surgical resection Patients with colorectal cancer and liver metastasis can still be treated. They should be staged with a PET scan in addition to standard staging. 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.

Question 52

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

Answer 52

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.

Question 53

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 ```

Answer 53

Insertion of a loose seton Fistula in ano in patients with Crohns disease should be managed with insertion of seton. In patients with IBD, management of fistula should be minimalistic and complex procedures best avoided. Laying open fistulas in this situation is likely to result in a chronic and non healing wound.

Question 54

An 82 year old lady presents with a carcinoma of the caecum. Approximately what proportion of patients presenting with this diagnosis will have synchronous cancer? ``` <1% 60% 50% 20% 5% ```

Answer 54

5% Synchronous colonic tumours are seen in 5% cases and all patients having a flexible sigmoidoscopy should have completion colonoscopy if tumours or polyps are found Synchronous lesions may occur in up to 5% of patients with colorectal cancer. A full and complete lumenal study with either colonoscopy, CT cologram or barium enema is mandatory in all patients being considered for surgery.

Question 55

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 ```

Answer 55

Repeat endoscopy in 3 years She is in the high risk group and according to the 2020 guidelines should undergo endoscopy at 3 years.

Question 56

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 ```

Answer 56

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.

Question 57

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 ```

Answer 57

Tuberculosis Causes of pruritus ani: Causes: Systemic (DM, Hyperbilirubinaemia, aplastic anaemia) Mechanical (diarrhoea, constipation, anal fissure) Infections (STDs) Dermatological Drugs (quinidine, colchicine) Topical agents

Question 58

Which of the following is not a typical feature of acute appendicitis? ``` Neutrophilia Profuse vomiting Anorexia Low grade pyrexia Small amounts of protein on urine analysis ```

Answer 58

Profuse vomiting Profuse vomiting and diarrhoea are rare in early appendicitis Whilst patients may vomit once or twice, profuse vomiting is unusual, and would fit more with gastroenteritis or an ileus. A trace of protein is not an uncommon occurrence in acute appendicitis. A free lying pelvic appendix may result in localised bladder irritation, with inflammation occurring as a secondary phenomena. This latter feature may result in patients being incorrectly diagnosed as having a urinary tract infection. A urine dipstick test is useful in differentiating between the two conditions.

Question 59

``` A 63 year old man presents with a 48 hour history of right iliac fossa pain. On examination he has a low grade pyrexia and is tender with some voluntary guarding in the right iliac fossa. Some of his blood tests are reproduced below: Hb 81 WCC 13.8 Platelets 438 Albumin 22 CRP 24 What is the best course of action? ``` ``` Undertake a laparotomy and right hemicolectomy Undertake a laparoscopic appendicectomy Arrange a CT scan Undertake an open appendicectomy Arrange a colonoscopy ```

Answer 59

Arrange a CT scan In the UK Hb units are g/L so the value of 81 is how this would typically be expressed. This man's investigations point to a more longstanding disease process (Hb and albumin), right sided colonic cancer being the most likely. For this reason a CT scan is a sensible option as it will adjust the surgical planning.

Question 60

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 ```

Answer 60

Sub total colectomy and end ileostomy This man requires surgery to remove the bleeding segment of bowel. Medical management has failed here. Note that a pan proctocolectomy is not a suitable option in the emergency setting because there is increased morbidity from the pelvic dissection. In the unlikely event that a sub total colectomy did not address the bleeding then consideration may have to be given to removal of the rectum but this would not usually be the case. Note that in this case, there is not really any benefit to be derived from imaging, endoscopy would be very dangerous and risk perforation as the bowel would be very friable.

Question 61

Which of the following features are not typical of Crohns disease? ``` Complex fistula in ano Small bowel strictures Skip lesions 'Rose thorn ulcers' on barium studies Pseudopolyps on colonoscopy ```

Answer 61

Pseudopolyps on colonoscopy Pseudopolyps are a feature of ulcerative colitis and occur when there is severe mucosal ulceration. The remaining islands of mucosa may then appear to be isolated and almost polypoidal.

Question 62

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

Answer 62

Inflammatory bowel disease 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.

Question 63

A 43 year old man has suffered from small bowel Crohns disease for 15 years. Following a recent stricturoplasty he develops an enterocutaneous fistula which is high output. Small bowel follow through shows it to be 15 cm from the DJ flexure. His overlying skin is becoming excoriated. What is the best course of action? Undertake a further laparotomy and construct a proximal diverting stoma Commence high dose steroids Commence TPN and octreotide Undertake a laparotomy and resect the affected segment Perform a small bowel bypass procedure

Answer 63

Commence TPN and octreotide This man has a high output and anatomically high fistula. Drying up the fistula with octreotide will not suffice, his nutrition is compromised and TPN will help.

Question 64

What is the commonest type of fistula in ano? ``` Trans-sphincteric Supra levator Complex supra levator Intersphincteric Suprasphincteric ```

Answer 64

Intersphincteric 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.

Question 65

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

Answer 65

Arrange a CT angiogram 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.

Question 66

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 ```

Answer 66

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.

Question 67

A 75 year old lady is admitted with large bowel obstruction. She was 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

Answer 67

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.

Question 68

What is the commonest tumour type encountered in the colon? ``` Squamous cell carcinoma Adenocarcinoma Lymphoma Anaplastic carcinoma Sarcoma ```

Answer 68

Adenocarcinoma | Adenocarcinoma are the most common and typically arise as a result of the adenoma - carcinoma sequence.

Question 69

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 ```

Answer 69

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)

Question 70

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 ```

Answer 70

Proctectomy 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.

Question 71

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 ```

Answer 71

Malignant transformation 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.

Question 72

A 22 year old man presents with a discharging area on his lower back. On examination there is an epithelial defect located 6cm proximal to the tip of his coccyx and located in the midline. There are two further defects located about 2cm superiorly in the same position. He is extremely hirsute. What is the most likely diagnosis? ``` Pre sacral tumour Sacrococcygeal teratoma Pilonidal sinus Fistula in ano Occult spina bifida ```

Answer 72

Pilonidal sinus Pilonidal sinuses are extremely common in hirsute individuals and typically present as midline sinuses in the natal cleft.

Question 73

What is the commonest malignant tumour of the anal canal? ``` Lymphoma Melanoma Squamous cell carcinoma Adenocarcinoma Sarcoma ```

Answer 73

Squamous cell carcinoma Anal cancers are usually squamous cell carcinomas

Question 74

A 67 year old man has had multiple episodes of 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 ```

Answer 74

Diverticular 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.

Question 75

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

Answer 75

Undertake a pan proctocolectomy 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.

Question 76

A 2 week infant has foul smelling material discharging from the umbilicus. What is the underlying problem? ``` Proximal enterocutaneous fistula Distal enterocutaneous fistula Entero-enteric fistula Colo-cutaneous fistula Vesico cutaneous fistula ```

Answer 76

Distal enterocutaneous fistula This baby has an enterocutaneous fistula at the umbilicus due to complete failure of the omphalomesenteric duct to obliterate. This is treated with resection. Remember that vitello intestinal duct anomalies are common and these are always distal.

Question 77

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 ```

Answer 77

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.

Question 78

Which of the following genes is not implicated in the adenoma-carcinoma sequence in colorectal cancer? ``` IGF1 gene c-myc APC p53 K-ras ```

Answer 78

IGF1 gene IGF1 gene mutation is implicated in some HNPCC tumours but not in the adenoma- carcinoma sequence. Other genes involved are: MCC DCC c-yes bcl-2

Question 79

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 ```

Answer 79

Fissure in ano 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.

Question 80

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 ```

Answer 80

Neostigmine 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.

Question 81

A 56 year old lady has just undergone a colonoscopy and a 1.5cm lesion was identified in the caecum. The histology report states that biopsies have been taken from a sessile serrated polyp with traditional features. What is the best management option? ``` Perform a right hemicolectomy List the patient for colonoscopic polypectomy Discharge the patient Re scope the patient in 6 months Re scope the patient at 3 years ```

Answer 81

List the patient for colonoscopic polypectomy These polyps represent an alternative pathway to progression to carcinoma and may be diagnostically confused with hyperplastic polyps. Hyperplastic polyps are more common in the left colon and confer no increased risk. SSA's are more common in the right colon and are usually larger. Those with 'traditional features' on histology have dysplasia with increased risk of malignant transformation.

Question 82

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 ```

Answer 82

Anal cancer 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.

Question 83

A 4 year old girl is admitted with lethargy and abdominal pain. On examination, she is febrile, temperature 38.1oC, pulse rate is 150 and blood pressure is 100/60. Her abdomen is soft but there is some right sided peritonism. Her WCC is 14 and urinanalysis is positive for leucocytes but is otherwise normal. What is the best course of action? Manage as urinary tract infection with oral antibiotics Manage as urinary tract infection with intravenous antibiotics Take to theatre for appendicectomy within 6 hours Undertake ultrasound scan Admit for serial clinical examination

Answer 83

Take to theatre for appendicectomy within 6 hours Children with appendicitis do not localize in the same way as adults and often the diagnosis is difficult and all too often made late. The findings of right sided peritonism are ominous and the low grade fever and tachycardia and WCC are strongly suggestive of appendicitis. The findings of an isolated leukocytosis are suggestive of appendicitis over UTI. The diagnosis of appendicitis is clinical and undertaking imaging is not going to change management which should comprise appendicectomy, this should be undertaken promptly.

Question 84

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 ```

Answer 84

Proctalgia fugax 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.

Question 85

A 55 year old man presents with tenesmus and rectal bleeding. On examination he has a large bulky rectal cancer at 5cm from the anal verge 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

Answer 85

Long course chemoradiotherapy 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.

Question 86

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 ```

Answer 86

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

Question 87

What is the earliest complication that can occur following construction of an ileostomy? ``` Prolapse Retraction Necrosis Parastomal hernia Dermatitis ```

Answer 87

Necrosis Read the question very carefully here. We did not ask for the most common complication, rather, we asked for the earliest one. Dermatitis is the most common, but its not the earliest. The earliest complications are vascular ones and these usually occurs as a result of either inadvertent mesenteric division or as a result of a stoma thats too tight. Construction of a stoma may be complicated by several factors. Necrosis may occur because of technical errors in mesenteric division, excessive tension or failure to construct a fascial defect of adequate size to permit safe passage of the mesentery and the bowel.

Question 88

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 ```

Answer 88

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

Question 89

At which of the following sites is the development of diverticulosis least likely? ``` Caecum Ascending colon Transverse colon Sigmoid colon Rectum ```

Answer 89

Rectum Rectal involvement with diverticular disease almost never occurs Because the rectum has a longitudinal muscle coat (blending of the tenia marks the recto-sigmoid junction), diverticular disease almost never occurs here. Right sided colonic diverticular disease is well recognised (though less common than left sided).

Question 90

A 43 year old female presents with recurrent urinary tract infections. She describes blood and frothy urine. She is 6 weeks post operative for a left hemicolectomy for crohn's disease. What is the most likely reason for this presentation? ``` Colovesical fistula Enterovesical fistula Entero-entero fistula Entero-colic fistula Vesico-cutaneous fistula ```

Answer 90

Colovesical fistula The commonest event here is an anastomotic leak. It is possible that the patient (who has Crohns) originally had a colovesical fistula that was then addressed with a resection. In the event that these leak, the fistula reforms.

Question 91

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 ```

Answer 91

Topical GTN 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.

Question 92

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 ```

Answer 92

Diverticular disease Diverticular disease is the commonest cause of lower GI bleeding in adults.

Question 93

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 ```

Answer 93

Right hemicolectomy 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.

Question 94

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 at 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 ```

Answer 94

Fissure in ano 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.

Question 95

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

Answer 95

Conservative management with close observation Most lower GI bleeds occur secondary to diverticular disease and will settle with conservative management. Attempts at endoscopic haemostasis are usually unsuccessful.

Question 96

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 ```

Answer 96

Arrange a CT colonoscopy 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.

Question 97

Which of the following cell types is most likely to be identified in the wall of a fistula in ano? ``` Squamous cells Goblet cells Columnar cells Ciliated columnar cells None of the above ```

Answer 97

Squamous cells A fistula is an abnormal connection between two epithelial lined surfaces, in the case of a fistula in ano it will be lined by squamous cells.

Question 98

As a busy surgical trainee on the colorectal unit you are given the unenviable task of reviewing the unit's histopathology results for colonic polyps. Which of the polyp types described below has the greatest risk of malignant transformation? ``` Hyperplastic polyp Tubular adenoma Villous adenoma Hamartomatous polyp Pseudopolyp ```

Answer 98

Villous adenoma Villous adenomas carry the highest risk of malignant transformation. Hyperplastic polyps carry little in the way of increased risk. Although, patients with hamartomatous polyp syndromes may have a high risk of malignancy, the polyps themselves have little malignant potential.

Question 99

What is the commonest site in the abdomen for fluid to collect following a perforated appendix? ``` Pelvis Hepatorenal pouch Between small bowel loops Right iliac fossa Lesser sac ```

Answer 99

Pelvis Following perforated appendicitis fluid is most likely to accumulate in the pelvis. Fluid may accumulate in the hepatorenal pouch although this is less common. Gravity favors the pelvis as the site of most collections. The incidence of these is higher with laparoscopic rather than open surgery.