General Surgery — MCQs
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A 44-year-old woman undergoes emergency laparoscopic surgery for suspected appendicitis. During the procedure, the appendix appears normal. The surgeon performs a thorough inspection and identifies clear fluid in the pelvis and a haemorrhagic 3 cm cyst on the right ovary. The patient is haemodynamically stable. What is the most appropriate intraoperative course of action?
A 51-year-old woman presents to the colorectal clinic with a 4-month history of fresh rectal bleeding and change in bowel habit. Colonoscopy identifies a 3.5 cm polypoid lesion in the mid-rectum at 10 cm from the anal verge. Biopsy confirms adenocarcinoma. Staging CT chest/abdomen/pelvis shows no evidence of metastatic disease. MRI pelvis reports: T3 tumour with mesorectal fascia involvement, and suspicious lymph nodes. What is the most appropriate initial treatment strategy?
A 38-year-old man presents to the emergency department with a 20-hour history of severe right iliac fossa pain. He underwent a renal transplant 2 years ago and is taking tacrolimus and prednisolone. On examination, he has a temperature of 38.4°C, heart rate 108 bpm, and marked tenderness with guarding in the right iliac fossa. CT scan shows an inflamed appendix with surrounding free fluid but no perforation. His WBC is 8.2 × 10⁹/L. What is the most appropriate management?
A 63-year-old man undergoes elective anterior resection for a T3 N1 M0 adenocarcinoma of the sigmoid colon. The histopathology report describes circumferential resection margin involvement by tumour. What is the most significant implication of this finding for the patient's prognosis and further management?
A 29-year-old woman at 18 weeks gestation presents to the emergency department with a 14-hour history of right-sided abdominal pain, initially periumbilical but now more lateral and superior than typical appendicitis. She has vomited once and has a temperature of 37.6°C. On examination, she has tenderness and guarding in the right flank area. Blood tests show WBC 15.8 × 10⁹/L and CRP 38 mg/L. Ultrasound is inconclusive. What is the most appropriate next step in management?
A 72-year-old man presents to the emergency department with a 3-day history of absolute constipation, abdominal distension, and colicky abdominal pain. He has not passed flatus for 48 hours. Plain abdominal radiograph shows gross dilatation of the caecum measuring 11 cm. CT scan confirms a stenosing lesion in the descending colon with no evidence of perforation. His vital signs are stable. What is the most appropriate initial management to prevent caecal perforation?
What is the most common location within the colon for the development of sporadic colorectal adenocarcinoma in the UK population?
A 45-year-old manual labourer presents to the surgical outpatient clinic with a 6-month history of a right groin swelling. He reports that the swelling becomes more prominent when he lifts heavy objects at work. On examination, with the patient standing, there is a visible bulge in the right groin that extends into the upper scrotum. The swelling is reducible and an expansile cough impulse is present. What is the most likely type of hernia?
A 16-year-old boy presents to the emergency department with a 10-hour history of central abdominal pain that has now localised to the right iliac fossa. He has vomited twice and has anorexia. On examination, his temperature is 37.8°C, heart rate 95 bpm, and blood pressure 118/72 mmHg. He has tenderness with guarding in the right iliac fossa. Blood tests show WBC 14.2 × 10⁹/L and CRP 45 mg/L. Which anatomical variant is most commonly associated with retrocaecal appendicitis?
A 66-year-old woman undergoes colonoscopy for investigation of iron deficiency anaemia (Hb 87 g/L, MCV 72 fL, ferritin 8 ng/mL). A 4.5 cm sessile polyp with central depression is identified in the sigmoid colon. The polyp appears to involve approximately 40% of the circumference. Attempted piecemeal endoscopic mucosal resection (EMR) achieves partial removal but the procedure is abandoned due to concerns about perforation risk. Biopsies from the residual polyp show tubulovillous adenoma with high-grade dysplasia and suspicious focus of submucosal invasion. CT chest/abdomen/pelvis shows no metastatic disease. What is the most appropriate management?
General Surgery UK Medical PG Practice Questions and MCQs
Question 181: A 44-year-old woman undergoes emergency laparoscopic surgery for suspected appendicitis. During the procedure, the appendix appears normal. The surgeon performs a thorough inspection and identifies clear fluid in the pelvis and a haemorrhagic 3 cm cyst on the right ovary. The patient is haemodynamically stable. What is the most appropriate intraoperative course of action?
- A. Perform appendicectomy, document findings, and refer to gynaecology (Correct Answer)
- B. Proceed with right oophorectomy to prevent future complications
- C. Perform cystectomy and appendicectomy
- D. Take biopsies of the ovarian cyst and close without further intervention
- E. Convert to laparotomy for comprehensive assessment by a gynaecologist
Explanation: ***Perform appendicectomy, document findings, and refer to gynaecology*** - In cases where the appendix appears macroscopically normal, performing an **appendicectomy** is standard practice to rule out **microscopic appendicitis** and prevent future diagnostic confusion. - A **haemorrhagic corpus luteum cyst** in a haemodynamically stable patient is typically physiological; the appropriate surgical management is to leave it alone and arrange **gynaecological follow-up** with imaging. *Proceed with right oophorectomy to prevent future complications* - **Oophorectomy** is an aggressive and unnecessary intervention for a 3 cm haemorrhagic cyst in a stable woman, leading to unnecessary **loss of fertility** and hormonal function. - Surgical removal of an ovary is only indicated for **torsion**, **malignancy**, or non-viable tissue, none of which are present here. *Perform cystectomy and appendicectomy* - Performing a **cystectomy** on a likely functional cyst increases the risk of **ovarian reserve damage** and adhesion formation without clinical benefit. - Since the patient is **haemodynamically stable** and the fluid is clear/haemorrhagic, the cyst will most likely **resolve spontaneously** without surgical trauma. *Take biopsies of the ovarian cyst and close without further intervention* - Biopsying a simple haemorrhagic cyst is not recommended due to the risk of **rupture**, seeding (if malignant), or **bleeding** from the vascular cyst wall. - Closing without an **appendicectomy** is incorrect because the patient's right iliac fossa pain could still be due to an **inflamed appendix** that appears normal to the naked eye. *Convert to laparotomy for comprehensive assessment by a gynaecologist* - **Laparotomy** is not indicated in a **haemodynamically stable** patient, as it increases morbidity, recovery time, and risk of complications compared to **laparoscopy**. - Laparoscopic visualization provides sufficient assessment for benign-appearing pathology like a 3 cm cyst, making conversion to open surgery **unnecessary**.
Question 182: A 51-year-old woman presents to the colorectal clinic with a 4-month history of fresh rectal bleeding and change in bowel habit. Colonoscopy identifies a 3.5 cm polypoid lesion in the mid-rectum at 10 cm from the anal verge. Biopsy confirms adenocarcinoma. Staging CT chest/abdomen/pelvis shows no evidence of metastatic disease. MRI pelvis reports: T3 tumour with mesorectal fascia involvement, and suspicious lymph nodes. What is the most appropriate initial treatment strategy?
- A. Immediate anterior resection with total mesorectal excision
- B. Neoadjuvant long-course chemoradiotherapy followed by surgery (Correct Answer)
- C. Neoadjuvant short-course radiotherapy followed by immediate surgery
- D. Transanal endoscopic microsurgery with adjuvant chemotherapy
- E. Primary chemotherapy followed by re-staging and surgical resection
Explanation: ***Neoadjuvant long-course chemoradiotherapy followed by surgery*** - This patient has locally advanced rectal cancer with **mesorectal fascia (MRF) involvement**, indicating a threatened **circumferential resection margin (CRM)**, which necessitates preoperative treatment. - **Long-course chemoradiotherapy** is the standard approach to induce **downstaging** and downsizing of the tumor, reducing the risk of local recurrence and improving the chance of an R0 resection by clearing the threatened margin. *Immediate anterior resection with total mesorectal excision* - Performing surgery immediately with **MRF involvement** carries a very high risk of a **positive circumferential resection margin (CRM)**, which is a major predictor of local recurrence and worse prognosis. - Neoadjuvant therapy is crucial to improve the likelihood of achieving a **negative CRM** and optimizing long-term oncological outcomes. *Neoadjuvant short-course radiotherapy followed by immediate surgery* - **Short-course radiotherapy** is typically favored for earlier-stage rectal cancers or when immediate surgery is desired, but it provides less opportunity for tumor **downstaging** compared to long-course treatment. - For a **T3 tumor with MRF involvement** and suspicious lymph nodes, **long-course chemoradiotherapy** is more effective at achieving significant tumor regression and improving the chance of a complete pathological response. *Transanal endoscopic microsurgery with adjuvant chemotherapy* - **Transanal endoscopic microsurgery (TEM)** is a local excision technique suitable only for very early-stage rectal cancers (e.g., T1N0) without features of high risk such as **lymphovascular invasion** or deep penetration. - This patient has a **T3 tumor with MRF involvement** and suspicious lymph nodes, making local excision inadequate for disease control and highly prone to recurrence. *Primary chemotherapy followed by re-staging and surgical resection* - While chemotherapy is essential for systemic disease control, **rectal cancer with MRF involvement** primarily benefits from **local radiation therapy** to achieve tumor regression and clear the surgical margins. - Primary chemotherapy alone without concurrent radiation would be less effective in addressing the local tumor burden and the threatened **circumferential resection margin**.
Question 183: A 38-year-old man presents to the emergency department with a 20-hour history of severe right iliac fossa pain. He underwent a renal transplant 2 years ago and is taking tacrolimus and prednisolone. On examination, he has a temperature of 38.4°C, heart rate 108 bpm, and marked tenderness with guarding in the right iliac fossa. CT scan shows an inflamed appendix with surrounding free fluid but no perforation. His WBC is 8.2 × 10⁹/L. What is the most appropriate management?
- A. Conservative management with intravenous antibiotics given the immunosuppression
- B. Urgent appendicectomy with involvement of the transplant team (Correct Answer)
- C. Interval appendicectomy after 6-8 weeks of antibiotic therapy
- D. Diagnostic laparoscopy with drainage of free fluid only
- E. CT-guided drainage of any collection and prolonged antibiotic therapy
Explanation: ***Urgent appendicectomy with involvement of the transplant team*** - **Acute appendicitis** in immunosuppressed patients requires prompt surgical intervention because they are at a much higher risk of rapid progression to **perforation** and **sepsis**. - Coordination with the **transplant team** is vital to manage perioperative **immunosuppressive medications** and protect the **renal allograft**, which is usually located in the right iliac fossa. *Conservative management with intravenous antibiotics given the immunosuppression* - Non-operative management has a high **failure rate** in immunocompromised individuals who cannot mount a sufficient immune response to contain the infection. - While the WBC is normal, this is a common masking effect of **prednisolone** and **tacrolimus**, rather than an indication of mild disease. *Interval appendicectomy after 6-8 weeks of antibiotic therapy* - Interval procedures are typically reserved for patients who present with a stable **appendiceal mass** or phlegmon, which is not indicated by this patient's acute symptoms. - Delaying definitive surgery in an **immunosuppressed patient** significantly increases the risk of interval complications and morbidity. *Diagnostic laparoscopy with drainage of free fluid only* - Peritoneal fluid in this context is likely **inflammatory exudate**; simple drainage does not address the primary source of infection, which is the **inflamed appendix**. - Leaving the appendix in situ would lead to persistent **peritonitis** and potential loss of the transplanted kidney due to adjacent inflammation. *CT-guided drainage of any collection and prolonged antibiotic therapy* - The CT scan explicitly stated there was **no perforation**, meaning there is no localized abscess or collection suitable for percutaneous drainage. - Primary surgical removal is the gold standard for **uncomplicated appendicitis**, especially when the patient exhibits signs of **guarding** and systemic distress.
Question 184: A 63-year-old man undergoes elective anterior resection for a T3 N1 M0 adenocarcinoma of the sigmoid colon. The histopathology report describes circumferential resection margin involvement by tumour. What is the most significant implication of this finding for the patient's prognosis and further management?
- A. It indicates the need for immediate re-operation to achieve clear margins
- B. It is associated with significantly increased risk of local recurrence and may warrant consideration of adjuvant radiotherapy (Correct Answer)
- C. It has no prognostic significance provided adequate lymph node harvest was achieved
- D. It automatically upstages the tumour to T4 regardless of other histological features
- E. It mandates conversion to an end colostomy with Hartmann's procedure
Explanation: ***It is associated with significantly increased risk of local recurrence and may warrant consideration of adjuvant radiotherapy*** - A positive **circumferential resection margin (CRM)**, defined as tumor within 1 mm of the margin, is a powerful independent predictor of **local recurrence** and poor survival in colorectal cancer. - This finding indicates that the surgical excision was not complete at the microscopic level, necessitating a **multidisciplinary team (MDT)** review to consider additional treatments like **adjuvant radiotherapy** or chemotherapy. *It indicates the need for immediate re-operation to achieve clear margins* - Immediate **re-operation** is rarely feasible or beneficial once the initial anatomical planes have been disrupted and inflammatory changes have begun. - Histopathology results are typically available several days post-operatively, making an "immediate" surgical correction clinically impractical. *It has no prognostic significance provided adequate lymph node harvest was achieved* - **CRM involvement** remains one of the most significant prognostic factors regardless of the number of **lymph nodes** harvested. - While lymph node status affects systemic staging, the CRM status specifically dictates the risk of **local failure** at the primary site. *It automatically upstages the tumour to T4 regardless of other histological features* - **T-staging** is determined by the depth of tumor penetration through the layers of the bowel wall, not by the distance to the surgical margin. - A **T3 tumor** remains T3 even if the CRM is involved; **T4 stage** requires direct invasion of other organs or perforation of the visceral peritoneum. *It mandates conversion to an end colostomy with Hartmann's procedure* - The status of the CRM does not dictate the type of reconstruction or the need for a **permanent stoma** once the primary resection is completed. - A **Hartmann's procedure** is typically a management choice for emergency presentations or high-risk anastomoses, not a standard response to microscopic margin involvement.
Question 185: A 29-year-old woman at 18 weeks gestation presents to the emergency department with a 14-hour history of right-sided abdominal pain, initially periumbilical but now more lateral and superior than typical appendicitis. She has vomited once and has a temperature of 37.6°C. On examination, she has tenderness and guarding in the right flank area. Blood tests show WBC 15.8 × 10⁹/L and CRP 38 mg/L. Ultrasound is inconclusive. What is the most appropriate next step in management?
- A. Perform diagnostic laparoscopy with conversion to open if appendicitis confirmed
- B. Arrange MRI abdomen and pelvis to visualise the appendix (Correct Answer)
- C. Commence broad-spectrum antibiotics and observe for 24 hours
- D. Proceed directly to open appendicectomy via gridiron incision
- E. Discharge with safety-netting advice and review in 48 hours
Explanation: ***Arrange MRI abdomen and pelvis to visualise the appendix***- **MRI** is the preferred second-line imaging modality for suspected appendicitis in pregnancy when an **ultrasound** is non-diagnostic, as it avoids **ionizing radiation**.- It offers high sensitivity and specificity for identifying the appendix, even when displaced **superiorly and laterally** by the gravid uterus in the second trimester.*Perform diagnostic laparoscopy with conversion to open if appendicitis confirmed*- **Diagnostic laparoscopy** is an invasive surgical procedure and should generally be preceded by definitive, non-ionizing imaging when the diagnosis is uncertain, especially in pregnancy.- Given the availability of a highly accurate and non-invasive imaging modality like **MRI**, proceeding directly to surgery without a confirmed diagnosis increases risks of **negative laparoscopy** and potential complications for both mother and fetus.*Commence broad-spectrum antibiotics and observe for 24 hours*- Conservative management without a definitive diagnosis in suspected appendicitis in pregnancy risks **perforation**, which is associated with much higher rates of **fetal loss** and maternal morbidity.- The patient's elevated inflammatory markers (**WBC/CRP**) and clinical signs require prompt diagnostic confirmation and intervention, not a period of observation with antibiotics alone.*Proceed directly to open appendicectomy via gridiron incision*- Proceeding directly to surgery without imaging confirmation significantly increases the rate of **negative appendicectomy**, which is linked to a higher risk of **preterm labor** and maternal complications.- The appendix's anatomical position is altered in pregnancy, typically displaced **superiorly and laterally**, meaning a standard **gridiron incision** might not be appropriate and could miss the appendix.*Discharge with safety-netting advice and review in 48 hours*- Discharging a pregnant patient with significant clinical signs such as **right flank tenderness** and **guarding**, coupled with **leukocytosis** and elevated CRP, is unsafe and risks **appendiceal rupture**.- Delaying diagnosis and management of appendicitis in pregnancy significantly increases the risk of complications like **peritonitis**, which is poorly tolerated by both the mother and the fetus and can lead to adverse pregnancy outcomes.
Question 186: A 72-year-old man presents to the emergency department with a 3-day history of absolute constipation, abdominal distension, and colicky abdominal pain. He has not passed flatus for 48 hours. Plain abdominal radiograph shows gross dilatation of the caecum measuring 11 cm. CT scan confirms a stenosing lesion in the descending colon with no evidence of perforation. His vital signs are stable. What is the most appropriate initial management to prevent caecal perforation?
- A. Immediate laparotomy with right hemicolectomy (Correct Answer)
- B. Emergency endoscopic decompression with stent placement across the stricture
- C. Immediate laparotomy with Hartmann's procedure
- D. Conservative management with nasogastric decompression and intravenous fluids
- E. Emergency laparotomy with defunctioning loop ileostomy and biopsy of the lesion
Explanation: ***Immediate laparotomy with right hemicolectomy*** - The patient has a **closed-loop obstruction** due to a competent ileocaecal valve, and a caecal diameter of **11 cm** indicates an imminent risk of **ischemic necrosis and perforation** (threshold >9-10 cm per Laplace's Law). - In the presence of impending caecal rupture, urgent surgical decompression via **right hemicolectomy** is the definitive management to remove the gangrenous or threatened bowel segment. *Emergency endoscopic decompression with stent placement across the stricture* - While **self-expanding metal stents (SEMS)** can be used as a bridge to surgery for left-sided lesions, they may not provide immediate enough relief for a **critically dilated caecum** at risk of bursting. - Stenting is often contraindicated if there is clinical or radiological evidence of **impending perforation** or bowel ischemia. *Immediate laparotomy with Hartmann's procedure* - A **Hartmann's procedure** (resection of the descending colon with end colostomy) addresses the obstructing lesion but does not immediately resolve the **impending caecal perforation** at the proximal end. - Resecting the primary lesion alone may leave behind a **non-viable caecum** if the ischemia has already progressed due to massive distension. *Conservative management with nasogastric decompression and intravenous fluids* - Conservative management is inappropriate for a **large bowel obstruction** with a caecal diameter exceeding **10 cm**, as the risk of perforation is too high. - Unlike adynamic ileus or Ogilvie syndrome, a physical **stenosing lesion** requires mechanical relief or resection rather than simple bowel rest. *Emergency laparotomy with defunctioning loop ileostomy and biopsy of the lesion* - A **defunctioning ileostomy** does not decompress the colon distal to the stoma in the setting of a competent **ileocaecal valve**, failing to relieve the pressure in the caecum. - Biopsy and diversion are insufficient when the patient presents with an **emergency complication** like impending rupture, which requires definitive resection.
Question 187: What is the most common location within the colon for the development of sporadic colorectal adenocarcinoma in the UK population?
- A. Caecum and ascending colon
- B. Transverse colon
- C. Descending colon
- D. Sigmoid colon and rectum (Correct Answer)
- E. Splenic flexure
Explanation: ***Sigmoid colon and rectum*** - In the UK and other Western populations, the **sigmoid colon and rectum** are the most common sites for sporadic colorectal adenocarcinoma, accounting for approximately **50-60%** of cases. - This distribution is clinically significant as cancers in these locations often present with **rectal bleeding** and changes in **bowel habits** because of the narrower lumen. *Caecum and ascending colon* - Right-sided cancers in the **caecum and ascending colon** account for about **25-30%** of colorectal adenocarcinomas. - These lesions are more likely to present with **iron-deficiency anaemia** rather than obstructive symptoms due to the wider lumen and liquid stool consistency. *Transverse colon* - The **transverse colon** is a much less common site, representing only approximately **10-15%** of cases. - Malignancies here may present with non-specific abdominal pain or signs of **bowel obstruction** as the tumour grows. *Descending colon* - The **descending colon** accounts for a small minority of cases compared to the sigmoid region. - Although it is part of the **left-sided colon**, the incidence of cancer here is significantly lower than in the anatomically adjacent **sigmoid colon**. *Splenic flexure* - The **splenic flexure** is a rare primary site for adenocarcinoma, often associated with a higher risk of **acute obstruction**. - It represents only a very small percentage of total colorectal cancer diagnoses in the general population.
Question 188: A 45-year-old manual labourer presents to the surgical outpatient clinic with a 6-month history of a right groin swelling. He reports that the swelling becomes more prominent when he lifts heavy objects at work. On examination, with the patient standing, there is a visible bulge in the right groin that extends into the upper scrotum. The swelling is reducible and an expansile cough impulse is present. What is the most likely type of hernia?
- A. Direct inguinal hernia medial to the inferior epigastric vessels
- B. Indirect inguinal hernia lateral to the inferior epigastric vessels (Correct Answer)
- C. Femoral hernia inferior and lateral to the pubic tubercle
- D. Pantaloon hernia with both direct and indirect components
- E. Spigelian hernia through the linea semilunaris
Explanation: ***Indirect inguinal hernia lateral to the inferior epigastric vessels***- The extension of the bulge into the **upper scrotum** is a classic sign of an indirect inguinal hernia, as it follows the path of the **spermatic cord** through the deep inguinal ring.- Anatomically, indirect hernias are congenital and emerge **lateral to the inferior epigastric vessels** due to a patent processus vaginalis.*Direct inguinal hernia medial to the inferior epigastric vessels*- Direct inguinal hernias protrude through a weakness in the **transversalis fascia** within Hesselbach's triangle, which is located **medial to the inferior epigastric vessels**.- They rarely extend into the **scrotum** as they do not traverse the entire inguinal canal via the deep ring.*Femoral hernia inferior and lateral to the pubic tubercle*- A femoral hernia presents as a swelling **inferior and lateral to the pubic tubercle**, passing through the **femoral canal** below the inguinal ligament.- These are more common in **females** and carry a higher risk of complications, but do not typically extend into the scrotum.*Pantaloon hernia with both direct and indirect components*- A pantaloon hernia is defined by having both direct and indirect components, straddling the **inferior epigastric vessels**.- While a mixed hernia can occur, the clear description of a single bulge extending into the scrotum makes a simple **indirect inguinal hernia** the most likely primary diagnosis.*Spigelian hernia through the linea semilunaris*- A Spigelian hernia is an **interparietal hernia** occurring through the spigelian fascia (linea semilunaris) and typically presents as a bulge in the **mid-to-lower abdomen** lateral to the rectus muscle.- This type of hernia would not present as a **groin swelling** extending into the scrotum.
Question 189: A 16-year-old boy presents to the emergency department with a 10-hour history of central abdominal pain that has now localised to the right iliac fossa. He has vomited twice and has anorexia. On examination, his temperature is 37.8°C, heart rate 95 bpm, and blood pressure 118/72 mmHg. He has tenderness with guarding in the right iliac fossa. Blood tests show WBC 14.2 × 10⁹/L and CRP 45 mg/L. Which anatomical variant is most commonly associated with retrocaecal appendicitis?
- A. The appendix lies posterior to the caecum and anterior to the psoas muscle
- B. The appendix lies posterior to the caecum and ascends towards the liver (Correct Answer)
- C. The appendix lies in the pelvis directed towards the left iliac fossa
- D. The appendix lies medial to the caecum in the paracolic gutter
- E. The appendix lies anterior to the terminal ileum in a preileal position
Explanation: ***The appendix lies posterior to the caecum and ascends towards the liver*** - This describes the **retrocaecal position**, which is the most common anatomical variation, occurring in approximately **65-75%** of individuals. - Retrocaecal appendicitis often presents with **atypical features**, such as flank pain or a positive **psoas sign**, because the inflamed appendix is shielded from the anterior abdominal wall by the gas-filled caecum. *The appendix lies posterior to the caecum and anterior to the psoas muscle* - While a retrocaecal appendix does lie anterior to the **psoas muscle**, this statement is a description of a specific anatomical relationship rather than the standard definition of the **retrocaecal variant**. - Irritation of the psoas muscle in this position leads to pain on **hip extension**, but it is the upward (ascending) trajectory that defines the classic variant. *The appendix lies in the pelvis directed towards the left iliac fossa* - This describes the **pelvic position**, which is the second most common variant, occurring in about **20-30%** of cases. - In this position, patients may present with **urinary frequency** or **tenesmus** due to irritation of the bladder or rectum. *The appendix lies medial to the caecum in the paracolic gutter* - This describes a **paracaecal** or **medial** position, which is significantly less common than the retrocaecal variant. - Appendicitis in this location typically presents with more classic **peritoneal signs** in the right iliac fossa earlier in the disease course. *The appendix lies anterior to the terminal ileum in a preileal position* - The **preileal position** is a rare variant where the appendix lies anterior to the distal part of the small bowel. - This position is associated with early **vomiting** and can mimic small bowel obstruction due to the proximity of the inflammation to the ileum.
Question 190: A 66-year-old woman undergoes colonoscopy for investigation of iron deficiency anaemia (Hb 87 g/L, MCV 72 fL, ferritin 8 ng/mL). A 4.5 cm sessile polyp with central depression is identified in the sigmoid colon. The polyp appears to involve approximately 40% of the circumference. Attempted piecemeal endoscopic mucosal resection (EMR) achieves partial removal but the procedure is abandoned due to concerns about perforation risk. Biopsies from the residual polyp show tubulovillous adenoma with high-grade dysplasia and suspicious focus of submucosal invasion. CT chest/abdomen/pelvis shows no metastatic disease. What is the most appropriate management?
- A. Completion EMR at specialist centre
- B. Endoscopic submucosal dissection (ESD) at tertiary centre
- C. Sigmoid colectomy with oncological resection and lymphadenectomy (Correct Answer)
- D. Surveillance colonoscopy in 3 months to assess residual polyp
- E. Repeat biopsies and decision based on definitive histology
Explanation: ***Sigmoid colectomy with oncological resection and lymphadenectomy*** - The presence of a large **4.5 cm sessile polyp** with a **central depression** and biopsy evidence of **suspicious submucosal invasion** strongly indicates invasive colorectal cancer. - This requires surgical resection to achieve clear **oncological margins** and perform a **lymphadenectomy**, as submucosal invasion carries a significant risk of **lymph node metastasis**. *Completion EMR at specialist centre* - **Endoscopic Mucosal Resection (EMR)** is not suitable when there is suspicion or confirmation of **submucosal invasion**, as it cannot adequately address potential **lymph node involvement**. - Prior attempted EMR can lead to **submucosal fibrosis** and scarring, making further endoscopic attempts, including completion EMR, technically challenging and increasing the **risk of perforation**. *Endoscopic submucosal dissection (ESD) at tertiary centre* - While **ESD** can achieve en-bloc resection for large polyps, it is contraindicated in cases with suspected or confirmed **submucosal invasion** requiring **lymphadenectomy**, which ESD cannot provide. - The history of a failed EMR attempt with potential scarring makes a subsequent **ESD** more difficult and prone to complications, further arguing against this approach in an invasive lesion. *Surveillance colonoscopy in 3 months to assess residual polyp* - Given the features of **high-grade dysplasia** and **suspicious submucosal invasion** in a large polyp, surveillance would be a dangerous delay in treating a likely **invasive adenocarcinoma**. - Delaying definitive management risks **progression** of the malignancy, increasing the likelihood of local spread and **metastasis**. *Repeat biopsies and decision based on definitive histology* - **Biopsies** from a large, complex polyp with suspected invasion can often **understage** the lesion, meaning a repeat biopsy might still miss the invasive component. - The **macroscopic features** (4.5 cm sessile polyp, central depression) combined with existing **high-grade dysplasia** and suspicious invasion provide sufficient evidence to proceed with **definitive surgical management**, rather than delaying for more biopsies.
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