Colorectal Sx

Question 1

Bright red rectal bleeding that occurs post defecation onto the paper and into the pan.DRE normal.

Answer 1

Haemorrhoids.
GRADE1&2 impalpable on DRE.
Location: 3, 7, 11 o’clock position
Internal or external
Treatment: Conservative, Rubber band ligation, Haemorrhoidectomy.

Question 2

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?

Answer 2

Exicional Haemorroidectomy.

Prolapsed haemorroids are best managed surgically if symptomatic.

Question 3

Pruritus ani

Answer 3

Causes:

Systemic (DM, Hyperbilirubinaemia, aplastic anaemia)
Mechanical (diarrhoea, constipation, anal fissure)
Infections (STDs)
Dermatological
Drugs (quinidine, colchicine)
Topical agents

Question 4

Colonic polyp is identified.
It has a lobular appearance and is located on a stalk in the sigmoid colon.

Answer 4

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 5

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?

Answer 5

T4 rectal cancers are managed with long course chemoradiotherapy.

This has a major impact in rectal cancer treatment and many patients will be offered neoadjuvent radiotherapy (both long and short course) prior to resectional surgery.

Question 6

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?

Answer 6

PAN PROCTOCOLECTOMY 7 ILEOANAL 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.

Question 7

A 55 year old man is found to have an anal cancer.
His staging investigations show a T2 lesion with no metastatic disease.
What is the most appropriate treatment?

Answer 7

Combined chemoradiotherapy is the standard treatment for anal cancer
First line treatment for anal cancer (which is very different from rectal cancer) is radical chemoradiotherapy.

Question 8

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.

Answer 8

NOTE AGE GENDER.
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 9

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.

Answer 9

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.

Question 10

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?

Answer 10

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 11

Carcinoma of the caecum. Approximately what proportion of patients presenting with this diagnosis will have synchronous cancer?

Answer 11

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 12

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?

Answer 12

Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin.

Question 13

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

Answer 13

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 14

A/ 56 year old man presents with his first attack of diverticulitis. Which of these complications?

Answer 14

Complications:
Diverticulitis
Haemorrhage
Development of fistula
Perforation and faecal peritonitis
Perforation and development of abscess
Development of diverticular phlegmon

Question 15

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?

Answer 15

CT Abdomen Pelvis

Question 16

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?

Answer 16

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

Apart from bleeding, which may be massive, these arteriovenous lesions cause little in the way of symptoms. The right side of the colon is more commonly affected.

Question 17

Recurrent episodes of knife like pain within his rectum. On examination, there is no abnormality to find on either proctoscopy or palpation.

Answer 17

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 18

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?

Answer 18

Sx then Chemo.
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 a higher longer term recurrence rates with all the non resectional strategies. There is no role for radiotherapy.

Question 19

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?

Answer 19

Medical Mx
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 20

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?

Answer 20

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 21

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?

Answer 21

Pilonidal sinus

Occur as a result of hair debris creating sinuses in the skin (Bascom theory).
Usually in the natal cleft of male patients after puberty.
It is more common in Caucasians.
The opening of the sinus is lined by squamous epithelium, but most of its wall consists of granulation tissue. Up to 50 cases of squamous cell carcinoma have been described in patients with chronic pilonidal sinus disease.
Hairs become trapped within the sinus.
Clinically the sinus presents when acute inflammation occurs, leading to an abscess. Patients may describe cycles of being asymptomatic and periods of pain and discharge from the sinus. Definitive treatment should never be undertaken when acute infection or abscess is present as this will result in failure.
Definitive treatments include the Bascom procedure (can’t be done during acute sepsis with abscess) with excision of the pits and obliteration of the underlying cavity. The Karydakis procedure involves wide excision of the natal cleft such that the surface is recontoured once the wound is closed. This avoids the shearing forces that break off the hairs and has reasonable results.