Colorectal Surgery Practice Questions

Q: A 65-year-old male presents with chronic constipation and unintentional weight loss. Colonoscopy reveals a constricting mass in the sigmoid colon. What is the most likely diagnosis?

Colorectal cancer. Colorectal cancer - The combination of **chronic constipation**, **unintentional weight loss**, and a **constricting mass** in the sigmoid colon on colonoscopy are highly indicative of colorectal cancer [1]. - Sigmoid colon is a common site for colorectal cancer, as over 65% of tumors occur in the rectosigmoid region [1]. - Sigmoid colon is a common site for colorectal cancer, and a **constricting lesion** suggests a malignant process, often presenting with colicky pain or weight loss [1]. *Ulcerative colitis* - Typically presents with **bloody diarrhea**, abdominal pain, and tenesmus, not primarily chronic constipation. - While it can increase the risk of colorectal cancer, the initial presentation with a **constricting mass** isn't characteristic of active ulcerative colitis. *Diverticulosis* - Usually **asymptomatic** or presents with episodes of diverticulitis (abdominal pain, fever), not primarily chronic constipation and weight loss with a constricting mass. - A constricting mass is not a typical finding for uncomplicated diverticulosis. *Irritable bowel syndrome* - Characterized by chronic abdominal pain and altered bowel habits (constipation, diarrhea, or both), but it does not cause **unintentional weight loss** or a **constricting mass** on colonoscopy [2]. - IBS is a **functional disorder** and does not involve structural abnormalities or malignancy [2].

Q: What is the most common symptom of rectal prolapse?

Protrusion of the rectum. ***Protrusion of the rectum*** - The most defining and common symptom of rectal prolapse is the **visible protrusion** of rectal tissue through the anus, especially during straining or defecation. - This symptom directly reflects the underlying pathology where the rectal wall telescopes out of the anal opening. *Rectal bleeding* - While rectal prolapse can cause bleeding due to **mucosal irritation** or **ulceration**, it is not the most common or direct symptom. - Rectal bleeding is also a symptom of many other conditions, such as **hemorrhoids** or **colorectal cancer**. *Painful defecation* - **Painful defecation** (proctalgia) may occur with rectal prolapse, particularly if the prolapsed tissue becomes incarcerated or ulcerated, but it's not the primary symptom. - Many patients experience discomfort or a feeling of incomplete evacuation rather than severe pain. *Fecal incontinence* - **Fecal incontinence** is a common associated symptom due to damage to the anal sphincter muscles and nerve stretch from the prolapse. - However, the **physical protrusion** of the rectum is the most direct and universally reported initial symptom that defines the condition itself.

Q: A 60-year-old male presents with rectal bleeding and a palpable mass on digital rectal examination. A biopsy confirms adenocarcinoma. What is the best initial step in management?

Full colonoscopy. ***Full colonoscopy*** - A definitive diagnosis of **rectal adenocarcinoma** has been made, but the extent of the disease and the presence of **synchronous lesions** in the rest of the colon must be determined. - A **full colonoscopy** allows for visualization of the entire colon, identification of additional polyps or tumors (present in 3-5% of colorectal cancer patients), and is essential before proceeding with further staging and treatment planning. - After colonoscopy, additional staging with **MRI pelvis** (for local staging) and **CT chest/abdomen/pelvis** (for distant metastases) would be performed. *Immediate surgery* - While surgery is often the definitive treatment for rectal cancer, it is performed only after comprehensive staging with colonoscopy, cross-sectional imaging, and determination of need for neoadjuvant therapy. - Doing surgery immediately without full staging can lead to incomplete resection, missed synchronous lesions, or inappropriate treatment sequencing. *Chemotherapy* - **Chemotherapy** is typically used in the **neoadjuvant** setting (with radiation for locally advanced rectal cancer) or **adjuvant** setting (after surgery for high-risk disease). - It's not the initial step because complete staging with colonoscopy and imaging must be done first to determine the treatment approach. *Radiation therapy* - **Radiation therapy** (often with concurrent chemotherapy as neoadjuvant chemoradiation) is commonly used for **locally advanced rectal cancer** to achieve tumor downstaging before surgery. - However, it cannot be initiated without first completing colonoscopy to rule out synchronous lesions and cross-sectional imaging for proper staging.

Q: Which surgical procedure is commonly used to treat severe ulcerative colitis?

Total colectomy. ***Total colectomy*** - **Total colectomy** involves the surgical removal of the entire colon, which is the most definitive treatment for severe, refractory ulcerative colitis, effectively eliminating the diseased organ. - This procedure usually necessitates an ileostomy or an ileal pouch-anal anastomosis (IPAA) to maintain bowel continuity and function. - Standard operations include **total proctocolectomy with IPAA** (for suitable candidates) or **total proctocolectomy with end ileostomy**. *Partial gastrectomy* - A **partial gastrectomy** involves the removal of a portion of the stomach and is primarily used to treat conditions such as severe peptic ulcer disease, gastric cancer, or morbid obesity. - This procedure does not address the pathology of ulcerative colitis, which affects the large intestine (colon and rectum). *Laparoscopic cholecystectomy* - **Laparoscopic cholecystectomy** is the minimally invasive surgical removal of the gallbladder, typically performed for symptomatic cholelithiasis (gallstones) or cholecystitis. - This procedure is unrelated to the treatment of inflammatory bowel disease like ulcerative colitis, as it targets a different organ system. *Hemicolectomy* - A **hemicolectomy** involves the surgical removal of only a section (left or right half) of the colon and is commonly performed for localized conditions like colon cancer or diverticular disease. - This is **inadequate for severe ulcerative colitis** because UC characteristically affects the colon in a **continuous pattern starting from the rectum** and extending proximally, often involving the entire colon. Leaving diseased colon segments would fail to control the disease and symptoms.

Q: A 75-year-old male presents with chronic constipation and abdominal distension. A barium enema reveals a narrowing in the sigmoid colon. What is the most likely diagnosis?

Colon cancer. ***Colon cancer*** - The patient's age (75 years), chronic constipation, abdominal distension, and the finding of a **narrowing (apple-core lesion)** in the sigmoid colon on barium enema are highly suggestive of **colorectal carcinoma**. [1] - **Sigmoid colon** is a common site for colorectal cancer, and a barium enema can effectively visualize obstructive lesions. [1] *Diverticulosis* - While diverticulosis is common in older adults and can cause constipation, it typically presents with **outpouchings** (diverticula) on barium enema, not a distinct narrowing indicative of an obstructive mass. [2] - Complications like **diverticulitis** can cause inflammatory strictures, but the primary finding is still diverticula. [2] *Ulcerative colitis* - Ulcerative colitis causes diffuse inflammation of the colon, typically starting in the rectum and extending proximally, resulting in findings like **mucosal ulcerations**, loss of haustra, and a **"lead pipe" appearance** on barium enema, not usually a focal narrowing. - It often presents with **bloody diarrhea**, which is not mentioned in this case. *Irritable bowel syndrome* - IBS is a **functional bowel disorder** characterized by abdominal pain and altered bowel habits (constipation, diarrhea, or both) without structural abnormalities. [3] - A barium enema would typically be normal in IBS, as it does not cause **anatomical narrowing** or strictures. [3]

Q: A 60-year-old male presents with chronic constipation and abdominal distension. A barium enema shows a 'coffee bean sign.' What is the most likely diagnosis?

Sigmoid volvulus. ***Sigmoid volvulus*** - The "coffee bean sign" on a plain abdominal film or barium enema is a **classic radiographic finding** for **sigmoid volvulus**, representing the dilated, redundant sigmoid colon. - **Chronic constipation** and **abdominal distension** in an older male are common presenting symptoms due to the twisting of the sigmoid colon on its mesentery. *Intussusception* - Intussusception typically presents with **acute, intermittent abdominal pain** and **currant jelly stools**, most commonly in pediatric populations. - The classic radiographic sign for intussusception is a **target sign** on ultrasound, not the "coffee bean sign." *Colon cancer* - Colon cancer can cause **chronic constipation** and **abdominal distension** due to obstruction, but it does not typically produce a "coffee bean sign." - Radiographic findings often include an **"apple core" lesion** on barium enema, indicating circumferential narrowing. *Crohn's disease* - Crohn's disease is an **inflammatory bowel disease** characterized by **transmural inflammation** that can affect any part of the gastrointestinal tract. - While it can cause chronic constipation and abdominal distension, it would not typically manifest with a "coffee bean sign" and often presents with **diarrhea, abdominal pain, and weight loss**.

Q: In a patient with acute diverticulitis confirmed by CT, what is the most common complication that may necessitate surgery?

Perforation. ***Perforation*** - **Perforation** is the most common complication of acute diverticulitis that necessitates emergency surgery, occurring in 15-25% of hospitalized patients with acute diverticulitis - Free perforation leads to **generalized peritonitis**, which is a life-threatening condition requiring urgent surgical intervention (Hartmann's procedure or primary resection) - Even contained perforation may require surgical intervention if not responsive to conservative management - This is the **primary indication for emergency surgery** in acute diverticulitis *Abscess formation* - **Abscess formation** occurs in 15-20% of acute diverticulitis cases and is indeed a common complication - However, many abscesses (especially those <4-5 cm) are successfully managed **non-operatively** with IV antibiotics - Larger abscesses can often be treated with **percutaneous drainage** followed by elective surgery - While some abscesses require surgery, they are often managed conservatively initially, making perforation the more common surgical indication *Hemorrhage* - **Hemorrhage** from diverticula causes significant lower GI bleeding but typically occurs **separate from acute diverticulitis** - Diverticular bleeding usually stops spontaneously in 70-80% of cases - When surgery is needed for bleeding, it's usually in the setting of diverticulosis, not acute inflammatory diverticulitis - Not a common complication requiring surgery during acute diverticulitis episodes *Fistula* - **Fistula formation** is a **chronic complication** of recurrent diverticulitis, not an acute presentation - Results from chronic inflammation eroding into adjacent organs (colovesical, colovaginal, coloenteric fistulas) - Requires elective surgery but is not an acute complication necessitating emergency intervention - Much less common than perforation or abscess formation

Q: A 70-year-old male presents with a long history of constipation and straining during defecation. He reports a sensation of a bulge from the rectum. What is the most appropriate surgical treatment?

Rectopexy. ***Rectopexy*** - The described symptoms of **constipation**, **straining**, and a **rectal bulge** strongly suggest a **rectal prolapse** or significant **rectocele**. - **Rectopexy** is the most appropriate surgical treatment for rectal prolapse, aiming to fix the rectum in its anatomical position, alleviating symptoms of bulging and improving bowel function. *Hemorrhoidectomy* - **Hemorrhoidectomy** is a procedure to remove hemorrhoids, which present with **bleeding**, **pain**, and **pruritus** but typically not a sensation of a rectal bulge requiring surgical fixation. - While straining can contribute to hemorrhoids, it doesn't address the primary issue of rectal protrusion. *Anterior resection* - **Anterior resection** involves removing a portion of the rectum, usually for **rectal cancer** or **severe diverticular disease**. - This procedure addresses different pathologies and is not indicated for isolated rectal prolapse or rectocele. *Sigmoid colectomy* - **Sigmoid colectomy** is the removal of part or all of the sigmoid colon, typically for conditions like **diverticulitis** or **colon cancer**. - It is not indicated for the surgical correction of rectal prolapse, which involves fixation of the rectum.

Question 1

A 65-year-old male presents with chronic constipation and unintentional weight loss. Colonoscopy reveals a constricting mass in the sigmoid colon. What is the most likely diagnosis?

Accepted Answer

Colorectal cancer

Answer

Ulcerative colitis

Answer

Diverticulosis

Answer

Irritable bowel syndrome

Question 2

A 70-year-old male with a history of chronic constipation now presents with a sudden onset of left lower quadrant pain. A CT scan shows thickened colon walls with pericolonic fat stranding. What is the likely diagnosis and the most appropriate treatment?

Accepted Answer

Diverticulitis, antibiotics and possible surgical intervention

Answer

Acute appendicitis, surgical intervention

Answer

Ischemic colitis, supportive care

Answer

Colon cancer, surgical resection

Question 3

What is the most common symptom of rectal prolapse?

Accepted Answer

Protrusion of the rectum

Answer

Rectal bleeding

Answer

Painful defecation

Answer

Fecal incontinence

Question 4

A 60-year-old male presents with rectal bleeding and a palpable mass on digital rectal examination. A biopsy confirms adenocarcinoma. What is the best initial step in management?

Accepted Answer

Full colonoscopy

Answer

Immediate surgery

Answer

Chemotherapy

Answer

Radiation therapy

Question 5

Which surgical procedure is commonly used to treat severe ulcerative colitis?

Accepted Answer

Total colectomy

Answer

Partial gastrectomy

Answer

Laparoscopic cholecystectomy

Answer

Hemicolectomy

Question 6

A 75-year-old male presents with chronic constipation and abdominal distension. A barium enema reveals a narrowing in the sigmoid colon. What is the most likely diagnosis?

Accepted Answer

Colon cancer

Answer

Diverticulosis

Answer

Ulcerative colitis

Answer

Irritable bowel syndrome

Question 7

A 60-year-old male presents with chronic constipation and abdominal distension. A barium enema shows a 'coffee bean sign.' What is the most likely diagnosis?

Accepted Answer

Sigmoid volvulus

Answer

Intussusception

Answer

Colon cancer

Answer

Crohn's disease

Question 8

What factors influence the choice between conservative management and surgical intervention in complicated acute diverticulitis?

Accepted Answer

Presence of abscess or bowel obstruction, and response to treatment

Answer

Surgery is always preferred in complicated cases

Answer

Surgery is only considered if the patient insists on it

Answer

Decision based on the availability of medical treatment

Question 9

In a patient with acute diverticulitis confirmed by CT, what is the most common complication that may necessitate surgery?

Accepted Answer

Perforation

Answer

Hemorrhage

Answer

Abscess formation

Answer

Fistula

Question 10

A 70-year-old male presents with a long history of constipation and straining during defecation. He reports a sensation of a bulge from the rectum. What is the most appropriate surgical treatment?

Accepted Answer

Rectopexy

Answer

Hemorrhoidectomy

Answer

Anterior resection

Answer

Sigmoid colectomy

Colorectal Surgery — MCQs

Colorectal Surgery — MCQs

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