24 SURGERY LE6_ Appendix, Colon, Rectum & Anus.pdf

Question 1

During fistulotomy for fistula-in-ano, the surgeon accidentally cuts the external sphincter muscle. What would be the effect of the injury on defecation?

A. Will affect squeeze pressure
B. Impaired continence
C. Will cause diarrhea
D. Will affect rectal compliance

Answer 1

Question 2

Impaired continence may result from poor rectal compliance, injury to the internal and/or external sphincter, or puborectalis, or neuropathy. Which of the following is most accurate?

A. Impaired continence is caused only by injury to the external sphincter
B. Impaired continence is due to rectal compliance alone
C. Impaired continence can result from several factors including sphincter and puborectalis injury, or neuropathy
D. Impaired continence is unrelated to sphincter injury

Answer 2

Question 3

What is the initial management for lower gastrointestinal bleeding (GIB) in a hypotensive patient?

A. Fluids
B. Blood transfusion
C. Surgical intervention
D. Anticoagulation therapy

Answer 3

Question 4

When should hemorrhoids be treated?

A. Only when symptomatic
B. Only in severe cases
C. Only if they are Grade 3 or higher
D. When there is a family history of hemorrhoids

Answer 4

Question 5

A 34-year-old male call center agent presents to the ER with recurrent bleeding from Grade 2 internal hemorrhoids after medication and diet modification. What is the appropriate management?

A. Repeat medication for 1 month
B. Band ligation
C. Sclerotherapy
D. Hemorrhoidectomy

Answer 5

Question 6

Local treatment with anesthesia is indicated for which of the following conditions?

A. Grade 2 internal hemorrhoids
B. Grade 1 internal hemorrhoids with bleeding
C. Thrombosed internal hemorrhoids
D. Skin tag (treatment only if symptomatic)

Answer 6

Question 7

With regards to survival following treatment of anal melanoma, which strategy implies a poor prognosis?

A. Local excision with adjuvant radiotherapy
B. Abdominoperineal resection (APR) with chemotherapy
C. Wide excision with free margins
D. Combined radiotherapy, chemotherapy, and immunotherapy

Answer 7

Question 8

What is the most common serious complication of an end colostomy?

A. Bleeding
B. Skin breakdown
C. Parastomal hernia
D. Colonic perforation during irrigation
E. Stomal prolapse

Answer 8

Question 9

What is the initial diagnostic test for a patient with abdominal pain and distention?

A. Colonoscopy
B. Abdominal scout film
C. Ultrasound (UTZ) of the abdomen
D. CT scan of the abdomen

Answer 9

Question 10

What is the best detection method for liver metastasis?

A. Ultrasound
B. Contrast-enhanced MRI with gadolinium
C. CT scan of the abdomen
D. PET scan

Answer 10

Question 11

One year after surgery, serum CEA determination, which had previously been normal, now shows elevated values. What is the next step?

A. Repeat determination after 2 months
B. Complete workup for metastasis
C. Adjuvant chemotherapy
D. Exploratory laparotomy

Answer 11

Question 12

Which gene is associated with Familial Adenomatous Polyposis (FAP)?

A. APC
B. KRAS
C. TP53
D. DCC

Answer 12

Question 13

Which of the following is a characteristic of Hereditary Nonpolyposis Colorectal Cancer (HNPCC)?

A. Younger patient
B. Complete workup for metastasis
C. Increased risk of adenomatous polyps
D. APC mutation

Answer 13

Question 14

Which type of polyps has the highest incidence of malignancy?

A. Villous
B. Tubular
C. Tubulovillous
D. Hyperplastic

Answer 14

Question 15

The ascending and proximal transverse colon are derived from which part of the embryonic gut?

A. Foregut
B. Midgut
C. Hindgut
D. All of the above

Answer 15

Question 16

Which of the following is true regarding colorectal cancer?

A. Surgery only
B. Adjuvant therapy is required for stage 2
C. Adjuvant therapy is required for stage 3
D. Chemotherapy and radiotherapy are required for all stages

Answer 16

Question 17

Colorectal cancer is most commonly found in which part of the colon?

A. Right colon
B. Transverse colon
C. Descending colon
D. Sigmoid and rectum

Answer 17

Question 18

Urgent open laparotomy is the recommended treatment for at least which stage of Hinchey Classification?

A. Stage 2
B. Stage 3
C. Stage 4
D. Any stage

Answer 18

✅ B. Stage 3
High-Yield Rationale:
* Hinchey Classification (Diverticulitis):
* Stage III: Purulent peritonitis → Urgent surgery
* Stage V: Fecal peritonitis → Urgent surgery
* Stage I-II: Managed conservatively (antibiotics, drainage if abscess >4cm)

Question 19

Lynch syndrome is caused by a mutation in which gene?

A. KRAS
B. APC
C. Error in mismatch repair genes
D. DCC

Answer 19

Question 20

A 70-year-old male presents with passage of blood in stool, decreasing caliber of stool, and a globular abdomen. DRE shows a friable mass 6 cm from the anal canal, with blood on the examining finger. What is the most likely diagnosis?

A. Rectal adenocarcinoma
B. Anal fissure
C. Hemorrhoids
D. Colorectal adenoma

Answer 20

Question 21

What is the most important prognostic factor in colorectal cancer?

A. Stage
B. Age
C. Family history
D. Tumor grade

Answer 21

Question 22

What is the treatment for pruritus ani?

A. 0.5% - 1.0% Hydrocortisone
B. Antifungal ointment
C. Warm sitz baths
D. Topical antibiotics

Answer 22

Question 23

Which of the following is true about Familial Adenomatous Polyposis (FAP)?

A. It is associated with extraintestinal manifestations
B. It only affects the colon
C. It is an autosomal recessive disorder
D. It has no familial inheritance

Answer 23

Question 24

What is the most common problem associated with colonic fistulas?

A. Electrolyte and fluid imbalance
B. Malnutrition, infection
C. Bowel obstruction
D. Sepsis

Answer 24

Question 25

What is the most common type of fistula-in-ano? A. Intersphincteric fistula B. Transsphincteric fistula C. Suprasphincteric fistula D. Extrasphincteric fistula

Answer 25

Question 26

A 24-year-old man is suspected of having acute appendicitis. On physical examination, his abdomen is soft and nondistended. He does not have pain with coughing or reproduction of tenderness in the right lower quadrant when palpated in the left lower quadrant. He experiences abdominal pain during extension of the right thigh while lying on his left side. He does not have pain with passive rotation of his right hip in a flexed position. Where do you suspect the location of the tip of his appendix to be? A. In the left lower quadrant B. Retrocecal over the psoas muscle C. Extraperitoneal and lying anterior to the cecum D. Displaced to the right upper quadrant E. In the pelvis

Answer 26

B. Retrocecal over the psoas muscle Rationale: * Psoas sign (pain on passive extension of the right thigh) suggests the inflamed appendix is irritating the psoas muscle, which lies retrocecal. * Retrocecal appendix may not cause classic RLQ tenderness or rebound. * Obturator sign (pain on internal rotation) suggests a pelvic appendix.

Question 27

Which of the following statements regarding the appendix is false? A. The blood supply to the appendix is from the appendicular artery, a branch of the ileocolic artery B. Innervation of the appendix is derived from the somatic nervous system C. The lymphatic drainage of the appendix goes through the ileocolic nodes D. The average length of an adult appendix is 9 cm E. The appendix contains large amounts of lymphoid aggregates, but it has no significant exocrine function

Answer 27

Question 28

Which of the following statements regarding the pathogenesis of appendicitis is false? A. Obstruction of the lumen may occur as a result of inspissated stool or a foreign body B. The antimesenteric border has the poorest blood supply and is usually the site of perforation C. Viral or bacterial infections can precede an episode of appendicitis D. Fecaliths are commonly responsible for appendicitis in children E. Obstruction of venous outflow and then arterial inflow results in gangrene

Answer 28

Question 29

A 38-year-old man presents with migratory right lower quadrant (RLQ) pain, leukocytosis, and a CT scan consistent with acute, uncomplicated appendicitis. He is physiologically normal and it is 2 AM. You are planning an appendectomy. What difference might be expected in his outcome if his operation is delayed until the next morning? A. Increased risk of surgical-site infection B. Decreased operative time C. Increased risk of perforation D. No difference in perforation rates, surgical-site infection, abscess, conversion rate, or operative time E. Increased risk of an intra-abdominal abscess

Answer 29

Question 30

You are performing a laparoscopic appendectomy on a 35-year-old male who presented with classic acute appendicitis. During the operation, you note that the appendix is necrotic and perforated at the base. What is the best way to proceed with the appendectomy? A. Perform a limited cecal resection using a stapling device B. Place an endoloop around the base of the appendix C. Irrigate and place a drain with plans to perform an interval appendectomy in 6 weeks D. Staple across the necrotic base of the appendix making sure the perforation is closed E. Perform an ileocecectomy

Answer 30

Question 31

Which of the following is true regarding the location of the appendix? A. The appendix is often retrocecal and extraperitoneal. B. After the fifth gestational month of pregnancy, the appendix is shifted posteriorly and laterally by the gravid uterus. C. The base of the appendix can always be found at the confluence of the cecal taenia. D. The tip of the appendix is found in the pelvis in the majority of cases. E. The position of the tip of the appendix does not determine the symptoms of the patient with appendicitis.

Answer 31

Question 32

When a mucocele of the appendix is found at the time of surgery, which of the following is an appropriate initial therapy? A. Routine right hemicolectomy with lymph node dissection B. Appendectomy C. Incisional biopsy with subsequent appendectomy if malignancy is confirmed by frozen section D. Needle aspiration of cystic fluid for cytologic examination E. Closure and observation

Answer 32

Question 33

A 35-year-old man is admitted to the emergency department complaining of pain in the umbilical region that moves to the right iliac fossa. Which is a corroborative sign of acute appendicitis? A. Referred pain in the right side with pressure on the left (Rovsing sign) B. Hyperanesthesia in the right lower abdomen C. Relief of pain in lower abdomen with internal rotation of right thigh D. Relief of pain in lower abdomen with extension of thigh E. Increase of pain with testicular elevation

Answer 33

Question 34

With regard to appendicitis in immunocompromised patients, which of the following statements is false? A. CT is particularly useful in immunocompromised patients B. Immunocompromised patients with appendicitis often have a fever, a normal WBC count, and nonspecific abdominal pain C. Cytomegalovirus (CMV) infections and Kaposi sarcoma can occlude the appendiceal orifice and cause acute appendicitis D. Unusual infections such as those caused by mycobacteria, protozoa, and fungi do not usually mimic appendicitis E. Typhlitis often mimics acute appendicitis

Answer 34

Question 35

While reviewing pathology of a recent laparoscopic appendectomy, you note that in addition to acute appendicitis, the patient had a 1.5-cm carcinoid tumor located at the base of the appendix. The patient is otherwise healthy and recovering well from surgery. What would you recommend? A. Right hemicolectomy B. Adjuvant chemotherapy C. Radical appendectomy D. No additional therapy necessary

Answer 35

Question 36

A 27-year-old man has a 1-day history of right lower quadrant pain and leukocytosis. Probable nonperforated acute appendicitis is diagnosed. What is the best antibiotic and surgical management for this patient? A. Operate and then await the results of peritoneal fluid cultures to tailor the selection of antibiotics B. Begin ceftriaxone and metronidazole (Flagyl), monitor the patient with serial abdominal examinations, and operate if he fails to improve C. Administer ceftriaxone and metronidazole (Flagyl) and proceed with surgery D. Begin clindamycin perioperatively, because Bacteroides fragilis is the most common organism involved in acute appendicitis, and proceed with surgery E. Administer cefazolin perioperatively to reduce the risk of wound infection and then operate

Answer 36

Question 37

Which of the following is true regarding appendiceal carcinoid tumors? A. Carcinoid tumors arise from the smooth muscle within the appendiceal wall B. Carcinoid tumor is the second most common tumor of the appendix C. For tumors greater than 2 cm, a formal right hemicolectomy is indicated D. All tumors less than 2 cm that do not involve the appendiceal base can be treated with an appendectomy alone E. Nearly 75% of appendiceal carcinoid tumors are located in the proximal one-third of the appendix

Answer 37

Question 38

With regard to appendicitis in the elderly, which statement is false? A. Perforation has an associated mortality rate of 50% B. Elderly patients have a higher rate of perforation because of omental atrophy C. Appendicitis may mimic bowel obstruction D. Symptoms of appendicitis along with anemia should raise suspicion for a concomitant cecal neoplasm E. Elderly patients tend to present later in the course of acute appendicitis

Answer 38

Question 39

A 68-year-old male with a complaint of watery diarrhea underwent a colonoscopy and was found to have a mass within the appendiceal orifice. This was biopsied, and the pathology was consistent with a carcinoid tumor. A CT of the chest, abdomen, and pelvis showed a 3-cm appendiceal base mass and two liver lesions. Which of the following is true? A. Synchronous treatment with a right hemicolectomy and radiofrequency ablation of the liver metastases is appropriate B. Carcinoid syndrome occurs when the primary tumor becomes larger than 2 cm and secretes hormones C. Octreotide decreases metastatic tumor progression and improves survival rates D. Appendiceal carcinoid tumors with metastases to the liver are fast-growing and have a 5-year survival rate of only 10% E. Hepatic resection of liver metastases is not recommended as a method for tumor debulking and symptom control

Answer 39

Question 40

28-year-old woman who is 28 weeks pregnant presents with right-sided abdominal pain, leukocytosis, and an abdominal ultrasound that does not visualize the appendix. What intervention would you recommend? A. Serial clinical observations B. Abdominal CT scan C. Exploratory laparoscopy D. Abdominal magnetic resonance imaging (MRI) scan

Answer 40

Question 41

A 79-year-old man has had abdominal pain for 4 days. An operation is performed, and a gangrenous appendix is removed. The stump is inverted. Why does acute appendicitis in elderly patients and in children have a worse prognosis? A. The appendix is longer in these age groups B. The appendix is in the preileal position C. The appendix is retrocecal D. The omentum and peritoneal cavity appear to be less efficient in localizing the disease in these age groups E. The appendix is in the pelvic position

Answer 41

Question 42

A 20-year-old, 28-week pregnant female presents to the emergency department with a 24-hour history of right upper quadrant abdominal pain. The white blood cell (WBC) count is 18,000. An ultrasound was done showing a normal gallbladder and viable fetus. The appendix was not visualized. What is the next best step? A. Proceed with laparoscopy after delivery B. Admit the patient for serial abdominal examinations and repeat lab tests in the morning C. Obtain a magnetic resonance imaging (MRI) and proceed with an appendectomy if positive D. Treat with antibiotics in an attempt to avoid an operation E. Obtain a CT abdomen/pelvis

Answer 42

Question 43

A 45-year-old male underwent a laparoscopic appendectomy. On final pathology, he was found to have a 1.4-cm carcinoid tumor in the mid-appendix with direct extension to the mesoappendix, negative margins, and no lymphovascular invasion. What is the best treatment plan? A. Medical treatment with octreotide B. Chemotherapy C. Right hemicolectomy D. No further treatment needed E. Ileocecectomy

Answer 43

Question 44

A 10-year-old boy presents to the emergency department complaining of generalized abdominal pain for the past 24 hours. Laboratory tests reveal a leukocytosis of 13,000, and he is tender in the RLQ on physical examination. He is taken to the operating room for laparoscopic appendectomy. Removal of the appendix has been associated with a protective effect of which of the following? A. Crohn colitis B. Carcinoid C. Ulcerative colitis D. Clostridium difficile E. Schedule a colonoscopy and consider an interval appendectomy in 8 weeks

Answer 44

Question 45

A 76-year-old female presents with a 5-day history of right lower quadrant abdominal pain and nausea. A computed tomography (CT) of the abdomen and pelvis shows perforated appendicitis with a 5-cm abscess. She was started on broad-spectrum antibiotics and underwent percutaneous drainage of the abscess. In 72 hours, she was afebrile, and her leukocytosis and symptoms had resolved. What should the next treatment step be? A. Ileocecectomy in 6 weeks B. Appendectomy prior to discharge C. Continue broad-spectrum antibiotics until drain removal D. Interval appendectomy in 4 weeks E. Schedule a colonoscopy and consider an interval appendectomy in 8 weeks

Answer 45

Question 46

A 43-year-old man has CT scan evidence of complicated appendicitis with a contained abscess in the RLQ. He is mildly tachycardic, afebrile, and normotensive with focal RLQ tenderness but no peritonitis. What is the optimal approach to this patient? A. Immediate laparotomy B. IV fluids, bowel rest, and broad-spectrum antibiotics C. Percutaneous drainage, IV fluids, bowel rest, and broad-spectrum antibiotics D. Laparoscopic exploration and abscess drainage

Answer 46

Question 47

What imaging finding would exclude appendicitis? A. A barium enema where a short (2 cm) appendix was clearly identified B. A computed tomographic (CT) scan with a nonvisualized appendix C. An ultrasound study with a compressible appendix that is <5 mm in diameter D. A CT scan showing an edematous but retrocecal appendix

Answer 47

Question 48

A 20-year-old woman is operated on through a right lower quadrant incision for presumed appendicitis, but the appendix is normal. At this point, which of the following would be an appropriate treatment? A. Exploration and appendectomy if no other pathology is found B. Exploration and diverticulectomy if a Meckel’s diverticulum is present and is normal by inspection and palpation C. Exploration, treatment of any associated pathologic condition as indicated, and avoiding removal of a healthy appearing appendix D. Midline laparotomy for complete exploration if no pathology can be seen through the right lower quadrant incision E. Exploration and ileal resection if the terminal ileum appears acutely inflamed

Answer 48

Question 49

On examination, patients presenting with appendicitis typically show maximal tenderness over which of the following? A. Inguinal region B. At the midpoint of a line between the umbilicus and the anterior superior iliac spine C. Immediately above the umbilicus D. At a point between the outer one-third and inner two-thirds of a line between the umbilicus and the anterior superior iliac spine E. At a point between the outer two-thirds and inner one-third of a line between the umbilicus and the anterior superior iliac spine

Answer 49

Question 50

What is the mortality rate from acute appendicitis? A. After rupture, appendicitis is 4–5% B. It has increased in the past 40 years C. For nonruptured appendicitis, it is 2% D. It is 80% if an abscess has formed E. In the general population, it is 4/10,000

Answer 50

Question 51

A 13-year-old boy complains of pain in the lower abdomen (mainly on the right side). Symptoms commenced 12 hours before admission. He had noted anorexia during this period. Examination revealed tenderness in the right iliac fossa, which was maximal 1 cm below McBurney’s point. In appendicitis, where does the pain frequently commence? A. In the back and moves to the right iliac fossa B. In the right flank C. In the right iliac fossa and remains there D. In the rectal region and moves to the right iliac fossa E. In the umbilical region and then moves to the right iliac fossa

Answer 51

Question 52

A 19-year-old female model presents to the emergency room with a 1-day history of lower abdominal pain. On examination, she is most tender in the right lower quadrant (RLQ) and also has pelvic tenderness. White blood cell (WBC) count is 13,000, and temperature is 100.6°F. A provisional diagnosis of uncomplicated appendicitis is made, and laparoscopic appendectomy is offered. Possible advantages of the laparoscopic technique include all EXCEPT? A. More scar formation B. Does not allow thorough inspection of the peritoneal contents C. Longer operative time D. No treatment for nonappendiceal disease E. Post-hospital recovery is longer

Answer 52

Question 53

At open operation, a normal appendix is found. What is the most common procedure a surgeon should do if he finds a normal appendix? A. Evaluate the pelvis for tubo-ovarian abscess, pelvic inflammatory disease, malignancy, or ectopic pregnancy B. Removal of appendix C. Evaluate the terminal ileum and cecum for signs of regional or bacterial enteritis D. Evaluate the upper abdomen for cholecystitis or perforated duodenal ulcer E. Evaluate for Meckel’s diverticulum

Answer 53

Question 54

Regarding laparoscopic appendectomy, which of the following is TRUE? A. It can be performed safely with minimal morbidity compared to open technique B. Wound complication rate is greater with open technique C. Procedure cost is less than with open technique D. Length of hospital stay is longer than with open technique E. Return to full feeding is less than with open technique

Answer 54