Colorectal Surgery — MCQs

An 80-year-old male patient complains of bleeding per rectum with alteration in bowel habits. On physical examination of the abdomen there is mass on the left side. Patient's history is positive for smoking, alcohol and regular nonvegetarian food. Barium enema of the patient is given in the below picture. All of the following statements regarding the diagnosis are true except: (Recent NEET Pattern 2016-17)

Colorectal Surgery Indian Medical PG Practice Questions and MCQs

Question 241: Identify the instrument in the image:

A. Langenbeck retractor
B. Joll retractor
C. Deaver retractor
D. Goligher retractor (Correct Answer)

Explanation: ***Goligher retractor*** - This image displays a **Goligher self-retaining retractor**, characterized by multiple blades that can be adjusted to provide broad and deep retraction. - It is often used in **abdominal and pelvic surgeries**, particularly in colorectal procedures, for optimal exposure of deep structures. *Langenbeck retractor* - A Langenbeck retractor is a **small, L-shaped handheld retractor** with a flat, right-angled blade. - It is typically used for **retracting small incisions** or superficial tissues, not large cavities. *Joll retractor* - A Joll retractor is a **self-retaining retractor** primarily used in **thyroid surgery**. - Its design is specific for neck anatomy, featuring two adjustable blades attached to a central bar. *Deaver retractor* - A Deaver retractor is a **large, flat, curved handheld retractor**, resembling a question mark. - It is commonly used for **deep abdominal retraction** to hold back organs, but it is not self-retaining nor does it have multiple interlocking blades like the one pictured.

Question 242: Identify the surgical instrument shown in the image:

A. Proctoscope
B. Sigmoidoscope
C. Anoscope (Correct Answer)
D. Colonoscope

Explanation: ***Anoscope*** - The image displays a short, rigid instrument with a removable obturator, designed for visualizing the **anal canal**. - Its typical use involves the examination of the **anus and rectum** for conditions such as hemorrhoids or anal fissures. *Proctoscope* - A proctoscope is generally a **longer and wider, rigid scope** used to visualize the rectum and distal sigmoid colon. - While an anoscope can sometimes be referred to as a short proctoscope, a typical proctoscope is designed for a more extensive view beyond the anal canal. *Sigmoidoscope* - A sigmoidoscope is a **longer, flexible or rigid instrument** used to examine the entire sigmoid colon, which is much further than the instrument shown can reach. - It allows for the detection of polyps or abnormalities in the **distal large intestine**. *Colonoscope* - A colonoscope is a much **longer and flexible instrument** designed to visualize the entire large intestine (colon) and often the terminal ileum. - It is used for comprehensive screening and diagnostic procedures like **colonoscopies**.

Question 243: The diagnosis of this patient with left-sided abdominal pain and tyre-like feel of abdomen is?

A. Sigmoid volvulus (Correct Answer)
B. Diverticulitis
C. Paralytic ileus
D. Intussusception

Explanation: ***Sigmoid volvulus*** - The image shows massively dilated loops of bowel forming an **omega loop** or "inverted U" appearance, characteristic of **sigmoid volvulus**. The "tyre-like feel" upon palpation is consistent with a distended, gas-filled colon. - Clinical presentation with **left-sided abdominal pain** and signs of **large bowel obstruction** further supports this diagnosis, especially with the characteristic radiological findings. *Diverticulitis* - Diverticulitis typically presents with **left lower quadrant pain**, fever, and localized tenderness, but not usually with the massive abdominal distension and "tyre-like" feel seen in major bowel obstruction. - Radiological findings in diverticulitis often include **pericolic fat stranding**, wall thickening, and diverticula, rather than dramatically dilated bowel loops. *Paralytic ileus* - **Paralytic ileus** involves generalized bowel distension due to decreased peristalsis, often affecting both small and large bowel, rather than the localized, massive dilation of a single segment as seen here. - While there is distension, the distinct "inverted U" or omega loop configuration pointing to a specific segment of the bowel causing obstruction is not a feature of paralytic ileus. *Intussusception* - **Intussusception** is more common in children and typically presents with intermittent abdominal pain, vomiting, and "current jelly" stools, not primarily with palpable mass or a "tyre-like" feel on the *sigmoid* colon as described. - Radiologically, intussusception might show a "target sign" on ultrasound or an absence of gas distal to the obstruction, not the massively dilated sigmoid loop seen in the radiograph.

Question 244: What is the preferred treatment for the shown lesion?

A. 5-fluorouracil + Mitomycin C
B. Mitomycin C + Cisplatin
C. 5-FU + Mitomycin C + Radiotherapy (Correct Answer)
D. Abdominoperineal resection (APR)

Explanation: ***5-FU + Mitomycin C + Radiotherapy*** - The image shows an **exophytic lesion near the anus**, which is highly suggestive of **anal squamous cell carcinoma (SCC)**. The preferred treatment for anal SCC is **chemoradiation**. - The regimen of 5-fluorouracil (5-FU) and Mitomycin C, combined with **radiotherapy**, is the **Nigro protocol**, which is the current standard of care for anal cancer, aiming for organ preservation and cure. - This non-surgical approach has replaced radical surgery for most anal cancers, with excellent cure rates and quality of life preservation. *5-fluorouracil + Mitomycin C* - While these chemotherapy agents are part of the standard treatment for anal SCC, they are typically used in conjunction with **radiotherapy** to achieve optimal outcomes. - Chemotherapy alone without radiation is generally insufficient for curative intent in anal SCC. *Mitomycin C + Cisplatin* - This combination includes two potent chemotherapy drugs, but it is not the standard protocol for anal SCC. - While cisplatin can be used in some anal cancer regimens (particularly as salvage therapy), the combination with Mitomycin C in the absence of 5-FU and radiotherapy is not the primary choice. *Abdominoperineal resection (APR)* - APR was historically the standard treatment for anal cancer but has been largely replaced by chemoradiation (Nigro protocol). - Surgery is now reserved for salvage therapy in cases of persistent or recurrent disease after chemoradiation failure. - The shift to chemoradiation has significantly improved quality of life by preserving the anal sphincter and avoiding permanent colostomy.

Question 245: A 29-year-old male who is a doctor by profession, gives a history of prolonged sitting in his OPD hours and presents with discharge and pain. Clinical presentation of the patient is given in the image. What is the most likely diagnosis?

A. Anal fissure
B. Pilonidal sinus (Correct Answer)
C. Anal fistula
D. Sentinel pile

Explanation: ***Pilonidal sinus*** - The image shows a **pit** or **opening** in the **natal cleft** with surrounding inflammation and discharge, which is characteristic of a pilonidal sinus. - The history of **prolonged sitting** (*a doctor by profession has prolonged sitting hours in OPD*) and the patient's age (29-year-old male) are common risk factors for pilonidal disease. *Anal fissure* - An anal fissure is a **tear** in the **lining of the anal canal**, typically causing severe pain during and after defecation, and often bright red rectal bleeding. - The lesion in the image is located in the **natal cleft**, not within the anal canal, and presents as a sinus with discharge rather than a linear tear. *Anal fistula* - An anal fistula is an abnormal tunnel connecting the **anal canal to the skin outside** the anus, usually presenting as a small opening with intermittent or persistent discharge of pus or blood. - While it involves discharge, an **anal fistula** typically has an external opening closer to the anus, and the image clearly shows the lesion in the **sacrococcygeal region**, consistent with a pilonidal sinus. *Sentinel pile* - A sentinel pile is a **skin tag** that often accompanies a **chronic anal fissure**, located at the external edge of the fissure. - It is essentially excess skin and usually does not present with **discharge** or the characteristic **sinus tract** seen in the image.

Question 246: A young male patient presents with a condition similar to the given image. What is the surgery of choice?

A. Delorme's procedure
B. Anterior resection
C. Abdominal rectopexy
D. Duhamel's procedure (Correct Answer)

Explanation: ***Duhamel's procedure*** - This image shows a severe case of **Hirschsprung's disease** in a young male patient, characterized by an **aganglionic segment of the colon** leading to functional obstruction and proximal colonic dilation. - The **Duhamel's procedure** is a surgical option for Hirschsprung's disease where the aganglionic segment is bypassed, and a side-to-side anastomosis is created between the pulled-through normal colon and the rectum. *Delorme's procedure* - This procedure is primarily used for **rectal prolapse**, involving mucosal stripping and plication of the muscular layer of the prolapsed rectum. - It is not the appropriate surgical intervention for **Hirschsprung's disease**, which involves an absence of ganglion cells. *Anterior resection* - Anterior resection is a common surgical procedure for **rectal or sigmoid colon cancer**, involving removal of a segment of the bowel with re-anastomosis. - It does not address the underlying **pathophysiology of Hirschsprung's disease**, which is the absence of ganglion cells. *Abdominal rectopexy* - Abdominal rectopexy is a surgical procedure for **rectal prolapse** where the rectum is mobilized and fixed to the sacrum. - This procedure is not indicated for **Hirschsprung's disease**, as it does not correct the fundamental problem of aganglionosis.

Question 247: 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.

Question 248: A 60-year-old male came with bleeding per rectum and was diagnosed to have carcinoma colon. The patient underwent extended hemicolectomy. Identify the instrument the surgeon is using: (AIIMS Nov 2016)

A. Ligasure vessel ligating system
B. Harmonic scalpel (Correct Answer)
C. Monopolar cautery
D. Hyfrecator

Explanation: ***Harmonic scalpel*** - The image displays a device with a thin tip and a handpiece featuring activation buttons, consistent with the appearance of a **harmonic scalpel**. - **Harmonic scalpels** use **ultrasonic vibrations** to cut and coagulate tissue simultaneously, minimizing thermal spread and smoke plume, especially useful in delicate dissections during surgery like a hemicolectomy. *Ligasure vessel ligating system* - A **Ligasure device** typically has larger, jaw-like tips designed for **vessel sealing**, which applies pressure and bipolar energy to fuse vessel walls. - The tip shown in the image is too fine for the characteristic **Ligasure** vessel sealing mechanism. *Monopolar cautery* - While a **monopolar cautery** pencil (or **Electrocautery Pencil**) also has a fine tip and control buttons, the pictured device's detailed tip structure and specialized cable suggest it's more advanced than a basic monopolar cautery, which primarily uses electrical current to cut or coagulate. - The distinctive design with a more elongated and precise tip is indicative of ultrasonic rather than electrical cutting. *Hyfrecator* - A **Hyfrecator** is a form of electrocautery primarily used for **desiccation and fulguration** of superficially located tissues, often in dermatology. - It uses a much lower power setting than typical surgical electrocautery and would not be the primary cutting instrument for extensive procedures like a hemicolectomy.

Question 249: A 35-year-old patient with history of significant weight loss and medically refractory constipation underwent a barium enema shown below. In how many % of cases Metastatic liver disease is found?

A. 10 %
B. 33 % (Correct Answer)
C. 15 %
D. 75 %

Explanation: ***33 %*** - Approximately **20-25% of colorectal cancer patients present with synchronous liver metastases** at initial diagnosis, and another **15-25% develop metachronous metastases** during follow-up. - The figure of **33% represents a reasonable approximation** of the overall incidence, considering both presentation and subsequent development of liver metastases. - The liver is the **most common site of distant metastasis** in colorectal cancer due to portal venous drainage from the colon directly to the liver. - This makes **33% the most accurate answer** among the given options for the cumulative incidence of metastatic liver disease. *75 %* - This is a **significant overestimation** of the true incidence of liver metastases in colorectal cancer patients. - While the liver is the most common metastatic site, **only 20-25% have liver metastases at presentation**, and the cumulative lifetime incidence reaches approximately 40-50%, not 75%. - This exaggerated figure does not align with current epidemiological data. *10 %* - This is **too low** and underestimates the true burden of liver metastatic disease in colorectal cancer. - Given that approximately one-quarter of patients present with liver metastases at diagnosis alone, 10% significantly underrepresents the actual incidence. *15 %* - This also **underestimates** the true incidence of liver metastases in colorectal cancer patients. - While 15% might represent a specific subset or early-stage disease, it does not reflect the overall cumulative incidence of metastatic liver disease.

Question 250: An 80-year-old male patient complains of bleeding per rectum with alteration in bowel habits. On physical examination of the abdomen there is mass on the left side. Patient's history is positive for smoking, alcohol and regular nonvegetarian food. Barium enema of the patient is given in the below picture. All of the following statements regarding the diagnosis are true except: (Recent NEET Pattern 2016-17)

A. High fiber and low animal fat diet is the major risk factor (Correct Answer)
B. Most common age is 8th decade of life
C. Liver is the most commonly affected organ due to this condition
D. 5-FU is used as chemotherapy in this condition

Explanation: ***High fiber and low animal fat diet is the major risk factor*** - A **high-fiber diet** is actually **protective** against colorectal cancer. It promotes healthy bowel movements and dilutes carcinogens. - A **low animal fat diet** is also generally considered protective, while a **high intake of red and processed meats** (animal fat) is a known risk factor for colorectal cancer. *Most common age is 8th decade of life* - The incidence of **colorectal cancer** significantly **increases with age**, with the majority of cases diagnosed in individuals **over 50 years old**. - The 8th decade of life (70s) is indeed a common age for diagnosis, fitting the patient's age of 80. *Liver is the most commonly affected organ due to this condition* - **Colorectal cancer** frequently metastasizes via the **portal venous system** to the liver, making the **liver the most common site for distant metastasis**. - This is a well-established pattern of spread for colorectal malignancies. *5-FU is used as chemotherapy in this condition* - **5-fluorouracil (5-FU)** is a foundational chemotherapeutic agent, often used in combination with other drugs, for the treatment of **colorectal cancer**. - It works by interfering with DNA and RNA synthesis, inhibiting cancer cell growth.

Practice by Chapter

Colorectal Anatomy and Physiology

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Diverticular Disease

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Inflammatory Bowel Disease

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Colorectal Polyps

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Colorectal Cancer

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Anorectal Abscess and Fistula

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Hemorrhoids

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Rectal Prolapse

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Fecal Incontinence

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Intestinal Stomas Creation and Management

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Pelvic Floor Disorders

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Enhanced Recovery After Colorectal Surgery

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