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Flashcards in Colorectal Surgery - Oxford MCQs Deck (21):
1

A 23-year-old man presents with 6 weeks of increasingly frequent 
stools with blood-stained mucus mixed with diarrhoea. There is 
generalized mild abdominal tenderness but no guarding. Temperature is 
37.6°C. Which is the singlemost likely diagnosis?★


A Crohn’s disease
B Diverticular disease
C Haemorrhoids
D Rectal cancer
E Ulcerative colitis

E

  • This is a classical presentation for ulcerative colitis 
  • The key features are:
    • Frequency (due to colonic involvement) 
    • Bloody mucus 
    • Urgency (due to rectal hypersensitivity) 
    • Diarrhoea 
  • Rectal cancer and diverticular disease typically present in the ageing population although both can be seen as young as patients in their 20s. 
  • The bleeding associated with rectal cancer is often small volume and mixed with normal looking stools whilst that of diverticular disease (as distinct from acute diverticulitis) is commonly episodic frank blood per rectum. 
  • Crohns disease can cause diarrhoea but is less commonly associated with blood in stools. 
  • Haemorrhoids can cause bright red rectal bleeding but not typically diarrhoea or mucus. 

2

A 24-year-old female undergoes a colonoscopy and is found to 
have multiple adenomatous polyps in the colon and rectum. Which 
is the singlemost likely genetic disorder to explain these findings? 


A Gardner’s syndrome
B Hereditary juvenile polyposis
C Lynch syndrome
D Peutz–Jeghers syndrome
E Sipple’s syndrome

A

  • This lady most likely has multiple adenomatous polyp syndome. 
  • Juvenile polyps are mucinous and not adenomatous although may be diagnosed in young adults. 
  • Similarly the polyps of Peutz-Jeghers syndrome are hamartomatous with a characteristic proliferation of smooth muscle at their core. 
  • Both these syndromes can increase the risk of colorectal carcinoma. 
  • Lynch syndrome is the name of the hereditary non-polyposis colon carcinoma and Sipple's syndrome is one form of inherited multiple endocrine neoplasia. 
  • Gardern's syndrome is a variant of familial adenomatous polyposis with the additional presence of osteomata and fibrous bone cysts. 

3

An isolated abnormality is seen in the descending colon during a 
colonoscopy to investigate 5 months of change in bowel habit and 
blood mixed with stools in a 72-year-old man. There is no family history of colorectal 
disease and he is otherwise fit and well. Biopsies are taken and the colonoscopy completed successfully.

Which is the singlemost appropriate investigation that should be 
arranged next? 


A Chest X-ray
B CT scan of chest, abdomen, and pelvis
C Liver ultrasound scan
D MRI scan of the pelvis
E Whole body CT positron emission tomography scan

B

  • This is a colonic carcinoma - the centre is ulcerated and bleeding freely. 
  • Biopsies should confirm the diagnosis.
  • The main issure are to:
    • Assess for presence of distant disease 
    • To assess if the primary could be surgically removed. 
    • The most likely organs for colorectal cancer to metastasize are:
      • Liver
      • Lungs 
  • Liver US may be used to evaluate abnormalities seen on CT scanning but is limited only to the liver in extent. 
  • A CT positron emission tomography scan is a useful examination to assess for occult metastatic disease or where contrast-enhanced CT scanning is equivocal but is not routinely used as a first-line investigation. 
  • CXR is very insensitive for small pulmonary abnormalities and has been completely replaced by thoracic CT scanning. 
  • Thus CT scanning of the chest, abdomen and plevis is the ideal first and often only staging investgation
  • A pelvic MRI is concerned with assessing local spread of rectal cancers. 

4

A 65-year-old man presents with rapid onset left iliac fossa pain 
and fever. He is tender in the left iliac fossa but there is no obvious 
palpable mass. Temperature is 37.7°C, pulse 84bpm, white cell count 
14 × 10 9/L, and CRP 54 mg/L. Which is the singlemost likely diagnosis? 


A Acute appendicitis
B Sigmoid cancer
C Crohn’s disease of the colon
D Acute sigmoid diverticulitis
E Ureteric colic

D

  • This is a common presenting complaint to the acute surgical team
  • Diverticula commonly occur in the sigmoid colon and when they become inflammed (diverticulitis) they case left iliac fossa pain, tenderness and fever. 
  • A perforated cancer may stimulate diverticulitis but it is less common and a palpable mass is usual. 
  • An acute presentation of colonic Crohn's disease would be very rare at this age and ureteric colic would not be associated with fever unless complicated by ascending infection

5

A 34-year-old man has a red, tender, fluctuant swelling in his natal 
cleft with a swelling off to the left of the midline in the tissue of the 
left buttock. There are visible midline pits in the natal cleft. Which is the 
singlemost appropriate treatment?


A Fistulotomy under anaesthetic
B Incision and drainage under anaesthetic
C Oral antibiotics
D Wide excision and asymmetric natal cleft closure
E Wide excision and packing with daily dressings

B

  • This is a pilonidal abscess. 
  • It may be mistaken for a perianal abscess or a fistula in ano but the presence of the midline pits and the disease process located in the natal cleft are almost diagnostic. 
  • Pilonidal abscesses occur superior to the perianal area in the natal cleft between the buttocks. 
  • Early infection where ther eis no suppuration may be treated by oral antibiotics but here there is a fluctuant swelling indicating an underlying abscess so incision and drainage is required although that is usually followed up by antibiotics. 
  • Wide excision either with or without primary closure is a definitive treatment for pilonidal sinus disease but is best not undertake where there is active sepsis which should be dealt with first 

6

A 28-year-old man has had a tender red swelling developing at his 
anal margin over 2 days. He has had recurrent episodes of similar 
symptoms with occasional discharge from the area. Examination reveals 
the external opening of a fistula in ano and an associated area of subcutaneous fluctuance. Which is the single most appropriate management 
plan?


A Examination under general anaesthetic
B Immediate antibiotics and review in outpatients
C Incision and drainage on the ward
D MRI scan
E Needle aspiration on the ward
 

A

  • This man most likely has a perianal abscess.
  • This will require examination under GA with incision and drainage although he should ideally be consented for appropriate management of a fistula if it is found. 
  • It is usually too painful to do this properly on the ward and underlying fistula will be missed if you do. 
  • Simple aspiration is inadequate. 
  • MRI scanning may be helpful for complex perianal fistulae or recurrent abscesses when surgery has failed to find the infection or fistula. 

7

A 52-year-old man has several years’ history of intermittent bright 
red blood on the toilet paper when wiping after defecation. There 
has been no mucus or change in bowel habit. Which is the single most 
appropriate first examination? 


A Colonoscopy
B CT colonography
C Endoanal ultrasound
D Flexible sigmoidoscopy
E Proctoscopy/rigid sigmoidoscopy

E

  • This man most likely has haemorrhoids causing his bleeding.
  • In the clinic proctoscopy and rigid sigmoidoscopy can be performed to make the diagnosis. 
  • Although a flexible sigmoidoscopy can be performed to make the diagnosis. 
  • Although a flexible sigmoidoscopy may be used to exclude any other diagnoses the simple clinic tests should be done to try to confirm the clinical suspicion. 
  • Colonscopy or CT colonography would only be indicated if another pathology was found at rigid sigmoidoscopy or if there was an extensive family history of coloretcal neoplasia. 

8

A 37-year-old woman has had sharp and persistent anal pain associated with defecation for 4 months. Occasionally, there are small 
amounts of blood on the toilet paper on wiping. There is a fissure present in the anal canal at the 6 o’clock position. Which is the single most 
appropriate treatment for her? 


A Anal dilatation
B Botox injection
C Diltiazem cream
D Lateral internal sphincterotomy
E Prednisolone suppositories

C

  • This is a simple fissure in ano. 
  • There is no reason to suspect an alternative or underlying diagnosis. 
  • Unless it fails to respond to first-line treatment further investigation under anaesthetic is not necessary and treatment should be started first. 
  • It is thought that the pathogenesis of anal fissures involve spasm of the internal anal sphincter with associated changes in anal blood flow and poor healing. 
  • Most cases of anal fissure will heal provided the pressure within the anal canal can be reduced, likely through anocutaneous blood flow. 
  • Any of the first four treatments will acheive that reduction but the one with lowest risk of side effects is diltiazem ointment. 
  • Diltiazem causes smooth muscle relaxation and helps to decrease the spasm. 
  • Anal dilatation is an outdated treatment which can cause faecal incontinence due to uncontrolled stretching of the anal sphincter. 
  • Botox injection and lateral sphincterotomy are usually reserved for classes which do not respond to topical treatment. 
  • Predsol will do little to improve the fissure and may delay healing. 

9

A 73-year-old woman has had sudden onset of acute profuse 
rectal bleeding 4h ago. She has had no abdominal pain. The 
pulse rate is 105bpm, blood pressure of 95/50mmHg, capillary refill 
time is 5sec and oxygen saturations are 96% on supplemental oxygen via 
a non-re-breathing reservoir. Which is the single most appropriate first 
step in her management? 


A Catheterize the patient
B Insert two large bore cannulae
C Organize flexible sigmoidoscopy
D Organize rigid sigmoidoscopy
E Organize mesenteric angiogram

B

  • This patient requires resuscitation in the first instance. 
  • Depending on the quantity of blood loss the patient may require significant fluid replacement and transfusion. 
  • Catheterization may be useful to monitor the urine output in an unstable patient but the first step is to establish acess and give IV fluids. 
  • Investigations can take place after resuscitation has been fully initiated. 

10

A 78-year-old man who is known to have sigmoid diverticular 
disease has developed left lower quadrant pain over the last 
8 days with 48h of constant severe pain, feeling febrile with sweating 
episodes and shakes. His temperature is fluctuating up to 39.2°C, the 
pulse is 84bpm, blood pressure 125/74mmHg, and there is localized 
tenderness in the left lower quadrant but no generalized guarding or 
tenderness. Intravenous fluids and antibiotics are started.

Which is the singlemost appropriate treatment he should be offered?


A Formation of a defunctioning loop colostomy
B Colonoscopy and colonic stent insertion
C Continued IV antibiotics and close monitoring
D CT guided drainage
E Sigmoid colectomy and end colostomy (Hartmann’s procedure)

D

  • Imaging will show an obvious well forme abscess to the left side of the patient with fluid an gas in it. 
    • This is typical for a diverticular abscess and fits with the clinical picture.
  • There is no clinical evidence for the presence of wide-spread intra abdominal infection so emergency operation and resection is not mandatory and ideally should be avoided in an elderly patient
  • A diverting loop stoma of any kind will not deal with the established abscess and neither will simple continued antibiotic therapy although the antibiotics must be continued with drainage. 
  • Drainge of the abscess is required and if this can be acheived by radiological guided methods this is ideal. 
  • Surgery, either drainage or resection should be reserved for failure of radiological drainage. 
  • A colonic stent would not only be applicable if there was obstruction without any evidence of infection since there is a risk of damage to the wal of the colon during insertion. 

11

A 74-year-old man who had a right hemicolectomy 5 days ago 
is now unwell with shortness of breath, generalized abdominal pain and mild distension. Temperature is 37.8°C, pulse 102bpm and  blood pressure 127/67mmHg. There is generalized abdominal tenderness with involuntary guarding on the left side. He is being given supplemental oxygen and has intravenous 0.9% saline running. Which is the  single most appropriate first step you should take? 


A Administer IV antibiotics
B Arrange an abdominopelvic CT scan
C Arrange an emergency laparotomy
D Request an erect chest X-ray
E Request an ultrasound scan and radiological drain

A

  • In this clinical setting it must be assumed that the patient has an anastomotic leak. 
  • Five days is a typical length of time after surgery for this to happen. 
  • The vague abdominal signs and left sided tenderness should not dissuade you from this diagnosis
  • A CT scan is the best investigation to confirm the diagnosis if the patient is stable enough and for those who are acutely unwell a prompt return to theatre for surgery is often appropriate. 
  • A minor leak with a contained collection might be identified by scan and a radiological drain placed but for all these courses of action infection is the predominant issue. 
  • The first step should always be resuscitation and IV antibiotics whilst the other plans are being made according to the status of the patient. 

12

A 65 year old diabetic man has a painless, smooth firm mass in the right iliac fossa. He also has a radiocephalic fistula. What does he most likely have? 

 

A Appendix mass
B Colonic carcinoma
C Diverticular abscess
D Femoral hernia
E Inguinal hernia
F Lymphoma
G Palpable bladder
H Pelvic abscess
I  Renal transplant

I - Renal Transplant

  • The radiocephalic fistula indicates that this patient has had hemodialysis
  • The fact that the mass is painless and non-tender effectively excludes inflammatory or septic causes. 
  • A chronically distended bladder may be asymptomatic but would be more likely palpable in the midline. 
  • A mass in the iliac fossae is likey to be a transplanted kidney. 

13

A 75-year-old woman has a haemoglobin of 9.8g/dL, mean corpuscular volume of 72fL, and ferritin of 6mcg/L. There is a palpable mass in the right iliac fossa. What does he most likely have? 

A Appendix mass
B Colonic carcinoma
C Diverticular abscess
D Femoral hernia
E Inguinal hernia
F Lymphoma
G Palpable bladder
H Pelvic abscess
I  Renal transplant

B - Colonic Carcinoma

  • Especially right sided lesions such as in the caecum is a common cause of iron deficiency anaemia (confirmed by the low ferritin level) 
  • Lymphoma may cause anaemia but not usually of an iron deficient pattern. 

14

A 10 year old boy with 1 week of vague abdominal pains, 24 hours of swinging pyrexia and a tender firm mass in the right iliac fossa. What does he most likely have? 

A Appendix mass
B Colonic carcinoma
C Diverticular abscess
D Femoral hernia
E Inguinal hernia
F Lymphoma
G Palpable bladder
H Pelvic abscess
I  Renal transplant

A - Appendix mass

  • At his age, the boy most likely had appendicitis which has now developed into an abscess. 
  • Appendicitis does not always present with classic signs and symptoms
  • Diverticulitis may present with a right sided mass of symptoms but it is rare and exceptionally so at this age. 
  • A pelvic abscess may result from appendicitis especially after surgical treatment but it is usually impalpable and diagnosed on CT or ultrasound imaging. 

15

A 75 year old woman with a 48 hours of vomiting, abdominal distension and a new swelling in the left groin whicih appears to arise from below the inguinal ligament. 

A Appendix mass
B Colonic carcinoma
C Diverticular abscess
D Femoral hernia
E Inguinal hernia
F Lymphoma
G Palpable bladder
H Pelvic abscess
I  Renal transplant

D - Femoral hernia

  • The clinical features are of intestinal obstruction. 
  • The location of the mass below the inguinal ligament makes an intra abdominal causee such as diverticular disease very unlikely. 
  • It is difficult to be ceertain whether an apparent hernial mass is truling arising below the inguinal ligament, the age and sex of the patient make a femoral hernia more likely as does the presentation (50% of femoral hernias present for the first time urgently with obstructive symptoms). 

16

A 70 year old man with 5 weeks of intermittent left iliac fossa pain, anorexia and anergia. He has lost 2kg of weight. He has had low grade fevers for the last 3 nights. There is a tender mass in the left lower quadrant. 

A Appendix mass
B Colonic carcinoma
C Diverticular abscess
D Femoral hernia
E Inguinal hernia
F Lymphoma
G Palpable bladder
H Pelvic abscess
I  Renal transplant

17

A 76-year-old man with a haemoglobin of 7.9g/dL, mean corpuscular volume of 72fL, and mean corpuscular haemoglobin of 32pg found on routine bloods tests during a GP medical check. What investigation would you order next?

A Barium enema (double contrast)
B Colonoscopy
C CT scan of the abdomen and pelvis
D Endoanal ultrasound scan
E Flexible sigmoidoscopy
F Plain abdominal X-ray
G MRI scan of the abdomen
H Transabdominal pelvic ultrasound scan
I  CT colonography

B - Colonscopy

  • This man is most likely to have an iron deficiency anaemia although ideally a serum ferritin should be performed to check that there is proven 
    iron deficiency.
  • The most likely causes in the lower GI tract are a proximal colonic carcinoma or large adenoma, colitis, or recurrent anorectal  bleeding causes such as haemorrhoids.
  • Although barium enema and CT  colonoscopy would both be likely to locate the pathology, neither would be able to confirm the diagnosis by biopsy so the best test is a colonoscopy.
  • The other two would be more likely used in patients unfit for  colonoscopy.

18

A 72 year old woman has 3 months of change in bowel habit including frequent diarrhoea and urgency but no blood in the stool. Her weight is stable and there are no masses palpable. What investigation would you order next? 

A Barium enema (double contrast)
B Colonoscopy
C CT scan of the abdomen and pelvis
D Endoanal ultrasound scan
E Flexible sigmoidoscopy
F Plain abdominal X-ray
G MRI scan of the abdomen
H Transabdominal pelvic ultrasound scan
I  CT colonography

B - Colonscopy

  • A change in bowel habit requires investigation of the whole large bowel.
  • Although most patients are concerned that the diagnosis may be related  to a tumour, colorectal inflammation such as colitis of one form or  another may be the cause.
  • Colonoscopy is the only examination which  allows both inspection of the colon and biopsies to be taken if no focal  lesions are found.

19

A 68 year old man with 10 days of progressive abdominal distention, colicky pain, reduced bowel frequency and 24 hours of vomiting presents. What investigation would you order next? 

A Barium enema (double contrast)
B Colonoscopy
C CT scan of the abdomen and pelvis
D Endoanal ultrasound scan
E Flexible sigmoidoscopy
F Plain abdominal X-ray
G MRI scan of the abdomen
H Transabdominal pelvic ultrasound scan
I  CT colonography

C - CT Scan of Abdomen and Pelvis 

  • The symptoms here suggest intestinal obstruction.
  • Although a plain  abdominal X-ray may well suggest obstruction, an abdominal CT scan is  more likely to confirm the diagnosis and may well suggest the underlying pathology which may help decisions on how to manage the patient. 
  • Any investigations which require the administration of bowel preparation, including colonoscopy, CT colonography, and barium enema are  contraindicated until the presence of obstruction has been assessed by  CT scan and a flexible sigmoidoscopy may not reach the level of any  pathology causing the symptoms

20

A 48 year old woman with 8 months of intermittent, bright red rectal bleeding on the toilet paper associated with defecation presents. The anus and rectum are normal to examination. What investigation would you order next? 

A Barium enema (double contrast)
B Colonoscopy
C CT scan of the abdomen and pelvis
D Endoanal ultrasound scan
E Flexible sigmoidoscopy
F Plain abdominal X-ray
G MRI scan of the abdomen
H Transabdominal pelvic ultrasound scan
I  CT colonography

E - Flexible Sigmoidoscopy

  • Bright red rectal bleeding usually arises from the rectum or sigmoid colon. 
  • A flexible sigmoidoscopy examines the rectum, sigmoid, and usually the  descending colon to the splenic flexure.
  • A  colonoscopy would assess  the same area as well as the rest of the colon but is associated with  an increased risk of complications compared to flexible sigmoidoscopy.

21

A 32 year old woman with a 6month history of pelvic discomfort and pressure in the rectum presents. Bowel habit has remained unchanged. There is no abdominal mass and no rectal abnormalities palpable. 

  • The symptoms suggest a pelvic mass. Investigations to assess the rectum  or large bowel such as flexible sigmoidoscopy, colonoscopy, and barium  enema may assess the large bowel but would not diagnose a pelvic mass. 
  • CT scanning would make the diagnosis but in a young woman would best  be avoided and a non-ionizing investigation used as first line.
  • MRI of the  abdomen is not ideal for assessment of the pelvis. Ultrasound scanning  is not associated with any risk and is non-invasive with high sensitivity for  detecting a pelvic mass