Hemorrhoids — MCQs
Bleeding in rupture of the uterus associated with a large broad ligament hematoma is controlled most simply by :
A 57-year-old man presents to the office with complaints of perianal pain during defecation and perineal heaviness for 1 month. He also complains of discharge around his anus, and bright red bleeding during defecation. The patient provides a history of having a sexual relationship with other men without using any methods of protection. The physical examination demonstrates edematous verrucous anal folds that are of hard consistency and painful to the touch. A proctosigmoidoscopy reveals an anal canal ulcer with well defined, indurated borders on a white background. A biopsy is taken and the results are pending. What is the most likely diagnosis?
The ideal indication for injection of sclerosing agents is:
What is the best way to control external hemorrhage?
Which of the following is NOT used as a sclerosing agent for hemorrhoids?
A young girl presents with abdominal pain and a recent change in bowel habit, with passage of mucus in stool. There is no associated blood in stool and symptoms are increased with stress. The most likely diagnosis is:
The internal anal sphincter is a part of which of the following?
A 60 year old male presents with bleeding per rectum. Proctoscopy reveals 2nd degree hemorrhoids. The treatment of choice is:
A 52 year old male patient comes with history of rectal bleeding, alteration in bowel habits and tenesmus. The ideal investigation would be:
Rectal prolapse occurs due to all EXCEPT:
Hemorrhoids Indian Medical PG Practice Questions and MCQs
Question 1: Bleeding in rupture of the uterus associated with a large broad ligament hematoma is controlled most simply by :
- A. Ligation of hypogastric artery
- B. Ligation of common iliac artery
- C. Suture of laceration
- D. Ligation of uterine artery (Correct Answer)
Explanation: ***Ligation of uterine artery*** - **Ligation of the uterine artery** is the **most simple and direct first-line approach** for controlling bleeding from uterine rupture with broad ligament hematoma. - The uterine artery provides the **primary blood supply** to the uterus and is easily accessible at the lower uterine segment, making it technically straightforward to ligate. - This method effectively controls bleeding by directly cutting off the major vascular supply to the area of rupture and the broad ligament hematoma. - Success rate is 80-90% for controlling hemorrhage, and it preserves blood flow to other pelvic structures. *Ligation of hypogastric artery* - **Ligation of the hypogastric artery** (internal iliac artery) is a **second-line procedure** requiring more extensive retroperitoneal dissection. - While effective, it is technically more difficult and time-consuming compared to uterine artery ligation, making it less "simple." - Reserved for cases where uterine artery ligation fails or when there is widespread pelvic bleeding from multiple sources. - It reduces blood flow to the entire pelvis, including bladder and rectum, not just the uterus. *Ligation of common iliac artery* - **Ligation of the common iliac artery** is an extreme measure with severe consequences, including compromised blood flow to the entire lower limb. - This is **not a standard procedure** for uterine rupture and carries unacceptable risks of leg ischemia and other complications. - Never considered a first-line approach for obstetric hemorrhage due to its extensive and potentially catastrophic effects. *Suture of laceration* - While **suturing the laceration** is essential for repairing the uterine defect, it does not provide adequate vascular control when a large broad ligament hematoma is present. - The hematoma indicates **significant vessel injury** within the broad ligament, requiring proximal vascular control first. - Suturing alone without controlling the bleeding source will not stop the hemorrhage and may lead to continued blood loss. - The correct approach is to first ligate the uterine artery for hemostasis, then repair the uterine tear.
Question 2: A 57-year-old man presents to the office with complaints of perianal pain during defecation and perineal heaviness for 1 month. He also complains of discharge around his anus, and bright red bleeding during defecation. The patient provides a history of having a sexual relationship with other men without using any methods of protection. The physical examination demonstrates edematous verrucous anal folds that are of hard consistency and painful to the touch. A proctosigmoidoscopy reveals an anal canal ulcer with well defined, indurated borders on a white background. A biopsy is taken and the results are pending. What is the most likely diagnosis?
- A. Anal cancer (Correct Answer)
- B. Polyps
- C. Anal fissure
- D. Hemorrhoids
- E. Proctitis
Explanation: ***Anal cancer*** - The patient's presentation with **perianal pain**, **bleeding**, **discharge**, and **edematous verrucous anal folds** (suggesting a lesion) are highly suspicious for anal cancer. His history of unprotected sexual relationships with men is a significant risk factor for **HPV infection**, which is a leading cause of anal squamous cell carcinoma. - The proctosigmoidoscopy findings of an **anal canal ulcer with well-defined, indurated borders** and a white background further point towards a malignant lesion, making anal cancer the most likely diagnosis. *Polyps* - While polyps can cause bleeding, they typically do not present with **indurated, painful verrucous lesions** or an ulcer with defined borders. - Polyps are usually soft and less likely to cause the severe perianal pain and perineal heaviness described. *Anal fissure* - An anal fissure is a **linear tear** in the anal canal, causing sharp pain during defecation and bright red blood. - It would not typically present with **edematous verrucous anal folds**, perineal heaviness, or an indurated ulcer as seen on proctosigmoidoscopy. *Hemorrhoids* - Hemorrhoids commonly cause **bright red bleeding** and can cause discomfort or heaviness. - However, they usually appear as swollen vascular cushions and do not typically present as **indurated, painful verrucous lesions** or an ulcer with defined borders. *Proctitis* - Proctitis is an inflammation of the rectum, causing rectal pain, tenesmus, and bleeding, often due to **inflammatory bowel disease** or **infections**. - While it can cause some of the symptoms, it wouldn't typically manifest as a distinct **indurated, verrucous lesion** or an ulcer with firm borders, which are more indicative of a mass.
Question 3: The ideal indication for injection of sclerosing agents is:
- A. External hemorrhoids
- B. Internal hemorrhoids (Correct Answer)
- C. Immediate surgery for strangulated hemorrhoids
- D. Surgical intervention for prolapsed hemorrhoids
Explanation: ***Internal hemorrhoids*** - Sclerotherapy is most effective for **first- and second-degree internal hemorrhoids**, where symptomatic bleeding is the primary concern. - The injected agent causes **fibrosis** and **scarring**, leading to fixation of the hemorrhoidal tissue and reduced blood flow. *External hemorrhoids* - External hemorrhoids are located **below the dentate line** and are covered by sensitive anoderm. - Sclerosing agents can cause **significant pain** and are generally ineffective for external hemorrhoids. *Immediate surgery for strangulated hemorrhoids* - **Strangulated hemorrhoids** are a medical emergency requiring **urgent surgical intervention** to prevent tissue necrosis. - Sclerotherapy is absolutely **contraindicated** in this scenario due to the risk of exacerbating ischemia and complications. *Surgical intervention for prolapsed hemorrhoids* - While sclerotherapy can be used for some early-stage prolapsed internal hemorrhoids (second degree), **surgical intervention** is more appropriate for **third- and fourth-degree prolapsed hemorrhoids**. - These more advanced hemorrhoids often require techniques like **hemorrhoidectomy** or stapling for definitive treatment.
Question 4: What is the best way to control external hemorrhage?
- A. Artery forceps
- B. Direct pressure (Correct Answer)
- C. Proximal tourniquet
- D. Elevation
Explanation: ***Direct pressure*** - Applying **direct pressure** to the wound with a clean cloth or hand is the most effective initial step to control external hemorrhaging, promoting clot formation. - This method is safe, readily available, and typically sufficient for stopping many types of external bleeding. *Artery forceps* - **Artery forceps** (hemostats) are used in surgical settings to clamp bleeding vessels, but they are generally not an appropriate first-line method for emergency external hemorrhage control outside a sterile environment. - Their improper use can cause further tissue damage or injury, and they are not always accessible. *Proximal tourniquet* - A **tourniquet** is a last resort for severe, life-threatening limb hemorrhage when direct pressure has failed, as it can cause significant tissue damage leading to limb ischemia. - It should be applied **proximal** to the wound, but its use is restricted due to the risk of limb loss. *Elevation* - **Elevation** of the injured limb above the level of the heart can help reduce blood flow to the area, but it is usually used as an adjunct to direct pressure, not as the primary or sole method for controlling significant bleeding. - It is often insufficient on its own for moderate to severe external hemorrhage.
Question 5: Which of the following is NOT used as a sclerosing agent for hemorrhoids?
- A. Polidocanol
- B. Phenol in olive oil
- C. Sodium morrhuate
- D. Quinine urea (Correct Answer)
Explanation: ***Quinine urea*** - **Quinine urea** was historically used as a sclerosing agent but is **no longer used** in modern practice due to significant adverse effects, including **tissue necrosis**, **gangrene**, and **anaphylaxis**. - Its use has been abandoned and replaced by safer alternatives, making it the agent that is NOT used for hemorrhoids today. *Phenol in olive oil* - **Phenol in olive oil** (typically 5%) is one of the most commonly used sclerosing agents for hemorrhoids, especially for **Grade I and early Grade II hemorrhoids**. - It induces an **inflammatory reaction** and subsequent fibrosis, fixing the hemorrhoidal tissue to the underlying musculature. *Sodium morrhuate* - **Sodium morrhuate** is a fatty acid salt derived from cod liver oil and is actively used as a sclerosing agent for hemorrhoids. - It generates a **local inflammatory response**, leading to venous thrombosis and fibrosis of hemorrhoidal tissue. *Polidocanol* - **Polidocanol** (Aethoxysklerol) is a modern sclerosing agent commonly used for hemorrhoid treatment. - It is effective, has a good safety profile, and works by damaging the vascular endothelium, causing thrombosis and fibrosis.
Question 6: A young girl presents with abdominal pain and a recent change in bowel habit, with passage of mucus in stool. There is no associated blood in stool and symptoms are increased with stress. The most likely diagnosis is:
- A. Amebiasis
- B. Irritable bowel syndrome (Correct Answer)
- C. Crohn's disease
- D. Ulcerative Colitis
Explanation: ***Irritable bowel syndrome*** - **Irritable bowel syndrome (IBS)** typically presents with **abdominal pain**, altered bowel habits (constipation, diarrhea, or mixed), and **mucus in stool** without blood [1]. - The symptoms are often exacerbated by **stress** and there is no evidence of structural or biochemical abnormalities [1]. *Amebiasis* - **Amebiasis** is an infection caused by *Entamoeba histolytica*, usually leading to **bloody diarrhea** (dysentery), abdominal pain, and fever. - The absence of blood in the stool and the presence of stress-related symptom exacerbation make amebiasis less likely. *Crohn's disease* - **Crohn's disease** is a type of inflammatory bowel disease characterized by **transmural inflammation** that can affect any part of the gastrointestinal tract. - Symptoms often include **abdominal pain**, diarrhea (which can be bloody), weight loss, and fatigue, and it does not typically show a direct correlation with stress as the primary exacerbating factor. *Ulcerative Colitis* - **Ulcerative colitis (UC)** is an inflammatory bowel disease characterized by **continuous inflammation** of the colon, typically starting in the rectum. - Key symptoms include recurrent **bloody diarrhea**, abdominal pain, and tenesmus, which are not described in this case, particularly the absence of blood.
Question 7: The internal anal sphincter is a part of which of the following?
- A. Puborectalis muscle
- B. Deep perineal muscles
- C. Internal longitudinal fibers
- D. Internal circular fibers (Correct Answer)
Explanation: ***Internal circular fibers*** - The **internal anal sphincter** is an involuntary muscle formed by the thickening of the **circular smooth muscle layer** of the rectum. - This sphincter maintains **tonic contraction** and is responsible for about 80% of resting anal pressure [1]. *Puborectalis muscle* - The **puborectalis muscle** is a voluntary muscle, forming a sling around the anorectal junction to maintain the **anorectal angle** [1]. - It is part of the **levator ani muscles**, which are skeletal muscles, not smooth muscle [1]. *Deep perineal muscles* - The **deep perineal muscles** are a group of skeletal muscles located in the urogenital diaphragm. - They are involved in functions such as **urinary continence** and **erection**, but do not form the internal anal sphincter. *Internal longitudinal fibers* - The **longitudinal muscle layer** of the rectum continues downwards as the conjoined longitudinal muscle, which blends with the external anal sphincter. - These fibers contribute to the **anorectal ring** and support the anal canal but do not form the internal anal sphincter itself.
Question 8: A 60 year old male presents with bleeding per rectum. Proctoscopy reveals 2nd degree hemorrhoids. The treatment of choice is:
- A. Cryotherapy
- B. Sclerotherapy
- C. Banding (Correct Answer)
- D. Surgery
Explanation: ***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.
Question 9: A 52 year old male patient comes with history of rectal bleeding, alteration in bowel habits and tenesmus. The ideal investigation would be:
- A. Contrast-enhanced CT scan
- B. Fecal occult blood test
- C. Colonoscopy (Correct Answer)
- D. Ultrasonogram
Explanation: ***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.
Question 10: Rectal prolapse occurs due to all EXCEPT:
- A. Whooping cough
- B. Fistula-in-Ano (Correct Answer)
- C. Marasmus
- D. Obstetric trauma
Explanation: The image displays a prominent **rectal prolapse**, characterized by the eversion of the rectal wall through the anus. This condition can be caused by various factors that increase intra-abdominal pressure or weaken the pelvic floor. ***Fistula-in-Ano*** - A **fistula-in-ano** is an abnormal connection between the anal canal and the perianal skin, typically resulting from an anal abscess. - While it can be associated with inflammatory bowel disease or local infection, it is a **separate pathological entity** that does not cause rectal prolapse. - Fistula-in-ano does not directly increase intra-abdominal pressure or weaken the pelvic floor muscles, and thus is **not a cause of rectal prolapse**. *Whooping cough* - **Whooping cough (pertussis)** leads to severe, paroxysmal coughing fits, which significantly increase **intra-abdominal pressure**. - This sustained increase in pressure, especially in children, can contribute to the development or worsening of **rectal prolapse**. *Obstetric trauma* - **Obstetric trauma**, particularly during childbirth, can cause significant damage to the **pelvic floor muscles** and ligaments. - Weakening of these supporting structures is a major predisposing factor for **rectal prolapse**, especially in multiparous women. *Marasmus* - **Marasmus** is a severe form of protein-energy malnutrition seen in children, characterized by significant weight loss and muscle wasting. - While less direct than other causes, it can contribute to rectal prolapse through chronic malnutrition, diarrhea, and weakened pelvic tissues in pediatric populations.
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