Colorectal Surgery Flashcards
A 22 year old man has a long history of ulcerative colitis. His symptoms are well controlled with steroids. However, attempts at steroid weaning and use of steroid sparing drugs have repeatedly failed. He wishes to avoid a permanent stoma. Which of the following is the best operative option?
Pan proctolectomy and end ileostomy Abdomino perineal excision of the colon and rectum and end colostomy Abdomino perineal excision of the colon and rectum and construction of an ileo anal pouch Pan proctocolectomy and construction of an ileo anal pouch Sub total colectomy and construction of an ileo anal pouch
Pan proctocolectomy and construction of an ileo anal pouch
In patients with UC where medical management is not successful, surgical resection may offer a chance of cure. Those patients wishing to avoid a permanent stoma may be considered for an ileoanal pouch. However, this procedure is only offered in the elective setting.
A 56 year old man presents with episodes of pruritus ani and bright red rectal bleeding. On examination there is a mass in the ano rectal region and biopsies confirm squamous cell cancer. What is the most likely cause?
Anal cancer Rectal cancer Soft tissue sarcoma Retro-rectal cyst Pilonidal sinus disease
These are features of anal cancer. Anal cancers arise from the cutaneous epithelium and are therefore typically squamous cell. They are usually sensitive to chemoradiotherapy.
A 25 year old man complains of passing painless bright red blood rectally. It has been occurring over the past week and tends to occur post defecation. He also suffers from pruritus ani. The underlying cause is likely to be amenable by treatment from which of the following modalities?
Topical GTN Topical diltiazem Rubber band ligation Injection sclerotherapy Lateral internal sphincterotomy
Rubber band ligation
The history of one of the haemorrhoidal bleeding. The recent HUBLE trial showed equivalence of banding vs HALO for haemorrhoids. Rubber band ligation has a 30% failure rate but is generally easy and well tolerated. Painful PR bleeding is more suggestive of a fissure which is treated with nitrates or surgery.
A 74 year old gentleman presents with an obstructing carcinoma of the splenic flexure. Attempts at placement of a colonic stent have failed. Which of the operative options listed below offers the best solution to this problem?
Sub total colectomy Extended right hemicolectomy Standard right hemicolectomy Standard left hemicolectomy Transverse colectomy
The question always causes confusion and to understand it the information needs to be carefully read. Firstly, the tumour is definitely at the splenic flexure and the second point is that the operation is definitely an extended right hemicolectomy. A left hemicolectomy or even the older operation of a transverse colectomy could be considered if the patient was not obstructed. However, when obstruction is present, an extended right hemicolectomy (which involves an ileocolic anastomosis) is relatively safe even in the obstructed setting.
A 45 year old female is diagnosed as having a carcinoma of the caecum. She undergoes a CT scan which shows a tumour invading the muscularis propria with some regional lymphadenopathy. What is the most appropriate initial treatment?
Right hemicolectomy External beam radiotherapy Chemotherapy Combined long course chemo radiotherapy Referral for palliative care
Right sided colonic cancers should proceed straight to surgery. Radiotherapy to this area is poorly tolerated and almost never offered as first line treatment. The decision as to whether or not chemotherapy is given is dependent upon the final histology.
A 65 year old lady is admitted with large bowel obstruction. On investigation with CT, she is found to have a tumour of the mid rectum with no evidence of metastatic disease. What is the most appropriate course of action?
Formation of a loop colostomy Laparotomy and Hartmanns procedure Pan proctocolectomy and end ileostomy Low anterior resection and covering loop ileostomy Low anterior resection and end colostomy
Formation of a loop colostomy
This patient has presented with large bowel obstruction. However, in the case of rectal cancer, she is incompletely staged as ability to completely resect the lesion can only be determined with MRI scanning and this information is not provided. Even if the lesion were resectable, in the emergency setting, it is often safer to undertake a simple procedure such as a loop colostomy and then complete surgery at a later date. A low anterior resection and loop ileostomy in this situation would almost certainly leak (and for the reasons outlined above, may be incomplete).
A 78 year old lady from a nursing home is admitted with a 24 hour history of absolute constipation and abdominal pain. On examination, she has a distended abdomen with a soft mass in her left iliac fossa. An x-ray is performed which shows a large dilated loop of bowel in the left iliac fossa which contains a fluid level. What is the most likely diagnosis?
Caecal volvulus Sigmoid volvulus Incarcerated femoral hernia Diverticular stricture Malignant colonic stricture
Sigmoid volvulus may present with an asymmetrical mass in an elderly patient. It may contain a fluid level, visible on plain films. It’s very rare for femoral hernia to cause large bowel obstruction.
A 56 year old lady is investigated with a colonoscopy for a change in bowel habit. However, due to adhesions from a previous hysterectomy, she experiences pain and requests the procedure be terminated. The endoscopist feels that he reached the splenic flexure. What is the best course of action?
Discharge the patient Arrange an abdominal CT scan Arrange a CT colonoscopy Arrange a barium enema Arrange a gastrograffin enema
Failed colonoscopy should be managed with a CT colonoscopy in the first instance (more accurate than barium studies). If the procedure is needed for therapeutic intervention then GA colonoscopy may be needed.
A 73 year old lady presents with large bowel obstruction. On examination, she has a rectal cancer 6cm from the anal verge which has occluded the colonic lumen. An abdominal x-ray shows a caecal diameter of 7cm. Which of the management strategies outlined below is the most appropriate?
Construction of a loop ileostomy Construction of a loop colostomy Construction of a venting caecostomy Abdomino-perineal resection of the colon and rectum Low anterior resection and loop ileostomy
Bowel obstruction due to RECTAL cancer should be treated by loop colostomy.
Bowel obstruction due to obstructing left sided COLON cancer is usually treated by resection of the primary lesion and formation of colostomy.
A 21 year old man presents with a 5 week history of painful bright red bleeding that typically occurs post defecation and is noted on the toilet paper. External inspection of the anal canal shows a small skin tag a the six o’clock position. The patient declines internal palpation. What is the most likely underlying diagnosis?
Fissure in ano Fistula in ano Haemorrhoidal disease Solitary rectal ulcer Internal rectal prolapse
Painful bright red rectal bleeding is usually due to a fissure
The presence of pain and the sentinel tag suggests a posterior fissure in ano.
A 66 year old man is admitted as an emergency with torrential rectal bleeding. Following resuscitation, an upper GI endoscopy is undertaken and it is normal. However, he continues to bleed. What is the most appropriate course of action?
Arrange a CT angiogram Arrange a laparotomy and sub total colectomy Undertake a colonoscopy Perform a laparoscopy and on table colonoscopy Arrange a capsule endoscopy
Heavy lower GI bleeding should be investigated with an angiogram. It is best to avoid emergency surgery as the bleeding site is very difficult to find. Unlike upper GI endoscopy, colonoscopy in patients who are acutely bleeding is often difficult and seldom helpful. If it is to be done, a therapeutic scope with twin working channels is useful.
A 55 year old man is found to have an anal cancer. His staging investigations show no metastatic disease. What is the most appropriate treatment?
Radical abdominoperineal excision of the anus and rectum Radical chemoradiotherapy Excision proctectomy External beam irradiation alone Chemotherapy alone
Combined chemoradiotherapy is the standard treatment for anal cancer
A 62 year old man has previously undergone a left hemicolectomy for carcinoma of the descending colon. On follow up imaging he is found to have two deposits of metastatic disease located in the right lobe of his liver. What is the best treatment strategy?
Chemotherapy alone Chemotherapy followed by surgical resection Radiofrequency ablation Chemoradiotherapy Palliation
Chemotherapy followed by surgical resection
Liver metastasis from colorectal cancer are still potentially curable. Without resection, survival at 5 years is around 5%. With resection, this figure rises to around 20%. The best outcomes are seen where chemotherapy is given, followed by resection. Radiofrequency ablation is an option for those patients who lack the physiological reserve for surgery. However, there is longer term recurrence rates will all the non resectional strategies. There is no role for radiotherapy.
A 55 year old man presents with tenesmus and rectal bleeding. On examination he has a large bulky rectal cancer at 5cm with tethering to the prostate gland. Imaging shows no distant disease. What is the most appropriate initial treatment modality?
Abdomino-perineral resection of the colon and rectum Pelvic exenteration Abdomino-perineal excision of the colon and rectum with prostatectomy Long course chemoradiotherapy Short course radiotherapy
Rectal cancers with threatened resection margins are managed with radiotherapy and chemotherapy initially. This is not the case with colonic cancers which are usually primarily resected.
T4 rectal cancers are managed with long course chemoradiotherapy. A dramatic response is not uncommon. To embark on attempted resection at this stage is to court failure.
A 21 year old female presents with a 24 hour history of increasingly severe ano-rectal pain. On examination, she is febrile and the skin surrounding the anus looks normal. She did not tolerate an attempted digital rectal examination. What is the most likely diagnosis?
Fissure in ano Haemorrhoidal disease Proctalgia fugax Solitary rectal ulcer Intersphincteric abscess
Intersphincteric abscess
The presence of fever and severe pain makes an abscess more likely than a fissure. Although fissures may be painful they do not, in themselves, cause fever. The usual management for this condition is examination of the ano-rectum under general anaesthesia and drainage of the sepsis.
A 22 year old man presents with a 6 day history of passage of bloody diarrhoea with passage of mucous and slime. He is passing an average of 8 to 9 bowel movements per day. On digital rectal examination there is no discrete abnormality to feel, but there is some blood stained mucous on the glove. What is the most likely diagnosis?
Solitary rectal ulcer syndrome Ulcerative colitis Irritable bowel syndrome Rectal cancer Diverticulitis
Ulcerative colitis
The passage of bloody diarrhoea together with mucus and a short history makes this a likely first presentation of inflammatory bowel disease. A rectal malignancy in a 22 year old would be a very unlikely event. The history is too short to be consistent with solitary rectal ulcer.
A 70 year old female is admitted with a history of passing brown coloured urine and abdominal distension. Clinically she has features of large bowel obstruction with central abdominal tenderness. She is maximally tender in the left iliac fossa. There is no evidence of haemodynamic instability. What is the most appropriate investigation?
Cystogram Abdominal X-ray of the kidney, ureters and bladder Computerised tomogram of the abdomen and pelvis Flexible sigmoidoscopy Barium enema
Computerised tomogram of the abdomen and pelvis
This lady is most likely to have a colovesical fistula complicating diverticular disease of the sigmoid colon. In addition she may also have developed a diverticular stricture resulting in large bowel obstruction. A locally advanced tumour of the sigmoid colon may produce a similar clinical picture. The best investigation of this acute surgical patient is an abdominal CT scan, this will demonstrate the site of the disease and also supply regional information such as organ involvement and other local complications such as a pericolic abscess. A barium enema would require formal bowel preparation and this is contra indicated where large bowel obstruction is suspected. A flexible sigmoidoscopy is unlikely to be helpful and the air insufflated at the time of endoscopy may make the colonic distension worse. A cystogram would provide only very limited information.
A 24 year old man is identified as having a 5cm carcinoid tumour of the appendix. Imaging and diagnostic work up does not demonstrate any distant disease. What is the best course of action?
Appendicectomy Right hemicolectomy Resection of the caecal pole External beam radiotherapy Observation with imaging
Right hemicolectomy
Large carcinoid tumours should be formally resected. In many cases, they will be identified as an incidental finding. In such cases, it can be difficult to distinguish between carcinoid tumours and other appendiceal neoplasms
Which of the following statements in relation to fistula in ano is untrue?
High fistulae are safest treated with a seton insertion Low fistulae may be laid open They are typically probed with Lockhart Mummary probes When discovered during incision and drainage of peri anal abscess; should always be probed to locate the internal opening When complicating Crohns disease, may respond to infliximab
When discovered during incision and drainage of peri anal abscess; should always be probed to locate the internal opening
Probing fistulae during acute sepsis is associated with a high complication rate and should not be undertaken routinely.
upper gastro intestinal endoscopy which is normal. A small bowel contrast study shows a terminal ileal stricture. A colonoscopy was performed which was normal but the endoscopist was unable to intubate the terminal ileum. One week after the colonoscopy she is admitted with small bowel obstruction. Steroids are administered but despite this she fails to improve. What is the most appropriate treatment?
Administration of steroids at increased dose Right hemicolectomy Small bowel resection Sub total colectomy Pan proctocolectomy
Right hemicolectomy
Crohns disease commonly affects the terminal ileum and in this case the ileocaecal valve, this means some form of colonic resection will be needed in addition to the small bowel resection.
A 78 year old lady is admitted with a 3 hour history of passage of dark red blood per rectum. Prior to this event, she was otherwise well with no major medical co-morbidities. On examination, she has a mild tachycardia but other vital signs are normal, abdomen is soft and non tender. Digital rectal exam reveals dark blood but no other findings. What is the most likely underlying cause?
Diverticular disease Meckels diverticulum Jejunal diverticulosis Angiodysplasia of the colon Colonic cancer
Diverticular disease is the commonest cause of lower GI bleeding in adults.
A 75 year old man is admitted with large bowel obstruction and on investigation is found to have a significant sigmoid diverticular stricture as the underlying cause. What is the most appropriate treatment?
Colonoscopy and pneumatic dilatation of the stricture Laparotomy and Hartmanns procedure Colonoscopy and insertion of self expanding metallic stent Loop ileostomy Laparotomy, sigmoid colectomy and colorectal anastomosis
Laparotomy and Hartmanns procedure
Diverticular strictures have a high complication rate with stent insertion. Where patients present with large bowel obstruction, the best option is to resect the affected area. Given the fact that there is underlying colonic obstruction, a primary anastomosis would be unwise. Diverticular strictures should not be dilated.
A 19 year old male presents with bright red rectal bleeding that occurs post defecation onto the paper and into the pan. Apart from constipation his bowel habit is normal. Digital rectal examination is normal. What is the most likely cause?
Haemorrhoidal disease Fissure in ano Solitary rectal ulcer Rectal cancer Crohns disease
This is likely to be haemorrhoidal disease. A sigmoidoscopy should always be performed to exclude more sinister pathology.
What is the most likely explanation for a 63 year old male to complain of a painless blood stained mucous rectal discharge 6 months following a Hartmann’s procedure?
Pelvic abscess Crohns disease Dysplasia of the rectal stump Diversion proctitis Fissure in ano
Diversion proctitis
Once the bowel has been disconnected, a degree of inflammation is commonly seen in the quiescent bowel. This is typically referred to as diversion colitis. Dysplasia is not usually seen in this context as a Hartmanns procedure is not usually a treatment modality used for IBD (which is the main risk factor for dysplasia).
A 48 year old lady has previously undergone a sigmoid colectomy for carcinoma. On follow up imaging she is found to have a 3cm foci of metastatic disease in segment IV of the liver. What is the most appropriate course of action?
Palliative chemotherapy External beam radiotherapy Brachytherapy Surgical resection alone Chemotherapy followed by surgical resection
The treatment of colorectal liver metastasis is usually with chemotherapy followed by surgical resection. Where surgery is performed for liver metastasis with curative intent, the 5 year survival is 20%. Palliation would generally only be considered if the patient were frail or widespread disease found on imaging. Radiotherapy is not part of the treatment of liver metastasis.
A 19 year old man presents with diarrhoea and rectal bleeding that has been present for the past two weeks. In addition, he has noticed that he has had faecal incontinence at night. What is the most likely cause?
Viral gastroenteritis Inflammatory bowel disease Intersphincteric abscess Irritable bowel syndrome and haemorrhoids Irritable bowel syndrome and a fissure in ano
Nocturnal diarrhea and incontinence is a key feature in the history and is strongly suggestive of a diagnosis of IBD. More benign IBS presentations seldom have nocturnal events or a short history.
A 63 year old man presents with episodic rectal bleeding the blood tends to be dark in colour and may be mixed with stool. His bowel habit has been erratic since an abdominal aortic aneurysm repair 6 weeks previously. What is the most likely cause?
Ischaemic colitis Diverticulitis Angiodysplasia Cancer Ulcerative colitis
Ischaemic colitis
The inferior mesenteric artery may have been ligated and being an arteriopath collateral flow through the marginal may be imperfect.
What is the commonest type of fistula in ano?
Trans-sphincteric Supra levator Complex supra levator Intersphincteric Suprasphincteric
Intersphincteric fistulas are the commonest type and the external opening may be internal or external. These are the classical type of fistula and will have an internal opening near the anal verge and obey Goodsalls rule. Primary fistulotomy in this situation usually poses little risk to continence.
A 33 year old lady is admitted with recurrent discharging fistula in ano. She is also known to have ano rectal Crohns disease. On examination, she is found to have a low anal fistula with involvement of a very small amount of the external anal sphincter muscle. What is the most appropriate course of action?
Insertion of a loose seton Fistulotomy Core fistulectomy Core fistulectomy and advancement flap Insertion of a cutting seton
Fistula in ano in patients with Crohns disease should be managed with insertion of seton.
