GIT Mock Flashcards
A 55 year old man with dyspepsia undergoes an upper GI endoscopy. An irregular erythematous area is seen to protrude proximally from the gastro-oesophageal junction. Apart from specialised intestinal metaplasia, which of the following cell types should also be present for a diagnosis of Barretts oesophagus to be made?
Goblet cell Neutrophil Lymphocytes Epithelial cells Macrophages
Goblet cells need to be present for a diagnosis of Barrett’s oesophagus to be made.
A 52 year old man with long standing Barretts oesophagus is diagnosed with high grade dysplasia on recent endoscopy. The lesions are multifocal and mainly distally sited. What is the best course of action?
Endoscopic surveillance at 3 monthly intervals Photodynamic therapy Nissens fundoplication Oesophagectomy External beam radiotherapy
Some may argue for local therapy. However, in young patients who are otherwise fit, multifocal disease such as this should probably be resected.
OESOPHAGECTOMY
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. 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.
What proportion of patients presenting for cholecystectomy for treatment of biliary colic due to gallstones will have stones in the common bile duct?
10% 30% 2% 50% 25%
Up to 10% of all patients may have stones in the CBD. Therefore, all patients should have their liver function tests checked prior to embarking on a cholecystectomy.
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
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.
Which of the following is not an extraintestinal feature of Crohns disease?
Iritis Clubbing Aphthous ulcers Erythema multiforme Pyoderma gangrenosum
ERYTHEMA
Extraintestinal manifestation of inflammatory bowel disease: A PIE SAC
Aphthous ulcers Pyoderma gangrenosum Iritis Erythema nodosum Sclerosing cholangitis Arthritis Clubbing
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?
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
First line treatment for anal cancer (which is very different from rectal cancer) is radical chemoradiotherapy.
An 82 year old man presents with dysphagia. He is investigated and found to have an adenocarcinoma of the distal oesophagus. His staging investigations have revealed a solitary metastatic lesion in the right lobe of his liver. What is the best course of action?
Arrange a PET CT scan
Arrange an endoscopic ultrasound
Assess fitness for liver resection prior to oesophagectomy
Assess fitness for oesophagectomy followed by liver resection
Insertion of metallic stent
T
he presence of distant disease in the context of oesophageal cancer renders him incurable. Further staging is not needed and surgery is not an option. Palliation is the preferred option and a metallic stent will achieve this.
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.
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.
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 banding
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 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
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.
The cell of origin in virtually all pancreatic carcinomas is which of the following?
The acinar cells The islet beta cells The islet alpha cells The interstitial fibroblasts The ductular epithelium
Over 90% of pancreatic carcinomas are adenocarcinomas and are thus of ductular epithelial origin.
During an Ivor Lewis Oesophagectomy for carcinoma of the lower third of the oesophagus which structure is divided to allow mobilisation of the oesophagus?
Vagus nerve Azygos vein Right inferior lobar bronchus Phrenic nerve Pericardiophrenic artery
The azygos vein is routinely divided during an oesophagectomy to allow mobilisation. It arches anteriorly to insert into the SVC on the right hand side.
A 68 year old man presents with iron deficiency anaemia. Which of these sites is most likely to require a biopsy in order to identify the underlying cause?
Duodenum Ileum Antrum Jejunum Right colon
In older adults, colorectal cancer is a major cause of iron deficiency anaemia and the right colon is the major site of occult blood loss. For this reason, colonic imaging is the first line investigation in such cases.
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
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.
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
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.
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 1 year old child has been unwell with a sore throat and fever for several days. He progresses to develop periumbilical abdominal discomfort and passes diarrhoea. The paediatricians call you because the ultrasound has shown a ‘target sign’ on the right side of the abdomen. What is the best initial course of action
Obtain intravenous access, administer fluids and antibiotics Undertake urgent fluoroscopic reduction Undertake urgent hydrostatic reduction Undertake a colonoscopy Undertake a laparotomy
Always ensure that children with intussusception are resuscitated first. Administration of antibiotics is also important. This should precede any intervention
A 1 year old child has been unwell with a sore throat and fever for several days. He progresses to develop periumbilical abdominal discomfort and passes diarrhoea. The paediatricians call you because the ultrasound has shown a ‘target sign’ on the right side of the abdomen. What is the best initial course of action
Obtain intravenous access, administer fluids and antibiotics Undertake urgent fluoroscopic reduction Undertake urgent hydrostatic reduction Undertake a colonoscopy Undertake a laparotomy
Always ensure that children with intussusception are resuscitated first. Administration of antibiotics is also important. This should precede any intervention
An 82 year old lady is taken to theatre for a common bile duct exploration. She has a stone impacted at the distal aspect of the common bile duct and despite best efforts it proves impossible to remove it. What is the best course of action?
Close the bile duct over a T Tube and arrange for a stent to be placed Undertake a choledochoduodenostomy Arrange for a repeat ERCP Construct a hepaticojejunostomy Bypass the gallbladder onto the jejunum
If a stone cannot be removed at surgery then the chances of succeeding at ERCP are slim. In this case, its probably best to bypass the distal bile duct and a choledochoduodenostomy is the best way of achieving this. There are long term risks of cholangitis which are less of a concern in older patients.
A 21 year old male is admitted with a 3 month history of intermittent right iliac fossa pain. He suffers from episodic diarrhoea and has lost 2 kilos in weight. On examination, he has some right iliac fossa tenderness and is febrile. What is the most likely cause?
Appendicitis Irritable bowel syndrome Inflammatory bowel disease Infective gastroenteritis Meckels diverticulum
The history of weight loss and intermittent diarrhea makes inflammatory bowel disease the most likely diagnosis. Conditions such as appendicitis and infections have a much shorter history. Although Meckels can bleed and cause inflammation, they seldom cause marked weight loss.
A 34 year old woman presents with recurrent peptic ulceration. She is on proton pump inhibitors and previously received Helicobacter pylori eradication therapy three months ago. Which of the following is likely to be raised on venous blood testing?
Secretin Cholecystokinin Gastrin Amylase Histamine
It is likely that this patient has an MEN I type gastrinoma (female, young age). As such, the serum gastrin levels are likely to be elevated.
Which of the following strategies is not employed in the management of acutely bleeding oesophageal varices?
Endoscopic sclerotherapy Intravenous vasopressin Intravenous beta blockers Endoscopic rubber band ligation of varices Insertion of Sengstaken Blakemore tube
Intravenous beta blockers are not typically used to manage an acute event, their value lies in prophylaxis by lowering portal venous pressure.
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
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).
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%
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.
A 34 year old lady is undergoing a laparoscopic cholecystectomy for cholecystitis. She has been unwell for the past 10 days. On attempting to dissect the gallbladder (which is distended), all that can be seen are the gallbladder fundus and dense adhesions make it difficult to dissect Calots triangle. What is the best course of action?
Perform an operative cholecystostomy
Dissect the adhesions off Calots triangle and continue with the cholecystectomy
Dissect out the bile duct and perform a cholangiogram
Arrange an ERCP
Arrange a PTC
Do not confuse cholecystostomy with cholecystectomy its a very common error and people lose easy marks as a result. Note the correct answer is cholecystostomy.
The timeframe of 10 days makes attempts at proceeding with surgery hazardous even in experienced hands. However, the patient is unwell and this will not settle without some form of intervention. If only the fundus can be seen, then it may be difficult to even proceed with a sub total cholecystectomy. Therefore, a cholecystostomy can be performed and this will usually allow the situation to settle. Definitive surgery can then be undertaken in more favourable circumstances.
With which of the conditions listed below is Boas’ sign classically associated?
Perforation of the thoracic oesophagus Acute cholecystitis Hepatocellular carcinoma Closed loop small bowel obstruction Acute diverticulitis
Boas’ sign refers to hyperaesthesia of the tip of the right scapula and is seen classically in association with acute cholecystitis.
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
Probing fistulae during acute sepsis is associated with a high complication rate and should not be undertaken routinely.
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
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 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
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 55 year old man presents with symptoms of dyspepsia and on upper GI endoscopy an area of patchy erythematous tissue is identified extending proximally from the gastro oesophageal junction. A biopsy is diagnostic of Barretts oesophagus with low grade dysplasia. Which of the following is the most appropriate next step?
Distal oesophagectomy
Upper GI endoscopy with quadrantic biopsies from the region
Photodynamic therapy
Endoscopic sub mucosal resection of the area
Argon plasma coagulation
In Barrett’s surveillance the safest option is quadrantic (i.e. 4 biopsies, one from each quarter of the oesophagus at 2cm intervals)
Low grade dysplasia in conjunction with Barretts oesphagus should be monitored with regular (6 monthly) upper GI endoscopy and quadrantic biopsies. If the disease remains static at 2 years then the screening frequency may be decreased.
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.
Which of the following variables is not included in the Rockall score?
Congestive cardiac failure Liver failure Systolic blood pressure < 100mmHg Aspirin usage Age
Patients should have their Rockall score calculated following endoscopy for upper GI haemorrhage
Mnemonic for Rockall score ABCDE A: Age B: Blood pressure drop (Shock) C: Co-morbidity D: Diagnosis E: Evidence of bleeding Rockall Score
Applies to upper gastrointestinal bleeding
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.
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.
A 15-month-old girl presents with a three day history of periorbital oedema. She is brought to hospital. On examination she has facial oedema and a tender distended abdomen. Her temperature is 39oC and her blood pressure is 90/45 mmHg. There is clinical evidence of poor peripheral perfusion. What is the most likely diagnosis?
Sickle cell crisis Intussusception Spontaneous bacterial peritonitis Henoch Schonlein purpura Appendicitis
The 15-month-old girl is a patient with nephrotic syndrome. Patients with this condition are at risk of septicaemia and peritonitis from Streptococcus pneumonia, due to the loss of immunoglobulins and opsonins in the urine.
A 34-year-old HIV positive man is referred to the surgical out patient department with jaundice and abnormal liver function tests. Liver function tests are as follows:
Albumin 34 g/l
ALP 540 iu/l
Bilirubin 67 µmol/l
ALT 45 iu/l
What is the most likely diagnosis?
Hepatic abscess Fungal obstruction of the bile duct Duodenal adenoma Primary biliary cirrhosis Sclerosing cholangitis
The LFTs clearly show a cholestatic picture. Given the background of HIV the most likely cause is sclerosing cholangitis.
A 1 day old infant is born with severe respiratory compromise. On examination, he has a scaphoid abdomen and an absent apex beat. Which of the following anomalies is most likely?
Situs inversus Morgagni hernia Necrotising enterocolitis Bochdalek hernia Cystic fibrosis
Bochdalek hernia is a diseases of 3 P’s and 3 B’s
1- Birth defect (congenital)
2- Posterior located
3- Big
4- Bad Prognosis
5- Pulmonary hyPoPlais is common
6- Placement of mesh may be needed to treat
A hernia is the most likely diagnosis given the abdominal findings. The large hernia may displace the heart although true dextrocardia is not present. The associated pulmonary hypoplasia will compromise lung development.
A 34 year old lady is admitted with jaundice and undergoes an ERCP. The procedure is technically difficult and she is returned to the ward still jaundiced. Unfortunately she now has severe generalised abdominal pain. What is the best course of action?
Arrange abdominal MRI scan Arrange MRCP Arrange an abdominal CT scan Undertake a laparotomy Undertake a laparotomy and biliary bypass
There are two main differential diagnoses here. One is pancreatitis, repeated trauma to the ampulla and duct (if partially cannulated) is a major risk factor for pancreatitis. The second is the possibility that the duodenum has been perforated. ERCP is performed using a side viewing endoscope, the manipulation of which can be technically challenging for the inexperienced operator in a patient with abnormal anatomy. A CT scan is the best investigation to distinguish between these two differential diagnoses.
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.
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.
A 43 year old male with long standing chronic hepatitis is being followed up. Recently his AFP is noted to be increased and an abdominal USS demonstrates a 2cm lesion in segment V of the liver. What is the most appropriate course of action?
PET CT scan Liver MRI USS guided liver biopsy Laparoscopic biopsy Segmental resection of segment V
Liver lesions that are suspicious of HCC should be scanned prior to resection as there is a risk of multifocal lesions that would either preclude or otherwise affect the decision to proceed with segmental resection.
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
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 56 year old lady presents with a 6 month history of dysphagia to solids. She has a long history of retrosternal chest pain that is worse on lying flat and bending forwards. She undergoes an upper GI endoscopy where a smooth stricture is identified. What is the most likely diagnosis?
Globus Adenocarcinoma Leiomyoma Benign stricture Squamous cell carcinoma
6 MONTH - NOT CANCER
SMOOTH - NOT CANCER
Benign stricture!
A six month history of dysphagia is a relatively long history and makes malignancy less likely. The lesion should be biopsied for histological confirmation. Long standing oesophagitis may be complicated by the development of strictures, Barretts oesophagus or both.
A 15-month-old girl presents with a three day history of periorbital oedema. She is brought to hospital. On examination she has facial oedema and a tender distended abdomen. Her temperature is 39oC and her blood pressure is 90/45 mmHg. There is clinical evidence of poor peripheral perfusion. What is the most likely diagnosis?
Sickle cell crisis Intussusception Spontaneous bacterial peritonitis Henoch Schonlein purpura Appendicitis
OEDEMA = NEPHROTIC
NEPHROTIC = LOSS OF PROTEINS Aaaaand IG!
LOSS OF IG = SPONT PERITONITIS! (Strepp. pn.)
The 15-month-old girl is a patient with nephrotic syndrome. Patients with this condition are at risk of septicaemia and peritonitis from Streptococcus pneumonia, due to the loss of immunoglobulins and opsonins in the urine.
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
RECTAL CA EMERGENCY = ONLY LOOP COLOSTOMY. NO RESECTION!
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).
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.
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.
FISTULA + CROHN = SETTON
CUTTING SETON IS ONLY FOR HIGH FISTULA AND IS CONTRAVERSIAL
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.
A 58 year old man with long standing Barretts oesophagus is found to have a nodule on endoscopic surveillence. Biopsies and endoscopic USS suggest this is at most a 1cm foci of T1 disease in the distal oesophagus 4 cm proximal to the oesophagogastric junction. What is the most appropriate course of action?
Radical radiotherapy alone Total oesophagectomy and gastric pull up Endoscopic mucosal resection Combined radical chemo radiotherapy Sub total oesophagectomy
1 CM OR 3 CM IN BARRETT= EMR
EMR is an reasonable option for small areas of malignancy occurring on a background of Barretts change. Segmental resections of the oesophagus are not practised and the only resectional strategy in this scenario would be an Ivor- Lewis type resection. The morbidity such a strategy in T1 disease is probably not justified.
A 34 year old lady is admitted with pancreatitis. The aetiology is unclear and it is classified as an attack of moderate severity according to the Glasgow criteria. Her imaging shows no gallstones and fluid around the pancreas. Which of the following is the most appropriate initial management option?
Laparotomy Laparoscopy Radiological aspiration of the fluid Active observation Administration of octreotide
STABLE LIGHT AP = OBSERVE! NO USE OF OCTREOTIDE
LEARN THIS!
Mnemonic for the assessment of the severity of pancreatitis: PANCREAS
(Ann R Coll Surg Engl 2000; 82: 16-17
P a02 < 60 mmHg A ge > 55 years N eutrophils > 15 x 10/l C alcium < 2 mmol/l R aised urea > 16 mmol/l E nzyme (lactate dehydrogenase) > 600 units/l A lbumin < 32 g/l S ugar (glucose) > 10 mmol/l
> 3 positive criteria indicates severe pancreatitis.
Acute early fluid collections are seen in 25% of patients with pancreatitis and require no specific treatment. Attempts at drainage may introduce infection and result in pancreatic abscess formation.
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%
10% ANR 90% POST. MOST OF THE FISTULAS ARE AT THE TAIL
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.
A 43 year old lady with repeated episodes of abdominal pain is admitted with small bowel obstruction. A laparotomy is performed and at surgery a gallstone ileus is identified. What is the most appropriate course of action?
Remove the gallstone via a proximally sited terminal ileal enterotomy and decompress the small bowel. Leave the gallbladder in situ.
Remove the gallstone via a proximally sited terminal ileal enterotomy and decompress the small bowel. Remove the gallbladder.
Remove the gallstone via a proximally sited terminal ileal enterotomy and decompress the small bowel. Perform a choledochoduodenostomy.
Remove the gallstone from an enterotomy at the site of the obstruction and leave the gallbladder in situ.
Remove the gallstone from an enterotomy at the site of the obstruction and remove the gallbladder.
DONT CUT IN A SITE OF OBSTRUCTION. IT IS ISCHAEMIC! MORE THAN DILATED PROXIMAL PART! SO CUT PROXIMALLY!
Gallstone ileus occurs as a result of the fistula developing between the gallbladder and the duodenum. These tend to become impacted somewhat proximal to the ileocaecal valve and cause small bowel obstruction. The correct management is to remove the gallstone from an enterotomy proximal to the site of stone impaction. The bowel at the site of impaction itself may not heal well and an enterotomy performed at this site may well result in the need for a resection. The standard surgical teaching is that under almost all circumstances the gallbladder should be left in situ, as the anatomy in this area is often hostile and unpredictable. Disconnecting it from the duodenum leaves a large defect that is difficult to close.
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
SSSSSIGMA = SSSSAFE! SO RESECT BUT MAKE A STOMA! HARTMANN!
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.
What is the commonest type of fistula in ano?
Trans-sphincteric Supra levator Complex supra levator Intersphincteric Suprasphincteric
SPHINCTER INVOLVEMENT I HIGHLY LIKELY
What is the commonest type of fistula in ano?
Trans-sphincteric Supra levator Complex supra levator Intersphincteric Suprasphincteric
SPHINCTER INVOLVEMENT I HIGHLY LIKELY
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
bulky = radiochemo. Then shall see
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.
painful stool + skin tag?
FISSURE!
Mostly anterior
Topical GTN or diltiazem -> sphincterotomy (10% incontinence) -> relapse -> flaps
What proportion of patients presenting for cholecystectomy for treatment of biliary colic due to gallstones will have stones in the common bile duct?
25%! TOO HIGH! SO USS + LIVER TESTS
Up to 10% of all patients may have stones in the CBD. Therefore, all patients should have their liver function tests checked prior to embarking on a cholecystectomy.
Where do bile salts absorb?
Ileum!
83yo Barrett high grade 3! cm. WHat to do?
EMR. 3 cm is ooooook
Bariatric operation most ineffective?
Intragastric balloon. Just a bridge
