Colorectal Surgery Practice Questions

Q: A 75-year-old male presents with chronic constipation and abdominal distension. A barium enema reveals a narrowing in the sigmoid colon. What is the most likely diagnosis?

Colon cancer. ***Colon cancer*** - The patient's age (75 years), chronic constipation, abdominal distension, and the finding of a **narrowing (apple-core lesion)** in the sigmoid colon on barium enema are highly suggestive of **colorectal carcinoma**. [1] - **Sigmoid colon** is a common site for colorectal cancer, and a barium enema can effectively visualize obstructive lesions. [1] *Diverticulosis* - While diverticulosis is common in older adults and can cause constipation, it typically presents with **outpouchings** (diverticula) on barium enema, not a distinct narrowing indicative of an obstructive mass. [2] - Complications like **diverticulitis** can cause inflammatory strictures, but the primary finding is still diverticula. [2] *Ulcerative colitis* - Ulcerative colitis causes diffuse inflammation of the colon, typically starting in the rectum and extending proximally, resulting in findings like **mucosal ulcerations**, loss of haustra, and a **"lead pipe" appearance** on barium enema, not usually a focal narrowing. - It often presents with **bloody diarrhea**, which is not mentioned in this case. *Irritable bowel syndrome* - IBS is a **functional bowel disorder** characterized by abdominal pain and altered bowel habits (constipation, diarrhea, or both) without structural abnormalities. [3] - A barium enema would typically be normal in IBS, as it does not cause **anatomical narrowing** or strictures. [3]

Q: A 60-year-old male presents with chronic constipation and abdominal distension. A barium enema shows a 'coffee bean sign.' What is the most likely diagnosis?

Sigmoid volvulus. ***Sigmoid volvulus*** - The "coffee bean sign" on a plain abdominal film or barium enema is a **classic radiographic finding** for **sigmoid volvulus**, representing the dilated, redundant sigmoid colon. - **Chronic constipation** and **abdominal distension** in an older male are common presenting symptoms due to the twisting of the sigmoid colon on its mesentery. *Intussusception* - Intussusception typically presents with **acute, intermittent abdominal pain** and **currant jelly stools**, most commonly in pediatric populations. - The classic radiographic sign for intussusception is a **target sign** on ultrasound, not the "coffee bean sign." *Colon cancer* - Colon cancer can cause **chronic constipation** and **abdominal distension** due to obstruction, but it does not typically produce a "coffee bean sign." - Radiographic findings often include an **"apple core" lesion** on barium enema, indicating circumferential narrowing. *Crohn's disease* - Crohn's disease is an **inflammatory bowel disease** characterized by **transmural inflammation** that can affect any part of the gastrointestinal tract. - While it can cause chronic constipation and abdominal distension, it would not typically manifest with a "coffee bean sign" and often presents with **diarrhea, abdominal pain, and weight loss**.

Q: In a patient with acute diverticulitis confirmed by CT, what is the most common complication that may necessitate surgery?

Perforation. ***Perforation*** - **Perforation** is the most common complication of acute diverticulitis that necessitates emergency surgery, occurring in 15-25% of hospitalized patients with acute diverticulitis - Free perforation leads to **generalized peritonitis**, which is a life-threatening condition requiring urgent surgical intervention (Hartmann's procedure or primary resection) - Even contained perforation may require surgical intervention if not responsive to conservative management - This is the **primary indication for emergency surgery** in acute diverticulitis *Abscess formation* - **Abscess formation** occurs in 15-20% of acute diverticulitis cases and is indeed a common complication - However, many abscesses (especially those <4-5 cm) are successfully managed **non-operatively** with IV antibiotics - Larger abscesses can often be treated with **percutaneous drainage** followed by elective surgery - While some abscesses require surgery, they are often managed conservatively initially, making perforation the more common surgical indication *Hemorrhage* - **Hemorrhage** from diverticula causes significant lower GI bleeding but typically occurs **separate from acute diverticulitis** - Diverticular bleeding usually stops spontaneously in 70-80% of cases - When surgery is needed for bleeding, it's usually in the setting of diverticulosis, not acute inflammatory diverticulitis - Not a common complication requiring surgery during acute diverticulitis episodes *Fistula* - **Fistula formation** is a **chronic complication** of recurrent diverticulitis, not an acute presentation - Results from chronic inflammation eroding into adjacent organs (colovesical, colovaginal, coloenteric fistulas) - Requires elective surgery but is not an acute complication necessitating emergency intervention - Much less common than perforation or abscess formation

Q: A 70-year-old male presents with a long history of constipation and straining during defecation. He reports a sensation of a bulge from the rectum. What is the most appropriate surgical treatment?

Rectopexy. ***Rectopexy*** - The described symptoms of **constipation**, **straining**, and a **rectal bulge** strongly suggest a **rectal prolapse** or significant **rectocele**. - **Rectopexy** is the most appropriate surgical treatment for rectal prolapse, aiming to fix the rectum in its anatomical position, alleviating symptoms of bulging and improving bowel function. *Hemorrhoidectomy* - **Hemorrhoidectomy** is a procedure to remove hemorrhoids, which present with **bleeding**, **pain**, and **pruritus** but typically not a sensation of a rectal bulge requiring surgical fixation. - While straining can contribute to hemorrhoids, it doesn't address the primary issue of rectal protrusion. *Anterior resection* - **Anterior resection** involves removing a portion of the rectum, usually for **rectal cancer** or **severe diverticular disease**. - This procedure addresses different pathologies and is not indicated for isolated rectal prolapse or rectocele. *Sigmoid colectomy* - **Sigmoid colectomy** is the removal of part or all of the sigmoid colon, typically for conditions like **diverticulitis** or **colon cancer**. - It is not indicated for the surgical correction of rectal prolapse, which involves fixation of the rectum.

Q: What is the most appropriate management for a patient with confirmed diverticulitis and an abscess larger than 4 cm?

Percutaneous drainage. ***Percutaneous drainage*** - For diverticulitis with an abscess larger than 4 cm, **percutaneous drainage** is the most appropriate initial management to control the infection and prevent progression to more severe complications. - This procedure removes infected fluid, reducing the **bacterial load** and improving the patient's clinical condition, often followed by antibiotics. *Antibiotic therapy alone* - While antibiotics are crucial for treating diverticulitis, they are often insufficient for abscesses larger than **4 cm** due to poor penetration into the abscess cavity. - Relying solely on antibiotics for a large abscess can lead to treatment failure, persistence of infection, or even **sepsis**. *Immediate colectomy* - **Immediate colectomy** is generally reserved for complicated diverticulitis with **perforation**, generalized peritonitis, or uncontained infection, which is not indicated here as the primary management for an abscess that can be drained. - An immediate colectomy carries higher risks of **morbidity and mortality** compared to less invasive approaches like percutaneous drainage. *Observation and diet modification* - **Observation and diet modification** are appropriate for uncomplicated diverticulitis or after resolution of an acute episode, but not for an active abscess. - An abscess requires active intervention due to the risk of **rupture**, sepsis, and other life-threatening complications.

Q: What is the first-line treatment for a patient diagnosed with acute diverticulitis without complications?

Antibiotics. ***Antibiotics*** - For **uncomplicated acute diverticulitis**, antibiotics covering common enteric bacteria (e.g., gram-negative rods and anaerobes) have traditionally been the first-line treatment. - This approach aims to reduce inflammation and prevent progression to complications like abscess formation or perforation. - **Note:** Recent evidence (AVOD, DIABOLO trials) suggests selective antibiotic use in truly uncomplicated cases, but antibiotics remain standard in most protocols, especially with fever, leukocytosis, or comorbidities. *Immediate surgery* - **Immediate surgery** is generally reserved for **complicated diverticulitis**, such as perforation with peritonitis, large abscess (>4cm), fistula, or obstruction. - It is not indicated for uncomplicated cases as a first-line treatment. - Elective surgery may be considered after recurrent episodes. *Probiotics* - While probiotics may have a role in gut health maintenance, there is **insufficient evidence** to support their use as a primary treatment for acute diverticulitis. - They are not a substitute for antibiotics or supportive care in managing the acute inflammatory process. *Dietary modification* - **Dietary modification** (clear liquids or low-residue diet during acute flare-ups, followed by high-fiber diet for prevention) is an important **supportive measure** and plays a role in management. - However, in the context of traditional teaching and most examination standards, antibiotics are considered the primary therapeutic intervention for acute inflammation, with dietary changes serving as adjunctive therapy. - Modern evidence supports conservative management with dietary modification alone in select uncomplicated cases.

Q: A patient presents with acute onset of left-sided lower abdominal pain and a palpable mass. A CT scan shows thickening of the sigmoid colon with surrounding inflammation. What is the most likely diagnosis?

Diverticulitis. ***Diverticulitis*** - Acute onset **left-sided lower abdominal pain** and a **palpable mass** are classic signs, as diverticula most commonly occur in the sigmoid colon. - **CT findings** of sigmoid colon thickening with surrounding inflammation directly point to inflammation and infection of diverticula. *Colon cancer* - While it can cause a **palpable mass** and sometimes pain, the acute inflammatory presentation and CT findings are less typical than for diverticulitis. - Often presents with insidious symptoms such as **changes in bowel habits**, rectal bleeding, or weight loss. *Ischemic colitis* - Characterized by acute abdominal pain, often with **bloody diarrhea**, particularly in older patients with vascular risk factors. - CT usually shows **bowel wall thickening**, but often with characteristic **thumbprinting** and less prominent surrounding inflammation compared to diverticulitis. *Crohn's disease* - A chronic inflammatory condition that can affect any part of the GI tract, often causing **abdominal pain**, diarrhea, and weight loss. - While it can cause bowel wall thickening and inflammation, an acute, isolated presentation in the sigmoid colon with a palpable mass is less characteristic than the typical presentation of **skip lesions** or **transmural inflammation** in other bowel segments.

Question 1

A 75-year-old male presents with chronic constipation and abdominal distension. A barium enema reveals a narrowing in the sigmoid colon. What is the most likely diagnosis?

Accepted Answer

Colon cancer

Answer

Diverticulosis

Answer

Ulcerative colitis

Answer

Irritable bowel syndrome

Question 2

A 60-year-old male presents with chronic constipation and abdominal distension. A barium enema shows a 'coffee bean sign.' What is the most likely diagnosis?

Accepted Answer

Sigmoid volvulus

Answer

Intussusception

Answer

Colon cancer

Answer

Crohn's disease

Question 3

What factors influence the choice between conservative management and surgical intervention in complicated acute diverticulitis?

Accepted Answer

Presence of abscess or bowel obstruction, and response to treatment

Answer

Surgery is always preferred in complicated cases

Answer

Surgery is only considered if the patient insists on it

Answer

Decision based on the availability of medical treatment

Question 4

In a patient with acute diverticulitis confirmed by CT, what is the most common complication that may necessitate surgery?

Accepted Answer

Perforation

Answer

Hemorrhage

Answer

Abscess formation

Answer

Fistula

Question 5

A 70-year-old male presents with a long history of constipation and straining during defecation. He reports a sensation of a bulge from the rectum. What is the most appropriate surgical treatment?

Accepted Answer

Rectopexy

Answer

Hemorrhoidectomy

Answer

Anterior resection

Answer

Sigmoid colectomy

Question 6

What is the most appropriate management for a patient with confirmed diverticulitis and an abscess larger than 4 cm?

Accepted Answer

Percutaneous drainage

Answer

Antibiotic therapy alone

Answer

Immediate colectomy

Answer

Observation and diet modification

Question 7

In a patient with toxic megacolon unresponsive to medical management, what key factors should be considered when deciding between subtotal colectomy and proctocolectomy with ileostomy?

Accepted Answer

Extent of colonic disease, patient’s nutritional status, and risk of future malignancy

Answer

Patient’s age and preference

Answer

Availability of surgical instruments

Answer

Immediate surgical intervention without further evaluation

Question 8

What is the first-line treatment for a patient diagnosed with acute diverticulitis without complications?

Accepted Answer

Antibiotics

Answer

Immediate surgery

Answer

Probiotics

Answer

Dietary modification

Question 9

A patient presents with acute onset of left-sided lower abdominal pain and a palpable mass. A CT scan shows thickening of the sigmoid colon with surrounding inflammation. What is the most likely diagnosis?

Accepted Answer

Diverticulitis

Answer

Colon cancer

Answer

Ischemic colitis

Answer

Crohn's disease

Question 10

A 50-year-old male presents with Stage III rectal cancer. He has undergone neoadjuvant chemoradiation. What are the critical intraoperative decisions that need to be made during the low anterior resection (LAR) procedure?

Accepted Answer

Achieving negative margins, deciding on the necessity of a diverting ileostomy, and assessing sphincter preservation

Answer

Determining the patient's dietary preferences

Answer

Length of the hospital stay

Answer

Availability of the operating room

Colorectal Surgery — MCQs

Colorectal Surgery — MCQs

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