Colorectal Surgery Practice Questions

Q: A 45 year old underwent surgery for rectal prolapse. At present, he complains of sexual dysfunction which is probably due to the injury of:

Pelvic autonomic nerves. ***Pelvic autonomic nerves*** - Surgical procedures in the **pelvic region**, such as for rectal prolapse, carry a risk of damaging the **pelvic autonomic nerves**, which are crucial for sexual function. - Injury to these nerves can lead to various forms of **sexual dysfunction**, including erectile dysfunction in men, due to impaired nerve signaling to the genital organs. *Urinary bladder* - While the urinary bladder is anatomically close to the rectum, direct injury to the bladder itself during rectal prolapse surgery typically leads to **urinary symptoms** (e.g., incontinence, retention), not primarily sexual dysfunction. - Though bladder dysfunction can indirectly impact sexual activity, it's not the direct cause of primary sexual dysfunction following injury in this context. *Rectum* - The surgery is performed on the rectum, and while complications can occur, direct injury to the rectal wall itself primarily results in issues such as **fecal incontinence, bleeding, or infection**. - The rectum's primary role is in digestion and defecation, and its injury does not directly cause sexual dysfunction unrelated to nerve damage. *Inferior mesenteric artery* - The **inferior mesenteric artery (IMA)** supplies blood to the distal colon and rectum, and its injury during surgery would primarily lead to **ischemia or necrosis** of the supplied bowel segments. - While a severely compromised blood supply could have systemic effects, direct injury to the IMA is not a direct or common cause of sexual dysfunction.

Q: A 22 year old young man came with history of occasional bleeding per rectum. On colonoscopy, numerous sessile polyps were seen in descending and sigmoid colon. On family history his elder brother was operated for thyroid malignancy. The young man should be advised:

Prophylactic panproctocolectomy. ***Prophylactic panproctocolectomy*** - This patient presents with multiple sessile polyps in the descending and sigmoid colon, along with a family history of **thyroid malignancy** in his brother. This constellation of findings is highly suggestive of **Familial Adenomatous Polyposis (FAP)**, specifically **Gardner syndrome**, which is a variant of FAP associated with extracolonic manifestations like thyroid tumors. - Due to the high risk of **colorectal cancer** development in FAP (nearly 100% by age 40 without intervention), **prophylactic panproctocolectomy** is the recommended treatment to prevent progression to malignancy. *Prophylactic anterior resection* - An anterior resection typically involves removing only a segment of the colon, which would be insufficient for a patient with FAP, as polyps can develop throughout the entire colon and rectum. - This procedure would leave a significant portion of the colon at risk for **neoplastic transformation**, necessitating further surgeries or intense surveillance. *Surveillance colonoscopy every 6 months* - While surveillance is crucial in risk assessment, for diagnosed FAP, particularly with symptomatic polyps and a family history suggestive of a syndrome, surveillance alone is inadequate due to the **high and inevitable risk of cancer**. - Delaying definitive surgical intervention would expose the patient to a very high probability of developing **colorectal carcinoma**. *Colonoscopic removal of all polyps* - Given the presence of **numerous sessile polyps**, endoscopic polypectomy would be impractical, incomplete, and would likely miss microscopic or nascent lesions. - This approach offers only temporary management and does not address the underlying genetic predisposition to continuous polyp formation and high malignancy risk.

Q: A colonic carcinoma involving muscularis propria, with one or two nodes involved with a solitary metastasis in the liver, the TNM stage would be:

T2 N1 M1. ***T2 N1 M1*** **(Correct Answer)** - **T2** indicates the tumor invades the **muscularis propria** in the TNM classification for colorectal cancer. - **N1** signifies involvement of **one to three regional lymph nodes**, which corresponds to "one or two nodes involved" in the question. - **M1** denotes the presence of **distant metastasis**, specifically a "solitary metastasis in the liver" as described. *T1 N2 M1* - **T1** describes a tumor that invades the **submucosa** but not the muscularis propria, which is less advanced than the scenario described. - **N2** would imply involvement of **four or more regional lymph nodes**, contradicting the "one or two nodes involved" stated in the question. *T1 N1 M1* - **T1** indicates invasion into the **submucosa**, not reaching the muscularis propria as specified in the case description. - The **N1** and **M1** components are consistent with the nodal involvement and distant metastasis, but the **T stage** is incorrect. *T2 N2 M1* - While **T2** is correct for invasion into the muscularis propria, **N2** incorrectly implies involvement of **four or more regional lymph nodes**. - The question states "one or two nodes involved," making **N1** the appropriate nodal classification.

Q: A 52 year old male patient comes with history of rectal bleeding, alteration in bowel habits and tenesmus. The ideal investigation would be:

Colonoscopy. ***Colonoscopy*** - **Colonoscopy** is the gold standard for investigating symptoms like rectal bleeding, altered bowel habits, and tenesmus, as it allows for direct visualization of the entire colon and rectum. - It enables **biopsy of suspicious lesions** for histopathological diagnosis, which is crucial for confirming conditions like colorectal cancer or inflammatory bowel disease. *Contrast-enhanced CT scan* - A **contrast-enhanced CT scan** is primarily used for **staging known malignancies** and assessing for distant metastases, not as a primary diagnostic tool for initial symptoms. - While it can identify large masses, it might miss smaller lesions and does not allow for tissue biopsy. *Fecal occult blood test* - A **fecal occult blood test** screens for blood in the stool, which indicates gastrointestinal bleeding but does not pinpoint the source or cause. - It has **low sensitivity and specificity** for diagnosing underlying conditions like colorectal cancer or inflammatory bowel disease and is mainly a screening tool. *Ultrasonogram* - An **ultrasonogram** is generally not effective for evaluating the colon and rectum due to bowel gas interference. - It is more commonly used for investigating abdominal organs like the liver, gallbladder, and kidneys, or for pelvic pathology, but not the primary investigation for these colorectal symptoms.

Q: A 60 year old male presents with bleeding per rectum. Proctoscopy reveals 2nd degree hemorrhoids. The treatment of choice is:

Banding. ***Banding*** - **Rubber band ligation** is the preferred treatment for **second-degree hemorrhoids** because it is effective, minimally invasive, and can be done in an outpatient setting. - The bands cause the hemorrhoid tissue to necrose and fall off within a few days, alleviating symptoms. *Cryotherapy* - **Cryotherapy** involves freezing the hemorrhoid tissue, but it is rarely used due to a **higher risk of complications** such as pain, prolonged discharge, and incomplete tissue destruction. - It is generally considered less effective and associated with more discomfort and potential for recurrence compared to other treatments. *Sclerotherapy* - **Sclerotherapy** involves injecting a chemical solution into the hemorrhoid to cause fibrosis and shrinkage, primarily used for **first-degree hemorrhoids**. - While it can be effective for smaller hemorrhoids, it is less effective than banding for **second-degree hemorrhoids** and has a higher recurrence rate for this grade. *Surgery* - **Surgical hemorrhoidectomy** is typically reserved for **third- and fourth-degree hemorrhoids** or those that have failed other less invasive treatments. - While highly effective, surgery is more invasive, carries **higher risks of complications**, and requires a longer recovery period, making it overtreatment for second-degree hemorrhoids.

Q: Gentleman of 56 years underwent laparoscopic left hemicolectomy for diagnosed left colonic carcinoma. Histopathology revealed the tumour to be invading submucosa and muscularis propria. Among the 16 regional lymph nodes harvested, 2 were positive for malignant deposits. His staging as per AJCC will be:

T2, N1, M0. ***T2, N1, M0*** - The tumor invades the **muscularis propria** but not through it, which is classified as **T2** in the AJCC staging for colorectal cancer. - The presence of **2 positive regional lymph nodes** (out of 16 harvested) is classified as **N1** disease. **M0** indicates no distant metastasis. *T2, N1, M1* - While the **T2** and **N1** classifications are correct for this case, **M1** signifies the presence of **distant metastasis**, which is not indicated in the provided information. - The staging is based on the **available pathological findings only**, which do not mention any distant spread. *T1, N1, M0* - **T1** classification indicates that the tumor invades the **submucosa** but not the muscularis propria, which contradicts the information that the tumor invaded the **muscularis propria**. - Although **N1** and **M0** are consistent with the provided information regarding lymph nodes and distant metastasis, the **T-stage is incorrect**. *T1, N0, M0* - **T1** is incorrect as the tumor invaded the **muscularis propria**. - **N0** is incorrect as there were **2 positive regional lymph nodes** which indicates nodal involvement.

Q: A 25-year-old woman with inflammatory bowel disease requires total colectomy with ileostomy. She is getting married in 6 months and wants to know about conversion to J-pouch. She has mild perianal disease and takes anti-TNF therapy. Evaluate the timing and appropriateness of J-pouch reconstruction.

Staged J-pouch after 3-6 months with temporary ileostomy. ***Staged J-pouch after 3-6 months with temporary ileostomy*** - This approach allows for **bowel recovery** after the initial colectomy and addresses the presence of **mild perianal disease**, which can worsen with immediate J-pouch construction. - The 3-6 month window aligns with the patient's desire for reconstruction before her wedding, providing sufficient time for healing and assessment. - **Anti-TNF therapy** increases perioperative complications, making staged reconstruction safer. *Alternative continent ileostomy procedure* - This procedure, like a **Kock pouch**, is complex and carries its own set of complications, making it a less favored primary option compared to a J-pouch. - It might be considered in cases where a J-pouch is contraindicated or fails, but not as a first-line alternative in this scenario. *Immediate J-pouch construction during colectomy* - This is generally not recommended in patients with **active inflammatory bowel disease** (even if mild) or those on **anti-TNF therapy**, as it significantly increases the risk of **anastomotic leaks** and pouch-related complications. - The presence of **perianal disease** further contraindicates an immediate approach due to increased infection risk. *Delay J-pouch until after marriage and pregnancy* - While pregnancy can influence J-pouch function, current evidence supports that a well-established J-pouch does not significantly impact fertility or pregnancy outcomes. - Delaying unnecessarily can cause the patient to endure a permanent ileostomy longer than desired, impacting her quality of life and wedding plans.

Q: A 28-year-old woman with ulcerative colitis requires emergency colectomy for toxic megacolon. She is 20 weeks pregnant with her first child. The obstetric team is concerned about fetal risks, while the surgical team emphasizes maternal life-threatening condition. The patient wants to prioritize fetal safety. Evaluate the management approach.

Immediate colectomy with fetal monitoring. ***Immediate colectomy with fetal monitoring*** - **Toxic megacolon** is a life-threatening complication that requires urgent surgical intervention to prevent **bowel perforation** and **sepsis**, which would be devastating for both mother and fetus. - While fetal stability is important, the mother's life must be prioritized, as fetal viability is impossible without a living mother; continuous **fetal monitoring** during and after surgery is crucial to assess fetal well-being. *Immediate delivery followed by colectomy* - At **20 weeks gestation**, the fetus is **non-viable**, meaning it cannot survive outside the womb. - Attempting immediate delivery would expose the mother to urgent surgery after a failed obstetric procedure, increasing her morbidity without improving fetal outcome. *Transfer to tertiary care center* - This patient has an **emergency condition** (**toxic megacolon**) that requires immediate intervention; delaying definitive treatment for transfer could lead to **bowel perforation** and **sepsis**, increasing mortality for both mother and fetus. - The necessary surgical expertise and resources for such an emergency are typically available at most acute care hospitals. *Delayed surgery with maximum medical management* - **Toxic megacolon** is a surgical emergency; delaying surgery and relying solely on medical management significantly increases the risk of **perforation**, **sepsis**, and maternal and fetal mortality. - Medical management is typically reserved for less severe forms of colitis or as a temporizing measure before surgery, and it has already failed as the patient developed toxic megacolon.

Q: A 35-year-old HIV-positive woman (CD4 count 180/μL, on HAART) develops extensive perianal condyloma acuminata resistant to conventional treatments. HPV typing shows type 16. What is the most appropriate management approach?

Wide surgical excision with histopathological examination. ***Wide surgical excision with histopathological examination*** - This is the most appropriate management due to the **extensive, treatment-resistant perianal condyloma acuminata** in an **HIV-positive patient with HPV type 16**, which carries a higher risk of **malignant transformation**. - **Surgical excision** allows for complete removal of the lesions and provides tissue for **histopathological examination** to rule out **dysplasia or squamous cell carcinoma**. *HPV vaccination* - While important for prevention, **HPV vaccination** is generally less effective as a primary treatment for **established, extensive lesions**, especially with existing infection. - It primarily aims to prevent new infections and may have some benefit in preventing recurrence, but it won't resolve the current burden of disease. *Interferon therapy* - **Interferon therapy** can be used for severe, recurrent, or difficult-to-treat warts, but its efficacy is variable and generally considered a **second-line or adjunctive treatment**. - Given the patient's **immunosuppressed status** and **resistance to conventional treatments**, a more definitive approach is needed. *Continue conservative management with topical imiquimod* - The patient has already demonstrated **resistance to conventional treatments**, suggesting that continued topical therapy with **imiquimod** is unlikely to be effective. - In an HIV-positive individual with **extensive lesions and high-risk HPV type 16**, waiting for a response to conservative therapy could delay definitive management and potentially increase the **risk of malignant progression**.

Q: A jeep driver presents with pain in the gluteal region along with swelling and pus discharge for the past 6 months. What is the most likely diagnosis?

Pilonidal sinus. ***Pilonidal sinus*** - This is the classic presentation of **pilonidal sinus disease**, historically known as **"Jeep disease"** due to its high incidence in military personnel during WWII who sat for prolonged periods in jeeps - The **occupational clue "jeep driver"** is pathognomonic for pilonidal sinus, as prolonged sitting causes friction and pressure in the **sacrococcygeal/natal cleft region** - Presents with **chronic pain, swelling, and intermittent pus discharge** in the gluteal region, typically over weeks to months - Risk factors include: prolonged sitting, friction, deep natal cleft, obesity, and excessive body hair - The **chronic 6-month duration** with ongoing discharge is characteristic of pilonidal sinus with secondary infection, not an acute abscess *Gluteal abscess* - While this can cause pain, swelling, and pus discharge, it typically presents **acutely** (days to weeks, not 6 months) - Does not have the specific **occupational association with prolonged sitting** (jeep driver) - Would be expected to either resolve with drainage/antibiotics or progress to sepsis, not persist chronically for 6 months - Lacks the classic "Jeep disease" eponym *Fistula in ano* - This involves an abnormal tract between the **anal canal and perianal skin** - Discharge would be localized **perianally**, close to the anus, not in the broader gluteal/sacrococcygeal region - Does not have the jeep driver occupational association *Fissure in ano* - A **tear in the anal canal lining** causing severe pain during defecation with **bright red bleeding** - Does not present with swelling or chronic pus discharge - Pain is characteristically related to bowel movements, not constant

Question 1

A 45 year old underwent surgery for rectal prolapse. At present, he complains of sexual dysfunction which is probably due to the injury of:

Accepted Answer

Pelvic autonomic nerves

Answer

Urinary bladder

Answer

Rectum

Answer

Inferior mesenteric artery

Question 2

A 22 year old young man came with history of occasional bleeding per rectum. On colonoscopy, numerous sessile polyps were seen in descending and sigmoid colon. On family history his elder brother was operated for thyroid malignancy. The young man should be advised:

Accepted Answer

Prophylactic panproctocolectomy

Answer

Prophylactic anterior resection

Answer

Surveillance colonoscopy every 6 months

Answer

Colonoscopic removal of all polyps

Question 3

A colonic carcinoma involving muscularis propria, with one or two nodes involved with a solitary metastasis in the liver, the TNM stage would be:

Accepted Answer

T2 N1 M1

Answer

T1 N2 M1

Answer

T1 N1 M1

Answer

T2 N2 M1

Question 4

A 52 year old male patient comes with history of rectal bleeding, alteration in bowel habits and tenesmus. The ideal investigation would be:

Accepted Answer

Colonoscopy

Answer

Contrast-enhanced CT scan

Answer

Fecal occult blood test

Answer

Ultrasonogram

Question 5

A 60 year old male presents with bleeding per rectum. Proctoscopy reveals 2nd degree hemorrhoids. The treatment of choice is:

Accepted Answer

Banding

Answer

Cryotherapy

Answer

Sclerotherapy

Answer

Surgery

Question 6

Gentleman of 56 years underwent laparoscopic left hemicolectomy for diagnosed left colonic carcinoma. Histopathology revealed the tumour to be invading submucosa and muscularis propria. Among the 16 regional lymph nodes harvested, 2 were positive for malignant deposits. His staging as per AJCC will be:

Accepted Answer

T2, N1, M0

Answer

T2, N1, M1

Answer

T1, N1, M0

Answer

T1, N0, M0

Question 7

A 25-year-old woman with inflammatory bowel disease requires total colectomy with ileostomy. She is getting married in 6 months and wants to know about conversion to J-pouch. She has mild perianal disease and takes anti-TNF therapy. Evaluate the timing and appropriateness of J-pouch reconstruction.

Accepted Answer

Staged J-pouch after 3-6 months with temporary ileostomy

Answer

Alternative continent ileostomy procedure

Answer

Immediate J-pouch construction during colectomy

Answer

Delay J-pouch until after marriage and pregnancy

Question 8

A 28-year-old woman with ulcerative colitis requires emergency colectomy for toxic megacolon. She is 20 weeks pregnant with her first child. The obstetric team is concerned about fetal risks, while the surgical team emphasizes maternal life-threatening condition. The patient wants to prioritize fetal safety. Evaluate the management approach.

Accepted Answer

Immediate colectomy with fetal monitoring

Answer

Immediate delivery followed by colectomy

Answer

Transfer to tertiary care center

Answer

Delayed surgery with maximum medical management

Question 9

A 35-year-old HIV-positive woman (CD4 count 180/μL, on HAART) develops extensive perianal condyloma acuminata resistant to conventional treatments. HPV typing shows type 16. What is the most appropriate management approach?

Accepted Answer

Wide surgical excision with histopathological examination

Answer

HPV vaccination

Answer

Interferon therapy

Answer

Continue conservative management with topical imiquimod

Question 10

A jeep driver presents with pain in the gluteal region along with swelling and pus discharge for the past 6 months. What is the most likely diagnosis?

Accepted Answer

Pilonidal sinus

Answer

Fistula in ano

Answer

Fissure in ano

Answer

Gluteal abscess

Colorectal Surgery — MCQs

Colorectal Surgery — MCQs

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