Elective colorectal procedures US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Elective colorectal procedures. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Elective colorectal procedures US Medical PG Question 1: A 62-year-old man presents to the emergency department with acute pain in the left lower abdomen and profuse rectal bleeding. These symptoms started 3 hours ago. The patient has chronic constipation and bloating, for which he takes lactulose. His family history is negative for gastrointestinal disorders. His temperature is 38.2°C (100.8°F), blood pressure is 90/60 mm Hg, and pulse is 110/min. On physical examination, the patient appears drowsy, and there is tenderness with guarding in the left lower abdominal quadrant. Flexible sigmoidoscopy shows multiple, scattered diverticula with acute mucosal inflammation in the sigmoid colon. Which of the following is the best initial treatment for this patient?
- A. Elective colectomy
- B. Dietary modification and antibiotics
- C. Volume replacement, analgesia, intravenous antibiotics, and endoscopic hemostasis
- D. Volume replacement, analgesia, intravenous antibiotics, and surgical hemostasis (Correct Answer)
- E. Reassurance and no treatment is required
Elective colorectal procedures Explanation: ***Volume replacement, analgesia, intravenous antibiotics, and surgical hemostasis***
- This patient presents with **acute complicated diverticulitis** with signs of **peritonitis** (left lower abdominal pain with guarding) and **septic shock** (fever 38.2°C, hypotension 90/60 mm Hg, tachycardia 110/min, drowsiness).
- Initial management requires **volume replacement** to address hypovolemia and shock, **analgesia** for pain control, and **broad-spectrum intravenous antibiotics** covering gram-negative and anaerobic organisms.
- The presence of **peritonitis with hemodynamic instability** indicates complicated diverticulitis requiring **surgical intervention** (typically sigmoid resection with colostomy - Hartmann procedure) after initial resuscitation.
- While the patient has rectal bleeding, the dominant clinical picture is **perforation/transmural inflammation** requiring surgery, not just bleeding control.
*Volume replacement, analgesia, intravenous antibiotics, and endoscopic hemostasis*
- **Endoscopic hemostasis** is appropriate for uncomplicated diverticular bleeding without signs of perforation or peritonitis.
- In this case, the patient has **guarding** (indicating peritonitis) and **septic shock**, suggesting transmural inflammation or perforation that cannot be managed endoscopically.
- Endoscopy is relatively contraindicated in acute diverticulitis with peritonitis due to risk of worsening perforation.
*Elective colectomy*
- While colectomy is the correct surgical approach, the term **"elective"** is inappropriate for this acute, life-threatening emergency.
- This patient requires **urgent/emergency surgery** after initial resuscitation, not scheduled elective surgery.
*Dietary modification and antibiotics*
- **Dietary modification** (high-fiber diet) is a preventive strategy for uncomplicated diverticular disease, not treatment for acute complicated diverticulitis.
- While antibiotics are necessary, this option fails to address the **septic shock, hypovolemia, and need for surgical intervention** in complicated diverticulitis with peritonitis.
*Reassurance and no treatment is required*
- The patient exhibits **life-threatening complications**: septic shock, peritonitis, and hemodynamic instability.
- **No treatment** would result in rapid deterioration, multi-organ failure, and death.
Elective colorectal procedures US Medical PG Question 2: A 26-year-old white man comes to the physician because of increasing generalized fatigue for 6 months. He has been unable to work out at the gym during this period. He has also had cramping lower abdominal pain and diarrhea for the past 5 weeks that is occasionally bloody. His father was diagnosed with colon cancer at the age of 65. He has smoked half a pack of cigarettes daily for the past 10 years. He drinks 1–2 beers on social occasions. His temperature is 37.3°C (99.1°F), pulse is 88/min, and blood pressure is 116/74 mm Hg. Physical examination shows dry mucous membranes. The abdomen is soft and nondistended with slight tenderness to palpation over the lower quadrants bilaterally. Rectal examination shows stool mixed with blood. His hemoglobin concentration is 13.5 g/dL, leukocyte count is 7,500/mm3, and platelet count is 480,000/mm3. Urinalysis is within normal limits. Which of the following is the most appropriate next step in management?
- A. D-xylose absorption test
- B. CT scan of the abdomen and pelvis with contrast
- C. Capsule endoscopy
- D. Colonoscopy (Correct Answer)
- E. Flexible sigmoidoscopy
Elective colorectal procedures Explanation: ***Colonoscopy***
- The patient presents with **bloody diarrhea** and **lower abdominal pain**, which are classic symptoms of inflammatory bowel disease (IBD), particularly **Crohn's disease** or **ulcerative colitis**. A colonoscopy allows for direct visualization of the colonic and terminal ileal mucosa, **biopsy collection** for histological confirmation, and assessment of disease extent and severity.
- While the patient's hemoglobin is currently normal, the presence of bloody stools indicates potential ongoing blood loss, and the history of fatigue suggests chronic inflammation. **Colonoscopy is the gold standard** for diagnosing and differentiating types of IBD.
*D-xylose absorption test*
- This test is used to assess **small bowel mucosal function** and carbohydrate absorption, typically in cases of suspected malabsorption like **celiac disease**.
- While malabsorption can cause fatigue, the patient's primary symptoms of bloody diarrhea and abdominal pain are not typical for isolated malabsorption, and a d-xylose test would not identify the source of bleeding.
*CT scan of the abdomen and pelvis with contrast*
- A CT scan can identify **extraintestinal manifestations** of IBD, abscesses, or bowel wall thickening, but it is **less sensitive** than colonoscopy for direct mucosal evaluation and cannot obtain biopsies for definitive diagnosis.
- It might be considered after colonoscopy for assessing transmural involvement or complications but is not the initial diagnostic step for primary luminal symptoms.
*Capsule endoscopy*
- Capsule endoscopy is primarily used to evaluate the **small bowel** for lesions beyond the reach of standard upper endoscopy and colonoscopy, such as obscure GI bleeding or suspected Crohn's disease confined to the small bowel.
- Given the patient's symptoms of **lower abdominal pain** and bloody diarrhea, the pathology is likely in the colon or terminal ileum, making colonoscopy more appropriate for initial evaluation. A capsule endoscopy does not visualize the colon.
*Flexible sigmoidoscopy*
- A flexible sigmoidoscopy visualizes the **rectum and a portion of the sigmoid colon**, which might be affected in ulcerative colitis.
- However, it would miss lesions in the more proximal colon or terminal ileum, which are common sites for Crohn's disease and some forms of ulcerative colitis, thus potentially leading to an incomplete diagnosis.
Elective colorectal procedures US Medical PG Question 3: A 64-year-old woman has progressively worsening abdominal pain 5 hours after an open valve replacement with cardiopulmonary bypass. The pain is crampy and associated with an urge to defecate. The patient reports having had 2 bloody bowel movements in the last hour. Her operation was complicated by significant intraoperative blood loss, which prolonged the operation and necessitated 2 transfusions of red blood cells. She has hypercholesterolemia and type 2 diabetes mellitus. The patient received prophylactic perioperative antibiotics and opioid pain management during recovery. Her temperature is 37.9°C (98.9°F), pulse is 95/min, and blood pressure is 115/69 mm Hg. Examination shows a soft abdomen with mild tenderness to palpation in the left quadrants but no rebound tenderness or guarding. Bowel sounds are decreased. Rectal examination shows blood on the examining finger. Which of the following is the most likely underlying cause of this patient's symptoms?
- A. Embolization of superior mesenteric artery
- B. Atherosclerotic narrowing of the intestinal vessels
- C. Small outpouchings in the sigmoid wall
- D. Infection with Clostridioides difficile
- E. Decreased blood flow to the splenic flexure (Correct Answer)
Elective colorectal procedures Explanation: ***Decreased blood flow to the splenic flexure***
- This patient's symptoms are highly suggestive of **ischemic colitis**, which often affects the **splenic flexure** due to its "watershed" area vulnerability. **Cardiopulmonary bypass** and significant **intraoperative blood loss** (leading to hypotension and hypoperfusion) are major risk factors for this condition.
- The presentation with **crampy abdominal pain**, **urgent defecation**, and **bloody bowel movements** shortly after cardiac surgery points to colonic ischemia.
*Embolization of superior mesenteric artery*
- While an acute **SMA embolism** could cause severe abdominal pain and bloody stools, it typically presents with **more diffuse and severe abdominal tenderness**, often with marked tenderness disproportionate to examination findings early on, and rapid progression to peritonitis.
- The patient's history of valvular disease and hypercholesterolemia increases the risk of embolization, but the **mild tenderness confined to left quadrants** and decreased bowel sounds are less typical of an acute SMA occlusion.
*Atherosclerotic narrowing of the intestinal vessels*
- This describes **chronic mesenteric ischemia**, which typically causes **postprandial abdominal pain** (intestinal angina) and weight loss, not acute abdominal pain and bloody diarrhea in the immediate postoperative period.
- While the patient has risk factors for atherosclerosis (hypercholesterolemia, diabetes), the acute onset of symptoms following cardiac surgery points to an acute ischemic event rather than chronic narrowing.
*Small outpouchings in the sigmoid wall*
- This refers to **diverticulitis** or **diverticular bleeding**. While diverticular bleeding can cause painless or painful bleeding, and diverticulitis can cause abdominal pain, the acute onset post-cardiac surgery in the setting of hypoperfusion makes ischemic colitis a more likely diagnosis.
- Diverticulitis typically presents with **localized left lower quadrant pain**, fever, and leukocytosis, but the systemic context of recent cardiac surgery and hypoperfusion strongly favors ischemia.
*Infection with Clostridioides difficile*
- **_Clostridioides difficile_ infection** typically causes **watery diarrhea**, often after antibiotic use, and usually takes several days to develop symptoms after exposure or antibiotic initiation.
- Although the patient received perioperative antibiotics, the onset of symptoms within hours of surgery and the presence of **frank bloody stools** are less characteristic of _C. difficile_ infection, which is more commonly associated with non-bloody diarrhea.
Elective colorectal procedures US Medical PG Question 4: You are a resident in the surgical ICU. One of the patients you are covering is a 35-year-old pregnant G1P0 in her first trimester admitted for complicated appendicitis and awaiting appendectomy. Your attending surgeon would like you to start the patient on moxifloxacin IV preoperatively. You remember from your obstetrics clerkship, however, that moxifloxacin is Pregnancy Category C, and animal studies have shown that immature animals exposed to fluoroquinolones like moxifloxacin may experience cartilage damage. You know that there are potentially safer antibiotics, such as piperacillin/tazobactam, which is in Pregnancy Category B. What should you do?
- A. Administer moxifloxacin since it is only Pregnancy Category C and, although studies may have revealed adverse effects in animals, there is no definite evidence that it causes risk in humans.
- B. Administer piperacillin/tazobactam instead of moxifloxacin without discussing with the attending since your obligation is to "first, do no harm" and both are acceptable antibiotics for complicated appendicitis.
- C. Discuss the adverse effects of each antibiotic with the patient, and then let the patient decide which antibiotic she would prefer.
- D. Wait to administer any antibiotics until you discuss your safety concerns with your attending. (Correct Answer)
- E. Administer moxifloxacin since the attending is the executive decision maker and had to know the patient was pregnant when deciding on an antibiotic.
Elective colorectal procedures Explanation: **Wait to administer any antibiotics until you discuss your safety concerns with your attending.**
- As a resident, you have a **professional and ethical obligation** to voice concerns about patient safety, especially regarding medication choices in vulnerable populations like pregnant women.
- Discussing your concerns with the attending physician allows for a **re-evaluation of the treatment plan** based on current evidence and patient-specific factors, ensuring the safest care.
*Administer moxifloxacin since it is only Pregnancy Category C and, although studies may have revealed adverse effects in animals, there is no definite evidence that it causes risk in humans.*
- While Category C means risk cannot be ruled out and benefits *may* outweigh risks, the presence of **known adverse effects in animal studies** and the availability of a safer alternative warrant reconsideration.
- Administering a drug with known potential harm without discussing alternatives or concerns goes against the principle of **prudence and patient safety**.
*Administer piperacillin/tazobactam instead of moxifloxacin without discussing with the attending since your obligation is to "first, do no harm" and both are acceptable antibiotics for complicated appendicitis.*
- While "first, do no harm" is paramount, **unilaterally changing a treatment plan** ordered by an attending physician is inappropriate and breaches professional hierarchy and communication protocols.
- The correct approach is to **communicate concerns** to the attending, allowing for a collaborative decision, rather than making independent substitutions.
*Discuss the adverse effects of each antibiotic with the patient, and then let the patient decide which antibiotic she would prefer.*
- While patient autonomy and informed consent are crucial, decisions about specific antibiotic choices, especially for a complicated condition like appendicitis, require **medical expertise**.
- As a resident, it is your role to present information but not to delegate such complex medical decisions to a patient, particularly when you yourself have **unresolved concerns** with the attending's order.
*Administer moxifloxacin since the attending is the executive decision maker and had to know the patient was pregnant when deciding on an antibiotic.*
- While the attending is the senior decision-maker, it is possible for **oversights or errors to occur**, even with experienced physicians.
- Assuming the attending "had to know" and therefore dismissing your own clinical judgment and knowledge of potential harm is **irresponsible** and compromises patient safety.
Elective colorectal procedures US Medical PG Question 5: A 31-year-old woman comes to the emergency department because of a 4-day history of fever and diarrhea. She has abdominal cramps and frequent bowel movements of small quantities of stool with blood and mucus. She has had multiple similar episodes over the past 8 months. Her temperature is 38.1°C (100.6°F), pulse is 75/min, and blood pressure is 130/80 mm Hg. Bowel sounds are normal. The abdomen is soft. There is tenderness to palpation in the left lower quadrant with guarding and no rebound. She receives appropriate treatment and recovers. Two weeks later, colonoscopy shows polypoid growths flanked by linear ulcers. A colonic biopsy specimen shows mucosal edema with distorted crypts and inflammatory cells in the lamina propria. Which of the following is the most appropriate recommendation for this patient?
- A. Obtain genetic studies now
- B. Obtain barium follow-through radiography in 1 year
- C. Obtain glutamate dehydrogenase antigen immunoassay now
- D. Start annual magnetic resonance cholangiopancreatography screening in 10 years
- E. Start annual colonoscopy starting in 8 years (Correct Answer)
Elective colorectal procedures Explanation: ***Start annual colonoscopy starting in 8 years***
- The patient's presentation with bloody diarrhea, abdominal cramps, and repetitive episodes is consistent with <b>inflammatory bowel disease (IBD)</b>, specifically likely <b>ulcerative colitis</b> given the left lower quadrant tenderness and colonic biopsy findings (distorted crypts, inflammatory cells in lamina propria).
- Patients with IBD, particularly ulcerative colitis affecting a significant portion of the colon and diagnosed at a younger age, are at increased risk for <b>colorectal cancer</b>. Annual colonoscopy screening is recommended 8–10 years after diagnosis for early detection and prevention.
*Obtain genetic studies now*
- While genetic factors play a role in IBD susceptibility, <b>genetic studies are not routinely indicated for diagnosis or management</b> of inflammatory bowel disease, nor do they guide current screening recommendations for colorectal cancer in IBD patients.
- Genetic studies would not provide immediate clinical benefit for this patient's acute symptoms or long-term management plan regarding cancer surveillance.
*Obtain barium follow-through radiography in 1 year*
- <b>Barium follow-through radiography</b> is primarily used to evaluate the small intestine, often in suspected Crohn's disease. This patient's symptoms and colonoscopy findings point towards colonic involvement, making this less appropriate.
- Furthermore, this imaging modality uses <b>ionizing radiation</b> and is less sensitive for detecting mucosal changes indicative of dysplasia or early cancer compared to colonoscopy.
*Obtain glutamate dehydrogenase antigen immunoassay now*
- <b>Glutamate dehydrogenase antigen immunoassay</b> is a test for <b><i>Clostridioides difficile</i> infection</b>. While C. difficile can cause severe diarrhea and colitis, the patient's history of recurrent episodes over 8 months and the specific colonoscopy findings (polypoid growths, linear ulcers, distorted crypts) are more characteristic of IBD.
- Although C. difficile infection can exacerbate IBD, it does not explain the chronic, recurrent nature of her illness or the long-term cancer surveillance needs.
*Start annual magnetic resonance cholangiopancreatography screening in 10 years*
- <b>MRCP screening</b> is used to monitor for <b>primary sclerosing cholangitis (PSC)</b>, a condition associated with IBD, particularly ulcerative colitis. However, PSC screening is performed <b>when clinically indicated</b> (e.g., elevated alkaline phosphatase, cholestatic symptoms), not as routine scheduled surveillance.
- This patient has no clinical features suggesting PSC at present, and there is no guideline recommending routine MRCP screening at a predetermined time interval for all IBD patients.
Elective colorectal procedures US Medical PG Question 6: One day after undergoing an open colectomy, a 65-year-old man with colon cancer experiences shivers. The procedure was originally scheduled to be done laparoscopically, but it was converted because of persistent bleeding. Besides the conversion, the operation was uneventful. Five years ago, he underwent renal transplantation because of cystic disease and has been taking prednisolone since then. He has a history of allergy to sulfonamides. He appears acutely ill. His temperature is 39.2°C (102.5°F), pulse is 120/min, respirations are 23/min, and blood pressure is 90/62 mm Hg. Abdominal examination shows a midline incision extending from the xiphisternum to the pubic symphysis. There is a 5-cm (2-in) area of purplish discoloration near the margin of the incision in the lower abdomen. Palpation of the abdomen produces severe pain and crackling sounds are heard. Laboratory studies show:
Hemoglobin 12.5 g/dL
Leukocyte count 18,600/mm3
Platelet count 228,000/mm3
Erythrocyte sedimentation rate 120 mm/h
Serum
Na+ 134 mEq/L
K+ 3.5 mEq/L
Cl- 98 mEq/L
HCO3- 22 mEq/L
Glucose 200 mg/dL
Urea nitrogen 60 mg/dL
Creatinine 3.2 mg/dL
Creatine kinase 750 U/L
Which of the following is the most appropriate next step in management?
- A. Surgical debridement (Correct Answer)
- B. Intravenous clindamycin therapy
- C. X-ray of the abdomen and pelvis
- D. Vacuum-assisted wound closure device
- E. CT scan of abdomen
Elective colorectal procedures Explanation: ***Surgical debridement***
- The patient's presentation with **fever**, **tachycardia**, **hypotension**, **purplish discoloration**, **severe pain**, and **crepitus** (crackling sounds) near the incision after abdominal surgery is highly suggestive of **necrotizing fasciitis**.
- **Surgical debridement** is the most urgent and critical step to remove necrotic tissue, control the spread of infection, and improve outcomes in necrotizing soft tissue infections.
*Intravenous clindamycin therapy*
- While broad-spectrum antibiotics, including clindamycin, are essential in managing necrotizing fasciitis, they are **adjunctive to surgical debridement**, not a standalone primary treatment.
- Delaying surgery for antibiotic therapy alone would worsen the patient's prognosis and could lead to rapid progression of the infection.
*X-ray of the abdomen and pelvis*
- An X-ray might show subcutaneous **gas (crepitus)**, which is consistent with necrotizing fasciitis due to gas-producing bacteria.
- However, the clinical presentation is already highly indicative of the diagnosis, and waiting for imaging would **delay critical surgical intervention**.
*Vacuum-assisted wound closure device*
- **VAC therapy** is used for wound management to promote healing after debridement, by creating negative pressure.
- It is **not a primary treatment** for an active, spreading necrotizing infection and should only be considered after adequate surgical debridement has been performed.
*CT scan of abdomen*
- A CT scan can confirm the presence of **gas in the soft tissues** and assess the extent of the infection, providing valuable information.
- However, like X-rays, obtaining a CT scan would **delay immediate surgical intervention**, which is paramount given the rapid progression of necrotizing fasciitis.
Elective colorectal procedures US Medical PG Question 7: Eight hours after undergoing an open right hemicolectomy and a colostomy for colon cancer, a 52-year-old man has wet and bloody surgical dressings. He has had episodes of blood in his stools during the past 6 months, which led to the detection of colon cancer. He has hypertension and ischemic heart disease. His younger brother died of a bleeding disorder at the age of 16. The patient has smoked one pack of cigarettes daily for 36 years and drinks three to four beers daily. Prior to admission, his medications included aspirin, metoprolol, enalapril, and simvastatin. Aspirin was stopped 7 days prior to the scheduled surgery. He appears uncomfortable. His temperature is 36°C (96.8°F), pulse is 98/min, respirations are 14/min, and blood pressure is 118/72 mm Hg. Examination shows a soft abdomen with a 14-cm midline incision that has severe oozing of blood from its margins. The colostomy bag has some blood collected within. Laboratory studies show:
Hemoglobin 12.3 g/dL
Leukocyte count 11,200/mm3
Platelet count 210,000/mm3
Bleeding time 4 minutes
Prothrombin time 15 seconds (INR=1.1)
Activated partial thromboplastin time 36 seconds
Serum
Urea nitrogen 30 mg/dL
Glucose 96 mg/dL
Creatinine 1.1 mg/dL
AST 48 U/L
ALT 34 U/L
γ-Glutamyltransferase 70 U/L (N= 5–50 U/L)
Which of the following is the most likely cause of this patient's bleeding?
- A. Factor VIII deficiency
- B. Liver dysfunction
- C. Erosion of blood vessels
- D. Insufficient mechanical hemostasis (Correct Answer)
- E. Platelet dysfunction
Elective colorectal procedures Explanation: ***Insufficient mechanical hemostasis***
- The patient's **coagulation studies are within normal limits** (normal PT, aPTT, bleeding time, and platelet count), ruling out most common intrinsic bleeding disorders.
- Given the timing (8 hours post-surgery) and the nature of bleeding (oozing from incision margins and colostomy site), **inadequate surgical closure or ligature** is the most probable cause.
*Factor VIII deficiency*
- This would present with a **prolonged activated partial thromboplastin time (aPTT)**, which is normal in this patient (36 seconds). His brother's death from a bleeding disorder is a red herring.
- Congenital factor deficiencies typically manifest earlier in life and cause more severe, spontaneous bleeding, not just post-operative oozing with normal coagulation factors.
*Liver dysfunction*
- Severe liver dysfunction would typically lead to **prolonged PT and aPTT** due to impaired synthesis of clotting factors.
- While the patient has elevated GGT, indicating some liver stress likely from alcohol, his AST and ALT are only mildly elevated, and his coagulation tests are normal.
*Erosion of blood vessels*
- This is less likely to cause widespread oozing and would typically present as a more significant, **pulsatile hemorrhage** or hematoma.
- While possible in a surgical field, the lack of significant hemodynamic compromise and normal coagulation points away from a major vessel erosion.
*Platelet dysfunction*
- This would typically result in a **prolonged bleeding time**, which is normal in this patient (4 minutes).
- Although the patient was on aspirin, it was stopped 7 days prior to surgery, which is typically sufficient for platelet function to recover.
Elective colorectal procedures US Medical PG Question 8: A 38-year-old man comes to the physician because of a 2-week history of severe pain while passing stools. The stools are covered with bright red blood. He has been avoiding defecation because of the pain. Last year, he was hospitalized for pilonidal sinus surgery. He has had chronic lower back pain ever since he had an accident at his workplace 10 years ago. The patient's father was diagnosed with colon cancer at the age of 62. Current medications include oxycodone and gabapentin. He is 163 cm (5 ft 4 in) tall and weighs 100 kg (220 lb); BMI is 37.6 kg/m2. Vital signs are within normal limits. The abdomen is soft and nontender. Digital rectal examination was not performed because of severe pain. His hemoglobin is 16.3 mg/dL and his leukocyte count is 8300/mm3. Which of the following is the most appropriate next step in management?
- A. Anal sphincterotomy
- B. Colonoscopy
- C. Botulinum toxin injection
- D. Sitz baths and topical nifedipine (Correct Answer)
- E. Tract curettage
Elective colorectal procedures Explanation: ***Sitz baths and topical nifedipine***
- The patient's presentation of severe pain with defecation, bright red blood on stools, and avoidance of defecation is highly suggestive of an **anal fissure**.
- **Sitz baths** provide symptomatic relief by promoting muscle relaxation and increasing blood flow, while **topical nifedipine** acts as a calcium channel blocker to relax the internal anal sphincter, reducing pain and promoting healing.
*Anal sphincterotomy*
- This is a surgical procedure typically reserved for **chronic, refractory anal fissures** that have failed conservative management.
- Performing it as a first-line treatment is **premature** and carries higher risks compared to less invasive options.
*Colonoscopy*
- While the patient has a family history of colon cancer, the clinical presentation with **severe anal pain** and **bright red blood** primarily points to an anal fissure.
- A colonoscopy is generally indicated for evaluating suspicion of malignancy or other colonic pathology, not as an initial step for acute, localized anal pain attributed to a likely fissure.
*Botulinum toxin injection*
- **Botulinum toxin injection** is a treatment for anal fissures, similar to calcium channel blockers, by relaxing the internal anal sphincter.
- It is typically considered when topical treatments have failed, but before surgical intervention, making it not the very first step in management.
*Tract curettage*
- **Tract curettage** is a procedure primarily used for treating **anal fistulas** or **pilonidal cysts/sinuses**, which are different conditions from an anal fissure.
- The patient had pilonidal sinus surgery previously, but his current symptoms are consistent with an anal fissure, not a recurrence of pilonidal disease or an anal fistula.
Elective colorectal procedures US Medical PG Question 9: A 31 year-old-man presents to an urgent care clinic with symptoms of lower abdominal pain, bloating, bloody diarrhea, and fullness, all of which have become more frequent over the last 3 months. Rectal examination reveals a small amount of bright red blood. His vital signs include: temperature 36.7°C (98.0°F), blood pressure 126/74 mm Hg, heart rate 74/min, and respiratory rate 14/min. Colonoscopy is performed, showing extensive mucosal erythema, induration, and pseudopolyps extending from the rectum to the splenic flexure. Given the following options, what is the most appropriate treatment to induce remission in this patient?
- A. Azathioprine
- B. Mesalamine
- C. Total proctocolectomy
- D. Sulfasalazine
- E. Systemic corticosteroids (Correct Answer)
Elective colorectal procedures Explanation: ***Systemic corticosteroids***
- The patient presents with classic symptoms of an acute **ulcerative colitis flare**, including bloody diarrhea, abdominal pain, and colonoscopy findings of extensive inflammation from the rectum to the splenic flexure (consistent with **left-sided colitis**).
- **Systemic corticosteroids** such as prednisone or methylprednisolone are the **most appropriate treatment to induce remission** during active flares of moderate to severe ulcerative colitis due to their potent **anti-inflammatory effects** and rapid onset of action.
- This patient has moderate to severe disease based on extent and symptom severity, warranting systemic corticosteroids rather than topical or aminosalicylate therapy alone.
*Azathioprine*
- **Azathioprine** is an **immunomodulator** used for maintaining remission in inflammatory bowel disease, not for acute flare treatment.
- Its onset of action is slow (weeks to months), making it unsuitable for immediate symptom control in an acute flare.
*Mesalamine*
- **Mesalamine** (an aminosalicylate) is a **first-line therapy** for inducing and maintaining remission in **mild to moderate** ulcerative colitis, particularly for proctitis or left-sided colitis.
- However, for extensive disease with significant symptoms as seen in this patient, **systemic corticosteroids** are preferred due to greater potency and more rapid induction of remission in moderate to severe flares.
*Total proctocolectomy*
- **Total proctocolectomy** is a surgical procedure that provides a **definitive cure** for ulcerative colitis by removing the entire colon and rectum.
- However, surgery is reserved for cases of **refractory disease** (failure of medical therapy), severe complications (e.g., toxic megacolon, perforation, severe hemorrhage), or high risk of dysplasia/cancer.
- This patient is presenting with an acute flare and should be managed medically first; surgery is not the initial treatment approach.
*Sulfasalazine*
- **Sulfasalazine** is an aminosalicylate similar to mesalamine, used for inducing and maintaining remission in mild to moderate ulcerative colitis.
- While effective for mild disease, systemic corticosteroids are preferred for moderate to severe acute flares due to their stronger and more rapid anti-inflammatory action when the disease is extensive and symptomatic.
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