Lower GI

Question 1

Treatment of colon cancer with liver mets

Answer 1

Chemo then surgery
Palliate if widespread or frail

Question 2

Conditions associated with anal fissures

Answer 2

Sexually transmitted diseases (syphilis, HIV)
Inflammatory bowel disease (Crohn’s up to 50%)
Leukaemia (25% of patients)
Tuberculosis
Previous anal surgery

Question 3

Mx of IBD with megacolon who has failed conservative tx

Answer 3

Sub total colectomy with loop ileostomy

Question 4

What can genital skin tags be associated with

Answer 4

Anal fissure

Question 5

Adenoma with the highest risk of dysplasia

Answer 5

Villous adenoma

Question 6

Diverticular disease vs diverticulitis presentation

Answer 6

D Disease can bleed- causing no symptoms apart from dark blood per rectum

Diverticulitis- fever, pain, rarely bleeds

Question 7

Mx of caecal obstruction

Answer 7

If > 12 cm, With functioning valve- will cause perf
Reusus with fluids- laparotomy 2-4 hours later

Question 8

Mx of high anatomical enter-cutaneous fistula

Answer 8

TPN and ocreotide

Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin.

Question 9

Mx of rectal cancer causing obstruction

Answer 9

As if a rectal canacer is adnvaced enough to cause obstruction- likey has spread

So best inital plan is to Create loop colostomy to aid obstrcution then plan definitive surgery if required

Question 10

Mx of rectal cancer near verge

Answer 10

Patients with T1, 2 and 3 /N0 disease on imaging do not require irradiation and should proceed straight to surgery.
Then AP resection
Patients with T4 disease will typically have long course chemo radiotherapy.

Question 11

Obstrcuted right colon cancer mx

Answer 11

Right hemicolectomy
Ileocolic anastomosis

Question 12

Follow up on polyps on colonoscopy

Answer 12

Colorectal cancer- Colonoscopy 1 year post resection

High risk- >5 adenomas, or 3 adenoma with 1 >1cm- 3 year

LNPCP( larger than 2cm)
Large non pedunculated colorectal polyps (LNPCP) R1 or non en bloc resection- Site check at 2-6 months and then a further scope at 12 months

Large non pedunculated colorectal polyps (LNPCP), R0 resection- one off scope 3 years

Question 13

High risk findings polyp

Answer 13

More than 2 premalignant polyps (adenoma <1cm) including 1 or more advanced colorectal polyps (>1cm)
OR
More than 5 pre malignant polyps

Question 14

If Surgery for UC?

Answer 14

segmental resections are not undertaken for UC

Question 15

Histological features of UC vs crohns

Answer 15

Crohns -Granulomas (non caseating epithelioid cell aggregates with Langhans’ giant cells)

UC-Crypt abscesses, Inflammatory cells in the lamina propria

Question 16

Features typical of crohns vs UC

Answer 16

Crohns- fistula, small bowel strictures, rose thorn ulcers, fat wrapping of terminal ileum

UC- pseudopolyps (mucosal islands)

Question 17

Treatment of fistulas in ano

Answer 17

Low fistula, intersphincteric- fistulotomy
Dentate line+ above or IBD- loose seton

Trans- seton then fistulotomy later
Supra- seton then fistuolotmy later

Question 18

Mx of bleeding rectal varices

Answer 18

IV terlipressin

Question 19

Types of laxatives

Answer 19

Bulk-ispaghula husk and methylcellulose

Osmotic-
Magnesium sulphate
Magnesium citrate
Sodium phosphate
Sodium sulphate
Potassium sodium tatrate
Polyethylene glycol
Docusate
Lactulose

Stimulant-
Bisacodyl
Sodium picosulphate
Senna

Question 20

What would imply T4 colon cancer

Answer 20

Broken out of colon- i.e tethered to prostate

Question 21

Mx of bleeding diverticula disease

Answer 21

Conservational and observation

Question 22

Solitary rectal ulcer syndrome sx

Answer 22

Solitary rectal ulcers are associated with chronic constipation and straining.
Indurated area located proximal to anal verge
It will need to be biopsied to exclude malignancy

Question 23

Mx of diverticular stricture causing obstruction in sigmoid

Answer 23

Hartmanns

Question 24

Features of acute appendicits

Answer 24

Neutrophillia
Protein on urine dip
Anorexia
Low grade pyrexia

No diarrhoea or profuse vomitting

Question 25

Low grade fever and a mass palpable in the right iliac fossa. The rest of his abdomen is soft. An abdominal USS demonstrates matted bowel loops surrounding a thickened appendix.

Answer 25

Appendix mass Antibiotics - no peritoneal signs no surgery

Question 26

Where fissures present usually

Answer 26

90% posteriorly 10% anteriorly

Question 27

Most common and earliest and other complications of a ileostomy

Answer 27

Dermatitis- common Earliest- necrosis Other- obstruction and prolapse

Question 28

What blood results point more towards colon cancer

Answer 28

Low Hb Low albumin

Question 29

Colonic pseudo obstruction, Ix, and mx

Answer 29

(Ogilvies syndrome)-Progressive and painless dilation of the colon. The abdomen may become grossly distended and tympanic Diagnosis involves excluding a mechanical bowel obstruction with a plain film and contrast enema. The underlying cause is usually electrolyte imbalance Patients who do not respond to supportive measures should be treated with attempted colonoscopic decompression and/ or the drug neostigmine

Question 30

Appendicits vs UTI urine

Answer 30

Urine often only leucocyte + in appendicitis

Question 31

If laparoscopic approach for appendicitis but no free fluid or peritonitis what do you do

Answer 31

Place in drain and ABx

Question 32

Angiodysplasia presentation

Answer 32

Brisk bleed- minor other symptoms colonoscopy shows a small erythematous lesion in the right colon

Question 33

Mx of familial polyposis coli when colonoscopy shows widespread polyps, with high grade dysplasia in a polyp

Answer 33

Pan proctocolectomy

Question 34

Management of colonocutaneous fistula

Answer 34

Peritonitic- surgery Wound sepsis- ABx Absent distal obstruction- heal spontaneously

Question 35

% of patients with synchronous colon cancer

Answer 35

5%

Question 36

Right standard vs extended hemicoletomy

Answer 36

Standard right hemicolectomy involves colonic division to the right of the middle colic vessels Extended right hemicolectomy involves division of the middle colic vessels and usually resection of the splenic flexure as well.

Question 37

Histological description of adenomas

Answer 37

Dysplastic

Question 38

Commonest anal fistula

Answer 38

Intersphincteric

Question 39

Mx of anal fissures

Answer 39

Stool softeners Topical GTN Then consider botulism injection In males a lateral internal sphincterotomy would be an acceptable alternative.

Question 40

Tx of pilondial abcess

Answer 40

Incision and drainage Definitive treatments such as a Bascoms procedure should not be undertaken when acute sepsis is present.

Question 41

Mx of obstructed sigmoid cancer

Answer 41

Sigmoidectomy and end colostomy

Question 42

Anal cancer management

Answer 42

Radical chemo Second line treatment for non metastatic disease is with salvage radical abdominoperineal excision of the anus and rectum

Question 43

Surgical mx of crohns with rectal disease only

Answer 43

Protectomy and end stoma Crohns disease is a contra indication to having an ileo-anal pouch as its associated with very poor pouch function and significant complications.

Question 44

Goodsall rule

Answer 44

Anterior- straight to opening i.e 3 o'clock to 3 Posterior - curved - will track to the posterior midline i.e 7 to 6 o'clock

Question 45

What does a T tube do in bile duct how is it managed when removed

Answer 45

Post cholecystectomy- T tube placed to keep CBD open When the bile duct is closed over a T Tube the latex in the T tube encourages tract fibrosis. This actually encourages a fistula to develop. The result is that when the tube is removed any bile which leaks will usually drain through the tract. Provided that there are no residual stones in the duct the fistula will slowly close. Persistent high volume drainage may be managed with ERCP and sphincterotomy.

Question 46

Imaging if failed colonoscopy

Answer 46

CT colonoscopy

Question 47

Extra-intestinal sx of crohns

Answer 47

Aphthous ulcers Pyoderma gangrenosum Iritis Erythema nodosum Sclerosing cholangitis Arthritis Clubbing

Question 48

Genes involved in adenoma-carcinoma sequence in colorectal cancer?

Answer 48

c myc APC p53 K ras

Question 49

Least likely place for diverticulitis

Answer 49

Rectum

Question 50

Biggest anal cancer RF

Answer 50

HPV

Question 51

Mx of prolapsed haemorrhoids and symptomatic

Answer 51

excisional haemorrhoidectomy

Question 52

What should you avoid in management of fistula if inflamed

Answer 52

Probing

Question 53

If resected colon cancer had nodal involvement what is the post op mx

Answer 53

Chemo

Question 54

Discharge and bleeding per rectum after hartmanns

Answer 54

Diversion proctitis Once the bowel has been disconnected, a degree of inflammation is commonly seen in the quiescent bowel.

Question 55

Active heavy rectal bleeding- endoscopy normal then what?

Answer 55

CT angio

Question 56

When to suspect enteric cutaneous fistula

Answer 56

Excessive draining and bubbles

Question 57

Mx of rectal prolapse

Answer 57

Rectopexy - this is an abdominal procedure. The rectum is mobilised and fixed onto the sacral promontary. A prosthetic mesh may be inserted. The recurrence rates are low and the procedure is well tolerated- suited to young pateints Perineal approaches include the Delormes operation, this avoids resection and is relatively safe but is associated with high recurrence rates. An Altmeirs operation involves a perineal excision of the sigmoid colon and rectum, it may be a more effective procedure than a Delormes but carries the risk of anastomotic leak

Question 58

Cell types of fistula wall

Answer 58

Sqaumous

Question 59

T staging of colon cancer

Answer 59

0- in situ in mucosa 1- in subserosa 2- to muscular propia 3- beyond propia but not out of bowel/to other organs 4- beyond bowel/to other organs

Question 60

EIM of crohns

Answer 60

Aphthous ulcers Pyoderma gangrenosum Iritis Erythemanodosum Sclerosing cholangitis Arthritis Clubbing

Question 61

What is the earliest complication that can occur following construction of an ileostomy?

Answer 61

Necrosis

Question 62

Causes of pruritus ani

Answer 62

Systemic (DM, Hyperbilirubinaemia, aplastic anaemia) Mechanical (diarrhoea, constipation, anal fissure) Infections (STDs) Dermatological DrugIs (quinidine, colchicine) Topical agents

Question 63

If nodal disease present in colon cancer

Answer 63

Chemo

Question 64

Least likely place for diverticulitis to occur in colon

Answer 64

Rectum