Colorectal Surgery Practice Questions

Q: Five-day self-subsiding pain is diagnostic of?

Thrombosed external hemorrhoids. **Explanation:** **Thrombosed external hemorrhoids** are characterized by the sudden onset of a painful, tense, bluish perianal lump. The pain is most intense during the first **24 to 72 hours**. After this peak, the pressure within the thrombus begins to decrease as the body starts to reabsorb the clot or the skin overlying it undergoes necrosis and the clot is expelled. Typically, the pain is **self-subsiding within 5 to 7 days**, making this clinical timeline a classic diagnostic hallmark for this condition. **Why other options are incorrect:** * **Anal Fissure:** Presents with sharp, "knife-like" pain specifically during and after defecation. The pain is chronic or recurrent and does not typically follow a 5-day self-subsiding pattern; it persists as long as the fissure remains unhealed. * **Fistula-in-ano:** Usually presents with chronic purulent discharge and intermittent swelling. Pain only occurs if an abscess forms, which requires drainage and does not subside spontaneously in a fixed 5-day window. * **Thrombosed internal hemorrhoids:** These are usually associated with prolapse (Grade IV) and strangulation. They cause severe, constant pain and require urgent intervention because they are prone to gangrene and infection, unlike the self-limiting nature of external thrombosis. **Clinical Pearls for NEET-PG:** * **Management:** If the patient presents within **<72 hours** and pain is severe, **elliptical excision** of the thrombus is preferred. If presenting after 72 hours, conservative management (Sitz bath, analgesics, stool softeners) is indicated as the pain is already subsiding. * **Anatomy:** External hemorrhoids arise from the **inferior hemorrhoidal plexus** and are covered by anoderm (richly innervated), explaining the acute pain. * **Differential:** Always rule out perianal abscess, which presents with fever and throbbing pain that worsens rather than subsides.

Q: Which of the following is NOT true about Gardner's syndrome?

Central Nervous System tumor. **Explanation:** Gardner’s syndrome is a phenotypic variant of **Familial Adenomatous Polyposis (FAP)**, caused by a germline mutation in the **APC gene** on chromosome 5q21. It is characterized by the classic triad of colonic polyposis, soft tissue tumors, and skeletal abnormalities. **Why Option A is the correct answer:** **Central Nervous System (CNS) tumors** (specifically medulloblastomas and glioblastomas) are associated with **Turcot Syndrome**, not Gardner’s syndrome. While both are variants of FAP, the presence of CNS involvement specifically defines Turcot syndrome (mnemonic: **T**urcot = **T**urban/Head). **Analysis of incorrect options:** * **B. Osteoma:** These are a hallmark of Gardner’s syndrome, most commonly occurring in the mandible, skull, and long bones. They often precede the diagnosis of colonic polyps. * **C. Desmoid tumor:** (Note: The option says "Dermoid," but in the context of Gardner's, it refers to **Desmoid tumors**). These are aggressive fibromatoses occurring in the abdominal wall or mesentery and are a significant cause of morbidity. * **D. Colonic polyps:** As a variant of FAP, Gardner’s syndrome involves hundreds to thousands of adenomatous polyps with a 100% risk of progression to colorectal cancer if left untreated. **High-Yield Clinical Pearls for NEET-PG:** * **Extra-colonic manifestations:** Epidermoid cysts, dental abnormalities (supernumerary teeth), and **CHRPE** (Congenital Hypertrophy of Retinal Pigment Epithelium). * **CHRPE** is often the earliest detectable clinical sign of the disease. * **Inheritance:** Autosomal Dominant. * **Management:** Total proctocolectomy with ileoanal pouch anal anastomosis (IPAA) is the standard prophylactic treatment.

Q: A 65-year-old man has had severe alternating constipation and diarrhea for two months. A stool hemoccult test is positive. Colonoscopy demonstrates a large annular, encircling mass 25 cm above the anal verge in the descending colon. To which of the following lymph nodes would this tumor be most likely to first metastasize?

Inferior mesenteric. **Explanation:** The patient presents with classic symptoms of left-sided colorectal cancer (annular mass, "apple-core" lesion, altered bowel habits). The primary determinant of lymphatic drainage in the colon is the arterial supply. **1. Why Inferior Mesenteric is Correct:** The tumor is located 25 cm above the anal verge in the **descending colon**. The descending colon is a hindgut derivative supplied by the **inferior mesenteric artery (IMA)**. Lymphatic drainage follows the arterial supply in a retrograde fashion: from epicolic and paracolic nodes to intermediate nodes along the colic arteries, and finally to the **inferior mesenteric nodes** (pre-aortic nodes at the origin of the IMA). **2. Why Incorrect Options are Wrong:** * **Gastroepiploic & Subpyloric:** These nodes drain the stomach and parts of the duodenum. They are associated with the celiac axis, not the hindgut. * **Internal Iliac:** These nodes primarily drain pelvic viscera, including the lower rectum (below the peritoneal reflection), the anal canal (above the pectinate line), and pelvic organs like the bladder and prostate. They are not the primary drainage site for the descending colon. **Clinical Pearls for NEET-PG:** * **Watershed Areas:** The splenic flexure (Griffith’s point) is the transition between the SMA (midgut) and IMA (hindgut) supply. * **Lymphatic Rule:** Lymph from the colon always follows the arteries. Right-sided tumors (cecum to proximal 2/3 transverse colon) drain to **Superior Mesenteric nodes**; left-sided tumors (distal 1/3 transverse colon to upper rectum) drain to **Inferior Mesenteric nodes**. * **Surgical Significance:** Radical resection for colon cancer (e.g., Left Hemicolectomy) requires ligation of the IMA at its origin to ensure complete lymphadenectomy of the apical (inferior mesenteric) nodes.

Q: Which of the following statements is true for Nigro's regimen?

All of the above.. **Nigro’s regimen** is the gold-standard primary treatment for **Squamous Cell Carcinoma (SCC) of the anal canal**. Historically, these tumors were treated with radical surgery (Abdominoperineal Resection), which resulted in a permanent colostomy. ### **Explanation of Options:** * **A is True:** It is specifically designed for anal canal neoplasms (SCC). It is not used for adenocarcinoma of the rectum. * **B is True:** It is a **definitive Chemoradiotherapy (CRT)** protocol. The classic regimen involves **5-Fluorouracil (5-FU)**, **Mitomycin-C**, and external beam radiation. This approach serves as an alternative to primary surgery, shifting the role of surgery to "salvage" only (for residual or recurrent disease). * **C is True:** Because the treatment is non-surgical, the anal sphincter mechanism is anatomicaly and functionally intact, allowing the patient to **preserve fecal continence** and avoid a permanent stoma. **Conclusion:** Since all individual statements are accurate, **Option D** is the correct answer. --- ### **High-Yield Clinical Pearls for NEET-PG:** * **Components:** 5-FU + Mitomycin C + Radiotherapy (45–55 Gy). * **Success Rate:** Complete remission is achieved in approximately 80–90% of cases. * **Follow-up:** Response is slow; clinical assessment should be done at 8–12 weeks post-treatment. * **Salvage Surgery:** If there is biopsy-proven persistent disease or recurrence, **Abdominoperineal Resection (APR)** is the procedure of choice. * **Staging:** Endorectal Ultrasound (ERUS) or MRI is the best modality for local T and N staging.

Question 1

Risk of malignancy in ulcerative colitis is more with which of the following factors?

Accepted Answer

Pseudopolyps

Answer

Onset in childhood

Answer

Extensive involvement of the colon

Answer

Disrupted architecture with crypt abscesses

Question 2

Which of the following is true about hemorrhoids?

Accepted Answer

Internal hemorrhoids bleed profusely and painlessly.

Answer

Hemorrhoids are diagnosed by digital rectal examination.

Answer

External hemorrhoids are located distal to the dentate line.

Answer

Internal hemorrhoids are covered by stratified squamous epithelium, not anoderm.

Question 3

A 40-year-old male patient presented with mild abdominal pain, mild constipation with a feeling of incomplete evacuation, and mucus in stools for the past 4 years. On examination, tenderness is present in the left iliac fossa. What is the most likely diagnosis?

Accepted Answer

Diverticular disease of the colon

Answer

Ulcerative colitis

Answer

Irritable bowel syndrome

Answer

Carcinoma of the colon

Question 4

Five-day self-subsiding pain is diagnostic of?

Accepted Answer

Thrombosed external hemorrhoids

Answer

Anal fissure

Answer

Fistula-in-ano

Answer

Thrombosed internal hemorrhoids

Question 5

What is the initial management for rectosigmoid obstructive carcinoma in an elderly frail patient?

Accepted Answer

Colostomy

Answer

Abdomino-perineal resection (APR)

Answer

Resection and primary anastomosis

Answer

Hamann procedure

Question 6

A 30-year-old patient presents with loose stools, lower abdominal pain, weight loss, diarrhea, and passage of blood and mucus. Sigmoidoscopy reveals a characteristic presentation. All of the following statements regarding this condition are true EXCEPT?

Accepted Answer

This condition is associated with the APC gene on chromosome 5.

Answer

More than 100 colonic adenomas are diagnostic of this condition.

Answer

Polyps and malignant tumors can develop in the duodenum and small bowel.

Answer

This condition is associated with benign mesenchymal tumors such as desmoid tumors and osteomas.

Question 7

Which of the following is NOT true about Gardner's syndrome?

Accepted Answer

Central Nervous System tumor

Answer

Osteoma

Answer

Dermoid tumor

Answer

Colonic polyps

Question 8

A 65-year-old man has had severe alternating constipation and diarrhea for two months. A stool hemoccult test is positive. Colonoscopy demonstrates a large annular, encircling mass 25 cm above the anal verge in the descending colon. To which of the following lymph nodes would this tumor be most likely to first metastasize?

Accepted Answer

Inferior mesenteric

Answer

Gastroepiploic

Answer

Internal iliac

Answer

Subpyloric

Question 9

Which of the following statements is true for Nigro's regimen?

Accepted Answer

All of the above.

Answer

It is a regimen for anal canal neoplasm.

Answer

It incorporates chemotherapy with radiation as an alternative to surgery.

Answer

Has the advantage of preserving continence.

Question 10

Which dietary factors are associated with an increased risk of colorectal cancer?

Accepted Answer

Low carbohydrate diet

Answer

High carbohydrate diet

Answer

High protein diet

Answer

High fat diet

Colorectal Surgery — MCQs

Colorectal Surgery — MCQs

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