Anorectal Disorders — MCQs
Which of the following is a characteristic feature of Crohn's disease?
A 57-year-old man presents to the office with complaints of perianal pain during defecation and perineal heaviness for 1 month. He also complains of discharge around his anus, and bright red bleeding during defecation. The patient provides a history of having a sexual relationship with other men without using any methods of protection. The physical examination demonstrates edematous verrucous anal folds that are of hard consistency and painful to the touch. A proctosigmoidoscopy reveals an anal canal ulcer with well defined, indurated borders on a white background. A biopsy is taken and the results are pending. What is the most likely diagnosis?
Which statement about pilonidal sinus is false?
Most common site for anal fissure is
All of the following are true regarding pilonidal sinus except:
Adenoidectomy is contraindicated in:
Which of the following statements about the upper half of the anal canal is true?
A young girl presents with abdominal pain and a recent change in bowel habit, with passage of mucus in stool. There is no associated blood in stool and symptoms are increased with stress. The most likely diagnosis is:
What is the treatment of choice for anal carcinoma?
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?
Anorectal Disorders Indian Medical PG Practice Questions and MCQs
Question 1: Which of the following is a characteristic feature of Crohn's disease?
- A. Sinus & fistula (Correct Answer)
- B. Mesenteric lymphadenitis
- C. Continuous involvement
- D. Crypt abscesses
Explanation: ***Sinus & fistula*** - **Transmural inflammation**, a hallmark of Crohn's disease, can extend through the bowel wall, leading to the formation of **sinus tracts** and **fistulae** (abnormal connections between organs or to the skin). [1] - These complications include enteroenteric, enterovesical, and perianal fistulae, which are highly characteristic of Crohn's. [1] *Continuous involvement* - Crohn's disease is characterized by **skip lesions**, meaning there are healthy segments of bowel interspersed with diseased segments, not continuous involvement. [1] - **Ulcerative colitis** typically presents with continuous inflammation, starting from the rectum and extending proximally. [1] *Mesenteric lymphadenitis* - While mesenteric lymph nodes can be involved in Crohn's disease due to inflammation, **mesenteric lymphadenitis** is more commonly associated with infectious etiologies or other inflammatory conditions, and not a primary defining characteristic. - It refers to inflammation of lymph nodes in the mesentery, which can cause abdominal pain but does not specifically differentiate Crohn's from other conditions. *Crypt abscesses* - **Crypt abscesses** are a characteristic histological feature of **ulcerative colitis**, where neutrophils infiltrate the glandular crypts. [1] - While they can occasionally be seen in Crohn's, they are much more common and prominent in ulcerative colitis and are not a defining feature of Crohn's.
Question 2: A 57-year-old man presents to the office with complaints of perianal pain during defecation and perineal heaviness for 1 month. He also complains of discharge around his anus, and bright red bleeding during defecation. The patient provides a history of having a sexual relationship with other men without using any methods of protection. The physical examination demonstrates edematous verrucous anal folds that are of hard consistency and painful to the touch. A proctosigmoidoscopy reveals an anal canal ulcer with well defined, indurated borders on a white background. A biopsy is taken and the results are pending. What is the most likely diagnosis?
- A. Anal cancer (Correct Answer)
- B. Polyps
- C. Anal fissure
- D. Hemorrhoids
- E. Proctitis
Explanation: ***Anal cancer*** - The patient's presentation with **perianal pain**, **bleeding**, **discharge**, and **edematous verrucous anal folds** (suggesting a lesion) are highly suspicious for anal cancer. His history of unprotected sexual relationships with men is a significant risk factor for **HPV infection**, which is a leading cause of anal squamous cell carcinoma. - The proctosigmoidoscopy findings of an **anal canal ulcer with well-defined, indurated borders** and a white background further point towards a malignant lesion, making anal cancer the most likely diagnosis. *Polyps* - While polyps can cause bleeding, they typically do not present with **indurated, painful verrucous lesions** or an ulcer with defined borders. - Polyps are usually soft and less likely to cause the severe perianal pain and perineal heaviness described. *Anal fissure* - An anal fissure is a **linear tear** in the anal canal, causing sharp pain during defecation and bright red blood. - It would not typically present with **edematous verrucous anal folds**, perineal heaviness, or an indurated ulcer as seen on proctosigmoidoscopy. *Hemorrhoids* - Hemorrhoids commonly cause **bright red bleeding** and can cause discomfort or heaviness. - However, they usually appear as swollen vascular cushions and do not typically present as **indurated, painful verrucous lesions** or an ulcer with defined borders. *Proctitis* - Proctitis is an inflammation of the rectum, causing rectal pain, tenesmus, and bleeding, often due to **inflammatory bowel disease** or **infections**. - While it can cause some of the symptoms, it wouldn't typically manifest as a distinct **indurated, verrucous lesion** or an ulcer with firm borders, which are more indicative of a mass.
Question 3: Which statement about pilonidal sinus is false?
- A. More common in males
- B. Mostly occurs in midline
- C. Usually occurs after 40 (Correct Answer)
- D. Associated with obesity
Explanation: ***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.
Question 4: Most common site for anal fissure is
- A. 3 O'clock
- B. 6 O'clock (Correct Answer)
- C. 2 O'clock
- D. 10 O'clock
Explanation: ***6 O'clock*** - The **posterior midline (6 o'clock position)** is the most common site for anal fissures, accounting for approximately **90% of all cases**. - This location is prone to tearing due to relatively **poor blood supply** and increased **mechanical stress** during defecation. - The posterior midline is the least supported part of the anal canal by the external anal sphincter. - **Note**: The **anterior midline (12 o'clock position)** is the second most common site, occurring in **10-25% of women** but rarely in men. *3 O'clock* - The **3 o'clock position (right lateral)** is an infrequent site for anal fissures. - Fissures in this location, especially if *lateral*, may suggest an underlying systemic disease such as **Crohn's disease**, **tuberculosis**, **HIV**, or **malignancy**. - Atypical fissures warrant thorough investigation. *2 O'clock* - The **2 o'clock position (anterior-lateral)** is not typically associated with anal fissures. - Similar to other atypical sites, a fissure here warrants investigation for secondary causes. - Consider inflammatory bowel disease or other pathological conditions. *10 O'clock* - The **10 o'clock position (left lateral)** is also a less common site for anal fissures compared to the posterior midline. - Fissures in lateral positions should raise suspicion for other conditions, such as **inflammatory bowel disease**, **tuberculosis**, **HIV**, or **malignancy**.
Question 5: All of the following are true regarding pilonidal sinus except:
- A. Most commonly occurs in sacrococcygeal region
- B. Obesity is a risk factor
- C. tendency for recurrence
- D. Seen predominantly in women (Correct Answer)
Explanation: ***Seen predominantly in women*** - Pilonidal sinus is **more prevalent in men** than in women, with a male-to-female ratio of about 3–4:1. - This higher incidence in males is often attributed to greater hairiness and occupational factors. *Most commonly occurs in sacrococcygeal region* - This is a **TRUE statement** - the sacrococcygeal region is the **most common site** for pilonidal sinus (>90% of cases). - While less commonly, pilonidal sinuses can also occur in other hairy areas such as the periumbilical region, axilla, and scalp (particularly in barbers). *Tendency for recurrence* - Pilonidal sinuses have a **high tendency for recurrence**, even after surgical intervention, especially with inadequate excision or conservative management. - Factors contributing to recurrence include presence of **remaining hair follicles** or insufficient removal of sinus tracts. *Obesity is a risk factor* - **Obesity** is a recognized risk factor for the development of pilonidal sinus. - Increased weight can lead to deeper gluteal clefts, increased sweating, and friction, which promote hair follicle damage and foreign body inflammatory reactions.
Question 6: Adenoidectomy is contraindicated in:
- A. SOM
- B. CSOM
- C. Bleeding disorder (Correct Answer)
- D. None of the options
Explanation: ***Bleeding disorder*** - Adenoidectomy involves surgical removal of tissue, which carries a risk of **intraoperative and postoperative bleeding**. - In individuals with a **pre-existing bleeding disorder**, this risk is significantly elevated, potentially leading to serious complications. *SOM* - **Serous otitis media (SOM)**, or otitis media with effusion, is often caused by Eustachian tube dysfunction, which can be exacerbated by adenoid hypertrophy. - Adenoidectomy can actually be a **treatment for recurrent SOM**, as it can relieve obstruction of the Eustachian tube. *CSOM* - **Chronic suppurative otitis media (CSOM)** involves a persistent perforation of the tympanic membrane with chronic ear discharge. - While adenoid hypertrophy can contribute to Eustachian tube dysfunction and recurrent acute otitis media that might lead to CSOM, an adenoidectomy is **not directly contraindicated** for CSOM itself. *None of the options* - This option is incorrect because **bleeding disorder** is a clear contraindication for adenoidectomy due to the increased risk of hemorrhagic complications.
Question 7: Which of the following statements about the upper half of the anal canal is true?
- A. Insensitive to pain. (Correct Answer)
- B. Drains to internal iliac lymph nodes.
- C. Lined by rectal mucosa.
- D. Supplied by the inferior rectal artery.
Explanation: The upper half of the anal canal is derived from the **hindgut** and is lined by **visceral epithelium**, which is innervated by the **autonomic nervous system** and therefore insensitive to pain, temperature, and touch. This anatomical distinction explains why **internal hemorrhoids**, located in the upper anal canal, are typically painless unless prolapsed or thrombosed. The upper anal canal drains primarily to the **internal iliac lymph nodes** and the **inferior mesenteric lymph nodes**, not solely the internal iliac. The lymphatic drainage pattern reflects its embryonic origin from the hindgut [1]. The upper half of the anal canal is lined by **columnar epithelium** (similar to the rectum in its uppermost part) and **transitional epithelium** in its mid-region, but not specifically by rectal mucosa throughout. The change from rectal mucosa to more specialized anal lining occurs at the **anorectal junction** [3]. The upper anal canal is primarily supplied by the **superior rectal artery**, which is a continuation of the inferior mesenteric artery. The **inferior rectal artery**, a branch of the internal pudendal artery, supplies the lower half of the anal canal [2].
Question 8: A young girl presents with abdominal pain and a recent change in bowel habit, with passage of mucus in stool. There is no associated blood in stool and symptoms are increased with stress. The most likely diagnosis is:
- A. Amebiasis
- B. Irritable bowel syndrome (Correct Answer)
- C. Crohn's disease
- D. Ulcerative Colitis
Explanation: ***Irritable bowel syndrome*** - **Irritable bowel syndrome (IBS)** typically presents with **abdominal pain**, altered bowel habits (constipation, diarrhea, or mixed), and **mucus in stool** without blood [1]. - The symptoms are often exacerbated by **stress** and there is no evidence of structural or biochemical abnormalities [1]. *Amebiasis* - **Amebiasis** is an infection caused by *Entamoeba histolytica*, usually leading to **bloody diarrhea** (dysentery), abdominal pain, and fever. - The absence of blood in the stool and the presence of stress-related symptom exacerbation make amebiasis less likely. *Crohn's disease* - **Crohn's disease** is a type of inflammatory bowel disease characterized by **transmural inflammation** that can affect any part of the gastrointestinal tract. - Symptoms often include **abdominal pain**, diarrhea (which can be bloody), weight loss, and fatigue, and it does not typically show a direct correlation with stress as the primary exacerbating factor. *Ulcerative Colitis* - **Ulcerative colitis (UC)** is an inflammatory bowel disease characterized by **continuous inflammation** of the colon, typically starting in the rectum. - Key symptoms include recurrent **bloody diarrhea**, abdominal pain, and tenesmus, which are not described in this case, particularly the absence of blood.
Question 9: What is the treatment of choice for anal carcinoma?
- A. Chemotherapy alone
- B. APR combined with radiotherapy
- C. Chemoradiation (Correct Answer)
- D. All of the options
Explanation: ***Chemoradiation*** - This combined modality is the **standard of care** for most anal carcinomas, achieving high cure rates while preserving sphincter function. - The combination of **chemotherapy** (e.g., 5-fluorouracil and mitomycin C) and **external beam radiation** works synergistically to destroy cancer cells. *Chemotherapy alone* - **Chemotherapy alone** is generally insufficient as a primary treatment for anal carcinoma. - It is often used in combination with radiation or for **metastatic disease**, but not as a monotherapy for curative intent in localized disease. *APR combined with radiotherapy* - **Abdominoperineal resection (APR)** combined with radiotherapy is typically reserved for **recurrent** or **persistent anal carcinoma** after failed chemoradiation, or for very advanced tumors. - APR is a highly morbid surgery leading to a **permanent colostomy**, and primary chemoradiation aims to avoid this outcome. *All of the options* - As **chemoradiation** is the preferred first-line treatment and other options are either inadequate or reserved for specific situations, stating "all of the options" is incorrect. - The treatment strategy for anal carcinoma involves a nuanced approach, prioritizing **organ preservation** with effective cancer control.
Question 10: 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.
Want unlimited practice?
Get full access to all questions, explanations, and performance tracking.
Start For Free