LE 6 review

Question 1

Q1: At what age should a 20-year-old man with a father diagnosed with stage IV rectal cancer at age 55 begin cancer screening?
A. 20
B. 40
C. 45
D. 50

Answer 1

B. 40
High-Yield Rationale: Individuals with a first-degree relative diagnosed with colorectal cancer should begin screening at 40 years old or 10 years earlier than the age at which the relative was diagnosed, whichever comes first.

Question 2

Q10: What is one of the primary values of performing a complete colonoscopy in colorectal cancer patients?
A. Identify the T and N stage
B. Accurate determination of tumor location
C. Determine resectability
D. Rule out synchronous polyp or cancer

Answer 2

D. Rule out synchronous polyp or cancer
High-Yield Rationale: Synchronous lesions occur in 5% of colorectal cancer cases, making full colonoscopy essential to identify additional tumors or polyps.

Question 3

Q19: Which of the following is TRUE about Crohn’s disease?
A. Inflammation is continuous throughout the bowels, including the rectum
B. Inflammation is limited to the mucosa and submucosa
C. Surgery is the mainstay of treatment during active remission
D. Skip lesions and bowel wall thickening are seen in active inflammation

Answer 3

D. Skip lesions and bowel wall thickening are seen in active inflammation
High-Yield Rationale: Crohn’s disease is characterized by skip lesions, transmural inflammation, and bowel wall thickening on imaging.

Question 4

Q27: What is the recommended management for a small perianal abscess?
A. Preoperative MRI to identify the exact type and location
B. Observation
C. Initial trial of antibiotic therapy
D. Incision and drainage as soon as diagnosed

Answer 4

D. Incision and drainage as soon as diagnosed
High-Yield Rationale: Perianal abscesses require prompt incision and drainage to prevent complications like fistula formation. MRI is not necessary for small abscesses.

Question 5

Q29: What is the BEST initial treatment for bleeding Grade I internal hemorrhoids?
A. Infrared photocoagulation
B. Rubber band ligation
C. Conservative management
D. Hemorrhoidectomy

Answer 5

C. Conservative management
High-Yield Rationale: Grade I internal hemorrhoids (bleeding but no prolapse) are best managed conservatively with high-fiber diet, sitz baths, and topical treatments.

Question 6

Q33: What is the MOST common location of chronic anal fissures?
A. Lateral or off midline
B. Anterior midline
C. Posterior midline
D. Circumferential

Answer 6

C. Posterior midline
High-Yield Rationale: Posterior midline fissures are the most common due to reduced blood supply in this area, making it prone to ischemia and poor healing.

Question 7

Q34: Which of the following factors inhibit spontaneous closure of intestinal fistulas?
A. Foreign body within the fistula tract
B. Distal obstruction of the intestine
C. All of the choices
D. Epithelialization of the fistula tract

Answer 7

C. All of the choices
High-Yield Rationale: Spontaneous closure of intestinal fistulas is prevented by foreign bodies, distal obstruction, epithelialization of the tract, and sepsis.

Question 8

Q44: A 16-year-old male presents with right lower quadrant pain for 3 days. Ultrasound reveals a 1.2 cm, aperistaltic, non-compressible, blind-ended tubular structure, and appendectomy is planned. Intraoperatively, the appendix is retrocecal and inflamed with minimal suppuration, and a Meckel’s diverticulum with inflammation at both the base and tip is noted. What is the BEST surgical plan?
A. Appendectomy and postoperative antibiotics
B. Appendectomy and wedge ileal resection
C. Appendectomy and ileostomy
D. Appendectomy alone

Answer 8

B. Appendectomy and wedge ileal resection
High-Yield Rationale: Inflamed Meckel’s diverticulum requires wedge resection to prevent complications like perforation and recurrent diverticulitis.

Question 9

Q45: Which statement is TRUE regarding colorectal polyps?
A. Adenomatous polyp is dysplastic with potential for progression to malignancy
B. Hamartomatous polyp is typically seen in patients with inflammatory bowel disease
C. Most colorectal polyps are diagnosed due to intestinal obstruction
D. Serrated polyp has histologic characteristics of hyperplasia without dysplasia

Answer 9

A. Adenomatous polyp is dysplastic with potential for progression to malignancy
High-Yield Rationale: Adenomatous polyps (especially villous types) have a high risk of malignant transformation due to dysplasia, forming the adenoma-carcinoma sequence.

Question 10

Q51: Which of the following factors will facilitate the spontaneous closure of an intestinal fistula?
A. Presence of foreign body
B. Presence of short fistulous tract
C. Epithelialization of the fistula tract
D. Proximal obstruction to the fistula site

Answer 10

B. Presence of short fistulous tract
High-Yield Rationale: Short, simple fistulas (<2 cm) without distal obstruction, foreign bodies, or epithelialization are more likely to spontaneously close.

Question 11

Q54: What is the recommended treatment for a 50-year-old male with rectal cancer located 1 cm from the anal verge, invading the external anal sphincters, with nodal metastasis but no liver metastasis?
A. Radiation therapy followed by low anterior resection, then chemotherapy
B. Abdominoperineal resection only
C. Abdominoperineal resection followed by chemotherapy
D. Radiation therapy followed by abdominoperineal resection, then chemotherapy

Answer 11

D. Radiation therapy followed by abdominoperineal resection, then chemotherapy
High-Yield Rationale: Locally advanced rectal cancer invading the external anal sphincter requires neoadjuvant chemoradiation, abdominoperineal resection (APR), then adjuvant chemotherapy.

Question 12

Q57: Which of the following is an example of an external fistula?
A. Enterocolonic
B. Cholecystoenteral
C. Colovesicular
D. Enterocutaneous

Answer 12

D. Enterocutaneous
High-Yield Rationale: External fistulas communicate with the skin (e.g., enterocutaneous fistula), while internal fistulas occur between organs (e.g., colovesicular, enterocolonic, and cholecystoenteral fistulas).

Question 13

Q59: What is the recommended treatment for Stage 2 rectal cancer?
A. Radiation therapy followed by surgery followed by chemotherapy
B. Surgery followed by chemotherapy
C. Surgery only
D. Surgery followed by adjuvant radiation therapy and chemotherapy

Answer 13

B. Surgery followed by chemotherapy
High-Yield Rationale: Stage 2 rectal cancer (T3-T4, N0) is best treated with surgery (low anterior resection or abdominoperineal resection) followed by adjuvant chemotherapy if there are high-risk features.

Question 14

Q61: Which statement is TRUE regarding colorectal adenomatous polyps?
A. The descending colon is the most common site
B. Villous type has the lowest risk of malignancy
C. The risk of synchronous polyps is about 40%
D. The risk of malignancy for a 1 cm polyp is 25%

Answer 14

C. The risk of synchronous polyps is about 40%
High-Yield Rationale: Synchronous polyps (multiple polyps found at the same time) occur in about 40% of cases, emphasizing the need for complete colonoscopy.

Question 15

Q62: What is the ideal treatment for ileo-colic intussusception?
A. Surgical reduction of the involved segment and lead point in adults
B. Radiologic reduction in the pediatric age group
C. Surgical reduction of the involved segment and lead point in children
D. Radiologic reduction in adults

Answer 15

B. Radiologic reduction in the pediatric age group
High-Yield Rationale: Children with ileocolic intussusception are managed with radiologic (air/contrast enema) reduction, while adults require surgery due to the high likelihood of a lead point (tumor or mass).

Question 16

Q66: Which of the following is TRUE about pseudomyxoma peritonei syndrome?
A. Intraoperative administration of frozen chemotherapy in the abdomen
B. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is the standard of care
C. Surgical resection is the only treatment
D. Parietal and visceral peritonectomies are contraindicated

Answer 16

B. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) is the standard of care
High-Yield Rationale: Pseudomyxoma peritonei (mucin-producing peritoneal malignancy) is best treated with cytoreductive surgery and HIPEC, improving survival.

Question 17

Q67: Which of the following is TRUE about the physical signs with their respective eponyms that help in discerning the location of the appendix?
A. Obturator sign is pain with external rotation of the hip
B. Dunphy’s sign is abdominal pain when sneezing
C. Rovsing’s sign is pain at the LLQ after release of gentle pressure at the RLQ
D. Iliopsoas sign is pain with flexion of the hip

Answer 17

B. Dunphy’s sign is abdominal pain when sneezing
High-Yield Rationale: Dunphy’s sign is sharp pain in the RLQ when coughing or sneezing, indicating peritoneal irritation in appendicitis.

Question 18

Q69: What is the recommended treatment for perforated sigmoid diverticulitis with generalized purulent peritonitis?
A. Image-guided percutaneous drainage of abscess
B. Sigmoidectomy with Hartmann’s procedure
C. Laparoscopic lavage and drainage procedure
D. Sigmoidectomy with primary anastomosis

Answer 18

B. Sigmoidectomy with Hartmann’s procedure
High-Yield Rationale: Generalized peritonitis from perforated diverticulitis requires Hartmann’s procedure (sigmoidectomy + colostomy), avoiding primary anastomosis in a contaminated field.

Question 19

Q70: What is the MOST common distant metastatic site of anal squamous cell carcinoma?
A. Lymph nodes
B. Bone
C. Liver
D. Lung

Answer 19

D. Lung
High-Yield Rationale: Squamous cell carcinoma (SCC) of the anus spreads via lymphatics (inguinal, pelvic nodes) and metastasizes most commonly to the lungs.

Question 20

Q74: Which of the following reduces the duration of post-operative ileus?
A. Nothing per orem for 1 week
B. Early post-operative enteral feeding
C. Prolonged use of opioid analgesics
D. Massive intraoperative IV fluid administration

Answer 20

B. Early post-operative enteral feeding
High-Yield Rationale: Early enteral feeding promotes gut motility and reduces post-op ileus duration, whereas opioids and excessive IV fluids delay recovery.

Question 21

Q75: Which of the following layers compose true diverticula?
A. Mucosa, submucosa, and muscularis propria
B. Mucosa only
C. Mucosa and submucosa
D. Mucosa, submucosa, muscularis propria, and adventitia

Answer 21

D. Mucosa, submucosa, muscularis propria, and adventitia
High-Yield Rationale: True diverticula (e.g., Meckel’s diverticulum) involve all layers of the bowel wall, unlike false diverticula (e.g., colonic diverticula), which lack the muscularis propria.

Question 22

Q78: Which diagnostic modality best identifies the T and N stage of rectal cancer?
A. Whole abdominal CT scan with contrast
B. Pelvic MRI
C. PET scan
D. Whole abdominal ultrasound

Answer 22

B. Pelvic MRI
High-Yield Rationale: Pelvic MRI is the best modality for staging rectal cancer, particularly for T (tumor depth) and N (nodal involvement) staging, due to its superior soft-tissue resolution.

Question 23

Q79: What is the BEST diagnostic modality for colonic diverticulitis?
A. Magnetic resonance imaging
B. X-ray
C. Ultrasound
D. Computed tomography (CT)

Answer 23

D. Computed tomography (CT)
High-Yield Rationale: CT scan of the abdomen with contrast is the gold standard for diagnosing diverticulitis, detecting complications like abscesses, perforations, or fistulas.

Question 24

Q80: What is the recommended treatment for a 3 cm squamous cell carcinoma of the anal canal with no nodal or distant metastasis?
A. Abdominoperineal resection only
B. Radiation therapy only
C. Neoadjuvant chemoradiation therapy followed by abdominoperineal resection
D. Combined chemotherapy and radiation therapy only

Answer 24

D. Combined chemotherapy and radiation therapy only
High-Yield Rationale: Standard treatment for localized anal squamous cell carcinoma is chemoradiation (Nigro protocol), avoiding the need for surgical resection unless disease persists.

Question 25

Q81: What term is used to define a Meckel's diverticulum found in an inguinal or femoral hernia sac? A. Petit's B. Spigelian C. Amyand's D. Littre's

Answer 25

D. Littre's High-Yield Rationale: Littre’s hernia is a hernia containing a Meckel's diverticulum, most commonly seen in the inguinal region.

Question 26

Q84: Which is considered a high-risk factor for Stage II colon cancer? A. Elderly patient B. 12 lymph node harvest with 3 nodes being positive for metastasis C. Local invasion of nearby organ or structure D. Absence of lymphovascular invasion

Answer 26

C. Local invasion of nearby organ or structure High-Yield Rationale: T4 tumors (invasion of nearby organs) are high-risk Stage II colon cancer, increasing the need for adjuvant chemotherapy.

Question 27

Q85: What is the recommended treatment for a well-differentiated sigmoid colon adenocarcinoma that has invaded the muscularis propria, with 1 out of 12 lymph nodes positive for metastasis, and no liver metastasis? A. Sigmoidectomy followed by adjuvant chemotherapy B. Sigmoidectomy followed by adjuvant chemotherapy and radiation therapy C. Sigmoidectomy D. Radiation therapy followed by sigmoidectomy followed by adjuvant chemotherapy

Answer 27

A. Sigmoidectomy followed by adjuvant chemotherapy High-Yield Rationale: Stage III colon cancer (lymph node-positive) requires surgical resection (sigmoidectomy) followed by adjuvant chemotherapy (e.g., FOLFOX regimen).

Question 28

Q86: Which of the following is NOT a cause of intestinal obstruction in Meckel’s diverticulum? A. Intussusception with the diverticulum acting as a lead point B. Entrapment of intestine by a mesodiverticular band C. Volvulus of the intestine around the fibrous band attaching the diverticulum to the umbilicus D. Fistula secondary to chronic diverticulitis

Answer 28

D. Fistula secondary to chronic diverticulitis High-Yield Rationale: Meckel’s diverticulum causes obstruction by intussusception, volvulus, or mesodiverticular bands, but fistula formation does not typically cause obstruction.

Question 29

Q87: What is the grade of hemorrhoids that prolapse through the anus but reduce spontaneously? A. IV B. III C. I D. II

Answer 29

D. II High-Yield Rationale: Grade II hemorrhoids prolapse but reduce spontaneously, while Grade III require manual reduction, and Grade IV are irreducible.

Question 30

Q89: Which of the following is/are TRUE regarding surgical treatment of colon cancer? A. Colon cancer with local invasion of nearby organs must be resected en bloc B. Minimally invasive surgery is associated with superior oncologic outcomes C. Negative surgical margin is a strong predictor of poor oncologic outcomes D. All of the above

Answer 30

A. Colon cancer with local invasion of nearby organs must be resected en bloc High-Yield Rationale: En bloc resection of colon cancer with adjacent organ invasion improves survival. However, minimally invasive surgery is equivalent, not superior, to open surgery in oncologic outcomes, and negative margins are good prognostic factors.

Question 31

Q91: What is the classic first symptom of colorectal cancer? A. Asymptomatic B. Weight loss C. Abdominal pain D. Hematochezia

Answer 31

A. Asymptomatic High-Yield Rationale: Colorectal cancer is often asymptomatic in early stages, with symptoms appearing later, including hematochezia, weight loss, or abdominal pain.

Question 32

Q96: What is the stage of a poorly differentiated sigmoid colon adenocarcinoma that has invaded the muscularis propria, with lymphovascular invasion, 1 out of 15 lymph nodes positive for metastasis, and no distant metastasis? A. T2N1M0 B. T3N1M0 C. T3N2M0 D. T2N0M0

Answer 32

B. T3N1M0 High-Yield Rationale: T3 → Tumor invades through muscularis propria into pericolorectal tissues N1 → 1–3 positive lymph nodes M0 → No distant metastasis Stage IIIA (AJCC TNM staging)

Question 33

Q98: Which of the following is TRUE regarding the diagnosis of colon cancer? A. Preoperative CT scan can identify the exact TNM stage of the disease B. Ultrasound or MRI are critical in TNM staging C. Colonoscopy with biopsy is the best initial diagnostic modality D. PET CT scan is the best diagnostic and staging imaging test

Answer 33

C. Colonoscopy with biopsy is the best initial diagnostic modality High-Yield Rationale: Colonoscopy with biopsy is the gold standard for diagnosing colorectal cancer, allowing direct visualization and histologic confirmation.

Question 34

Q99: Which statement is TRUE regarding colorectal cancer screening? A. FOBT has good sensitivity for detecting polyps >1 cm in size B. Flexible sigmoidoscopy is very sensitive in detecting polyps in the entire colon and rectum C. Barium enema uses computed tomography scan technology D. Colonoscopy always requires full bowel preparation and sedation

Answer 34

D. Colonoscopy always requires full bowel preparation and sedation High-Yield Rationale: Colonoscopy is the gold standard for colorectal cancer screening, requiring full bowel preparation and conscious sedation for patient comfort.

Question 35

Q2: What is the stage of sigmoid colon adenocarcinoma if it invades the uterus and urinary bladder, with no lymph node metastasis and normal liver? A. II B. III C. IV D. I

Answer 35

C. IV High-Yield Rationale: Stage IV colon cancer is defined as tumor invasion into adjacent organs (T4b) or distant metastasis. Invasion of the uterus and urinary bladder classifies it as T4b, making it Stage IV.

Question 36

Q5: A 26-year-old female presents with colicky abdominal pain and non-bilious vomiting for 1 day. She has a history of appendectomy. Exam shows increased abdominal girth, no tenderness, and tympanitic percussion. Abdominal X-ray shows air-fluid levels. What is the next BEST step? A. Schedule the patient for an exploratory laparotomy B. Order a fleet enema C. Request a CT scan of the abdomen with contrast D. Insert a nasogastric tube with open drainage

Answer 36

D. Insert a nasogastric tube with open drainage High-Yield Rationale: Postoperative adhesions are the most common cause of small bowel obstruction (SBO). NG decompression and supportive care are first-line treatments unless strangulation or perforation is suspected.

Question 37

Q6: A 30-year-old male underwent appendectomy for acute appendicitis. 1 week later, the final histopathology report shows adenoma of the appendix. What should be done next? A. Observe B. Perform cytoreductive surgery C. Perform a right hemicolectomy D. Refer the patient to an oncologist

Answer 37

C. Perform a right hemicolectomy High-Yield Rationale: Adenocarcinoma of the appendix often requires right hemicolectomy, especially if the tumor is >2 cm, has lymphovascular invasion, or involves the base of the appendix.

Question 38

Q9: Which of the following signs of acute appendicitis is described as pain with coughing? A. Dunphy's sign B. Iliopsoas sign C. Obturator sign D. Rovsing's sign

Answer 38

A. Dunphy's sign High-Yield Rationale: Dunphy's sign is sharp pain in the RLQ triggered by coughing or movement, indicating peritoneal irritation.

Question 39

Q13: What is the BEST surgery for T3N0M0 rectal cancer located 8 cm from the anal verge? A. Transanal excision B. Anterior resection C. Low anterior resection D. Abdominoperineal resection

Answer 39

C. Low anterior resection High-Yield Rationale: Low anterior resection (LAR) is preferred for mid-to-upper rectal cancers (5-12 cm from the anal verge) to preserve sphincter function.

Question 40

Q14: What is the diagnosis if a plain abdominal X-ray shows a bent inner tube appearance with convexity of the loop lying in the left upper quadrant? A. Sigmoid diverticulitis B. Sigmoid volvulus C. Intussusception D. Cecal volvulus

Answer 40

B. Sigmoid volvulus High-Yield Rationale: Sigmoid volvulus presents as a "bent inner tube" or "coffee bean" sign, usually displaced to the left upper quadrant.

Question 41

Q17: What is the BEST treatment for intersphincteric fistula-in-ano? A. LIFT (Ligation of Intersphincteric Fistula Tract) B. Advancement flap C. Seton placement D. Fistulotomy

Answer 41

D. Fistulotomy High-Yield Rationale: Fistulotomy is the gold standard for intersphincteric fistulas, as it has high cure rates with minimal risk of incontinence.

Question 42

Q18: Which type of colorectal polyp is premalignant? A. Serrated B. Inflammatory C. Hyperplastic D. Hamartomatous

Answer 42

A. Serrated High-Yield Rationale: Serrated polyps (sessile serrated adenomas) have malignant potential and are considered precursors to colorectal cancer.