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Flashcards in Colon - Shelf-Life Deck (21):
1

A 52 year old man with a history of intermittent rectal bleeding presents to his primary care physician for evaluation. His father and mother have a history of colorectal polyps. His mother was recently diagnosed with colon cancer. The physicians recommends colonscopy, but the patient refuses and instead only wants to have a barium enema because he is claustrophobic and fears of being able to withstand being in the CT scanner. Which of the following statements are true regarding barium enema and its ability to detect colorectal pathology? 

A. Abnormal findings can be observed

B. Diagnosis and therapy are possible 

C. Evaluates the entire colon 

D. Reaches where 60-70% of polyps occur 

C - Evaluates the entire colon 

  • Barium enema does evaluate the entire colon and is complentary to flexible sigmoidoscopy. 
  • However, any abnormal finding needs to be evaluated with colonscopy. 
  • Thus, colonscopy would be the better test to perform in this patient. 

Why are the other answers wrong? 

  • Abnormal findings need to be further evaluated with colonscopy. 
  • Diagnosis is possible with barium enema but therapy can only be performed when colonscopy and biopsy/fulgeration. 
  • Flexible sigmoidoscopy can be used to reach an area where 60-70% of colon polyps and cancers occur. 

2

Regarding risk factors for colorectal carcinoma, which of the following patients would portend the most significant risk, and thus, would warrant screening with colonscopy? 

A. 27 year old man with a family history of colon polyps in his 50 year old father. 

B. 29 year old man with Crohn disease diagnosed 5 years ago

C. 40 year old man with intermittent rectal bleeding after bowel movements 

D. 55 year old man with ulcerative colitis diagnosed at age 14

E. 70 year old man with internal and external haemorrhoids 

D - 55 year old man with ulcerative colitis diagnosed at age 15

  • Regarding risk factors for colorectal cancer, everyone over the age of 50 is at risk. 
  • However, patients with ulcerative colitis are at increased risk and that risk is 12-20% after 30 years of diagnosis. 
  • Thus, such patients should be screened with periodic colonscopy 

Why are other answers wrong? 

  • This patient in option A is at low risk for colorectal cancer at his age. 
  • Patient B is at increased risk for colorectal cancer but less so than a patient with ulcerative colitis. 
  • Patient C is at low risk for colon cancer because he is under the age of 50. 
  • Patient E although is over 50 and is at risk for developing colon cancer, he is at lower risk that the patient with a 30 year history of ulcerative colitis. 

3

A 35 year old woman with a history of multiple hamartomas scattered throughout the gastrointestinal tract presents to her primary care physician for follow up. The physical examination is done. There are pigmented spots on the palmar surfaces of her hands and around her lips. This patient is at risk for which of the following medical problems? 

A. Brain cancer

B. Breast cancer

C. Skin cancer

D. Thyroid cancer

E. Uterine cancer

B. Breast cancer

  • This patient has Peutz-Jeghers syndrome. 
  • Characterised by single or multiple hamartomas that can be scattered throughout the GI tract in the small bowel, colon and stomach. 
  • Pigmented spots around the:
    • lips
    • oral mucosa
    • face
    • palmar surfaces 
  • There is a slightly increased risk of various carcinomas such as:
    • stomach
    • ovary
    • breast
    • cervix
    • lung

Why are the other answers wrong? 

  • PJ syndrome does not have an increased risk for any of the other cancers mentioned. 

4

A 57 year old man with a history of vague left lower quadrant pain, bloating and alternating constipation and diarrhea presents to his primary care physician for follow up. Physical examination is unremarkable. Barium enema reveals multiple sigmoid diverticuli. What is the most likely explanation for these findings? 

A. Aperistaltic segment

B. High fiber diet

C. Increased luminal pressure

D. Mass lesion in the rectum 

E. Polyposis coli 

C. Increased intraluminal pressure 

  • This patient likely has diverticulosis. 
  • This is caused by increased intraluminal pressure which causes the inner layer of the colon to bulge through this area of weakness in the colon wall. 
  • Low fiber diet, positive family history and increase in age are considered to be risk factors. 

Why are other answers wrong? 

  • Aperistaltic segment is not thought to be an etiologic factor in developing diverticulosis. 
  • Low fiber diet can cause constipation which can increase intraluminal pressures. 
  • The barium enema did not reveal evidence of a mass lesion. 
  • The barium enema did not reveal evidence of colon polyps. 

5

A 68 year old man with a history of vague left lower quadrant pain, bloating and alternating constipation and diarrhea presents to his primary care physician for follow up. He has a known history of diverticulosis. Most recently, he complains of passing air through his his penis as we as fecal matter. Furthermore, he has had four urinary tract infections in the last 6 months. What is the most appropriate next step in the management of this patient? 

A. Anoscopy

B. DRE

C. CT Abdo and Pelvis

D. Rigid sigmoidoscopy

E. Ultrasound

C - CT scan of the abdomen and pelvis 

  • This patient with known diverticulosis now has diverticulitis with evidence of a colovsecial fistula. 
  • Typical features include passage of:
    • passage of air with urination 
    • passage of fecal matter with urination 
    • recurrent urinary tract infections. 
  • The best test to diagnose this is CT scan of the abdomen and pelvis 

Why are other answers wrong? 

  • Anoscopy will not evaluate the sigmoid colon and will miss identification of the fistula. 
  • DRE while important in the general physical examination, will miss this lesion 
  • Sigmoidoscopy may only show erythema but not the fistual tract unless it is large 
  • Ultrasound will not identify a colovesical fistula 

 

 

6

A 26 year old woman complains of a 6 month history of blood diarrhea, abdominal pain and intermittent fevers. She has a history of irritable bowel syndrome but has had a worsening of her symptoms during the time period. Her past medical history is unremarkable. Physical examination reveals abdominal distension. Bowel sounds are present in all quadrants. Rectal examination reveals multiple anal fissures. What is the most appropriate diagnostic testing for this patient? 

A. Anoscopy 

B. Colonscopy 

C. Flexible sigmoidoscopy 

D. Rigid sigmoidoscopy 

E. No further diagnostic testing is required for this patient 

 

B - Colonoscopy 

  • This patient likely has ulcerative colitis. 
  • Colonscopy may reveal thickened, friable mucosa. 
  • Fissures and pseudopolyps may also be present 
  • This disease almost always involves the rectum and extends backward toward the caecum in varying degrees. 

Why are other answers wrong? 

  • Anoscopy is a limited procedure and will not allow visualization of the entire colon 
  • Flexible sigmoidoscopy will allow visualization of the rectum and sigmoid colon but will miss higher levels of the colon 
  • For reasons, described above rigid sigmoidoscopy will miss lesions at higher levels on the colon, such as the ascending colon or cecum. 
  • This patient requires further testing to establish a definitive diagnosis 

7

A 71 year old woman presents to her primary care physician complaining of rectal bleeding. She had some mild left sided abdominal cramps but subsided within a few minutes. She has never had a prior episode of rectal bleeding. Physical examination reveals mild left lower quadrant abdominal pain without evidence of guarding or rebound tenderness. Rectal examination reveals no fresh blood in the rectal vault. Colonscopy reveals several outpouchings of the sigmoid colon wall without evidence of bleeding or perforation. The remainder of the colonscopy is within normal limits. WBC is normal. What is the most appropriate treatment for this patient? 

A. Antibiotic therapy 

B. Left hemicolectomy 

C. Right hemicolectomy 

D. Subtotal colectomy 

E. Watchful waiting 

E - Watchful waiting 

  • This patient has diverticulosis. 
  • This is due to the presence of outpouchings in the wall of the colon that occur where the arterial supply penetrates the bowel wall. 
  • For the patient who stops bleeding and is asymptomatic requires no further treatment 

Why are other answers wrong? 

  • IV antibiotic therapy is not required in this patient as there is no evidence of infection 
  • Elective colectomy is not recommended at the first episode. 
  • Thus left hemicolectomy is not required 
  • Elective colectomy is not recommended at first episode 
  • Thus right hemicolectomy is not required 

8

A 85 year old man is brough to A&E because of an acute abdominal pain and progressive abdominal distention. He is a resident of a local nursing home. He has not been eating because of progressive nausea. Abdominal radiographs were conducted. (coffee bean shape is on the radiograph) 

What is the initial treatment for this patient? 

A. Gastrograffin enema 

B. High fiber diet 

C. Lactulose 

D. Rectal tube decompression 

E. Surgical resection 

D - Rectal tube decompression 

  • This patient has sigmoid volvulus. 
  • The centrally located sigmoid loop is outlined by trapped air. 
  • This condiction can be reduced with a rectal tube, which is the treatment of choice. 
  • IN addition, one can consider decompression with enema.

why are other answers wrong? 

  • Gastrograffin enema is not a treatment of sigmoid volvulus. 
  • High fiber diet has no role in the treatment of volvulus. 
  • High fiber diet has no role in the treatment of volvulus. 
  • Lactulose is unlikely to be of benefit in the management of this patient. 
  • Cecal calculus is treated with surgical intervention 

9

A 41 year old woman with Crohn disease has undergone multiple surgical procedures. She has undergone an ileostomy recently but still has evidence of some distal jejunal disease. Her current medications include prednisone and aminosalycyclic acid. Which of the following effects of prolonged therapy with glucocorticoids are possible for the patient? 

A. Antibody production 

B. Collagen formation 

C. Fibroblast dysfunction 

D. Inflammatory cells migration 

E. Wound healing 

C - Fibroblast dysfunction 

  • This patient would be expected to have fibroblast dysfunction 
  • Patients with IBD require treatment with exogenous corticosteroids. 
  • These agents suppress the immune system and impair inflammatory cell migration 

Why are other answers wrong? 

  • Antibody production is impaired
  • This is appropriate in Crohn disease 
  • Other effects of corticosteroids include impaired wound healing
  • Collagen formation will not occur normally 
  • Inflammatory cell migration is not a significant effect of glucocorticoids 
  • Wound healing is a less common effect of glucocorticoids 

10

A 36 year old woman with recurrent gastrointestinal bleeding presents to her primary care physician with another bout of bleeding. The differential diagnosis for her condition includes angiodysplasia and diverticular disease. Which of the following features would favour the diagnosis of colonic diverticulosis? 

A. Bleeding is brisk 

B. Bleeding occurs due to colonic wall weakness 

C. Bleeding is sudden 

D. Bleeding is self-limiting 

E. Submucosal colonic wall degeneration in the sigmoid colon 

B - Bleeding occurs due to the colonic wall weakness 

  • In both diverticular disease and angiodysplasia, bleeding is:
    • brisk 
    • sudden 
    • often self limiting 
  • This does not differentiate between these conditions. 
  • However, in patients with colonic diverticulosis, bleeding occurs when a blood vessel breaks as it passes through the weakened wall of the diverticulum 

Why are other answers wrong? 

  • Bleeding is brisk in both conditions 
  • Bleeding is sudden in both angiodysplasia and diverticular disease 
  • Submucosal colonic wall degeneration occurs in the cecum and ascending colon in patients with colonic angiodysplasia 

11

A 41 year old man with a history of intermittent rectal bleeding presents to his primary care physician for evaluation. He has never been treated for this condition before. Physical examination of the heart, lungs and abdomen is unremarkbale. Which of the following management steps is likely to be least cost-effective in the search for the cause of bleeding in this patient? 

A. Anorectal examination 

B. Anoscopy 

C. Bleeding scan 

D. Colonscopy 

E. Proctosigmoidoscopy 

C - Bleeding scan 

  • This patient has intermittent lowe gastrointestinal bleeding. 
  • A careful history, physical examination and diagnostic evalution of the lower GI tract are recommended. 
  • Bleeding scan is costly and will not likely provide further information to the source of bleeding. 
  • Thus, it is not recommended in this patient as a first line management step. 

Why are other answers wrong? 

  • Anorectal examination may provide the source of bleeding in this patient and may reveal the presence of a fissure, fistula or external haemorrhoids. 
  • Anoscopy is a cost effective diagnostic test and may reveal any of the above pathologies 
  • Colonscopy would evaluate the entire lower GI tract from anus to cecum
  • Proctosigmoidoscopy may reveal the presence of a fissure, fistula or external haemorrhoids as well as any other inflammatory or neoplastic lesion of the rectum and sigmoid colon 

12

A 57 year old man has recurrent lower gastrointestinal bleeding. Colonscopy is performed and fails to localise the source of bleeding. His most recent hematocrit is 24% after 3 units of packed red blood cells. Selective visceral arteriography is considered by the treating physician. Advantages of this procedure include: 

A. Embolization procedure must be done separately 

B. Noninvasive test

C. Precise localiztion of bleeding 

D. Works well for bleeding <0.1 mL/min 

C - Precise localization of bleeding 

  • Selective visceral arteriography localizes the bleeding more precisely. 
  • It can be used for therapeutic embolization at the same time as the diagnostic procedure. 
  • It is an invasive test and requires a higher rate of bleeding (>0.5 mL/min) 

Why are other answers wrong? 

  • Embolization can be done at the same time as the diagnostic procedure.
  • B is an invasive test 
  • And for D - technitium-99 sulfur colloid isotope scan works well for bleeding <0.1 mL/min. 

13

A 57 year old man with known diverticulosis with bouts of diverticulutis is hospitalised on the medical service because of recurrent left lower quadrant pain. CT scan is performed and reveals the presence of diverticulosis with a 2cm area of inflammatory mass without evidence of fluid within the mass. What is the most likely diagnosis? 

A. Acute diverticulitis 

B. Diverticular abscess 

C. Diverticular phlegmon 

D. Sigmoid colon carcinoma 

E. Transsigmoidal fistulization 

C - Diverticular phlegmon 

  • This patient has a diverticular phlegmon 
  • This is the local response to diverticular inflammation and can lead to the formation of an inflammatory mass
  • This is the definition of a phlegmon
    • The mass is not fluid filled 
  • Treatment involves bowel rest and IV antibiotics 

Why are the other answers wrong? 

  • A diverticulum may become inflammed when a fecalith obstructs its neck 
  • An abscess suggests a fluid collection 
  • Phlegmon does not have a fluid collection - only a mass of inflammatory tissue
  • The CT scan does not reveal evidence of a colorectal carcinoma
  • The CT scan does not reveal evidence of fistulization 
  • Peridiverticular absces may erdoe into the adjacent viscera which can form a fistula 

14

A 63 year old man with recurrent diverticular disease presents to A&E with left lower quadrants, fever, chills and nausea and vomiting for 3 days. Physical examination reveals tenderness in the left lower quadrant without evidence of guarding or rebound tenderness. CT scan is perofrmed and reveals the presence of diverticulosis and diverticulitis with a 2cm area of inflammatory mass without evidence of fluid within the mass. What is the most appropriate treatment for this patient? 

A. Antibiotics, bowel rest and IV fluids 

B. CT guided percutaneous drainage 

C. open drainge of abscess 

D. Surgical resection with end colostomy 

E. Watchful waiting 

A - Antibiotics, bowel rest and IV fluids 

  • This patient has a diverticular 
  • This is the local response to diverticular inflammation and can lead to the formation of an inflammatory mass. 
  • This is the defintion of a phlegmon. 
  • This mass is not fluid filled. 
  • Treatment involves bowel rest and IV antibiotics 

Why are other answers wrong? 

  • CT guided drainage is appropriate for the treatment of diverticular abscess. 
  • This patient does not have a fluid collection suggestive of a diverticular abscess. 
  • There is no reason to perform surgical resection with colostomy given the CT findings above 
  • Watchful waiting is inappropriate for this patient with a diverticular phlegmon

15

A 36 year old woman with ulcerative colitis presents to her physician for a follow-up visit. She has been treated with corticosteroid enemas and sulfasalazine. Physical examination of the heart, lungs and abdomen is unremarkable. Examination of the lower limbs reveals the presence of red, tender papules. What is the most likely reason for this finding? 

A. Coagulopathy 

B. Clubbing

C. Erythema nodosum 

D. Scleritis 

E. Uveitis 

 

C - Erythema nodosum 

  • This patient has ulcerative colitis and demonstrates some extra-intestinal features of the disease 
  • Erythema nodosum is a dermatologic manifestation which is characterised by symmetric red, tender papules on the extensor surface of the limbs. 

Why are the other answers wrong?

  • Coagulopathy and thromboembolism are vascular complications of ulcerative colitis 
  • Clubbing is another dermatologic manifestation of this condition 
  • Scleritis is an ocular manifestation of this condition 
  • Uveitis is an ocular manifestation of this condition 

16

A 28 year old woman with ulcerative colitis presents to her physician for a follow up visit. She has been treated with corticosteroid enemas and sulfasalazine. She now complains of worsening diarrhea. Her latest erythrocyte sedimentation rate is within normal limits. The rationale behind the use of antidiarrheal agents in this patient would include which of the following? 

A. Induce remission of ulcerative colitis 

B. Prevent sigmoid colon cancer development 

C. Prevent rectal cancer development 

D. Prevent disease recurrence 

E. Reduce diarrheal episodes 

 

E - Reduce diarrheal episodes

  • Antidiarrheal agents may be used in patients with inflammatory bowel disease to reduce bowel frequency. 
  • They do not affect the course of the disease 
  • Bowel rest and total parenteral nutrition are indicated for patients with severe diarrheal disease 

Why are other answers wrong? 

Antidiarrheal agents do not induce remission of ulcerative colitis, prevent sigmoid colon cancer development or prevent rectal cancer development and do not prevent disease recurrence. 

17

A 74 year old man with a history of recurrent anal canal fistuals presents with the same complaint of anorectal pain and drainage. Physical examination reveals an extrasphincteric anorectal fistula. He hs never had an anoscopy performed. Which of the following diagnositic considerations would be pertinent in this patient? 

A. Anorectal carcinoma

B. External haemorrhoids 

C. Internal haemorrhoids 

D. Pilonidal sinus 

E. Thrombosed external haemorrhoid 

A - Anorectal carcinoma 

  • This patient has a history of recurrent anal canal fistulas. 
  • It is important to know that low rectal or anal canal carcinomas may present as fistulas. 
  • In a patient with recurrent fistuals, this diagnosis must be considered and ruled out. 

Why are other answers wrong? 

  • External haemorrhoids are unlikely in this patient and were not noted in the physical examination findings for this patient.
  • Internal haemorrhoids may be felt on digital rectal examination 
  • Pilonidal sinus may be present as a pit in the intergluteal fold
  • Thrombosed external haemorrhoids would be easily visible on anal canal examination

18

A 54 year old man is in the operating room undergoing repair of an extrasphinteric fistula-in-ano. He has no prior surgical history. His current medical problems include hypertension, diabetes mellitus, recurrent sinusitis and irritable bowel syndrome. Principles of surgical management of this condition include which of the following? 

A. Avoidance of tract guide in fistula tract

B. Elimination of primary opening of fistula tract 

C. IV corticosteroids periperatively 

D. Partial unroofing of fistual tract 

E. Washout of the rectal canal with antibiotic irrigation 

B - Elimination of primary opening of fistual tract 

  • Principles of surgical repair of the fistula include unroofing of the fistula, elimination of the primary opening of the fistula tract and establishing adequate drainage. 
  • It is prudent to open the entire fistula tract with a guide in place. 

Why are the other answers wrong? 

  • It is prudent to place a tract guide in the fistula tract
  • IV corticosteroids are not recommended in fistula repair 
  • Complete unroofing of the fistula tract is recommended 
  • Washout of the rectal canal with antibiotic irrigation is not required as part of the fistula repair. 

19

A 37 year old hirsute man presents to the ambulatory care clinic complaining of anal pain for 2 weeks. On physical examination of the sacrococcygeal area, he is found to have a hair follice that appears inflammed. The area is tender to palpation. Should a sinus tract be associated with this lesion - which direct would it be expected to run? 

A. Caudad

B. Cephalad

C. Lateral 

D. Medial 

E. Ventral 

B - Cephalad 

  • This patient has a pilonidal sinus
  • This occurs in hirsute patients in their third decade of life
  • Physical examination reveals an infected hair follice
  •  The area is tender to palpation 
  • Sinus tract usually run cephalad in greater than 90% of cases

20

A 24 year old man complaining of skin flushing, chronic watery diarrhea with cramps and difficulty with breathing. He presents to the emergency department for evaluation. Physical examination reveals a cardiac murmur and diffuse wheeze bilaterally heard most at the bronchi. Should he be found to have a gastrointestinal source for this problem, which of the following locations would be most likely? 

A. Appendix 

B. Cecum 

C. Descending colon 

D. Jejunum 

E. Sigmoid colon 

A - Appendix 

  • Likely diagnosis of a carcinoid tumour 
  • The most frequent location is in the appendix 
  • Clinical manifestations include:
    • cutaneous flushing 
    • watery diarrhea with abdominal cramps 
    • bronchospasm 
    • valvular lesions of the right side of the heart 
  • This is more common in young patients such as the one presented in this question. 

Why are the other answers wrong? 

  • Cecum is not the most common location for carcinoid tumours 
  • Descending colon is a common location for colorectal carcinoma 
  • Approximately 30% of carcinoids localise to the small intestine 
  • The sigmoid colon is a common location for colorectal cancer and diverticular disease 

21

A 39 year old woman with longstanding Crohn disease of the ileum and cecum undergoes robotic small bowel resection with extracorporeal anastomosis. The surgical specimen is sent to pathology for further analysis. Which of the following features would be noted upon histologic study of the specimen? 

A. Continuous involvement of the specimen with disease 

B. Ectopic colonic mucosa 

C.