LE6 (older) Flashcards
Q: A 50-year-old male is undergoing a screening colonoscopy under intravenous (IV) sedation. In the recovery room, distention and tachycardia are noted. Which of the following is the best next step?
A:
A. Admit to hospital, IV antibiotics, and bowel rest
B. Serial abdominal exam for 6 hours
C. Exploratory laparotomy
D. Diagnostic laparoscopy
E. Chest X-ray upright
E. Chest X-ray upright
Rationale: This presentation suggests colonic perforation, a known complication of colonoscopy. An upright chest X-ray is the initial diagnostic step to assess for free air under the diaphragm, indicating perforation. Immediate intervention depends on the findings and patient stability.
Q: Eight years after an abdominal resection for locally advanced rectal cancer, a patient presents with the absence of air and fecal material in the colostomy bag for 1 day. There is no associated abdominal pain, tenderness, or tachycardia. Which of the following is true regarding this condition?
A:
A. Insert NGT, NPO, Foley catheter, IV hydration
B. CT scan of the whole abdomen
C. Exploratory laparotomy
D. A and B
E. A and C
D. A and B (Insert NGT, NPO, Foley catheter, IV hydration & CT scan of the whole abdomen)
Rationale: This suggests a colostomy obstruction, possibly due to adhesions or stenosis. Initial conservative management includes NPO, NG decompression, IV fluids, and a Foley catheter. A CT scan evaluates the obstruction’s severity and guides further management.
Q: A 47-year-old male with perforated diverticulitis underwent a sigmoidectomy with end colostomy creation. On post-op day 1, the colostomy appears dusky, and by day 3, necrosis is observed. What is the best management?
A:
A. Re-exploration in the OR, on-table bowel prep, and primary colonic anastomosis
B. Observation and reevaluation of the colostomy in 12 to 24 hours
C. IV antibiotics
D. Re-exploration in the OR, segmental colon resection, and placement of a stoma at the same time
D. Re-exploration in the OR, segmental colon resection, and placement of a stoma at the same time
Rationale: Colostomy necrosis requires immediate surgical intervention. The necrotic bowel segment is resected, and a new stoma is created. Delayed management risks peritonitis and sepsis.
Q: A 37-year-old male diagnosed with ulcerative colitis (UC) 2 years ago presents with jaundice. Workup confirms primary sclerosing cholangitis (PSC). Which of the following is additionally recommended?
A:
A. Immediate screening colonoscopy
B. Immediate colonoscopy with random biopsies
C. Colonoscopy with random biopsies 8 to 10 years after UC diagnosis
D. Screening colonoscopy at age 50
E. Symptom-driven colonoscopy as needed
B. Immediate colonoscopy with random biopsies
Rationale: PSC is strongly associated with UC and carries an increased risk of colorectal cancer. Therefore, immediate colonoscopy with biopsies is warranted, regardless of UC symptom duration.
Q: Which of the following is most likely to contribute to an anastomotic leak following colorectal surgery for cancer?
A:
A. Short operative time
B. Male gender
C. Ascending colon tumors
D. Linear stapler
B. Male gender
Rationale: Male gender is a known risk factor due to a narrower pelvis and more difficult surgical access. Other risk factors include smoking, malnutrition, and preoperative radiation.
Q: Which of the following is true about Familial Adenomatous Polyposis (FAP)?
A:
A. Patients with gene mutation should begin flexible sigmoidoscopy at age 20
B. It is associated with extraintestinal manifestations
C. Patients with prophylactic proctocolectomy have a lower risk of developing periampullary carcinoma
D. Upper endoscopy should be performed every 5 years
B. It is associated with extraintestinal manifestations
Rationale: FAP has several extraintestinal manifestations, including desmoid tumors, osteomas, and congenital hypertrophy of the retinal pigment epithelium (CHRPE).
Q: A 55-year-old woman with 16 years of pancolitis from UC undergoes surveillance colonoscopy. No polyps are detected, but random biopsy samples reveal high-grade dysplasia in the ascending and sigmoid colon. What is the recommended management?
A:
A. Repeat colonoscopy in 6 months with additional random biopsies
B. Sigmoid colectomy
C. Restorative proctocolectomy with ileal pouch-anal anastomosis
D. Total colectomy with ileorectal anastomosis
E. Total proctocolectomy with ileostomy
E. Total Proctocolectomy with Ileostomy
High-Yield Rationale:
- High-grade dysplasia (HGD) in UC is a strong indication for definitive surgical management due to the high risk of progression to colorectal cancer (CRC).
- Total proctocolectomy with ileostomy is recommended because:
- It removes the entire colon and rectum, eliminating malignancy risk.
- UC involves continuous colonic inflammation, so segmental resections (e.g., sigmoid colectomy) are not sufficient.
- Unlike Crohn’s disease, a proctocolectomy is curative for UC.
Why Not the Other Options?
- A. Repeat colonoscopy in 6 months → Incorrect
- Once high-grade dysplasia is found, surveillance is no longer appropriate. The risk of missed or synchronous malignancy is too high.
- B. Sigmoid colectomy → Incorrect
- UC is a pan-colonic disease, meaning a segmental colectomy does not prevent cancer in the remaining colon.
- C. Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA) → Reasonable alternative but not always preferred
- IPAA is an option, especially for patients who want to avoid a permanent ileostomy.
- However, it may not be suitable for all patients, particularly those with poor sphincter function or severe inflammation.
- D. Total colectomy with ileorectal anastomosis → Incorrect
- This leaves the rectum intact, which still has high malignancy risk, requiring ongoing surveillance.
- Only considered if rectal involvement is minimal, which is not the case in longstanding pancolitis.
Bottom Line:
In longstanding UC with high-grade dysplasia, the best option is total proctocolectomy with ileostomy to eliminate malignancy risk.
Q: A 56-year-old man presents with a 2-day history of fever, tachycardia, nausea, and pain in both lower quadrants. WBC count is 24,000 cells/μL. CT shows a thickened sigmoid colon with fat stranding and fluid in multiple abdominal areas. What is the optimal management?
A:
A. Immediate sigmoid colectomy, end colostomy, and drainage of abscess
B. CT-guided drainage followed in 6 weeks by a colonoscopy and sigmoid colectomy
C. CT-guided drainage alone
D. IV antibiotics followed in 6 weeks by a colonoscopy and sigmoid colectomy
A. Immediate sigmoid colectomy, end colostomy, and drainage of abscess
Rationale: This represents complicated diverticulitis with perforation and abscess formation. Immediate surgery (Hartmann’s procedure) is indicated due to systemic signs of sepsis.
Q: Which of the following is true regarding familial juvenile polyposis?
A:
A. It is autosomal dominant
B. The risk of colon cancer is 100% by age 50
C. The polyps are hyperplastic
D. Once a polyp is detected, total proctocolectomy is recommended
A. It is autosomal dominant
Rationale: Familial juvenile polyposis is an autosomal dominant disorder with an increased risk of gastrointestinal malignancies but not a 100% cancer risk.
Q: Which of the following is FALSE regarding colonic polyps?
A:
A. Tubulovillous adenomas have a higher malignancy risk than tubular adenomas
B. Some hyperplastic polyps are NOT premalignant
C. The polyps in Peutz-Jeghers syndrome are hyperplastic
D. Pseudopolyps are commonly found in FAP
C. The polyps in Peutz-Jeghers syndrome are hyperplastic
High-Yield Rationale:
- Peutz-Jeghers syndrome (PJS) polyps are hamartomatous, not hyperplastic.
- Hamartomatous polyps consist of disorganized but non-neoplastic tissue.
- Hyperplastic polyps are generally non-neoplastic but can have malignant potential if part of the serrated pathway.
-
Why are the other options TRUE?
-
A. Tubulovillous adenomas have a higher malignancy risk than tubular adenomas → TRUE.
- Malignancy risk: Villous > Tubulovillous > Tubular.
- Tubulovillous adenomas have 25-50% villous components, increasing their malignant potential.
-
B. Some hyperplastic polyps are NOT premalignant → TRUE.
- Most hyperplastic polyps are benign, except serrated polyps, which can progress to cancer via the serrated neoplastic pathway.
-
D. Pseudopolyps are commonly found in FAP → TRUE.
- Pseudopolyps (also seen in ulcerative colitis) are regenerating mucosal islands surrounded by areas of chronic inflammation.
-
A. Tubulovillous adenomas have a higher malignancy risk than tubular adenomas → TRUE.
Q: A 72-year-old man presents with mild diffuse abdominal pain and diarrhea that is positive on fecal immunochemical test. His medical history is unremarkable. WBC count and hematocrit are normal. A CT scan shows thickening of the colonic wall at the hepatic flexure with some associated pericolic fat stranding. What is the best next step in management?
A:
A. Mesenteric angiography
B. Diagnostic laparoscopy
C. Exploratory laparotomy
D. Colonoscopy
D. Colonoscopy
Rationale: The findings suggest colonic pathology, possibly malignancy. Colonoscopy is the best next step to evaluate for colorectal cancer or another pathology.
Q: A 56-year-old male patient is found to have rectal adenocarcinoma just proximal to the dentate line. Which of the following is true about wide local excision (WLE) of such a lesion?
A:
A. WLE is an option provided the tumor is 4 cm or less
B. Staging should include careful assessment for inguinal lymphadenopathy
C. The presence of lymphatic invasion precludes WLE
D. WLE is reasonable provided the invasion remains within the serosa
E. WLE is not a recommended option
E. WLE is not a recommended option
Rationale: Rectal adenocarcinoma proximal to the dentate line requires oncologic resection, not WLE, due to the risk of lymphatic spread.
Q: A 48-year-old man presents with a 1-day history of nausea, vomiting, abdominal distention, and obstipation. He has no history of surgery or medical problems. Physical exam reveals a tympanic mass in the left lower quadrant and mild tenderness. WBC count is 12,000. A plain abdominal radiograph shows a markedly dilated, kidney-shaped loop of bowel with haustral markings from the left lower quadrant to the right upper quadrant. What is the best treatment?
A:
A. Cecostomy
B. Operative detorsion with colonopexy
C. Sigmoidectomy and Hartmann’s procedure
D. Endoscopic detorsion
E. Right hemicolectomy and primary anastomosis
D. Endoscopic detorsion
Rationale: This presentation is classic for sigmoid volvulus. Endoscopic detorsion is the first-line treatment unless there is perforation or peritonitis.
Q: Which of the following is true regarding diverticular diseases of the lower GI tract?
A:
A. Symptomatic diverticulosis is managed expectantly
B. The rectum can be affected
C. Incidentally discovered cecal diverticula require surgical management due to a high risk of complications
D. Elective sigmoid resection is performed after 2 symptomatic attacks
A. Symptomatic diverticulosis is managed expectantly
Rationale: Diverticulosis is usually asymptomatic and managed with dietary fiber. Surgery is considered for recurrent or complicated cases.
Q: A 65-year-old man undergoing a screening colonoscopy has a 1.5 cm pedunculated polyp removed from the sigmoid colon. Histopathology reveals a well-differentiated adenocarcinoma confined to the polyp. What is the best next step in management?
A:
A. Expectant management
B. Segmental resection
C. Colonoscopy annually
D. Resection of the sigmoid colon with primary anastomosis
C. Colonoscopy annually
Rationale: If the cancer is well-differentiated and confined to the polyp, surveillance colonoscopy is appropriate instead of immediate colectomy.
Q: The recommended initial treatment of anal canal melanoma is:
A:
A. Abdominal perineal resection (APR)
B. Wide local excision (WLE)
C. WLE with regional lymph node dissection
D. Radiation therapy
E. Radiation therapy with chemotherapy
B. Wide local excision (WLE)
Rationale: WLE is preferred when possible due to the poor prognosis of anal melanoma, though APR may be needed in advanced cases.
Q: A 65-year-old man presents with a 2-day history of left lower quadrant abdominal pain, nausea, and low-grade fever. His temperature is 100.5°F and WBC count is 14,000 cells/uL. He has localized moderate left lower quadrant pain without rebound. Antibiotics are started. Which of the following is NOT indicated as the next step?
A:
A. Flexible sigmoidoscopy
B. Plain x-rays of the abdomen
C. CT scan
D. NPO, IV hydration, and IV antibiotics
A. Flexible sigmoidoscopy
Rationale: In acute diverticulitis, sigmoidoscopy or colonoscopy is contraindicated due to the risk of perforation. Imaging (CT) is preferred for diagnosis.
Q: Which of the following is true regarding epidermoid cancers of the anal canal?
A:
A. They are associated with EBV
B. They tend to behave similarly regardless of cell type
C. They are often asymptomatic
D. Small tumors can generally be excised locally
E. Chemotherapy alone is an appropriate treatment option
B. They tend to behave similarly regardless of cell type
Rationale: Epidermoid cancers of the anal canal, including squamous cell and basaloid types, have similar behavior and treatment strategies.
Q: A 15-year-old boy with a family history of familial adenomatous polyposis (FAP) undergoes APC gene testing, which is positive. Flexible sigmoidoscopy shows 8 adenomatous polyps in the sigmoid, but colonoscopy reveals no other polyps. What is the recommended management?
A:
A. Repeat sigmoidoscopy in 6 months
B. Total proctocolectomy with continent ileostomy
C. Restorative proctocolectomy with ileal pouch-anal anastomosis
D. Total colectomy with ileorectal anastomosis
C. Restorative Proctocolectomy with Ileal Pouch-Anal Anastomosis (IPAA)**
High-Yield Rationale:
- Surgery is mandatory in FAP once adenomatous polyps develop to prevent colorectal cancer (CRC).
- Restorative Proctocolectomy with IPAA is the preferred surgical option in most cases because:
- It removes the colon and rectum, eliminating the primary site of malignancy risk.
- It preserves continence by creating an ileal pouch that functions similarly to the rectum.
- Mucosectomy may be considered to reduce cancer risk in the anal transition zone.
- Downsides: Up to 50% of patients develop some incontinence.
Why Not the Other Options?
- A. Repeat sigmoidoscopy in 6 months → Incorrect
- Surveillance is insufficient once polyps develop in FAP, as progression to cancer is inevitable.
- B. Total Proctocolectomy with Continent Ileostomy (Brooke Ileostomy) → Not the first-line choice
- This is only used when IPAA is not feasible (e.g., poor sphincter function).
- D. Total Colectomy with Ileorectal Anastomosis (IRA) → Alternative but not preferred
- IRA preserves the rectum, requiring lifelong rectal surveillance due to continued cancer risk.
- Preferred only in select cases with low rectal polyp burden where frequent endoscopic monitoring is possible.
Bottom Line:
IPAA is the best surgical approach in most FAP cases as it eliminates the colonic and rectal cancer risk while maintaining continence.
Q: The LEAST likely cause of a rectovaginal fistula is:
A:
A. Obstetric injury
B. Colon carcinoma
C. Crohn’s disease
D. Diverticulitis
B. Colon carcinoma
Rationale: While colon carcinoma can cause fistulas, obstetric trauma and inflammatory conditions like Crohn’s disease are more common causes.
Q: A 30-year-old male presents with redness, pain, and fluctuance in the intergluteal cleft, about 4 cm posterior to the anus. There is considerable hair adjacent to the lesion. Which of the following is the most appropriate management?
A:
A. Incision and drainage in the intergluteal cleft
B. Incision and drainage lateral to the intergluteal cleft
C. En bloc excision of the sinus tract with flap reconstruction
D. Excision with primary closure
E. Unroofing the tract and marsupialization
A: A. Incision and drainage in the intergluteal cleft
Rationale:
Classic presentation of a pilonidal abscess.
I&D in the midline is the initial treatment.
Definitive management may involve excision with marsupialization for recurrent cases.
Q: Which of the following is true regarding the blood supply to the rectum?
A:
A. The superior and middle rectal arteries arise from the IMA
B. The middle rectal veins drain into the internal iliac veins
C. Inferior rectal veins drain into the inferior mesenteric vein
D. The superior rectal veins drain into the IVC
E. There is excellent collateralization between the superior and middle rectal arteries
B. The middle rectal veins drain into the internal iliac veins
Rationale:
Superior rectal vein → drains into the IMV → portal system.
Middle rectal vein → drains into the internal iliac vein → systemic circulation.
Inferior rectal vein → drains into the internal pudendal vein → systemic circulation.
Q: Which of the following is true regarding hidradenitis suppurativa?
A:
A. It may mimic a complex anal fistula
B. It is due to an infection of the eccrine sweat glands
C. Radical excision and skin grafting are typically necessary
D. It may progress beyond the anal verge into the anal canal
A: A. It may mimic a complex anal fistula
Rationale:
Hidradenitis suppurativa is a chronic inflammatory skin disorder affecting apocrine sweat glands.
It can form sinus tracts and abscesses, resembling an anal fistula, but lacks a direct connection to the rectum.
Q: A 68-year-old woman presents with a massive lower GI bleed. Her initial blood pressure in the ED is 70/60 mmHg, with a heart rate of 120 bpm. After volume resuscitation, her blood pressure increases to 120/80 mmHg. A nasogastric aspirate is negative for blood. What is the next step in management?
A:
A. Colonoscopy
B. Mesenteric angiography
C. Tagged red cell scan
D. Exploratory laparotomy
A. Colonoscopy
Rationale:
• Massive lower GI bleeding in an elderly patient is most commonly due to diverticular bleeding or angiodysplasia.
• Since the patient responded to resuscitation (BP improved to 120/80 mmHg), she is now hemodynamically stable, making colonoscopy the next best step.
• Colonoscopy is the diagnostic and therapeutic modality of choice in stable patients with lower GI bleeding.
Q: A 65-year-old institutionalized patient presents with a 2-day history of abdominal distention, nausea, and obstipation. Physical examination reveals marked distention with mild tenderness. WBC count is 10,000 cells/uL. Plain films show a massively dilated, inverted U-shaped (omega sign) loop of bowel. What is the best management?
A:
A. Endoscopic detorsion and insertion of a rectal tube
B. Endoscopic detorsion followed by elective sigmoid colectomy
C. Endoscopic detorsion followed by elective sigmoid colectomy in case of recurrence
D. Exploratory laparotomy with sigmoid colectomy, on-table lavage, and primary anastomosis
B. Endoscopic detorsion followed by elective sigmoid colectomy
Rationale:
- The patient presents with sigmoid volvulus, as indicated by the massively dilated, inverted U-shaped (omega sign) loop of bowel.
- First-line management for non-perforated, non-ischemic sigmoid volvulus is endoscopic detorsion using either a rigid sigmoidoscope or a flexible endoscope.
- However, recurrence rates are high (up to 40%), so after successful detorsion, an elective sigmoid colectomy is recommended to prevent recurrence.
- A. Endoscopic detorsion alone → Not sufficient because of the high recurrence rate; definitive surgical management is needed.
- C. Endoscopic detorsion followed by elective colectomy in case of recurrence → Delaying surgery until recurrence increases the risk of complications. Prophylactic surgery is preferred.
- D. Exploratory laparotomy with sigmoid colectomy, lavage, and primary anastomosis → This is needed only if there is bowel ischemia, perforation, or peritonitis (not present in this patient).
Thus, the best approach is endoscopic detorsion followed by elective sigmoid colectomy to prevent future volvulus episodes.
Q: Which of the following is true about hereditary nonpolyposis colon cancer (HNPCC) (Lynch Syndrome)?
A:
A. Modified Amsterdam criteria require one family member to be diagnosed before age 40
B. Screening colonoscopy should begin at age 12
C. It is considered an autosomal recessive syndrome
D. Colonic malignancy has the same prognosis as sporadic cancer
D. Colonic malignancy has the same prognosis as sporadic cancer
Rationale: Lynch syndrome follows an autosomal dominant inheritance pattern and carries an increased risk of colorectal and other cancers, but the prognosis is similar to sporadic cases when matched for stage.
Q: Rectal bleeding due to chronic radiation proctitis that is unresponsive to enemas is best managed by:
A:
A. Argon plasma coagulation
B. Proximal diverting colostomy
C. Steroid or sucralfate enemas
D. Formalin
E. Proctectomy
A. Argon plasma coagulation
Rationale: Argon plasma coagulation is a safe and effective endoscopic treatment for chronic radiation proctitis with bleeding.
Q: A 74-year-old man with biopsy-proven rectal adenocarcinoma is undergoing a low anterior resection. Which layers of the proximal segment must be stapled through when resecting the distal portion?
A:
A. Mucosa, submucosa, circular muscle layer, longitudinal muscle layer, and serosa
B. Mucosa, submucosa, longitudinal muscle layer, circular muscle layer, and serosa
C. Mucosa, submucosa, longitudinal muscle layer, and circular muscle layer
D. Mucosa, submucosa, circular muscle layer, and serosa
C. Mucosa, submucosa, longitudinal muscle layer, and circular muscle layer**
High-Yield Rationale:
- The wall of the rectum consists of five layers:
1. Mucosa
2. Submucosa
3. Circular muscle layer
4. Longitudinal muscle layer
5. Serosa (only present in the proximal rectum but absent in the mid and lower rectum)
-
Why C is Correct?
- The mid and lower rectum lack serosa (as highlighted in the reference).
- In a low anterior resection, the distal portion of the resected specimen is from the mid or lower rectum, where serosa is absent.
- This means the staple line only includes the mucosa, submucosa, circular muscle, and longitudinal muscle layers.
Why Not the Other Options?
- A, B, and D include serosa, which is incorrect because the mid and lower rectum lack serosa.
- B has the incorrect order of muscle layers.
Bottom Line:
For low anterior resection of the rectum, stapling through the mid or lower rectum does not include serosa, making C the correct answer.
Q: Which layer of muscle joins together to form the external anal sphincter?
A:
A. Circumferential muscle layer
B. Longitudinal muscle layer
C. Puborectalis muscle
D. Circular muscle layer
C. Puborectalis muscle
Rationale: The external anal sphincter is formed by the puborectalis muscle, which plays a key role in maintaining continence.
Q: Twelve hours after hemorrhoidal banding, a 45-year-old man presents to the emergency department with rectal and abdominal pain and an inability to urinate. His temperature is 102°F and heart rate is 110 bpm. What is the best management?
A:
A. Placement of Foley catheter
B. Broad-spectrum IV antibiotics
C. Broad-spectrum IV antibiotics and rectal examination under anesthesia
D. Stool softeners and oral antibiotics
E. In-and-out catheterization of the bladder and stool softeners
C. Broad-spectrum IV antibiotics and rectal examination under anesthesia
Rationale: The patient likely has perineal sepsis, a rare but life-threatening complication of hemorrhoidal banding. Prompt surgical evaluation and IV antibiotics are critical.
Q: Approximately 3 hours after a hemorrhoidectomy, a patient continues to have bleeding from the anus. The nurse has changed the pad multiple times and has attempted to pack the rectum with gauze. What is the next best step in management?
A:
A. Rubber banding the bleeding site
B. Rectal packing with epinephrine gauze
C. Suture ligation
D. Ice packs
E. Foley catheter balloon compression
C. Suture ligation
Rationale: Persistent post-hemorrhoidectomy bleeding suggests an arterial source, which requires direct visualization and suture ligation.
Q: A 65-year-old woman presents to the emergency department with severe perianal pain for 12 hours after straining during a bowel movement. Physical examination reveals an exquisitely tender perianal mass with bluish discoloration under the perianal skin. What is the best management?
A:
A. Stool softeners and sitz baths
B. Rubber band ligation
C. Stab incision and drainage with the patient under local anesthesia in the ED
D. Elliptical excision of skin and drainage with the patient under local anesthesia in the ED
E. Rectal examination under general anesthesia with incision and drainage
D. Elliptical excision of skin and drainage with the patient under local anesthesia in the ED
Rationale: This presentation is consistent with a thrombosed external hemorrhoid. The best treatment is elliptical excision with drainage.
Q: A 58-year-old mother of 10 suffers from fecal incontinence. Dysfunction at which point of the defecation pathway can lead to fecal incontinence?
A:
A. Injury to the puborectalis
B. Decreased rectal contraction
C. Repair of the internal or external sphincter during delivery
D. Hypertrophic internal or external sphincter
A. Injury to the puborectalis
Rationale: The puborectalis muscle forms a sling around the rectum and plays a critical role in maintaining continence. Injury can lead to fecal incontinence.
Q: A 49-year-old male physician with no cancer history adheres to a high-protein, high-fiber diet and exercises regularly. His fecal immunohistochemical test (FIT) is positive. What should be the next step?
A:
A. No further evaluation; vitamin C can cause false positives
B. No further evaluation; all positive FITs require an FOBT
C. Repeat FIT in 1 year
D. Colonoscopic evaluation
D. Colonoscopic evaluation
High-Yield Rationale:
- Fecal Immunochemical Test (FIT) detects human hemoglobin, making it more specific for lower GI bleeding than guaiac-based Fecal Occult Blood Test (FOBT).
- Any positive FIT requires a follow-up colonoscopy, as it may indicate:
- Colorectal cancer (CRC)
- Adenomatous polyps
- Inflammatory conditions (e.g., colitis, diverticulosis)
Why Not Other Options?
- A. No, vitamin C can produce a false-positive result → Incorrect
- Vitamin C can interfere with FOBT, but FIT is not affected by diet.
- B. No, all positive FIT requires further investigation with FOB → Incorrect
- A positive FIT does not require another stool test; it directly warrants colonoscopy.
- C. Yes, all positive FIT requires further investigation with FIT in 1 year → Incorrect
- Delaying evaluation is inappropriate when FIT is positive; colonoscopy should be done immediately.
Key Takeaway:
- FIT is a more accurate screening tool for colorectal cancer.
- A positive FIT result should always be followed by colonoscopy to identify the source of bleeding.
Q: A 22-year-old college student presents with intermittent diarrhea for the past 5 days after returning from Mexico. He has also had previous episodes of diarrhea unrelated to travel. Which of the following tests is NOT appropriate?
A:
A. Stool wet-mount and stool culture
B. Colonoscopy
C. Sudan red stain for stool sample
D. Whole abdominal CT scan
D. Whole abdominal CT scan
Rationale: Diarrhea evaluation should start with stool analysis, culture, and colonoscopy if needed. A CT scan is not typically required for infectious diarrhea.
Q: A 72-year-old man undergoes emergency exploratory laparotomy for a perforated sigmoid colon mass. What is the most appropriate surgical procedure?
A:
A. Repair of perforation
B. Repair of perforation and diverting colostomy
C. Sigmoidectomy and primary anastomosis
D. Sigmoidectomy and Hartmann’s procedure
E. Sigmoidectomy, Hartmann’s procedure, and diverting ileostomy
D. Sigmoidectomy and Hartmann’s procedure
Rationale: In an unstable patient with perforation, Hartmann’s procedure is preferred to avoid anastomotic leakage.
Q: A 19-year-old man with medically refractory ulcerative colitis undergoes a total colectomy with J-pouch creation. What are some of the late complications of reconstruction?
A:
A. More than 8 bowel movements per day
B. Nocturnal incontinence
C. Small bowel obstruction
D. A and C
E. AOTA (All of the above)
E. All of the above
Rationale: Pouchitis, increased stool frequency, nocturnal incontinence, and small bowel obstruction are common complications following J-pouch reconstruction.
Q: A 46-year-old woman with rectal adenocarcinoma underwent a low anterior resection with a diverting loop ileostomy. She is now scheduled for ileostomy reversal. What workup should be done before the procedure?
A:
A. Whole abdominal CT scan
B. No examination is needed
C. PET scan
D. Colonoscopy to evaluate for new polyps
E. Contrast study of the distal segment
E. Contrast study of the distal segment
Rationale: A contrast enema or distal contrast study is needed to ensure no anastomotic stricture before ileostomy reversal.
Q: A 55-year-old woman undergoes colonoscopy for hematochezia. A circumferential mass in the ascending colon obstructs 70% of the lumen. Biopsy reveals well-differentiated adenocarcinoma. What is the next step?
A:
A. Schedule elective right hemicolectomy and primary anastomosis
B. Schedule elective right hemicolectomy with proximal and distal colostomy
C. PET scan
D. CT scan of the chest and abdomen
E. Barium enema
D. CT scan of the chest and abdomen
Rationale: Staging with a CT scan is crucial to assess for metastasis before definitive surgery.
Q: A 55-year-old woman undergoes colonoscopy due to hematochezia. A circumferential mass in the ascending colon obstructs 70% of the lumen. Biopsy confirms well-differentiated adenocarcinoma. What is the most appropriate procedure?
A:
A. Diverting ileostomy
B. Right hemicolectomy and primary anastomosis
C. Right hemicolectomy and colostomy
D. Segmental resection of the ascending colon
E. Chemotherapy
B. Right hemicolectomy and primary anastomosis
Rationale: Right-sided colon cancers are best treated with right hemicolectomy and anastomosis unless contraindications exist.
Q: A 50-year-old woman who underwent a total colectomy with ileal pouch-anal reconstruction 5 years ago presents to the emergency room with diarrhea, malaise every 2 weeks, and severe abdominal pain. What is the most appropriate differential diagnosis?
A:
A. Parasitic infection, ulcerative colitis of the remaining rectum, undiagnosed Crohn’s disease
B. Bacterial or viral infection, undiagnosed Crohn’s disease, and pouchitis
C. Rectal cancer of the remaining rectum, bacterial or viral infection, and undiagnosed Crohn’s disease
D. Parasitic infection, bacterial or viral infection, and pouchitis
B. Bacterial or viral infection, undiagnosed Crohn’s disease, and pouchitis
Rationale: Pouchitis is a common complication of ileal pouch-anal anastomosis, often presenting with diarrhea, abdominal pain, and malaise. Crohn’s disease must also be considered.
Q: A 68-year-old man is undergoing a right hemicolectomy for a cecal mass. He asks about postoperative infection prevention. When should antibiotics always be used for this procedure?
A:
A. Oral antibiotics should be used in combination with bowel preparation
B. Parenteral antibiotic prophylaxis at the time of surgery and after the skin incision is made, redosed as needed during the procedure
C. Parenteral antibiotic prophylaxis at the time of surgery before the skin incision is made
D. Oral antibiotics should be used postoperatively to decrease the risk of anastomotic leak
C. Parenteral antibiotic prophylaxis at the time of surgery before the skin incision is made
Rationale: Prophylactic antibiotics should be administered before the skin incision to reduce surgical site infections.
Q: A 22-year-old woman presents with a 3-year history of bloody diarrhea, abdominal pain, and anorectal fistulas. Her father had similar symptoms in his 20s and underwent multiple abdominal surgeries. What is the percentage of patients with this disease who have affected family members?
A:
A. 5-10%
B. 10-20%
C. 10-30%
D. 20-40%
C. 10-30%
Rationale: Crohn’s disease has a strong genetic component, with 10-30% of patients having a family history of the disease.
Q: A 25-year-old man is undergoing workup for ulcerative colitis, Crohn’s disease, or indeterminate colitis. Which findings would indicate Crohn’s disease?
A:
A. Atrophic mucosa, crypt abscesses, inflammatory pseudopolyps, continuous involvement of the rectum and colon
B. Mucosal ulcerations, noncaseating granulomas, fibrosis, strictures, and fistulas in the colon with deep serpiginous ulcers
C. Atrophic mucosa, noncaseating granulomas, strictures, and “cobblestone” appearance on endoscopy
D. Mucosal ulcerations, crypt abscesses, inflammatory pseudopolyps, continuous involvement of the rectum and colon
B. Mucosal ulcerations, noncaseating granulomas, fibrosis strictures, and fistulas in the colon with deep serpiginous ulcers**
High-Yield Rationale:
- Crohn’s disease (CD) is a transmural inflammatory condition that affects any part of the GI tract from mouth to anus, most commonly the terminal ileum and colon.
- Hallmark diagnostic findings of Crohn’s disease include:
- Skip lesions (discontinuous involvement)
- Transmural inflammation (extends through all layers of the bowel wall)
- Noncaseating granulomas (on histology)
- Deep serpiginous ulcers and a cobblestone appearance (on endoscopy)
- Strictures, fibrosis, and fistula formation (complications from chronic inflammation)
Why Not the Other Options?
- A. (Atrophic mucosa, crypt abscesses, inflammatory pseudopolyps, continuous involvement)
- Describes Ulcerative Colitis (UC), not Crohn’s disease. UC has continuous involvement, starting from the rectum.
- C. (Atrophic mucosa, noncaseating granulomas, cobblestone appearance)
- Close, but atrophic mucosa is more characteristic of UC.
- D. (Mucosal ulcerations, crypt abscesses, continuous involvement)
- Crypt abscesses and continuous involvement are hallmarks of UC, not Crohn’s.
Key Takeaway:
- Crohn’s disease = Skip lesions, transmural inflammation, deep ulcers, fistulas, and strictures.
- Ulcerative colitis = Continuous inflammation, limited to mucosa/submucosa, crypt abscesses, and pseudopolyps.
- Endoscopic appearance of Crohn’s disease = Deep serpiginous ulcers + Cobblestone pattern.
Q: What structures are most likely to be affected by extracolonic manifestations in inflammatory bowel disease (IBD)?
A:
A. Liver, biliary tree, joints, skin, eyes
B. Biliary tree, lungs, heart, spleen
C. Joints, skin, biliary tree, bladder
D. Skin, liver, pancreas, joints, eyes
A. Liver, biliary tree, joints, skin, eyes
Rationale: IBD is associated with primary sclerosing cholangitis, arthritis, erythema nodosum, uveitis, and pyoderma gangrenosum.
Q: What is the first-line therapy for inflammatory bowel disease in the outpatient setting?
A:
A. Salicylates, such as sulfasalazine and 5-acetyl salicylic acid
B. Antibiotics, such as metronidazole and fluoroquinolones
C. Corticosteroids
D. Azathioprine and 6-mercaptopurine
A. Salicylates, such as sulfasalazine and 5-acetyl salicylic acid
Rationale: Sulfasalazine and mesalamine (5-ASA) are first-line treatments for mild-to-moderate IBD.
Q: A 26-year-old man with ulcerative colitis presents to the ER with severe abdominal pain, fever, and peritonitis. What factors would indicate the need for stoma creation instead of primary anastomosis, EXCEPT?
A:
A. Long-standing ulcerative colitis with multiple colon polyps
B. Albumin of 2.2 in a patient who has been on corticosteroids
C. Blood glucose level of 300 in a patient who finished a corticosteroid course one week ago
D. BMI of 14
A. Long-standing history of ulcerative colitis with multiple colon polyps**
High-Yield Rationale:
- Primary anastomosis vs. Stoma Creation
- In patients with ulcerative colitis (UC) undergoing colectomy, primary anastomosis is only feasible if the patient is stable, well-nourished, and has no sepsis or perforation.
- If the patient is severely malnourished, has ongoing inflammation, or has been on corticosteroids, a stoma (ileostomy) is preferred to allow for healing before anastomosis.
Why is A Incorrect?
- A long-standing history of UC with multiple colon polyps is an indication for colectomy, but NOT for stoma creation instead of anastomosis.
- The presence of multiple colon polyps raises concern for dysplasia or malignancy, making surgery necessary, but it does not indicate poor healing or require delaying anastomosis.
- If the patient is otherwise nutritionally stable, a primary anastomosis can be performed (e.g., IPAA).
Why Are the Other Options Correct Indicators for Stoma Creation?
- B. Low Albumin (22.0 g/L) in a Patient on Corticosteroids → Correct Indicator
- Severe hypoalbuminemia (<30 g/L) suggests malnutrition and poor wound healing.
- Corticosteroids impair anastomotic healing, making primary anastomosis risky.
- Stoma creation allows time for nutritional optimization before reversal.
-
C. Blood Glucose 300 mg/dL After Recent Corticosteroid Course → Correct Indicator
- Hyperglycemia impairs wound healing and increases infection risk.
- This patient likely has steroid-induced hyperglycemia or diabetes, making anastomotic leakage more likely.
-
D. BMI of 14 → Correct Indicator
- BMI <16 indicates severe malnutrition, increasing the risk of poor wound healing and anastomotic failure.
- Patients with extreme malnutrition often require a staged approach with stoma first.
Key Takeaway:
- Stoma is preferred in unstable, malnourished, or immunosuppressed patients.
- UC with multiple polyps is an indication for colectomy but NOT necessarily for stoma over primary anastomosis.
- Correct Answer = A (EXCEPT option).
Q: A 24-year-old woman with ulcerative colitis presents with fever, severe abdominal pain, and bloody stools. What is NOT an indication for emergency surgery?
A:
A. Hemorrhage with continued decrease in hematocrit despite transfusion
B. Hemodynamic instability requiring ICU transfer with worsening status over 45 hours
C. Severe abdominal pain and diarrhea unresponsive to bowel rest, hydration, and corticosteroids
D. Cecum measured at 8 cm in diameter on CT scan
D. Cecum measured at 8 cm in diameter on CT scan
Rationale: Toxic megacolon is diagnosed when cecal dilation is ≥9 cm. A cecum measuring 8 cm is not yet an absolute indication for surgery.
Q: A 55-year-old woman with long-standing Crohn’s disease presents with a new area of induration, fluctuance, and foul-smelling drainage from a former surgical site. What is NOT an indication for surgery in Crohn’s disease?
A:
A. Internal fistula or abscess
B. Obstruction
C. Toxic megacolon
D. Strictures
E. Abdominal pain
E. Abdominal pain
Rationale: Surgery is reserved for complications such as obstruction, strictures, fistulas, abscesses, and toxic megacolon, but not for isolated abdominal pain.
Q: A 23-year-old man presents with severe pain during defecation that started two months ago. He has restricted eating to avoid bowel movements. Rectal exam reveals an anal fissure. What finding suggests this fissure is due to Crohn’s disease?
A:
A. Deep and broad ulcer located in the posterior midline position
B. Shallow and broad ulcer located in the anterior position
C. Deep and narrow ulcer located in the lateral position
D. Shallow and narrow ulcer located in the posterior midline position
C. Deep and narrow ulcer located in the lateral position
Rationale: Anal fissures in Crohn’s disease are atypically located (lateral) and may be deep or multiple. Most benign fissures occur in the posterior midline.
Q: A 65-year-old man presents to the ER with fever, normal heart rate, and 2 days of abdominal pain. A CT scan shows diverticulitis with scant free air and minimal fluid collection associated with the sigmoid colon. What is the most appropriate management?
A:
A. Colonoscopy
B. NPO, IV hydration, and IV antibiotics
C. Sigmoidectomy and Hartmann’s procedure
D. CT-guided drainage of fluids
E. Diverting ileostomy
B. NPO, IV hydration, and IV antibiotics
Rationale: Uncomplicated diverticulitis without large abscesses or peritonitis is best managed conservatively with bowel rest, IV fluids, and antibiotics.
Q: A 72-year-old woman presents to discuss surgical management of her long-standing diverticulosis. What is an indication for colectomy in this patient?
A:
A. Three episodes of diverticulitis requiring hospitalization in an otherwise asymptomatic patient
B. A single episode of diverticulitis in an immunosuppressed patient
C. A current episode of complicated diverticulitis resulting in peritonitis
D. Inability to exclude malignancy in a patient who was recently hospitalized
B. A single episode of diverticulitis in an immunosuppressed patient**
High-Yield Rationale:
- Elective colectomy for diverticulitis is NOT always necessary after multiple episodes unless specific risk factors are present.
- Immunosuppressed patients are an exception → They are advised to undergo colectomy after a single episode because they:
- Have a higher risk of complications (e.g., perforation, abscess, sepsis).
- Often have blunted inflammatory responses, delaying diagnosis and worsening outcomes.
Why Not the Other Options?
- A. Three episodes requiring hospitalization in an asymptomatic patient → Incorrect
- Surgery is not required just based on the number of episodes unless symptoms persist or complications occur.
- C. A current episode of complicated diverticulitis resulting in frequent peritonitis → Incorrect
- Urgent or emergency surgery (not elective) is needed for perforation, abscess, or peritonitis.
- D. Inability to exclude malignancy → Incorrect
- Colonoscopy should be performed first (4-6 weeks after recovery). Surgery is indicated only if malignancy is confirmed.
Key Takeaway:
- Immunosuppressed patients should undergo colectomy after a single episode of diverticulitis due to their high risk of severe disease progression.
- Elective colectomy is otherwise considered selectively based on complications, recurrence, and quality of life.
Q: A 63-year-old woman presents to the ER with a 2-day history of left lower quadrant abdominal pain, fever (38.6°C), and WBC count of 15,000. CT scan shows colonic inflammation with a pericolic abscess. What is her Hinchey stage?
A:
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
A. Stage I
Rationale:
Stage I is characterized by a localized pericolic or mesenteric abscess.
Management: IV antibiotics, bowel rest, and percutaneous drainage if the abscess is >2 cm.
No generalized peritonitis, so no urgent surgery is required unless there is no improvement.
Q: A 62-year-old woman presents to the ER with severe left lower quadrant abdominal pain and fever (39°C). CT scan shows colonic inflammation with a retroperitoneal abscess. What is her Hinchey stage?
A:
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
B. Stage II
Rationale:
Stage II involves a larger, more distant abscess, such as pelvic, retroperitoneal, or intra-abdominal abscess.
Management: IV antibiotics and CT-guided percutaneous drainage if the abscess is large (>3 cm).
Surgery is reserved for worsening symptoms or recurrence.
Q: A 62-year-old woman presents to the ER with severe abdominal pain, fever (39°C), rigid abdomen, and WBC count of 21,000. CT scan shows diverticula, free intraabdominal air, and free fluid. In the OR, fecal material is found intraabdominally. What is her Hinchey stage?
A:
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
D. Stage IV
Rationale:
Stage IV = Fecal peritonitis, which is the most severe stage.
Signs:
Free air and free fluid on CT
Peritoneal signs (rigid abdomen, severe pain, rebound tenderness)
Fecal contamination intraoperatively
Management: Emergency laparotomy with sigmoid colectomy and colostomy (Hartmann’s procedure).
Q: A 58-year-old man presents to the clinic with a 2-month history of passing air while urinating. He has a history of diverticulitis, with his last hospitalization 6 months ago. What is the most common fistula in complicated diverticulitis?
A:
A. Colovaginal fistula
B. Coloenteric fistula
C. Colocutaneous fistula
D. Colovesicular fistula
D. Colovesicular fistula
Rationale: Colovesicular fistula is the most common fistula in complicated diverticulitis, presenting with pneumaturia or fecaluria.
Q: What is the most predominant microorganism in feces?
A:
A. Escherichia coli
B. Bacteroides
C. Haemophilus influenzae
D. Pseudomonas
B. Bacteroides
Rationale: Bacteroides spp. are the most common anaerobic bacteria in the gut and a major cause of intraabdominal infections.
Q: During a fistulotomy for fistula-in-ano, the surgeon accidentally cuts the external sphincter muscle. What effect will this injury have on the patient’s defecation?
A:
A. No effect on resting and involuntary sphincter tone
B. No effect on most voluntary tone
C. Will affect resting pressure
D. Will affect squeeze pressure
D. Will affect squeeze pressure
Rationale: The external sphincter is responsible for voluntary control of defecation. Damage results in reduced squeeze pressure and potential incontinence.
Q: Hemorrhoids are a normal part of anorectal anatomy and contribute to anal continence. Treatment is only necessary when:
A:
A. Symptomatic
B. Excessive anal tissue is present
C. Hemorrhoidal tissue is present
D. Portal hypertension is present
A. Symptomatic
Rationale: Hemorrhoids should only be treated if symptomatic, causing pain, bleeding, or prolapse.
Q: A 34-year-old call center agent presents to the ER with recurrent bleeding from Grade 2 internal hemorrhoids after medical treatment and dietary modification. What is the most appropriate treatment plan?
A:
A. Resume medication for 1 month
B. Rubber band ligation
C. Sclerotherapy
D. Hemorrhoidectomy
B. Rubber band ligation
Rationale: Rubber band ligation is preferred for Grade 2 internal hemorrhoids that do not respond to conservative treatment.
Q: A 65-year-old male presents with a rectal mass with anal extension. Biopsy confirms adenocarcinoma. The best prognosis is seen when which lymph nodes are involved?
A:
A. Inguinal
B. Peri-rectal
C. Inferior mesenteric
D. Para-aortic
B. Peri-rectal
Explanation:
* Peri-rectal lymph node involvement (N1) indicates early-stage nodal spread, which still allows for curative treatment, leading to a better prognosis.
* Rectal cancer follows a stepwise lymphatic spread:
1. Peri-rectal nodes (N1)
2. Inferior mesenteric nodes (N2)
3. Para-aortic nodes (N3, distant metastasis - worse prognosis)
* When cancer is confined to the peri-rectal nodes, prognosis is still favorable compared to involvement of higher-tier nodes.
Q: Which treatment strategy for anal melanoma implies the poorest prognosis?
A:
A. Local excision with adjuvant radiotherapy
B. Abdominoperineal resection (APR) with chemotherapy
C. Wide excision with free margins
D. Combined radiotherapy, chemotherapy, and immunotherapy
D. Combined radiotherapy, chemotherapy, and immunotherapy
Rationale: Anal melanoma has a very poor prognosis, and multimodal therapy (radiation, chemotherapy, and immunotherapy) is often used for palliation in advanced cases.
Q: What vessels are ligated when a surgeon performs a left hemicolectomy?
A:
A. Sigmoidal, left colic, and right branch of middle colic artery
B. Ileocolic, right colic, right branch of middle colic artery
C. Left colic and left branch of middle colic artery
C. Left colic and left branch of middle colic artery
Q: What is the most common serious complication of an end colostomy?
A:
A. Bleeding
B. Skin breakdown
C. Parastomal hernia
D. Colonic perforation during irrigation
E. Stomal prolapse
C. Parastomal hernia
Rationale: Parastomal hernia is a common long-term complication of end colostomies due to increased intraabdominal pressure.
Q: One year after surgery for colorectal cancer, a patient’s serum CEA levels are now elevated after previously being normal. What is the next step?
A:
A. Repeat determination after 6 months
B. Colonoscopy
C. Adjuvant chemotherapy
D. Staging laparotomy
E. Chest and abdominal CT scan
E. Chest and abdominal CT scan
Rationale: Rising CEA levels suggest possible recurrence or metastasis, and CT imaging is needed for staging.
Q: Diverticular disease most commonly affects which part of the colon?
A:
A. Ascending
B. Transverse
C. Sigmoid
D. Descending
C. Sigmoid
Rationale: The sigmoid colon is the most commonly affected site due to its high intraluminal pressure.
Q: Which diagnostic modality is primarily used to evaluate the depth of invasion of malignant rectal tumors?
A:
A. MRI
B. CT scan
C. Endorectal ultrasound
D. Colonoscopy
A. MRI**
Updated High-Yield Rationale:
- MRI is the preferred imaging modality for evaluating the depth of invasion of malignant rectal tumors (T-staging).
- MRI with an endorectal coil significantly improves accuracy in assessing:
- Tumor penetration through the rectal wall (T-staging)
- Involvement of the mesorectal fascia (circumferential resection margin, CRM)
- Lymph node involvement
Why Not the Other Options?
- B. CT scan → Less sensitive for local invasion
- Used mainly for detecting distant metastases (liver, lungs) rather than local rectal tumor staging.
- Cannot reliably differentiate between rectal wall layers.
-
C. Endorectal ultrasound (ERUS) → Best for early-stage rectal cancer (T1-T2)
- ERUS is more accurate for early rectal tumors (T1-T2) but less reliable for advanced (T3-T4) tumors.
- Cannot assess extramural spread or mesorectal lymph nodes well.
-
D. Colonoscopy → Detects tumors but does not assess depth of invasion
- Essential for biopsy and visualization but does not provide T-staging information.
Bottom Line:
✅ MRI is the best imaging modality for rectal cancer staging, especially for T3-T4 tumors and assessing CRM.
✅ ERUS is useful for early-stage tumors but less effective for deeper invasion.
✅ CT scan is primarily for metastatic workup, not local staging.
Q: Patients with Gardner’s syndrome, a form of multiple polyposis of the colon, usually have all of the following EXCEPT:
A: Polyps by the age of 20
B. Osteomas of the mandible and skull
C. Epidermal cysts of the skin
D. None of the above (NOTA)
E. All of the above (AOTA)
D. NOTA (None of the above)
Rationale: Gardner’s syndrome is associated with colonic polyps, osteomas, and epidermal cysts.
Q: Endogenous microflora participate in the metabolism of all of the following EXCEPT:
A: Bilirubin
B. Bile acids
C. Lecithin
D. Cholesterol
E. Vitamin K
C. Lecithin
Rationale: Gut bacteria play roles in bile acid metabolism, cholesterol breakdown, and vitamin K synthesis but do not metabolize lecithin.
Q: During a fistulotomy for fistula-in-ano, the surgeon accidentally cuts the internal sphincter muscle. What would be the effect on defecation?
A:
A. No effect on most of the resting and involuntary sphincter tone
B. No effect on most of the voluntary tone
C. Will affect resting pressure
D. Will affect squeeze pressure
C. Will affect resting pressure
Rationale: The internal sphincter is responsible for resting tone, and its injury reduces resting anal pressure, potentially leading to incontinence.
Q: A 79-year-old man has had abdominal pain for 4 days. An operation is performed, and a gangrenous appendix is removed. The stump is inverted. Why does acute appendicitis in elderly patients and children have a worse prognosis?
A:
A. The appendix is retrocecal.
B. The appendix is in the preileal position.
C. The omentum and peritoneal cavity are less efficient in localizing the disease in these age groups.
D. The appendix is longer in these age groups.
E. The appendix is in the pelvic position.
C. The omentum and peritoneal cavity are less efficient in localizing the disease in these age groups.
Rationale: In elderly patients and children, the omentum is less effective at walling off infection, leading to delayed presentation and increased risk of perforation.
Q: Which of the following statements regarding the appendix is false?
A: The appendix contains large amounts of lymphoid aggregates but has no significant exocrine function.
B: The blood supply to the appendix is from the appendicular artery, a branch of the ileocolic artery.
C: The lymphatic drainage of the appendix goes through the ileocolic nodes.
D: The average length of an adult appendix is 9 cm.
E: Innervation of the appendix is derived from the somatic nervous system.
E. Innervation of the appendix is derived from the somatic nervous system.
Rationale: The appendix is innervated by the autonomic nervous system (not somatic), specifically the sympathetic and parasympathetic nervous system (T10).
This is why early appendicitis presents with vague, visceral pain at the umbilicus before localizing to the RLQ.
Q: A 76-year-old female presents with a 5-day history of right lower quadrant abdominal pain and nausea. CT shows perforated appendicitis with a 5-cm abscess. She was started on broad-spectrum antibiotics and underwent percutaneous drainage. In 72 hours, she is afebrile, and her leukocytosis and symptoms have resolved. What is the next step in management?
A:
A. Schedule a colonoscopy and consider an interval appendectomy in 8 weeks.
B. Interval appendectomy in 4 weeks.
C. Ileocecectomy in 6 weeks.
D. Continue broad-spectrum antibiotics until drain removal.
E. Appendectomy prior to discharge.
A. Schedule a colonoscopy and consider an interval appendectomy in 8 weeks.
Rationale:
Initial management: Broad-spectrum antibiotics + percutaneous drainage.
Follow-up:
Colonoscopy to rule out underlying malignancy (especially in elderly patients).
Interval appendectomy in 6-8 weeks is often recommended if the patient is high risk for recurrent appendicitis.
Q: A patient suspected of having acute appendicitis undergoes exploration. An inflamed terminal ileum consistent with Crohn’s disease is found. Which of the following is true?
A: The normal appendix should always be removed.
B: Perforated bowel and advanced Crohn’s disease with obstruction should be resected.
C: Only the tip of the appendix should be resected if the base is found to be involved with Crohn’s disease.
D: All grossly involved bowel, including the appendix, should be resected.
E: An inflamed appendix, cecum, and terminal ileum should be resected.
B. Perforated bowel and advanced Crohn’s disease with obstruction should be resected.
Rationale:
If the appendix is inflamed but not perforated, do not remove it, as this could cause a fistula in Crohn’s patients.
If there is perforation or obstruction, segmental resection of diseased bowel is required.
Q: A 28-year-old woman who is 28 weeks pregnant presents with right-sided abdominal pain, leukocytosis, and an abdominal ultrasound that does not visualize the appendix. What is the next best step?
A:
A. Serial clinical observations.
B. Exploratory laparoscopy.
C. Abdominal CT scan.
D. Abdominal MRI scan.
D. Abdominal MRI scan.
Rationale: MRI is the preferred imaging modality in pregnant patients when ultrasound is inconclusive.
Q: During laparoscopic appendectomy on a 35-year-old male with perforated appendicitis, the appendix is necrotic and perforated at the base. What is the best way to proceed?
A:
A. Staple across the necrotic base of the appendix, ensuring the perforation is closed.
B. Place an endoloop around the base of the appendix.
C. Irrigate and place a drain with plans for an interval appendectomy in 6 weeks.
D. Perform a limited cecal resection using a stapling device.
E. Perform an ileocecectomy.
D. Perform a limited cecal resection using a stapling device.
Rationale: A necrotic perforation at the base requires resection of the involved cecum to prevent stump blowout.
Q: A 45-year-old male underwent a laparoscopic appendectomy. Pathology revealed a 1.4-cm tumor in the mid-appendix with direct extension to the mesoappendix, negative margins, and no lymphovascular invasion. What is the best treatment plan?
A:
A. Chemotherapy.
B. No further treatment needed.
C. Right hemicolectomy.
D. Ileocecectomy.
E. Medical treatment with octreotide.
C. Right hemicolectomy.
Rationale:
Indications for right hemicolectomy in appendiceal cancer:
Tumor size >2 cm
Extension into mesoappendix ✅
Lymphovascular invasion or positive margins
Simple appendectomy is only sufficient if the tumor is ≤2 cm and confined to the appendix.
Q: When a mucocele of the appendix is found at surgery, which of the following is an appropriate initial therapy?
A:
A. Incisional biopsy with subsequent appendectomy if malignancy is confirmed by frozen section.
B. Closure and observation.
C. Routine right hemicolectomy with lymph node dissection.
D. Appendectomy.
D. Appendectomy.
Rationale:
Simple appendectomy is appropriate unless:
Malignancy is suspected → Right hemicolectomy.
Perforation or pseudomyxoma peritonei is present → More extensive resection needed.
Q: Regarding appendicitis in the elderly, which statement is FALSE?
A:
A. Symptoms of appendicitis along with anemia should raise suspicion for a concomitant cecal neoplasm.
B. Appendicitis may mimic bowel obstruction.
C. Elderly patients tend to present later in the course of acute appendicitis.
D. Elderly patients have a higher rate of perforation due to omental atrophy.
E. Perforation has an associated mortality rate of 50%.
E. Perforation has an associated mortality rate of 50%.
Rationale:
Perforated appendicitis has a higher mortality in elderly patients (~10-20%) but NOT 50%.
Other statements are true:
Elderly patients present later → Higher perforation rates.
Symptoms can mimic bowel obstruction.
Appendicitis + anemia → Suspect cecal malignancy.
Q: A 35-year-old man is admitted with umbilical pain that moves to the right iliac fossa. Which is a corroborative sign of acute appendicitis?
A:
A. Increase in pain with testicular elevation.
B. Hyperesthesia in the right lower abdomen.
C. Relief of pain in the lower abdomen with thigh extension.
D. Relief of pain in the lower abdomen with internal rotation of the right thigh.
E. Referred pain in the right side with pressure on the left
E. Referred pain in the right side with pressure on the left (Rovsing’s sign).
Rationale:
Rovsing’s sign: Pressing on the left lower quadrant (LLQ) causes RLQ pain, indicating peritoneal irritation.
Other signs of appendicitis:
Psoas sign: Pain with right thigh extension (retrocecal appendix).
Obturator sign: Pain with internal rotation of the thigh (pelvic appendix).
Dunphy’s sign: RLQ pain worsens with coughing.
Q: With regard to appendicitis in immunocompromised patients, which of the following statements is FALSE?
A:
A. Typhlitis often mimics acute appendicitis.
B. Cytomegalovirus (CMV) infections and Kaposi sarcoma can occlude the appendiceal orifice and cause acute appendicitis.
C. Immunocompromised patients with appendicitis often have a fever, a normal WBC count, and nonspecific abdominal pain.
D. CT is particularly useful in immunocompromised patients.
E. Unusual infections such as those caused by mycobacteria, protozoa, and fungi do not usually mimic appendicitis.
E. Unusual infections such as those caused by mycobacteria, protozoa, and fungi do not usually mimic appendicitis.
Rationale:
Immunocompromised patients can have atypical infections (e.g., mycobacteria, fungi, protozoa) that mimic appendicitis.
Typhlitis (neutropenic enterocolitis) presents similarly to appendicitis.
CMV infections and Kaposi sarcoma can cause appendiceal obstruction, leading to appendicitis.
Q: A 20-year-old, 28-week pregnant female presents with a 24-hour history of right upper quadrant abdominal pain and WBC count of 18,000. Ultrasound shows a normal gallbladder and viable fetus, but the appendix is not visualized. What is the next best step?
A:
A. Treat with antibiotics to avoid surgery.
B. Proceed with laparoscopy after delivery.
C. Admit for serial abdominal examinations and repeat labs.
D. Obtain an MRI and proceed with appendectomy if positive.
E. Obtain a CT abdomen/pelvis.
D. Obtain an MRI and proceed with appendectomy if positive.
Rationale:
MRI is the preferred imaging modality for appendicitis in pregnancy if ultrasound is inconclusive.
CT is avoided due to radiation risks.
Early surgical intervention is preferred over observation if appendicitis is suspected.
Q: Which of the following is TRUE regarding the location of the appendix?
A:
A. The position of the tip of the appendix does not determine the symptoms of appendicitis.
B. The tip of the appendix is found in the pelvis in the majority of cases.
C. The appendix is often retrocecal and extraperitoneal.
D. The base of the appendix can always be found at the confluence of the cecal taeniae.
D. The base of the appendix can always be found at the confluence of the cecal taeniae.
Rationale:
The appendix is attached to the cecum at the point where the three taenia coli converge.
The position of the tip varies (retrocecal, pelvic, subcecal, preileal, postileal).
Retrocecal position is most common (60-65%).
Q: What imaging finding would exclude appendicitis?
A:
A. A CT scan with a nonvisualized appendix.
B. An ultrasound showing a compressible appendix <5 mm in diameter.
C. A CT scan showing an edematous but retrocecal appendix.
D. A barium enema where a short (2 cm) appendix is clearly identified.
B. An ultrasound showing a compressible appendix <5 mm in diameter.
Rationale: A normal appendix should be compressible and ≤5 mm in diameter; a noncompressible appendix suggests appendicitis.
Q: Which of the following is TRUE regarding appendiceal carcinoid tumors?
A:
A. Nearly 75% of appendiceal carcinoid tumors are located in the proximal one-third of the appendix.
B. Carcinoid tumor is the second most common tumor of the appendix.
C. Carcinoid tumors arise from the smooth muscle within the appendiceal wall.
D. All tumors <2 cm that do not involve the appendiceal base can be treated with appendectomy alone.
E. For tumors >2 cm, a formal right hemicolectomy is indicated.
E. For tumors >2 cm, a formal right hemicolectomy is indicated.
Rationale: Tumors >2 cm or with mesoappendiceal invasion require right hemicolectomy due to increased metastatic risk.
Q: A 68-year-old male undergoes colonoscopy for watery diarrhea, revealing a mass at the appendiceal orifice. Biopsy confirms a carcinoid tumor. CT shows a 3-cm appendiceal base mass and two liver lesions. Which statement is TRUE?
A:
A. Synchronous treatment with right hemicolectomy and radiofrequency ablation of liver metastases is appropriate.
B. Octreotide decreases metastatic tumor progression and improves survival.
C. Hepatic resection of liver metastases is not recommended.
D. Carcinoid syndrome occurs when the primary tumor is >2 cm and secretes hormones.
E. Appendiceal carcinoid tumors with liver metastases have a 5-year survival rate of only 10%.
A. Synchronous treatment with right hemicolectomy and radiofrequency ablation of liver metastases is appropriate.
Explanation:
1. Right hemicolectomy is the preferred surgical approach for appendiceal carcinoid tumors located at the base and >2 cm in size, as it ensures complete resection with appropriate lymphadenectomy.
2. Liver metastases from neuroendocrine tumors (NETs) can be managed with hepatic resection or radiofrequency ablation (RFA), especially when limited to the liver, to prolong survival and control symptoms.
3. Octreotide (a somatostatin analog) helps in symptom control and reduces hormone secretion but is not the primary treatment for metastatic disease.
4. Carcinoid syndrome is typically associated with hepatic metastases rather than tumor size alone.
5. Appendiceal carcinoid tumors with liver metastases have a relatively favorable prognosis, with a 5-year survival rate of 20–40% after resection, contrary to the 10% survival stated in option E.
Q: Pathology from a recent appendectomy reveals acute appendicitis and a 1.5-cm carcinoid tumor at the base of the appendix. The patient is otherwise healthy. What is the best treatment?
A:
A. Right hemicolectomy.
B. No additional therapy necessary.
C. Adjuvant chemotherapy.
D. Radical appendectomy.
A. Right hemicolectomy.
Rationale: Tumors >1 cm at the base of the appendix require right hemicolectomy due to higher risk of lymph node metastasis.
Q: A 20-year-old woman undergoes an RLQ incision for presumed appendicitis, but the appendix is normal. What is the best next step?
A:
A. Midline laparotomy for complete exploration.
B. Exploration and diverticulectomy if a normal-appearing Meckel’s diverticulum is found.
C. Exploration and ileal resection if the terminal ileum appears inflamed.
D. Exploration and appendectomy if no other pathology is found.
C. Exploration and ileal resection if the terminal ileum appears inflamed.
Rationale: If the terminal ileum appears inflamed, it may indicate Crohn’s disease or Meckel’s diverticulitis, warranting resection.
Q: A 24-year-old man with suspected appendicitis experiences pain when extending his right thigh while lying on his left side. He has no pain with passive rotation of his right hip. Where is the tip of his appendix likely located?
A:
A. In the pelvis.
B. In the left lower quadrant.
C. Displaced to the right upper quadrant.
D. Extraperitoneal and anterior to the cecum.
E. Retrocecal over the psoas muscle.
E. Retrocecal over the psoas muscle.
Rationale: The psoas sign (pain with thigh extension) suggests a retrocecal appendix causing irritation of the psoas muscle.
Q: A 38-year-old man with uncomplicated appendicitis is scheduled for an appendectomy at 2 AM. What difference might be expected if the operation is delayed until morning?
A:
A. Increased risk of intra-abdominal abscess.
B. Decreased operative time.
C. Increased risk of perforation.
D. No difference in perforation rates, surgical-site infection, abscess, conversion rate, or operative time.
D. No difference in perforation rates, surgical-site infection, abscess, conversion rate, or operative time.
Rationale: Studies show that a short delay (<12 hours) in surgery for uncomplicated appendicitis does not increase complications.
Q: A 10-year-old boy presents to the emergency department with generalized abdominal pain for 24 hours. Labs show leukocytosis (13,000), and RLQ tenderness is noted. He undergoes laparoscopic appendectomy. Removal of the appendix has been associated with a protective effect against which condition?
A:
A. Carcinoid
B. Clostridium difficile
C. Crohn’s colitis
D. Ulcerative colitis
D. Ulcerative colitis
Rationale: An inverse association exists between appendectomy and ulcerative colitis, though routine resection for prevention is not recommended.
Q: A 27-year-old man with a 1-day history of RLQ pain and leukocytosis is diagnosed with probable nonperforated acute appendicitis. What is the best antibiotic and surgical management?
A:
A. Administer ceftriaxone and metronidazole (Flagyl) and proceed with surgery.
B. Begin clindamycin perioperatively, as Bacteroides fragilis is the most common organism.
C. Administer cefazolin perioperatively to reduce wound infection risk, then operate.
D. Operate first and await peritoneal fluid cultures to tailor antibiotics.
E. Start ceftriaxone and metronidazole, monitor with serial exams, and operate if no improvement.
A. Administer ceftriaxone and metronidazole (Flagyl) and proceed with surgery.
Rationale: Ceftriaxone and metronidazole provide broad-spectrum coverage against Bacteroides fragilis and Gram-negative bacteria, which are common in appendicitis.
Q: Which of the following statements regarding the pathogenesis of appendicitis is FALSE?
A:
A. Fecaliths are commonly responsible for appendicitis in children.
B. Obstruction of the lumen may occur due to inspissated stool or a foreign body.
C. Obstruction of venous outflow and arterial inflow results in gangrene.
D. The antimesenteric border has the poorest blood supply and is usually the site of perforation.
E. Viral or bacterial infections can precede an episode of appendicitis.
A. Fecaliths are commonly responsible for appendicitis in children.
Rationale: Lymphoid hyperplasia, rather than fecaliths, is the most common cause of appendicitis in children.
Q: On examination, patients with appendicitis typically show maximal tenderness at:
A:
A. The midpoint between the umbilicus and the anterior superior iliac spine.
B. Immediately above the umbilicus.
C. The inguinal region.
D. A point between the outer two-thirds and inner one-third of a line from the umbilicus to the anterior superior iliac spine.
E. A point between the outer one-third and inner two-thirds of a line from the umbilicus to the anterior superior iliac spine.
E. A point between the outer one-third and inner two-thirds of a line from the umbilicus to the anterior superior iliac spine.
Rationale:
The classic site of maximal tenderness in acute appendicitis is McBurney’s point, which is located at the junction of the outer one-third and inner two-thirds of a line drawn from the umbilicus to the anterior superior iliac spine (ASIS). This corresponds to the location of the base of the appendix, where inflammation causes the most significant localized pain.
Q: A 13-year-old boy with RLQ pain and anorexia is diagnosed with appendicitis. Where does appendicitis pain frequently begin?
A:
A. In the back and moves to the RLQ
B. In the umbilical region and then moves to the RLQ
C. In the rectal region and moves to the RLQ
D. In the right flank
E. In the RLQ and remains there
B. In the umbilical region and then moves to the RLQ
Rationale: Appendicitis pain starts in the periumbilical region due to visceral innervation, later localizing to the RLQ with peritoneal involvement.
Q: What is the mortality rate from acute appendicitis?
A:
A. 4–5% after rupture
B. 4/10,000 in the general population
C. 80% if an abscess has formed
D. It has increased in the past 40 years
E. 2% for nonruptured appendicitis
A. 4–5% after rupture
Q: A 19-year-old female model presents with 1 day of lower abdominal pain, RLQ tenderness, and leukocytosis (WBC 13,000). A provisional diagnosis of uncomplicated appendicitis is made, and laparoscopic appendectomy is offered. Possible advantages of laparoscopic appendectomy include all EXCEPT:
A:
A. No treatment for non-appendiceal disease.
B. Inability to thoroughly inspect peritoneal contents.
C. Longer post-hospital recovery.
D. More scar formation.
E. Longer operative time.
C. Longer post-hospital recovery.
Rationale: Laparoscopic appendectomy has shorter recovery times and less postoperative pain compared to open appendectomy.
Q: Regarding laparoscopic appendectomy, which statement is TRUE?
A:
A. It can be performed safely with minimal morbidity compared to open surgery.
B. Wound complication rate is higher than in open surgery.
C. Hospital stay is longer than with open surgery.
D. Procedure cost is lower than open surgery.
E. Return to full feeding takes longer than open surgery.
A. It can be performed safely with minimal morbidity compared to open surgery.
Rationale: Laparoscopic appendectomy is associated with lower wound infection rates and faster recovery.
Q: During open appendectomy, a normal appendix is found. What is the most common procedure the surgeon should perform?
A:
A. Evaluate the pelvis for tuboovarian abscess, pelvic inflammatory disease, malignancy, or ectopic pregnancy.
B. Remove the appendix.
C. Evaluate the terminal ileum and cecum for regional enteritis or bacterial enteritis.
D. Evaluate the upper abdomen for cholecystitis.
B. Remove the appendix.
Rationale: A normal appendix should be removed to prevent future diagnostic confusion and appendicitis.
Q: A 60-year-old female undergoes screening colonoscopy under IV sedation. Near the end of the procedure, she briefly becomes unresponsive. In the recovery room, a chest X-ray reveals free air under the diaphragm. The patient is asymptomatic with normal vitals except for tachycardia. What is the best next step?
A:
A. Admit to hospital, IV antibiotics, and bowel rest
B. Serial abdominal exam for 6 hours
C. Exploratory laparotomy
D. Diagnostic laparoscopy
D. Diagnostic laparoscopy
💡 Rationale:
Pneumoperitoneum in a symptomatic patient usually requires emergency surgery (exploratory laparotomy) due to visceral perforation.
Colonoscopy, particularly with insufflation, can cause benign pneumoperitoneum from microperforations or transmural passage of air.
Patients without abdominal pain, fever, or leukocytosis can be managed conservatively with IV antibiotics, bowel rest, and observation.
However, diagnostic laparoscopy is preferred in this case to confirm whether a microperforation requires intervention.
Q: Ten years after abdominoperineal resection for rectal cancer, a patient presents with a progressively enlarging hernia adjacent to his stoma, interfering with colostomy bag placement. Which statement is TRUE?
A:
A. Treatment includes a hernia belt and weight loss.
B. Prophylactic mesh placement at the initial operation decreases the risk.
C. This complication is more common with loop ileostomy than end colostomy.
D. Chronic obstructive pulmonary disease is the strongest risk factor.
D. Chronic obstructive pulmonary disease (COPD) is the strongest risk factor.
💡 Rationale:
Parastomal hernias occur in up to 50% of stoma patients, with end colostomy having the highest risk and loop ileostomy the lowest risk.
Risk factors include: older age, obesity, malnutrition, immunosuppression, inflammatory bowel disease (IBD), and COPD (the strongest risk factor).
Prophylactic mesh placement at initial surgery reduces recurrence rates (from 55% to 7.8% in studies).
Supportive treatment (hernia belts, weight loss) can help in asymptomatic cases, but symptomatic cases require surgical repair with mesh reinforcement.
Q: A 42-year-old morbidly obese male undergoes sigmoidectomy with end colostomy for perforated diverticulitis. On rounds, the colostomy is dusky but appears viable beneath the fascia. What is the best management?
A:
A. Re-exploration in the OR, on-table bowel prep, and primary colonic anastomosis
B. Observation and reevaluation in 12-24 hours
C. IV antibiotics
D. Re-exploration in the OR, segmental colon resection, and stoma placement at the same site
E. Re-exploration in the OR, resection of ischemic colon, and stoma relocation
E. Re-exploration in the OR, resection of ischemic colon, and stoma relocation
Rationale: Dusky mucosa suggests ischemia, requiring urgent re-exploration to prevent necrosis.
Q: A 37-year-old male with ulcerative colitis presents with jaundice and is diagnosed with primary sclerosing cholangitis. What additional screening is recommended?
A:
A. Immediate screening colonoscopy
B. Immediate colonoscopy with random biopsies
C. Colonoscopy with random biopsies at 8-10 years after UC diagnosis
D. Screening colonoscopy at age 50
E. Symptom-driven colonoscopy as needed
B. Immediate colonoscopy with random biopsies
Rationale: PSC is associated with an increased risk of colorectal cancer in UC patients, warranting immediate surveillance.
Q: Which of the following is LEAST likely to contribute to an anastomotic leak after colorectal cancer surgery?
A:
A. Female gender
B. Prolonged operative time
C. Low rectal tumors
D. Multiple firings of the linear stapler
A. Female gender
Rationale: Male gender is associated with a higher anastomotic leak risk due to a narrower pelvis and more difficult dissection.
Q: Which of the following is TRUE regarding familial adenomatous polyposis (FAP)?
A:
A. Screening with flexible sigmoidoscopy should begin at age 20.
B. It is not associated with extraintestinal manifestations.
C. Prophylactic proctocolectomy reduces periampullary carcinoma risk.
D. Upper endoscopy should be performed every 1-3 years.
D. Upper endoscopy should be performed every 1-3 years.
Rationale: FAP patients are at risk for duodenal and periampullary carcinoma, necessitating regular upper endoscopy.
Q: A 45-year-old woman with a 15-year history of pancolitis undergoes surveillance colonoscopy. No polyps are detected, but random biopsies reveal high-grade dysplasia in the sigmoid colon. What is the recommended management?
A:
A. Repeat colonoscopy in 6 months
B. Sigmoid colectomy
C. Total colectomy with ileorectal anastomosis
D. Total proctocolectomy with ileostomy
E. Restorative proctocolectomy with ileal pouch–anal anastomosis
E. Restorative proctocolectomy with ileal pouch–anal anastomosis
💡 Rationale:
High-grade dysplasia in UC patients is an indication for surgery, as it is associated with an increased risk of colorectal cancer.
Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) is the preferred surgical treatment to preserve bowel function.
Repeat colonoscopy (A) is not appropriate, as high-grade dysplasia warrants definitive treatment.
Segmental resection (B) and total colectomy with ileorectal anastomosis (C) are not recommended because they leave residual colonic mucosa at risk for cancer.
Total proctocolectomy with ileostomy (D) is an option, but IPAA is preferred for functional outcomes unless contraindicated.
Q: A 56-year-old man presents with fever, nausea, and LLQ pain. CT shows a thickened sigmoid colon with fat stranding and a 5-cm pelvic abscess. What is the optimal management?
A:
A. Immediate sigmoid colectomy, end colostomy, and abscess drainage
B. CT-guided drainage followed by colonoscopy and sigmoid colectomy in 6 weeks
C. CT-guided drainage alone
D. IV antibiotics followed by colonoscopy and sigmoid colectomy in 6 weeks
E. IV antibiotics alone
B. CT-guided drainage followed by colonoscopy and sigmoid colectomy in 6 weeks
Rationale: Large abscesses (>3 cm) should be drained percutaneously, followed by interval colectomy.
Q: Which of the following is TRUE regarding familial juvenile polyposis?
A:
A. It is autosomal recessive.
B. The polyps are hamartomas.
C. The risk of colon cancer is 100% by age 50.
D. Once a polyp is detected, total proctocolectomy is recommended.
B. The polyps are hamartomas.
Rationale: Juvenile polyps are hamartomas and have a variable risk of malignancy, necessitating surveillance.
Q: Which of the following is TRUE regarding colonic polyps?
A:
A. Tubulovillous adenomas have a lower malignancy risk than tubular adenomas
B. Some hyperplastic polyps are premalignant
C. The polyps in Peutz-Jeghers syndrome are hyperplastic
D. Pseudopolyps are commonly found in FAP
B. Some hyperplastic polyps are premalignant
Rationale: While most hyperplastic polyps are benign, those in the proximal colon (sessile serrated adenomas) have premalignant potential and are associated with the serrated pathway to colorectal cancer. Tubulovillous adenomas have a higher malignancy risk than tubular adenomas. The polyps in Peutz-Jeghers syndrome are hamartomas, not hyperplastic. Pseudopolyps are more commonly found in ulcerative colitis rather than FAP.
Q: A 75-year-old woman presents with mild diffuse abdominal pain and diarrhea. A fecal immunochemical test is positive. Her medical history is unremarkable, and her laboratory results show a normal WBC count and hematocrit. A CT scan reveals mild thickening of the colonic wall at the splenic flexure with associated pericolic fat stranding. Which of the following is the best next step in management?
A:
A. Mesenteric angiography
B. Diagnostic laparoscopy
C. Exploratory laparotomy
D. Colonoscopy
D. Colonoscopy
Rationale: The CT findings suggest ischemic colitis, which often presents with mild thickening of the colonic wall and pericolic fat stranding. The next step should be colonoscopy, as it allows direct visualization of the mucosa and confirms ischemia. Mesenteric angiography is used for acute mesenteric ischemia, which typically presents with severe pain and metabolic acidosis. Surgery (laparoscopy/laparotomy) is indicated only for peritonitis or clinical deterioration.
Q: A 69-year-old woman is treated with oral metronidazole for an uncomplicated case of pseudomembranous colitis. She develops a recurrence 2 weeks later. What is the best next step?
A:
A. Oral metronidazole is the treatment of choice.
B. Oral vancomycin is the treatment of choice.
C. IV vancomycin is the treatment of choice.
D. Sigmoidoscopy is typically required before treatment.
A. Oral metronidazole is the treatment of choice
💡 Rationale:
Pseudomembranous colitis is predominantly caused by Clostridium difficile.
First-line treatment for an initial episode is oral metronidazole for 10–14 days.
A first recurrence is also treated with a repeat course of metronidazole.
Oral vancomycin (B) is reserved for second recurrences or complicated cases (e.g., severe disease or toxic megacolon).
IV vancomycin (C) is not used for C. difficile infections as it does not achieve effective colonic levels.
Sigmoidoscopy (D) is not routinely required for diagnosis; PCR testing for C. difficile toxins is preferred.
Q: A 38-year-old woman presents with nausea, vomiting, abdominal distention, and obstipation. Abdominal X-ray shows a markedly dilated, kidney-shaped loop of bowel. What is the best treatment option?
A:
A. Cecostomy
B. Operative detorsion with cecopexy
C. Right hemicolectomy with an ileostomy and mucus fistula
D. Initial endoscopic detorsion with a subsequent right hemicolectomy
E. Right hemicolectomy with primary anastomosis
E. Right hemicolectomy with primary anastomosis ✅
💡 Rationale:
Cecal volvulus occurs when the cecum rotates over itself (axial ileocolic volvulus) or flips upward and anteriorly (cecal bascule).
Key imaging finding → Dilated “kidney-shaped” loop of bowel with haustral markings projecting from RLQ to LUQ.
Unlike sigmoid volvulus, endoscopic decompression is difficult.
Best treatment: Right hemicolectomy with primary anastomosis (E) even without bowel prep.
Cecopexy (B) has a high recurrence rate.
If ischemic/gangrenous bowel is present, a right hemicolectomy with ileostomy and mucus fistula (C) may be necessary.
Q: Which of the following is TRUE regarding diverticular disease of the lower GI tract?
A:
A. It occurs most commonly in the descending colon.
B. The rectum can be affected.
C. Incidentally discovered cecal diverticula require surgery due to high risk.
D. Sigmoid resection should be preceded by mechanical bowel prep with oral and IV antibiotics.
D. Sigmoid resection should be preceded by mechanical bowel prep with oral and IV antibiotics.
Rationale: Sigmoid diverticulosis is the most common form, and elective resection is best performed with preoperative bowel prep and perioperative antibiotics.
Q: A 55-year-old man develops severe LLQ pain four hours after a colonoscopy with polypectomy. CT shows free intraperitoneal air. What is the best management?
A:
A. Diverting proximal colostomy
B. Resection of sigmoid colon with end colostomy and rectal oversew
C. Resection of sigmoid colon with primary anastomosis
D. Primary closure of the perforation
C. Resection of sigmoid colon with primary anastomosis.
Rationale: Colonic perforation post-polypectomy requires urgent surgery, typically with segmental colectomy and anastomosis unless peritonitis mandates colostomy.
Q: Which of the following is TRUE regarding chemotherapy for colon carcinoma?
A:
A. Bevacizumab is a monoclonal antibody against epidermal growth factor receptor (EGFR).
B. 5-fluorouracil and leucovorin prolong survival in stage III colon cancer.
C. The combination of 5-fluorouracil and leucovorin prolongs survival in stage IV colon cancer.
D. Radiation therapy is commonly used in colon cancer management.
B. 5-fluorouracil and leucovorin prolong survival in stage III colon cancer.
Rationale: Adjuvant chemotherapy with 5-FU and leucovorin reduces recurrence and improves survival in stage III colon cancer.
Q: A 65-year-old man with LLQ pain and fever is treated with antibiotics. What is the next best step in management?
A:
A. Flexible sigmoidoscopy
B. Plain X-rays of the abdomen
C. CT scan
D. Gastrografin enema
C. CT scan
Rationale: CT scan is the gold standard for diagnosing acute diverticulitis and evaluating for complications like abscess or perforation.
Q: An important energy source for colonocytes, particularly in diversion colitis, is:
A:
A. Amino acids
B. Propionate
C. Ketone bodies
D. Glucose
B. Propionate
Rationale: Short-chain fatty acids (SCFAs), particularly butyrate and propionate, are crucial for colonic mucosal health, especially in conditions like diversion colitis.
Q: A 15-year-old boy with a family history of familial adenomatous polyposis (FAP) has APC gene testing, which is positive. Flexible sigmoidoscopy shows eight adenomatous polyps in the sigmoid colon. What is the recommended management?
A:
A. Repeat sigmoidoscopy in 6 months
B. Total proctocolectomy with continent ileostomy
C. Restorative proctocolectomy with ileal-pouch anal anastomosis
D. Total colectomy with ileorectal anastomosis
C. Restorative proctocolectomy with ileal-pouch anal anastomosis.
Rationale: FAP requires prophylactic colectomy due to near 100% risk of colon cancer. Ileal-pouch anal anastomosis is preferred for continence preservation.
Q: The most common cause of a rectovaginal fistula is:
A:
A. Obstetric injury
B. Colon carcinoma
C. Crohn’s disease
D. Diverticulitis
A. Obstetric injury
Rationale: Obstetric trauma (e.g., prolonged labor, perineal tears, or forceps delivery) is the most frequent cause of rectovaginal fistulas.
Q: A 75-year-old woman presents for follow-up after four episodes of uncomplicated diverticulitis over the past year, each requiring hospitalization for IV antibiotics and bowel rest. She is diabetic. CT scans showed sigmoid inflammation with fat stranding, and colonoscopy revealed diffuse diverticulosis without malignancy. What is the most appropriate surgical intervention?
A:
A. Sigmoid colectomy with proximal margin at an area without hypertrophy of the muscularis propria and distal margin where the taenia splay out
B. Total colectomy with ileoproctostomy
C. Left colectomy with proximal margin at the end of diverticulosis and distal margin where the taenia splay out
D. Sigmoid colectomy with proximal margin at an area without muscularis propria hypertrophy and distal margin at the rectosigmoid junction
A. Sigmoid colectomy with proximal margin at an area without hypertrophy of the muscularis propria and distal margin where the taenia splay out.
Rationale:
Elective sigmoid colectomy is the procedure of choice for patients with recurrent diverticulitis, especially when multiple hospitalizations have occurred
.
The resection should always be extended to the rectum distally to minimize the risk of recurrence.
The proximal extent of the resection should include all thickened or inflamed bowel but does not need to remove all diverticula
.
Laparoscopy is commonly used in elective cases, but the fundamental principle remains proper resection margins.
Q: A hernia containing the appendix is known as:
A:
A. Petit hernia
B. Amyand hernia
C. Littre hernia
D. Spigelian hernia
B. Amyand**
Rationale:
An Amyand hernia is a rare type of inguinal hernia that contains the appendix, which may be normal, inflamed, or even perforated. This condition is named after Claudius Amyand, the surgeon who first described it in the 18th century.
Why not the other options?
- A. Petit hernia → A type of lumbar hernia that occurs through the inferior lumbar triangle.
- C. Littre hernia → A hernia containing a Meckel’s diverticulum (not the appendix).
- D. Spigelian hernia → A rare ventral hernia that occurs along the semilunar line (Spigelian fascia), often at the lateral edge of the rectus abdominis.
Thus, the correct answer is B. Amyand hernia.
Q: A 35-year-old man presents with anorexia, RLQ pain, and fever. At surgery, the appendix appears normal, but both the cecum and terminal ileum are red and inflamed. What is the best management?
A:
A. Right hemicolectomy
B. Appendectomy
C. Close wound without further intervention
D. Biopsy of the cecal wall
C. Close wound without further intervention
Rationale: This presentation is consistent with regional enteritis (Crohn’s disease). Appendectomy should be avoided if the cecum is inflamed, as this increases the risk of enterocutaneous fistula formation.
Q: A 65-year-old woman presents with a massive lower GI bleed. BP is 80/60 mmHg, HR is 120 bpm, and NG aspirate is negative for blood. After resuscitation, BP improves to 120/80 mmHg. What is the next step?
A:
A. Colonoscopy
B. Mesenteric arteriography
C. Tagged red cell scan
D. Exploratory laparotomy
A. Colonoscopy
Rationale:
• Presentation is nearly identical to the first case.
• Since BP stabilized after resuscitation, she is now a candidate for colonoscopy, which is the preferred diagnostic and therapeutic tool for lower GI bleeding.
• Colonoscopy allows localization of the bleeding site and possible intervention (e.g., coagulation or clipping of bleeding lesions).
Q: A 65-year-old institutionalized patient presents with abdominal distention, nausea, and obstipation for 2 days. Abdominal X-ray reveals a massively dilated, inverted U-shaped (omega sign) loop of bowel. What is the best management?
A:
A. Endoscopic detorsion
B. Endoscopic detorsion followed by elective sigmoid colectomy
C. Endoscopic detorsion followed by elective sigmoid colectomy in case of recurrence
D. Exploratory laparotomy with sigmoid colectomy, on-table lavage, and primary anastomosis
B. Endoscopic detorsion followed by elective sigmoid colectomy
Rationale:
- The patient presents with sigmoid volvulus, as indicated by the massively dilated, inverted U-shaped (omega sign) loop of bowel.
- First-line management for non-perforated, non-ischemic sigmoid volvulus is endoscopic detorsion using either a rigid sigmoidoscope or a flexible endoscope.
- However, recurrence rates are high (up to 40%), so after successful detorsion, an elective sigmoid colectomy is recommended to prevent recurrence.
- A. Endoscopic detorsion alone → Not sufficient because of the high recurrence rate; definitive surgical management is needed.
- C. Endoscopic detorsion followed by elective colectomy in case of recurrence → Delaying surgery until recurrence increases the risk of complications. Prophylactic surgery is preferred.
- D. Exploratory laparotomy with sigmoid colectomy, lavage, and primary anastomosis → This is needed only if there is bowel ischemia, perforation, or peritonitis (not present in this patient).
Thus, the best approach is endoscopic detorsion followed by elective sigmoid colectomy to prevent future volvulus episodes.
Q: Which of the following is TRUE about hereditary nonpolyposis colorectal cancer (HNPCC, Lynch syndrome)?
A:
A. Modified Amsterdam criteria require 1 family member to be diagnosed before age 40
B. Screening colonoscopy should begin at age 12
C. It is considered an autosomal recessive syndrome
D. Colonic malignancy has the same prognosis as sporadic cancer
D. Colonic malignancy has the same prognosis as sporadic cancer
Rationale: HNPCC is an autosomal dominant condition. Although it causes early-onset colorectal cancer, the prognosis is similar to sporadic cases if detected early.
Q: Which of the following is TRUE about colonic physiology?
A:
A. The colon absorbs the majority of water in the GI tract
B. Ammonia reabsorption is unaffected by luminal pH
C. Sodium is absorbed actively via Na⁺/K⁺ ATPase
D. Chloride is secreted
C. Sodium is absorbed actively via Na⁺/K⁺ ATPase
Rationale: Water absorption occurs mainly in the small intestine (jejunum). The colon actively absorbs sodium, with water following passively.
Q: A 74-year-old man with biopsy-proven rectal adenocarcinoma is undergoing a low anterior resection. Which layers must be stapled through when resecting the distal portion of the rectum?
A:
A. Mucosa, submucosa, circular muscle layer, longitudinal muscle layer, and serosa
B. Mucosa, submucosa, longitudinal muscle layer, circular muscle layer, and serosa
C. Mucosa, submucosa, longitudinal muscle layer, and circular muscle layer
D. Mucosa, submucosa, circular muscle layer, and serosa
C. Mucosa, submucosa, longitudinal muscle layer, and circular muscle layer
Rationale: The rectum lacks serosa, so the stapler only passes through the mucosa, submucosa, and muscle layers.
Q: Which layer of muscle forms the internal anal sphincter?
A:
A. Circumferential muscle layer
B. Longitudinal muscle layer
C. Puborectalis muscle
D. Circular muscle layer
D. Circular muscle layer
Rationale:
- The inner circular muscle layer of the rectum coalesces to form the internal anal sphincter.
- This sphincter is involuntary and plays a crucial role in maintaining continence at rest.
- The external anal sphincter, on the other hand, is composed of skeletal muscle and is under voluntary control.
Why not the other options?
- A. Circumferential muscle layer → This is not a specific term used in anatomy; the correct term is circular muscle layer.
- B. Longitudinal muscle layer → This contributes to the rectal wall structure but does not form the internal anal sphincter.
- C. Puborectalis muscle → This is part of the external anal sphincter complex, providing voluntary control over defecation.
Thus, the inner circular muscle layer forms the internal anal sphincter, making D. Circular muscle layer the correct answer.
Q: A 24-year-old woman undergoes total colectomy for ulcerative colitis. Where is the most appropriate site to ligate the inferior mesenteric vein?
A:
A. The presacral fascia separates the rectum from the presacral venous plexus and the pelvic nerves; Waldeyer fascia extends forward and downward and attaches to the fascia propria at the anorectal junction. Denonvilliers fascia separates the rectum from the prostate and seminal vesicles in men and from the vagina in women.**
B. The presacral fascia extends forward and downward and attaches to the fascia propria at the anorectal junction; Waldeyer fascia separates the rectum from the prostate and seminal vesicles in men and from the vagina in women; Denonvilliers fascia separates the rectum from the presacral venous plexus and pelvic nerves.
C. The presacral fascia separates the rectum from the prostate and seminal vesicles in men and from the vagina in women; Waldeyer fascia extends forward and downward and attaches the fascia propria at the anorectal junction; Denonvilliers fascia separates the rectum from the presacral venous plexus and the pelvic nerves.
D. None of the above.
A. The presacral fascia separates the rectum from the presacral venous plexus and the pelvic nerves; Waldeyer fascia extends forward and downward and attaches to the fascia propria at the anorectal junction. Denonvilliers fascia separates the rectum from the prostate and seminal vesicles in men and from the vagina in women.
Rationale:
- The inferior mesenteric vein (IMV) is typically ligated during a total colectomy at the inferior border of the pancreas before it drains into the splenic vein.
- Understanding the anatomical relationships of fasciae in the pelvic region is crucial for safe dissection and avoiding injury to nearby structures.
- Presacral fascia: Separates the rectum from the presacral venous plexus and pelvic nerves, which is key for identifying safe ligation planes.
- Waldeyer fascia: Extends forward and downward and attaches to the fascia propria at the anorectal junction.
- Denonvilliers fascia: Separates the rectum from the prostate and seminal vesicles in men and from the vagina in women.
Thus, A is the best answer as it correctly describes the key anatomic landmarks used during a total colectomy for ulcerative colitis.
Q: Choose the correct definition of intestinal malrotation:
A:
A. At 4 weeks gestation, the midgut herniates through the abdominal cavity, rotates 270° clockwise around the SMA, and returns to the abdomen by week 10.
B. At 4 weeks gestation, the midgut herniates through the abdominal cavity, rotates 270° counterclockwise around the SMA, and returns to the abdomen by week 12.
C. At 6 weeks gestation, the midgut herniates through the abdominal cavity, rotates 270° clockwise around the SMA, and returns to the abdomen by week 12.
D. At 6 weeks gestation, the midgut herniates through the abdominal cavity, rotates 270° counterclockwise around the SMA, and returns to the abdomen by week 10.
D. At 6 weeks gestation, the midgut herniates through the abdominal cavity, rotates 270° counterclockwise around the SMA, and returns to the abdomen by week 10.
Rationale: Intestinal malrotation results from failure of 270° counterclockwise rotation around the SMA. It typically presents with bilious vomiting due to volvulus.
Q: A 62-year-old man undergoes an emergent left hemicolectomy with a diverting loop ileostomy for perforated diverticulitis. If he has a high-output ileostomy and is at risk for diversion colitis, which fatty acids are not being absorbed?
A:
A. Butyric and propionic acid
B. Propionic and palmitic acid
C. Pricosic and butyric acid
D. Lauric and palmitic acid
A. Butyric and propionic acid
Rationale: Short-chain fatty acids (SCFAs), such as butyric and propionic acid, are the primary energy source for colonic epithelial cells. Lack of colonic exposure to SCFAs in diversion colitis leads to inflammation and mucosal atrophy.
Q: A 58-year-old mother of 10 suffers from fecal incontinence. Which of the following is the most likely cause?
A:
A. Injury to the puborectalis
B. Decreased rectal contraction
C. Repair of internal/external sphincter during delivery
D. Hypertrophic internal and external anal sphincters
A. Injury to the puborectalis
Rationale: The puborectalis muscle forms a sling around the distal rectum and is essential for maintaining continence. Injury during childbirth is a common cause of fecal incontinence.
Q: A healthy 48-year-old physician tests positive for a fecal occult blood test (FOB). She has no cancer history and follows a high-protein, high-fiber diet with vitamin C supplementation. Should she have further colon screening?
A:
A. No, vitamin C can cause a false-positive FOB.
B. Yes, all positive FOB results require colonoscopy.
C. Yes, all positive FOB results require repeat FOB in 1 year.
D. None of the above.
B. Yes, all positive FOB results require colonoscopy.
Rationale: Any positive FOB requires further investigation with colonoscopy, as it does not differentiate between benign and malignant causes.
Q: A 22-year-old college student presents with intermittent diarrhea for 5 days after returning from Mexico. However, she has had recurrent diarrhea episodes for 2 years, unrelated to travel. What is the next step in workup?
A:
A. Stool wet mount and stool culture
B. Add Sudan Red to stool culture
C. Sigmoidoscopy (only if peritoneal signs present)
D. All of the above
D. All of the above
Rationale: Chronic diarrhea in a young patient requires evaluation for infectious, inflammatory, and malabsorption causes. Testing includes stool cultures, microscopic stool analysis, and endoscopy (if needed).
Q: A 76-year-old man undergoes an emergent sigmoidectomy with a Hartmann procedure for a perforated colon mass. Where should the colostomy be placed?
A:
A. Above the beltline, within the rectus abdominis muscle, away from the costal margin
B. Above the beltline, within rectus abdominis muscle, near the costal margin
C. Below the beltline, within the rectus abdominis muscle, away from the costal margin
D. Below the beltline, within the rectus abdominis muscle, near the costal margin
C. Below the beltline, within the rectus abdominis muscle, away from the costal margin.
Rationale: Placing the colostomy within the rectus abdominis muscle prevents herniation and provides better appliance fitting.
Q: A 19-year-old man undergoes total colectomy with J-pouch creation for medically refractory ulcerative colitis. What are some late complications of ileal pouch-anal reconstruction?
A:
A. More than 8 bowel movements per day
B. Nocturnal incontinence
C. Small bowel obstruction
D. A and C
E. All of the above
E. All of the above
Rationale: Pouchitis, increased stool frequency, nocturnal incontinence, and small bowel obstruction are common complications following J-pouch reconstruction.
Q: A 46-year-old woman with rectal adenocarcinoma undergoes a low anterior resection with a diverting loop ileostomy. Before ileostomy reversal, what workup is required?
A:
A. Digital rectal exam to check the anastomosis
B. No examination is needed
C. Flexible sigmoidoscopy or contrast enema to check patency
D. Colonoscopy to evaluate for new polyps
C. Flexible sigmoidoscopy or contrast enema to check patency.
Rationale: Before ileostomy reversal, an endoscopic or radiographic study is required to ensure the anastomosis is intact and functional.
Q: A 75-year-old woman undergoes a right hemicolectomy with end ileostomy for perforated diverticulitis. What is the most concerning short-term complication requiring revision?
A:
A. Skin breakdown from succus entericus
B. Stoma necrosis above the level of the fascia
C. Stoma necrosis below the level of the fascia
D. Stomal retraction below the fascia
C. Stoma necrosis below the level of the fascia
Rationale: Stomal necrosis below the level of the fascia requires revision, as it may indicate ischemia of the bowel segment.
Q: A 19-year-old man undergoes total colectomy with J-pouch creation for medically refractory ulcerative colitis. What are some late complications of ileal pouch-anal reconstruction?
A:
A. More than 8 bowel movements per day
B. Nocturnal incontinence
C. Pouchitis
D. Small bowel obstruction
E. All of the above
E. All of the above
Rationale: Pouchitis, increased stool frequency, nocturnal incontinence, and small bowel obstruction are common complications following J-pouch reconstruction.
Q: A 68-year-old man is undergoing a right hemicolectomy for a cecal mass. He asks about the best antibiotic prophylaxis to decrease postoperative infection. When should antibiotics always be used for this procedure?
A:
A. Oral antibiotics should be used in combination with bowel preparation
B. Parenteral antibiotic prophylaxis at the time of surgery and after skin incision is made, with redosing as needed during the procedure
C. Parenteral antibiotic prophylaxis at the time of surgery before the skin incision is made
D. Oral antibiotics should be used postoperatively to decrease the risk of anastomotic leak
C. Parenteral antibiotic prophylaxis at the time of surgery before the skin incision is made
Rationale: Antibiotic prophylaxis should be administered before skin incision, as studies show this significantly reduces surgical site infections (SSI). Redosing is required for prolonged procedures (>4 hrs) or excessive blood loss (>1.5L). Oral antibiotics may be used preoperatively but not postoperatively.
Q: A 50-year-old woman who underwent total colectomy with ileal-pouch-anal reconstruction 5 years ago presents with diarrhea, malaise, and severe abdominal pain every 2 weeks. What is the most appropriate differential diagnosis?
A:
A. Parasitic infection, ulcerative colitis of the remaining rectum, undiagnosed Crohn’s disease
B. Bacterial or viral infection, undiagnosed Crohn’s disease, and pouchitis
C. Parasitic infection, bacterial or viral infection, and pouchitis
B. Bacterial or viral infection, undiagnosed Crohn’s disease, and pouchitis
Rationale: Pouchitis is the most common long-term complication of ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. Symptoms include diarrhea, abdominal pain, urgency, and malaise, and it responds well to antibiotics (ciprofloxacin or metronidazole).
Q: A 22-year-old woman presents with a 3-year history of bloody diarrhea, abdominal pain, and anorectal fistulas. Her father had similar symptoms in his 20s and required multiple surgeries. What percentage of patients with this disease have an affected family member?
A:
A. 5-10%
B. 10-20%
C. 10-30%
D. 20-40%
C. 10-30%
Rationale: Inflammatory bowel disease (IBD), including Crohn’s disease and ulcerative colitis, has a genetic component. About 10-30% of patients have a family history of IBD.
Q: A 25-year-old man is undergoing workup for ulcerative colitis vs. Crohn’s disease. Which of the following diagnostic findings is most consistent with Crohn’s disease?
A:
A. Atrophic mucosa, crypt abscesses, inflammatory pseudopolyps, scarred and shortened colon, continuous involvement of the rectum and colon
B. Mucosal ulcerations, noncaseating granulomas, fibrosis, strictures, and fistulas in the colon with deep serpiginous ulcers
C. Atrophic mucosa, noncaseating granulomas, strictures, cobblestone appearance on endoscopy
D. Mucosal ulcerations, crypt abscesses, inflammatory pseudopolyps, continuous involvement of the rectum and colon
B. Mucosal ulcerations, noncaseating granulomas, fibrosis, strictures, and fistulas in the colon with deep serpiginous ulcers
Rationale: Crohn’s disease is a transmural inflammatory process that can affect any part of the GI tract. Key features include:
Skip lesions (non-continuous inflammation)
Cobblestone appearance
Strictures and fistulas
Noncaseating granulomas
Deep serpiginous ulcers on colonoscopy
Q: What structures are most commonly affected by extracolonic disease in inflammatory bowel disease (IBD)?
A:
A. Liver, biliary tree, joints, skin, eyes
B. Joints, skin, biliary tree, bladder
C. Biliary tree, lungs, heart, spleen
D. Skin, liver, pancreas, joints, eyes
A. Liver, biliary tree, joints, skin, eyes
Rationale: IBD has multiple extracolonic manifestations, including:
PSC (Primary Sclerosing Cholangitis) → Liver & Biliary Tree
Uveitis → Eyes
Erythema nodosum, pyoderma gangrenosum → Skin
Arthritis → Joints
Q: What is the first-line therapy for inflammatory bowel disease (IBD) in the outpatient setting?
A:
A. Salicylates such as sulfasalazine and 5-aminosalicylic acid (5-ASA)
B. Antibiotics, such as metronidazole and fluoroquinolones
C. Corticosteroids
D. Azathioprine and 6-mercaptopurine
A. Salicylates such as sulfasalazine and 5-aminosalicylic acid (5-ASA)
Rationale: 5-ASA drugs (such as mesalamine) are first-line therapy for mild to moderate IBD. They reduce inflammation without systemic immunosuppression.
Q: A 26-year-old man with ulcerative colitis presents with severe abdominal pain, fever, and a rigid abdomen. He is ill-appearing. Which finding would indicate that a stoma is required instead of primary anastomosis?
A:
A. Long-standing history of ulcerative colitis with multiple colon polyps
B. Albumin of 2.2 in a patient who has been on corticosteroids
C. Blood glucose of 300 in a patient who finished a corticosteroid course 3 weeks ago
D. Diarrhea >10 times/day for months with albumin of 3.6
B. Albumin of 2.2 in a patient who has been on corticosteroids
Rationale: A low albumin level (malnutrition) and prolonged corticosteroid use increase the risk of anastomotic failure. In these cases, a stoma is preferred over primary anastomosis.
Q: A 24-year-old woman with ulcerative colitis presents with fever, severe abdominal pain, and bloody stools for 5 days. What are the indications for emergency surgery?
A:
A. Continued hemorrhage despite blood transfusions
B. Hemodynamic instability requiring ICU transfer after 48 hours
C. Severe abdominal pain and diarrhea unresponsive to bowel rest, IV fluids, and corticosteroids
D. Cecum measuring 11 cm in diameter on CT scan
D. Cecum measuring 11 cm in diameter on CT scan
Rationale: Toxic megacolon (cecum >9 cm) is an emergency requiring surgical intervention.
- A 55-year-old woman with a history of longstanding Crohns disease presents to the clinic with a 1-month long history of abdominal pain and a new area of induration, fluctuance, and foul-smelling drainage from a former midline incision. What are the most common indications for surgery?
A. Internal fistula or abscess
B. Obstruction
C. Toxic megacolon
D. Strictures
A. Internal fistula or abscess
Explanation:
• The most common indications for surgery in Crohn’s disease include:
• Symptomatic strictures causing obstruction.
• Internal fistulas (e.g., enteroenteric, enterocutaneous, enterovesical, enterovaginal).
• Intra-abdominal abscesses that do not respond to drainage and antibiotics.
• Perforation leading to peritonitis.
• Dysplasia or cancer arising from long-standing disease.
• In this patient, the presence of fluctuance, foul-smelling drainage, and a history of Crohn’s disease suggests a fistula or abscess formation, making surgical intervention necessary
Q: A 23-year-old man presents with severe pain with defecation for 2 months. He has started eating less to avoid bowel movements. On rectal exam, a fissure is found. What would indicate that this fissure is due to Crohn’s disease?
A:
A. Deep and broad ulcer in the lateral position
B. Shallow and broad ulcer in the anterior position
C. Deep and narrow ulcer in the posterior midline position
D. Shallow and narrow ulcer in the lateral position
A. Deep and broad ulcer in the lateral position
Rationale: Fissures in Crohn’s disease tend to be deep, broad, and located laterally, whereas benign fissures occur in the posterior midline.
Q: A 65-year-old man presents to the ER with fever, abdominal pain, and bloody stools for the past 2 days. A CT scan reveals diverticulitis with scant free air and a small fluid collection associated with the sigmoid colon. What is the etiology of diverticulosis?
A:
A. Lack of dietary fiber causes smaller stool volume requiring higher intraluminal pressure
B. Chronic contraction causes muscular hypertrophy and causes the colon to act as segments rather than a continuous tube
C. The mucosa and muscularis mucosa herniate through the colon wall
D. AOTA (All of the Above)
D. AOTA (All of the Above)
Rationale: Diverticulosis occurs due to a combination of factors:
Low-fiber diet → Smaller stool volume → Higher intraluminal pressure
Chronic contraction → Muscular hypertrophy → Segmented colon movement
Herniation of mucosa/muscularis mucosa → Diverticulum formation
Q: A 72-year-old woman presents to the clinic to discuss surgical management of her long-standing diverticulosis. What would be an indication for a colectomy in this patient?
A:
A. Three episodes of diverticulitis requiring hospitalization in an otherwise asymptomatic patient
B. A single episode of diverticulitis in an immunosuppressed patient
C. A current episode of complicated diverticulitis resulting in feculent peritonitis
D. Inability to exclude malignancy in a patient recently hospitalized for her first episode of complicated diverticulitis
A. Three episodes of diverticulitis requiring hospitalization in an otherwise asymptomatic patient
Rationale: Elective sigmoid colectomy is recommended for recurrent, severe, or complicated diverticulitis. Immunosuppressed patients and those with complicated diverticulitis (peritonitis, fistula, obstruction) may need early surgical intervention.
Q: A 63-year-old woman presents with a 2-day history of left lower quadrant abdominal pain and fever (38.6°C). WBC count: 15,000. CT scan shows colonic inflammation with an associated pericolic abscess.
What is her Hinchey stage?
A:
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
A. Stage I
Rationale: Hinchey staging system for diverticulitis:
Stage I – Pericolic or mesenteric abscess
Stage II – Pelvic, retroperitoneal, or distant intra-abdominal abscess
Stage III – Purulent peritonitis (no fecal contamination)
Stage IV – Fecal peritonitis
Q: A 68-year-old woman presents with left lower quadrant pain, fever (39°C), and WBC 12,000. CT scan reveals colonic inflammation with a retroperitoneal abscess.
What is her Hinchey stage?
A:
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
B. Stage II
Rationale: Stage II diverticulitis involves a distant abscess (e.g., retroperitoneal, pelvic).
Q: A 62-year-old woman presents with severe left lower quadrant abdominal pain, fever (39°C), WBC 21,000. CT scan shows diverticula, intra-abdominal free air, and free fluid. During emergent laparotomy, feculent material is found intra-abdominally.
What is her Hinchey stage?
A:
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
D. Stage IV
Rationale: Feculent peritonitis = Stage IV, requiring emergency surgery.
Q: A 58-year-old man presents with the sensation of urinating air for 2 months. He has a history of diverticulitis, with his last hospitalization 6 months ago.
What is the most common fistula associated with complicated diverticulitis?
A: Colovaginal fistula
B: Coloenteric fistula
C: Colocutaneous fistula
D: Colovesical fistula
D. Colovesical fistula
Rationale: Colovesical fistulas (65%) are the most common, followed by colovaginal fistulas (25%).
Q: What is the predominant microorganism in the feces?
A:
A. E. coli
B. Bacteroides
C. H. influenza
D. Pseudomonas
B. Bacteroides
Rationale: Bacteroides fragilis is the most abundant anaerobe in feces.
Q: During fistulotomy for fistula-in-ano, the external sphincter muscle is accidentally cut. What would be the effect on defecation?
A:
A. No effect on resting and involuntary sphincter tone
B. No effect on voluntary tone
C. Will affect resting pressure
D. Will affect squeeze pressure
D. Will affect squeeze pressure
Rationale: The external anal sphincter contributes to voluntary control. Cutting it decreases squeeze pressure, leading to incontinence.
Q: Hemorrhoids are a normal part of the anorectal anatomy and play a role in anal continence. Treatment is necessary when:
A:
A. Symptomatic
B. Excessive anal tissue is present
C. Hemorrhoidal tissue is present
D. Portal hypertension is present
A. Symptomatic
Rationale: Only symptomatic hemorrhoids require treatment (bleeding, pain, prolapse, thrombosis).
Q: A 34-year-old male call center agent presents to the ER with recurrent bleeding from Grade 2 internal hemorrhoids after medical treatment and diet modification.
What is the most appropriate treatment plan?
A: Resume medication for 1 month
B: Rubber band ligation
C: Sclerotherapy
D: Hemorrhoidectomy
B. Rubber band ligation
Rationale:
Grade 1 Hemorrhoids → Medical therapy (fiber, sitz baths, topical agents)
Grade 2 Hemorrhoids → Rubber band ligation
Grade 3 Hemorrhoids → Rubber band ligation or surgical hemorrhoidectomy
Grade 4 Hemorrhoids → Hemorrhoidectomy
Q: A 65-year-old man presents to the clinic with a rectal mass extending into the anal canal. Biopsy confirms adenocarcinoma. Poorest prognosis is seen when which lymph nodes are involved?
A:
A. Inguinal
B. Peri-rectal
C. Inferior mesenteric
D. Para-aortic
D. Para-aortic
Explanation:
* Para-aortic lymph node involvement represents distant metastasis (M1 disease), which significantly worsens prognosis.
* Higher-stage nodal spread (N3) is associated with lower survival rates, as it often indicates widespread disease.
* The stepwise spread of rectal cancer follows this order:
1. Peri-rectal nodes (N1) → Best prognosis
2. Inferior mesenteric nodes (N2) - Intermediate prognosis
3. Para-aortic nodes (N3/M1) → Poorest prognosis
Why Not the Other Options?
* A. Inguinal nodes → More common in anal cancer rather than rectal cancer.
* B. Peri-rectal nodes → First level of nodal spread and still resectable, leading to a better prognosis.
* C. Inferior mesenteric nodes → Worse than peri-rectal involvement but better than para-aortic metastasis.
Q: With regards to survival following treatment of anal melanoma, the strategy proven most effective is:
A:
A. Local excision with adjuvant radiotherapy
B. APR (Abdominoperineal resection) with chemotherapy
C. Wide excision with free margins
D. Combined radiotherapy, chemotherapy, and immunotherapy
C. Wide excision with free margins
Rationale:
Wide local excision (WLE) is preferred due to high morbidity associated with APR.
Adjuvant therapy is usually ineffective in improving survival.
Melanoma has poor outcomes overall, but local control is best with WLE.
Q: What vessels are ligated when a surgeon performs a right hemicolectomy?
A:
A. Right colic, right branch of middle colic artery
B. Ileocolic, right colic, right branch of middle colic artery
C. Ileocolic, right colic, right and left branch of middle colic artery
D. Right colic, middle colic, right and left branch of middle colic artery
B. Ileocolic, right colic, right branch of middle colic artery
Rationale:
A right hemicolectomy involves removing the cecum, ascending colon, and proximal transverse colon, requiring ligation of the following vessels:
Ileocolic artery (a branch of the SMA)
Right colic artery (if present, from the SMA)
Right branch of the middle colic artery (from the SMA)
Q: What is the most common complication of an end colostomy?
A:
A. Bleeding
B. Skin breakdown
C. Parastomal hernia
D. Colonic perforation during irrigation
E. Stomal prolapse
C. Parastomal hernia
Rationale:
Parastomal hernias occur in up to 50% of colostomies, due to weakness in the abdominal wall fascia.
Skin breakdown is also common but less severe than herniation.
Q: One year after surgery for colon cancer, a patient’s previously normal serum CEA levels become elevated. The next step is:
A:
A. Repeat determination after 2 months
B. Complete workup for metastasis
C. Adjuvant chemotherapy
D. Exploratory laparotomy
B. Complete workup for metastasis
Rationale:
CEA (Carcinoembryonic Antigen) is a tumor marker for colorectal cancer recurrence.
Elevated CEA post-treatment → Requires full metastatic workup (CT chest/abdomen, PET scan).
Surgery is not first-line without evidence of resectable disease.
Q: Diverticular disease most commonly affects the:
A:
A. Ascending colon
B. Transverse colon
C. Sigmoid colon
D. Descending colon
C. Sigmoid colon
Rationale:
Sigmoid colon is the most common site because of high intraluminal pressure and narrow diameter.
Right-sided (ascending) diverticulosis is more common in Asian populations.
Q: The diagnostic modality primarily used to evaluate the depth of invasion of malignant rectal tumors is:
A:
A. MRI
B. CT scan
C. Endorectal ultrasound (ERUS)
D. Colonoscopy
A. MRI
Q: Patients with Gardner’s syndrome (a form of multiple polyposis of the colon) usually have all of the following EXCEPT:
A: Polyps by the age of 20
B: Osteomas of the mandible and skull
C: Epidermoid cysts of the skin
D: Mucosal pigmentation
D. Mucosal pigmentation
Explanation:
Gardner’s syndrome is a variant of familial adenomatous polyposis (FAP) and is associated with:
Colorectal polyps (by age 20)
Osteomas of the skull and mandible
Epidermoid cysts of the skin
Desmoid tumors
Mucosal pigmentation is NOT a feature of Gardner’s syndrome. Instead, Peutz-Jeghers syndrome (another polyposis syndrome) is associated with mucocutaneous pigmentation.
Q: Endogenous microflora participate in the metabolism of all the following EXCEPT:
A: Bilirubin
B: Lecithin
C: Vitamin K
D: Bile acids
E: Cholesterol
B. Lecithin
Rationale:
Gut bacteria help metabolize bilirubin, vitamin K, bile acids, and cholesterol.
Lecithin is not significantly metabolized by gut flora.
Q: During a fistulotomy for fistula-in-ano, the external sphincter muscle is accidentally cut. What would be the effect on defecation?
A:
A. No effect on resting and involuntary sphincter tone
B. Will affect resting pressure
C. No effect on most voluntary tone
D. Will affect squeeze pressure
D. Will affect squeeze pressure
Rationale:
External anal sphincter provides voluntary control over defecation.
Damage leads to decreased squeeze pressure and incontinence.
Q: A 65-year-old man presents to the ER with fever, abdominal pain, and bloody stools for the past 2 days. A CT scan reveals diverticulitis with scant free air and a small fluid collection associated with the sigmoid colon. What is the etiology of diverticulosis?
A:
A. Lack of dietary fiber causes smaller stool volume requiring higher intraluminal pressure
B. Chronic contraction causes muscular hypertrophy and causes the colon to act as segments rather than a continuous tube
C. The mucosa and muscularis mucosa herniate through the colon wall
D. AOTA (All of the Above)
D. AOTA (All of the Above)
Rationale:
Low-fiber diet → Smaller stool volume → Higher pressure
Chronic contraction → Muscular hypertrophy
Mucosa/muscularis herniation → Diverticulum formation
Q: The appendix is an immunologic organ that participates in the secretion of which immunoglobulin?
A:
A. IgA
B. IgM
C. IgE
D. IgG
A. IgA
Rationale:
The appendix contains lymphoid tissue that contributes to mucosal immunity.
It secretes IgA, which plays a role in gut-associated lymphoid tissue (GALT) and mucosal defense.
Q: Who established the role of surgical removal of an inflamed appendix as a cure for acute appendicitis in 1886?
A:
A. John Fitch
B. Theodor Kocher
C. Charles McBurney
D. Reginald Fitz
D. Reginald Fitz
Rationale:
Reginald Fitz first described appendicitis and recommended surgical intervention in 1886.
Charles McBurney later refined the surgical approach.
Q: The dominant causal factor of acute appendicitis is:
A:
A. Infection
B. Idiopathic
C. Obstruction of lumen
D. Walking after a heavy meal
C. Obstruction of lumen
Rationale:
Fecaliths (most common), lymphoid hyperplasia, parasites, and tumors can obstruct the appendiceal lumen, leading to increased intraluminal pressure, bacterial overgrowth, ischemia, and inflammation.
Q: What is the typical sequence of symptom appearance in acute appendicitis?
A:
A. Anorexia, vomiting, abdominal pain
B. Vomiting, abdominal pain, anorexia
C. Vomiting, anorexia, abdominal pain
D. Anorexia, abdominal pain, vomiting
D. Anorexia, abdominal pain, vomiting
Rationale:
McBurney’s triad:
Anorexia (earliest sign)
Abdominal pain (initially periumbilical, then migrates to RLQ)
Vomiting (late sign)
Q: A patient with acute appendicitis prefers to:
A:
A. Eat
B. Lie prone
C. Lie supine
D. Walk around
C. Lie supine
Rationale:
Patients avoid movement and prefer lying still, as movement exacerbates peritoneal irritation.
Q: Which of the following is NOT a differential diagnosis for acute appendicitis in a 22-year-old male?
A: Pelvic inflammatory disease (PID)
B: Acute gastroenteritis
C: Urinary tract infection
D: Testicular torsion
A. Pelvic inflammatory disease (PID)
Rationale:
PID occurs in females.
Testicular torsion, gastroenteritis, and UTIs can mimic appendicitis in males.
Q: What is the definitive treatment for acute appendicitis?
A:
A. Antibiotics
B. Early operative intervention
C. Observation
D. Pain relievers
B. Early operative intervention (Appendectomy)
Rationale:
Surgery is the standard treatment to prevent perforation.
Antibiotics alone may be used in selected cases but have higher recurrence rates.
Q: What is the treatment for carcinoid tumors of the appendix greater than 2 cm?
A:
A. Simple appendectomy
B. Observation
C. Right hemicolectomy
D. Chemotherapy
C. Right hemicolectomy
Rationale:
> 2 cm carcinoid tumors, involving the base of the appendix, or with lymphovascular invasion require right hemicolectomy.
Smaller (<2 cm, confined to the tip) can be treated with appendectomy.
Q: What is the preferred treatment for acute appendicitis?
A:
A. Observation and bowel rest
B. Antibiotics and observation
C. Pain relievers
D. Appendectomy
D. Appendectomy
Rationale:
Early surgery prevents perforation and complications like peritonitis or abscess formation.
Q: What is the correct sequence of steps in the physical examination of an acute abdomen?
A:
A. Inspection, auscultation, palpation
B. Palpation, inspection, auscultation
C. Auscultation, palpation, inspection
D. Inspection, palpation, auscultation
A. Inspection, auscultation, palpation
Rationale:
Inspection is done first to observe for distension, scars, or visible peristalsis.
Auscultation follows to assess bowel sounds before palpation, as palpation can alter bowel sounds.
Palpation is done last to evaluate tenderness, rigidity, rebound, and masses.
Q81: Which sign is positive when pressure applied to the left lower quadrant results in right lower quadrant pain or tenderness?
A:
A. Murphy’s sign
B. Obturator sign
C. Rovsing’s sign
D. Psoas sign
C. Rovsing’s sign
Explanation:
Rovsing’s sign is positive when pressure applied to the left lower quadrant (LLQ) causes pain in the right lower quadrant (RLQ).
It indicates peritoneal irritation and is commonly seen in acute appendicitis.
Why Not the Other Options?
A. Murphy’s sign → Associated with acute cholecystitis (pain upon deep inspiration while palpating the RUQ).
B. Obturator sign → Pain with internal rotation of the flexed thigh, indicating a pelvic appendix.
D. Psoas sign → Pain with hip extension, suggesting a retrocecal appendix.
Q82: What are the most important and useful steps in the evaluation of patients with abdominal pain?
A:
A. Ultrasound and abdominal X-rays
B. CT scan and ultrasound
C. History and physical examination
D. Physical examination and CT scan
C. History and physical examination
Explanation:
The most important and initial steps in evaluating abdominal pain are history-taking and physical examination.
History helps determine location, onset, nature, radiation, aggravating/relieving factors, associated symptoms.
Physical examination provides key clinical signs that guide further imaging and management.
Q83: Acute appendicitis is most commonly associated with which of the following signs and symptoms?
A: WBC count > 20,000/mm³
B: Frequent loose stools
C: Temperature above 40°C
D: Anorexia, abdominal pain, and RLQ tenderness
D. Anorexia, abdominal pain, and RLQ tenderness
Rationale:
Classic appendicitis triad: Anorexia + RLQ pain + Tenderness.
High fever (≥40°C) and WBC > 20,000 → Suggest perforation or sepsis.
Diarrhea is rare in appendicitis unless pelvic appendix is inflamed.
Q84: During the evaluation of abdominal pain, which of the following pain characteristics are important to elicit?
A: Character
B: Severity
C: Duration
D: All of the above
D. All of the above
Rationale:
Pain history guides differential diagnosis.
Sudden onset → Perforation, ischemia.
Colicky → Obstruction, stones.
Sharp/localized → Peritoneal irritation.
Q85: What is the most reliable physical finding associated with acute appendicitis?
A: Cutaneous hyperesthesia
B: Psoas sign
C: Tenderness on rectal exam
D: Localized right lower quadrant tenderness
D. Localized RLQ tenderness
Rationale:
McBurney’s point tenderness is the most sensitive sign of appendicitis.
Psoas sign suggests retrocecal appendix.
Rectal tenderness → May indicate pelvic appendix involvement.
Q86: Which statement is NOT true regarding acute appendicitis?
A: Anorexia is usually present
B: Pain often begins in the epigastric/umbilical area
C: Symptoms of diarrhea may occur
D: Vomiting usually precedes pain
D. Vomiting usually precedes pain
Rationale:
Pain first, then vomiting is the classic sequence.
Diarrhea can occur if the inflamed appendix is near the rectum.
Q87: A 23-year-old woman presents at mid-cycle with RLQ pain, fever (39°C), and vomiting. WBC count: 12,500/mm³. Most likely diagnosis?
A: Acute gastroenteritis
B: Acute appendicitis
C: Pelvic inflammatory disease (PID)
D: Ectopic pregnancy
B: Acute appendicitis
Q88: What is the appropriate course of action for the patient in the preceding question ?
A: Hydration
B: Appendectomy
C: Antibiotics and observation
D: Pain relievers
B. Appendectomy
Explanation:
Since the patient in Q87 is most likely suffering from acute appendicitis, the definitive treatment is surgical removal of the appendix (appendectomy).
Management of Acute Appendicitis:
Immediate appendectomy (Gold standard treatment)
Reduces risk of perforation and peritonitis.
Can be performed laparoscopically (preferred) or open.
If perforation with abscess is present, some cases may require initial antibiotics and percutaneous drainage, followed by interval appendectomy after 6-8 weeks.
Supportive Care (Preoperative and Postoperative)
IV fluids for hydration.
IV antibiotics (ceftriaxone + metronidazole) to prevent postoperative infections.
Pain management (opioids sparingly, NSAIDs).
Early ambulation to prevent complications.
Q89: Which are included in the differential diagnosis for RLQ pain in a male patient?
A: Acute mesenteric adenitis, gastroenteritis, acute appendicitis
B: Acute appendicitis, ovarian cyst, gastroenteritis
C: Gastroenteritis, ovarian cyst, acute appendicitis
D: Acute mesenteric adenitis, torsion of the fallopian tube, acute appendicitis
A. Acute mesenteric adenitis, gastroenteritis, acute appendicitis
Rationale:
Ovarian and fallopian tube pathologies are NOT applicable to male patients.
Mesenteric adenitis and gastroenteritis can mimic appendicitis.
Q90: A point 1½–2 inches from the anterior superior iliac spine (ASIS) on a line drawn to the umbilicus is called:
A: Semmes’ point
B: McBurney’s point
C: McArthur’s point
D: Fitz’s point
B. McBurney’s point
Rationale:
McBurney’s point = One-third distance from ASIS to umbilicus.
Most reliable landmark for appendicitis tenderness.
Q91: What is a gynecologic cause of hemoperitoneum?
A:
A. Ruptured spleen
B. Ruptured ectopic pregnancy
C. Ruptured bladder
D. Ruptured aortoiliac aneurysm
B. Ruptured ectopic pregnancy
Rationale:
Most common gynecologic cause of hemoperitoneum → Ruptured ectopic pregnancy.
Other causes: Ruptured ovarian cyst, uterine rupture, endometriosis.
Q92: Which is a surgical cause of abdominal pain?
A:
A. Acute hepatitis
B. Acute adrenal insufficiency
C. Acute appendicitis
D. Acute pericarditis
C. Acute appendicitis
Rationale:
Acute appendicitis is a surgical emergency.
Other surgical causes: Perforated ulcer, intestinal obstruction, volvulus.
Q93: Which is a NON-surgical cause of abdominal pain?
A: Acute appendicitis
B: Perforated duodenal ulcer
C: Acute gastroenteritis
D: Perforated sigmoid diverticulitis
C. Acute gastroenteritis
Rationale:
Acute appendicitis and perforation cases require surgery.
Acute gastroenteritis is managed medically.
Q94: What is a positive obturator sign?
A:
A. Internal or external rotation of the flexed hip causes pain
B. Passively extending the hip or actively flexing the hip against resistance causes pain
C. Detection of increased abdominal muscle tone during palpation
D. Sudden withdrawal of the hand after pressing the abdomen causes increased tenderness
A. Internal or external rotation of the flexed hip causes pain
Rationale:
Suggests pelvic appendicitis due to irritation of the obturator internus muscle.
Q95: What is a positive iliopsoas sign?
A:
A. Internal or external rotation of the flexed hip causes pain
B. Passively extending the hip or actively flexing the hip against resistance causes pain
C. Detection of increased abdominal muscle tone during palpation
D. Sudden withdrawal of the hand after pressing the abdomen causes increased tenderness
B. Passively extending the hip or actively flexing the hip against resistance causes pain
Rationale:
Suggests retrocecal appendicitis due to irritation of the psoas muscle.
Q96: What is rebound tenderness?
A:
A. Internal or external rotation of the flexed hip causes pain
B. Passively extending the hip or actively flexing the hip against resistance causes pain
C. Detection of increased abdominal muscle tone during palpation
D. Sudden withdrawal of the hand after pressing the abdomen causes increased tenderness
D. Sudden withdrawal of the hand after pressing the abdomen causes increased tenderness
Rationale:
Indicates peritoneal irritation (classic for peritonitis/appendicitis).
Q97: What is muscle guarding?
A:
A. Internal or external rotation of the flexed hip causes pain
B. Passively extending the hip or actively flexing the hip against resistance causes pain
C. Detection of increased abdominal muscle tone during palpation
D. Sudden withdrawal of the hand after pressing the abdomen causes increased tenderness
C. Detection of increased abdominal muscle tone during palpation
Rationale:
Involuntary contraction of abdominal muscles due to peritoneal inflammation.
Q98: In which patient is a careful menstrual history important in evaluating abdominal pain?
A: 5-year-old female
B: 75-year-old female
C: 25-year-old male
D: 35-year-old female
D. 35-year-old female
Rationale:
Reproductive-aged women require pregnancy and menstrual cycle assessment to rule out ectopic pregnancy, ovarian cysts, or PID.
Q99: Non-specific mesenteric lymphadenitis is common in the elderly.
A: True
B: False
B. False
Rationale:
Mesenteric lymphadenitis is more common in children, adolescents, and young adults.
Q100: Was the first successful appendectomy performed in 1836?
A: True
B: False
B. False
Rationale:
The first successful appendectomy was performed in 1759 in Bordeaux.
