Colorectal Surgery — MCQs
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A patient presents with abdominal distension, obstipation and vomiting. The patient reports a long history of intermittent obstructive symptoms and distension. On radiological examination this is the presentation of the patient. Which of the following statement regarding his condition would be false?
A 47-year-old man comes to Surgery OPD with history of recurrent episodes of UTI. He gives history of the urine being frothy and occasionally having bubbles. The probable diagnosis is :
Which one of the following statements is true regarding "injection sclerotherapy" for haemorrhoids ?
In a 65 year old, double contrast barium enema shows cancer of colon with an apple core appearance. Colonoscopic biopsy shows adenocarcinoma. What will be the next step of management?
A 45 year old underwent surgery for rectal prolapse. At present, he complains of sexual dysfunction which is probably due to the injury of:
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:
A colonic carcinoma involving muscularis propria, with one or two nodes involved with a solitary metastasis in the liver, the TNM stage would be:
A 52 year old male patient comes with history of rectal bleeding, alteration in bowel habits and tenesmus. The ideal investigation would be:
A 60 year old male presents with bleeding per rectum. Proctoscopy reveals 2nd degree hemorrhoids. The treatment of choice is:
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:
Colorectal Surgery Indian Medical PG Practice Questions and MCQs
Question 251: A patient presents with abdominal distension, obstipation and vomiting. The patient reports a long history of intermittent obstructive symptoms and distension. On radiological examination this is the presentation of the patient. Which of the following statement regarding his condition would be false?
- A. Coffee bean appearance is seen on X-ray
- B. Risk of reoccurrence is up to $40 \%$
- C. Urgent sigmoid colectomy and anastomosis if fecal peritonitis present (Correct Answer)
- D. Endoscopic detorsion is used as initial treatment
Explanation: ***Urgent sigmoid colectomy and anastomosis if fecal peritonitis present*** - In cases of **fecal peritonitis** due to perforated sigmoid volvulus, the segment of bowel is typically **resected** due to perforation, but **anastomosis is usually delayed** (Hartmann's procedure) because of high rates of anastomotic leakage in contaminated fields. - A primary anastomosis in the setting of fecal peritonitis is generally contraindicated due to the high risk of **sepsis** and **anastomotic dehiscence**. *Endoscopic detorsion* - **Endoscopic detorsion** is often the initial treatment for an uncomplicated sigmoid volvulus to relieve obstruction and decompression. - This procedure is a temporizing measure and does not prevent recurrence, so definitive surgery is typically performed electively later. *Coffee bean appearance* - The **"coffee bean" sign** on abdominal radiography is highly characteristic of **sigmoid volvulus**, indicating a dilated, gas-filled loop of sigmoid colon. - This radiographic finding is consistent with the presented symptoms of obstruction and distension. *Risk of reoccurrence is up to 40%* - After successful endoscopic detorsion for sigmoid volvulus, the **recurrence rate** is indeed high, often reported to be between **40% and 90%** if no definitive surgical intervention follows. - Due to this high recurrence risk, elective surgery (e.g., sigmoid colectomy) is recommended after initial detorsion to prevent future episodes.
Question 252: A 47-year-old man comes to Surgery OPD with history of recurrent episodes of UTI. He gives history of the urine being frothy and occasionally having bubbles. The probable diagnosis is :
- A. Tubercular cystitis
- B. Colovesical fistula (Correct Answer)
- C. Urethrocutaneous fistula
- D. Anaerobic bacterial infection
Explanation: ***Colovesical fistula*** - The presence of **pneumaturia (gas/bubbles in urine)** and **frothy urine** is pathognomonic of colovesical fistula, indicating abnormal communication between the colon and bladder with gas passage from bowel to bladder. - **Recurrent UTIs** occur in >50% of cases due to constant contamination of the bladder with fecal bacteria. - Other features include **fecaluria** (fecal matter in urine) - though less common than pneumaturia. - Most commonly caused by diverticular disease (65%), followed by colorectal cancer and Crohn's disease. *Tubercular cystitis* - While it can cause recurrent UTIs and bladder irritation, it does not typically present with **pneumaturia** or frothy urine. - Presents with sterile pyuria, dysuria, hematuria, and frequency. - Diagnosis requires identification of *Mycobacterium tuberculosis* in urine culture or bladder biopsy. *Urethrocutaneous fistula* - This involves an abnormal communication between the urethra and the skin, leading to urine leakage onto the skin surface. - Does not cause gas to enter the bladder or result in **pneumaturia**. - May cause recurrent UTIs if fistula leads to inadequate bladder emptying, but not the presenting features. *Anaerobic bacterial infection* - Although anaerobic bacteria can cause UTIs, they do not produce sufficient gas to cause **pneumaturia** without an underlying anatomical defect. - **Pneumaturia** is a mechanical sign indicating an abnormal connection with a gas-containing organ (colon), not merely infection.
Question 253: Which one of the following statements is true regarding "injection sclerotherapy" for haemorrhoids ?
- A. Injection of sclerosant is made above the dentate line (pectinate line) (Correct Answer)
- B. Sclerotherapy is the treatment of choice for the prolapsed haemorrhoids
- C. In patients with haemorrhoids at 3 o'clock, 7 o'clock and 11 o'clock positions, the injection is made in the sitting position
- D. Sclerotherapy is the ideal treatment for acute external haemorrhoids
Explanation: ***Injection of sclerosant is made above the dentate line (pectinate line)*** - Sclerotherapy involves injecting a **sclerosing agent** into the submucosa of internal hemorrhoids, specifically where they are **rich in blood vessels** and above the **pain-sensitive dentate line** to minimize discomfort. - Injecting above the dentate line helps to **avoid pain receptors** and induce fibrosis, which reduces blood flow and shrinks the hemorrhoid. *Sclerotherapy is the treatment of choice for the prolapsed haemorrhoids* - **Sclerotherapy** is generally effective for **Grade I and II internal hemorrhoids** that bleed but may not prolapse or prolapse only minimally. - For **prolapsed hemorrhoids (Grade III and IV)**, band ligation, excisional hemorrhoidectomy, or other surgical interventions are typically more effective. *In patients with haemorrhoids at 3 o'clock, 7 o'clock and 11 o'clock positions, the injection is made in the sitting position* - Injections for hemorrhoids are typically performed in the **left lateral (Sims') position** or **lithotomy position**, which provides optimal exposure and patient comfort. - The **sitting position** is not used for this procedure due to poor access and difficulty in maintaining a stable posture for the injection. *Sclerotherapy is the ideal treatment for acute external haemorrhoids* - **Sclerotherapy** is contraindicated for **external hemorrhoids** because they lie below the dentate line and are highly sensitive to pain. - Acute external hemorrhoids, especially if thrombosed, are usually managed with **excision of the thrombus** or conservative measures, not sclerotherapy.
Question 254: In a 65 year old, double contrast barium enema shows cancer of colon with an apple core appearance. Colonoscopic biopsy shows adenocarcinoma. What will be the next step of management?
- A. Surgery
- B. Radiotherapy
- C. Chemotherapy
- D. CECT to stage disease (Correct Answer)
Explanation: ***CECT to stage disease*** - **CECT (Contrast-Enhanced CT) of chest, abdomen, and pelvis is the essential next step** after histological confirmation of colon adenocarcinoma. - **Staging is mandatory** before any treatment decision to determine: - **Local extent** of tumor (T stage) - **Lymph node involvement** (N stage) - **Distant metastases** (M stage - liver, lungs, peritoneum) - **Resectability** and surgical planning - Even with the "apple core" appearance indicating an advanced primary tumor, **treatment decisions cannot be made without knowing the overall disease burden**. - **CEA (Carcinoembryonic Antigen) levels** are also typically obtained during staging. *Surgery* - **Surgical resection is the definitive treatment** for localized, resectable colon cancer and would be performed **after staging**, not before. - Surgery involves removing the tumor with adequate margins and regional lymphadenectomy. - However, **staging must precede surgery** to: - Determine if the disease is metastatic (which would change surgical approach) - Plan the extent of resection - Counsel the patient appropriately - Decide on neoadjuvant therapy if indicated - The "apple core" appearance suggests an advanced primary but does not indicate acute obstruction requiring emergency surgery in this stable patient who has already undergone barium enema and colonoscopy. *Chemotherapy* - **Chemotherapy** is typically given as: - **Adjuvant therapy** after surgery for stage III (node-positive) or high-risk stage II disease - **Palliative therapy** for metastatic (stage IV) disease - **Neoadjuvant therapy** is not standard for colon cancer (unlike rectal cancer) - Chemotherapy is not the immediate next step; staging and then surgery (if resectable) come first. *Radiotherapy* - **Radiotherapy has limited role in colon cancer** (unlike rectal cancer where it is commonly used). - It may be used for: - **Palliation** of symptoms (pain, bleeding) in advanced disease - Rare cases of **locally advanced unresectable disease** - It is not a primary treatment modality and is not the next step in this case.
Question 255: A 45 year old underwent surgery for rectal prolapse. At present, he complains of sexual dysfunction which is probably due to the injury of:
- A. Pelvic autonomic nerves (Correct Answer)
- B. Urinary bladder
- C. Rectum
- D. Inferior mesenteric artery
Explanation: ***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.
Question 256: 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:
- A. Prophylactic anterior resection
- B. Prophylactic panproctocolectomy (Correct Answer)
- C. Surveillance colonoscopy every 6 months
- D. Colonoscopic removal of all polyps
Explanation: ***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.
Question 257: A colonic carcinoma involving muscularis propria, with one or two nodes involved with a solitary metastasis in the liver, the TNM stage would be:
- A. T2 N1 M1 (Correct Answer)
- B. T1 N2 M1
- C. T1 N1 M1
- D. T2 N2 M1
Explanation: ***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.
Question 258: 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 259: 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 260: 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:
- A. T2, N1, M0 (Correct Answer)
- B. T2, N1, M1
- C. T1, N1, M0
- D. T1, N0, M0
Explanation: ***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.
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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