Colorectal Surgery Practice Questions

Q: Bleeding vessel in hemorrhoids is

Superior rectal artery. Superior rectal artery - Hemorrhoidal bleeding primarily originates from the **terminal branches of the superior rectal artery** within the hemorrhoidal plexus. - The hemorrhoidal cushions contain **arteriovenous anastomoses**, and bleeding occurs from rupture or erosion of the **arterial component**. - This explains why hemorrhoidal bleeding is typically **bright red** (oxygenated arterial blood) and can be brisk. - Modern surgical treatments like **hemorrhoidal artery ligation (HAL)** specifically target these arterial branches, confirming the arterial source of bleeding. Superior rectal vein - While the superior rectal vein drains the hemorrhoidal plexus and is dilated in hemorrhoids, it is **not the primary source of bleeding**. - The venous component contributes to the cushion engorgement but the **actual bleeding is arterial** in nature. - This is an older, outdated concept that has been revised with modern understanding of hemorrhoidal pathophysiology. Middle rectal vein - The middle rectal vein drains the **muscular wall of the rectum** and has minimal involvement in the hemorrhoidal venous plexus. - It is not a significant contributor to hemorrhoidal bleeding. Middle rectal artery - The middle rectal artery provides collateral blood supply to the rectum but plays a **minor role** compared to the superior rectal artery. - The **superior rectal artery** is the dominant arterial supply to the internal hemorrhoidal plexus and is the primary bleeding source.

Q: Comment on the diagnosis of a film shown of a 65-year-old man with acute abdomen:

Colocolic intussusception. ***Colocolic intussusception*** - This is a rare form of intussusception where a **proximal segment of the colon telescopes into a distal segment** within the colon itself. - In adults, it is often associated with a **lead point**, such as a tumor, polyp, or lipoma, which can be visualized on imaging. *Sigmoid volvulus* - Characterized by the **twisting of the sigmoid colon** around its mesentery, often presenting with a characteristic "coffee bean" sign on abdominal X-ray. - While it causes acute abdomen, it is distinguishable from intussusception by its specific radiological appearance and underlying mechanism of obstruction. *Ileocolic intussusception* - This involves the **terminal ileum telescoping into the cecum**, and it is the most common type of intussusception in children. - In adults, it is also typically associated with a lead point but the segment of bowel involved is different from colocolic intussusception. *Toxic megacolon* - This is a severe complication of inflammatory bowel disease or infectious colitis, characterized by **non-obstructive colonic dilation** and signs of systemic toxicity. - Imaging would reveal a dilated colon, often with loss of haustra, but without the specific "target sign" or "pseudokidney sign" indicative of intussusception.

Q: A patient with a complex rectovaginal fistula (secondary to obstetric trauma with tissue loss) should be initially treated with

Colostomy. ***Colostomy*** * Initial treatment involves **fecal diversion** via a colostomy to allow for inflammation reduction and tissue healing around the fistula. * This step is crucial for optimising conditions for a more successful definitive repair later. *Immediate primary repair* * **Immediate primary repair** is generally not recommended due to high risk of failure in the presence of acute inflammation, infection, or poor tissue quality. * These factors can lead to **dehiscence** and recurrence of the fistula. *Vaginal repair (Colporrhaphy)* * **Vaginal repair** is a definitive surgical approach but should only be performed after proper preparation, which includes fecal diversion and allowing inflammation to subside. * Attempting this as an initial step without prior **diversion** significantly increases the risk of breakdown and failure. *Rectal resection (Anterior resection)* * **Rectal resection** is a more extensive surgical procedure usually reserved for complex fistulas, higher fistulas, or those associated with severe local tissue destruction, not typically for initial management. * It is a reconstructive procedure that may follow diversion, once the tissue is healthy enough for repair.

Q: Which is the most common site for colorectal cancer metastasis?

Liver. ***Liver*** - The liver is the **most common site** for colorectal cancer metastasis due to its direct vascular connection via the **portal venous system**. - Blood from the colon and rectum drains into the **portal vein**, which then carries cancer cells directly to the liver. *Brain* - While brain metastases can occur, they are **relatively rare** and typically late manifestations in the course of colorectal cancer. - The brain is **not the primary organ** for initial metastatic spread from colorectal cancer. *Peritoneum* - **Peritoneal carcinomatosis** is a significant mode of spread, especially in advanced colorectal cancer, but it is **less common** than liver metastasis. - This type of spread involves the **lining of the abdominal cavity**, often leading to ascites and bowel obstruction. *Lungs* - **Pulmonary metastasis** is the **second most common** site for colorectal cancer after the liver. - Cancer cells reaching the lungs usually do so via the **systemic circulation** after passing through or bypassing the liver.

Q: Which statement about pilonidal sinus is false?

Usually occurs after 40. ***Usually occurs after 40*** - This statement is **false** because pilonidal sinus typically affects younger individuals, particularly those between **15 and 30 years of age**. - Its incidence significantly **decreases after the age of 40**, making late onset uncommon. *More common in males* - This statement is **true** as pilonidal sinus has a **higher prevalence in males** than females, with a male-to-female ratio of about 3:1 to 4:1. - This increased prevalence is often attributed to **hairiness** and certain occupational or lifestyle factors more common in men. *Mostly occurs in midline* - This statement is **true** as pilonidal sinuses primarily develop in the **natal cleft**, specifically in the **midline** between the buttocks. - They often begin as small pits or tracts at the top of the gluteal fold, allowing **hair and debris to collect**. *Associated with obesity* - This statement is **true** because **obesity** is a recognized risk factor for the development of pilonidal sinus. - Increased weight can lead to **deeper natal clefts** and increased skin friction, which can trap more hair and promote the formation of cysts and sinus tracts.

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.

Question 1

Bleeding vessel in hemorrhoids is

Accepted Answer

Superior rectal artery

Answer

Superior rectal vein

Answer

Middle rectal vein

Answer

Middle rectal artery

Question 2

Comment on the diagnosis of a film shown of a 65-year-old man with acute abdomen:

Accepted Answer

Colocolic intussusception

Answer

Sigmoid volvulus

Answer

Toxic megacolon

Answer

Ileocolic intussusception

Question 3

A patient with a complex rectovaginal fistula (secondary to obstetric trauma with tissue loss) should be initially treated with

Accepted Answer

Colostomy

Answer

Immediate primary repair

Answer

Vaginal repair (Colporrhaphy)

Answer

Rectal resection (Anterior resection)

Question 4

Which is the most common site for colorectal cancer metastasis?

Accepted Answer

Liver

Answer

Brain

Answer

Peritoneum

Answer

Lungs

Question 5

Which statement about pilonidal sinus is false?

Accepted Answer

Usually occurs after 40

Answer

More common in males

Answer

Mostly occurs in midline

Answer

Associated with obesity

Question 6

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 7

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 8

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 9

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 10

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

Accepted Answer

Total colectomy

Answer

Partial gastrectomy

Answer

Laparoscopic cholecystectomy

Answer

Hemicolectomy

Colorectal Surgery — MCQs

Colorectal Surgery — MCQs

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