[SEM2] Esophageal/COLON/RECTUM/ANUS

Question 1

What is the anatomical transition point between the pharynx and esophagus?
A. C4 vertebra
B. C5 vertebra
C. C6 vertebra
D. C7 vertebra

Answer 1

C. C6 vertebra ✅
High-Yield Rationale:
The pharynx transitions into the esophagus at the level of the cricoid cartilage, which corresponds to the C6 vertebra. This is a key landmark in head and neck anatomy and also marks the start of the esophageal tract.

Question 2

Q: A 9-year-old child swallows a 50¢ coin. What is the least likely site of esophageal lodgment?
A. Upper esophageal sphincter (cricopharyngeus)
B. Aortic arch / left main bronchus crossing
C. Lower esophageal sphincter (LES at diaphragmatic hiatus)
D. Thoracic inlet

Answer 2

C. Lower esophageal sphincter (LES) ✅
High-Yield Rationale:
There are 3 physiologic esophageal narrowings:

UES (cricopharyngeus)

Aortic arch/left main bronchus (T4–T5)

LES (esophageal hiatus at T10)

Most foreign bodies get stuck proximally, particularly at the UES. LES is the least likely because it’s more distal and often passed unless large or abnormal motility is present.

Question 3

Q: A 35-year-old female presents with dysphagia and is found to have superior gastric lymphadenopathy. What is the most likely site of esophageal malignancy?
A. Cervical esophagus
B. Upper thoracic esophagus
C. Mid-thoracic esophagus
D. Lower thoracic or abdominal esophagus

Answer 3

D. Lower thoracic or abdominal esophagus ✅
High-Yield Rationale:
The lower esophagus drains into superior gastric and celiac lymph nodes. Therefore, malignancy in this region can present with superior gastric lymphadenopathy, often seen in CT staging.

Question 4

A 30-year-old presents with heartburn and no alarm symptoms. What is the best initial management?
A. Order upper endoscopy
B. Prescribe antibiotics
C. Empiric PPI + lifestyle changes
D. Refer for manometry

Answer 4

C. Empiric PPI + lifestyle changes ✅
High-Yield Rationale:
For patients < 40 years old with typical GERD symptoms and no red flags, proceed with empiric therapy (PPI, diet/lifestyle). No endoscopy needed unless symptoms persist or worsen.

Question 5

A 41-year-old presents with epigastric pain and heartburn. What is the next best step?
A. Start empiric PPI
B. Upper GI series
C. Order EGD + start PPI
D. Order manometry

Answer 5

C. Order EGD + start PPI ✅
High-Yield Rationale:
Patients ≥ 40 years old should undergo baseline EGD even without red flags due to increased malignancy risk. Empiric PPI may be started simultaneously.

Question 6

A patient with GERD symptoms reports recent weight loss and hematemesis. What is the immediate next step?
A. Empiric therapy
B. Abdominal ultrasound
C. Refer to ENT
D. Perform EGD

Answer 6

D. Perform EGD ✅
High-Yield Rationale:
Any red flags (e.g., weight loss, dysphagia, vomiting, lymphadenopathy) warrant urgent EGD, regardless of age.
Dysphagia grading:

Mild: can eat solids with fluids

Severe: cannot swallow saliva

Question 7

A smoker with epigastric pain and hoarseness post-meals is suspected to have GERD. What is the best approach?
A. Only prescribe cough suppressants
B. Start antibiotics for aspiration
C. EGD + PPI + lifestyle modification
D. Send for chest X-ray

Answer 7

C. EGD + PPI + lifestyle modification ✅
High-Yield Rationale:
GERD with respiratory symptoms (hoarseness, wheezing) and risk factors like smoking/alcohol may indicate chronic GERD complications (e.g., Barrett’s esophagus). Start evaluation with EGD.

Question 8

In what position is physiologic (normal) gastroesophageal reflux most likely to occur?
A. Supine while asleep
B. Prone position
C. Upright and awake
D. Left lateral decubitus

Answer 8

C. Upright and awake ✅
High-Yield Rationale:
Physiologic reflux is common when upright and awake, due to transient LES relaxation. This is normal unless it causes symptoms or complications.

Question 9

What is the most common cause of a traction diverticulum of the esophagus?
A. Achalasia
B. Scleroderma
C. Tuberculosis
D. GERD

Answer 9

C. Tuberculosis ✅
High-Yield Rationale:
A traction diverticulum is a true diverticulum involving all layers of the esophageal wall. It results from external traction by inflamed adjacent structures, most commonly mediastinal lymphadenitis due to TB. Other causes include chronic infections or malignancy.
💡 Exam Tip: TB + esophageal outpouching = traction diverticulum

Question 10

Which of the following is the strongest predictor of postoperative complications in esophageal cancer surgery?
A. Age ≥ 70
B. FEV1 < 1.25
C. Serum albumin < 3.0
D. Ejection fraction < 40%

Answer 10

C. Serum albumin < 3.0 ✅
High-Yield Rationale:
Low serum albumin is the most sensitive predictor of poor surgical outcomes. It reflects nutritional status, which directly correlates with healing capacity and immunity, making it more predictive than age or cardiopulmonary parameters.

Question 11

What is the minimum gross margin required when resecting an esophageal tumor?
A. 0.5 cm
B. 1 cm
C. 2 cm
D. 5 cm

Answer 11

C. 2 cm ✅
High-Yield Rationale:
A 2 cm gross tumor-free margin is considered oncologically adequate for esophageal and colorectal resections. However, wider margins may be taken depending on the tumor’s location and invasiveness.

Question 12

A 65-year-old presents with dysphagia and regurgitation of undigested food. What is the best management?
A. Lifestyle modification
B. NGT insertion
C. Diverticulectomy
D. PPIs and diet changes

Answer 12

C. Diverticulectomy ✅
High-Yield Rationale:
Classic signs of Zenker’s diverticulum include regurgitation of undigested food, halitosis, and dysphagia. Surgical excision (diverticulectomy) is indicated when the diverticulum is symptomatic, large, or causing aspiration.

Question 13

What is the most accurate test for assessing the depth of esophageal tumor invasion (T-staging)?
A. CT scan
B. PET scan
C. Endoscopic esophageal ultrasound (EUS)
D. Barium swallow

Answer 13

C. Endoscopic esophageal ultrasound (EUS) ✅
High-Yield Rationale:
EUS is the most precise modality for T-staging in esophageal cancer. It allows direct visualization of esophageal wall layers and nearby periesophageal lymph nodes, making it superior for local staging compared to CT or PET.

Question 14

After confirming esophageal cancer on EGD and biopsy, what is the next best step for staging?
A. PET scan
B. Barium swallow
C. CT chest and abdomen with IV + oral contrast
D. MRI of thorax

Answer 14

C. CT chest and abdomen with IV + oral contrast ✅
High-Yield Rationale:
Following diagnosis by EGD + biopsy, the next step is CT chest/abdomen to evaluate:

Regional and distant metastases (e.g., liver, lungs, para-aortic nodes)

Tumor extent

Bronchial/esophageal involvement
🧠 Tip: EGD → Confirm cancer → CT scan for staging before treatment planning

Question 15

A 38-year-old male presents with a fistula-in-ano. What is the most appropriate surgical procedure for a superficial tract not involving the sphincter?
A. Fistulectomy
B. Seton placement
C. Fistulotomy
D. Colostomy

Answer 15

C. Fistulotomy ✅
High-Yield Rationale:
Fistulotomy is the procedure of choice for low/simple fistulas that do not involve the anal sphincter complex. It involves laying open the tract and allowing it to heal by secondary intention.
⚠️ Avoid in high fistulas or those that cross the sphincter → risk of incontinence.

Question 16

Injury to the external anal sphincter most significantly affects which function?
A. Resting tone
B. Rectal compliance
C. Squeeze pressure
D. Peristalsis

Answer 16

C. Squeeze pressure ✅
High-Yield Rationale:
The external anal sphincter is under voluntary control and is responsible for squeeze pressure.
In contrast, the internal sphincter provides resting tone through involuntary control (smooth muscle).

Question 17

What is the most appropriate outpatient treatment for Grade II internal hemorrhoids?
A. Hemorrhoidectomy
B. Rubber band ligation
C. Fistulectomy
D. Anal dilation

Answer 17

B. Rubber band ligation ✅
High-Yield Rationale:
Grade II hemorrhoids (prolapse with spontaneous reduction) are best treated with rubber band ligation, an outpatient procedure.
Always combine with dietary fiber + lifestyle changes for long-term success.

Question 18

Can rubber band ligation be used for external hemorrhoids?
A. Yes, it’s standard
B. Only in thrombosed cases
C. No – not recommended
D. Yes, with sedation

Answer 18

C. No – not recommended ❌
High-Yield Rationale:
Rubber band ligation is ONLY for internal hemorrhoids (above the dentate line).
The area below the dentate line (external hemorrhoids) is richly innervated → ligation here causes severe pain.

Question 19

After colostomy creation, what does “maturation of the colostomy” mean in the recovery room?
A. Placing NG tube
B. Wound debridement
C. Finalizing stoma formation and checking viability
D. Reversal of stoma

Answer 19

C. Finalizing stoma formation and checking viability ✅
High-Yield Rationale:
“Maturation” involves:

Everting and fixing the colostomy to the skin

Ensuring viable, pink stoma

Checking for patency, bleeding, or ischemia
Done post-op to confirm proper healing and functionality.

Question 20

A patient presents with a tender, erythematous bulge at the 9 o’clock anal position, fever, and pain with defecation. What is the most probable diagnosis?
A. External hemorrhoids
B. Anal fissure
C. Fistula-in-ano
D. Perianal abscess

Answer 20

D. Perianal abscess ✅
High-Yield Rationale:
Classic presentation: painful perianal swelling + fever + difficulty defecating.
Perianal abscess is the acute phase of cryptoglandular infection and must be diagnosed quickly to prevent sepsis or chronic fistula.

Question 21

What is the most appropriate treatment for a confirmed perianal abscess?
A. Oral antibiotics only
B. Sitz baths and fiber
C. Urgent incision and drainage (I&D) + antibiotics
D. Observation and repeat imaging

Answer 21

C. Urgent incision and drainage (I&D) + antibiotics ✅
High-Yield Rationale:
Surgical drainage is the cornerstone of treatment.
Antibiotics are adjunctive, especially in diabetics or immunocompromised.
Delaying I&D can lead to fistula formation or systemic infection.

Question 22

What is the origin of most perianal abscesses, and what chronic condition can they lead to?
A. Hemorrhoidal thrombosis → anal fissure
B. Cryptoglandular infection → fistula-in-ano
C. Constipation → rectal prolapse
D. IBD → toxic megacolon

Answer 22

B. Cryptoglandular infection → fistula-in-ano ✅
High-Yield Rationale:
Most perianal abscesses originate from cryptoglandular infections.
If not fully treated, or if spontaneously drained, they can lead to a chronic fistula-in-ano.

Question 23

During I&D of a perianal abscess, what should the surgeon look for?
A. Hemorrhoids
B. Internal opening in the anal crypts
C. External fissures
D. Pus pocket in the rectum

Answer 23

B. Internal opening in the anal crypts ✅
High-Yield Rationale:
~50% of perianal abscess cases have an internal opening indicating a fistula tract.
Identifying it early allows definitive fistula treatment, though not always required at first surgery.

Question 24

After I&D of a perianal abscess, what advice should be given to the patient?
A. Early wound closure and strict bed rest
B. Avoid fiber until wound heals
C. Daily dressing, high-fiber/high-fluid diet, and allow secondary healing
D. Start laxatives and resume heavy lifting

Answer 24

C. Daily dressing, high-fiber/high-fluid diet, and allow secondary healing ✅
High-Yield Rationale:
Post-op care involves open wound healing (secondary intention), preventing constipation, and promoting proper hygiene.
Fiber and fluid help reduce strain and contamination of the healing site.

Question 25

A patient with a colostomy 2 months ago now presents with abdominal pain and a visible bulge at the stoma site. What is the most likely serious complication? A. Stomal necrosis B. Parastomal hernia C. Stomal stenosis D. Stoma prolapse

Answer 25

B. Parastomal hernia ✅ High-Yield Rationale: Parastomal hernia is the most common late complication after colostomy. It presents with: Bulge at stoma site Pain or signs of obstruction Risk: Incarceration and strangulation of the bowel (e.g., small bowel trapped through hernia defect) → surgical repair needed to prevent ischemia. 🧠 Hernia management always aims to prevent incarceration and strangulation.

Question 26

A 60-year-old has a hepatic flexure tumor causing proximal bowel dilation. What is the appropriate surgical management? A. Sigmoid colectomy B. Right hemicolectomy C. Extended right hemicolectomy D. Segmental colectomy

Answer 26

C. Extended right hemicolectomy ✅ High-Yield Rationale: Obstructing right colon tumors (hepatic flexure) require extended right hemicolectomy to include: Terminal ileum to mid-transverse colon Ligation of ileocolic + right and middle colic branches Ensures oncologic margins and adequate lymph node harvest.

Question 27

A 58-year-old with complete obstruction due to hepatic flexure tumor needs resection. What is the best approach? A. Hartmann's procedure B. Loop colostomy only C. Primary anastomosis after resection D. Sigmoidectomy

Answer 27

C. Primary anastomosis after resection ✅ High-Yield Rationale: For right-sided tumors, primary anastomosis is usually safe even in obstruction due to cleaner luminal content and good healing. Left-sided tumors often require staged or diverted surgery due to higher risk of anastomotic leak.

Question 28

A patient with an obstructing rectal tumor should initially undergo what procedure? A. Immediate LAR B. Sigmoidectomy C. Proximal diverting colostomy D. Abdominoperineal resection

Answer 28

C. Proximal diverting colostomy ✅ High-Yield Rationale: Initial diversion relieves obstruction. Follow with neoadjuvant chemoradiation, then LAR (low anterior resection) after downstaging. This allows sphincter preservation and lower recurrence risk.

Question 29

What is the preferred treatment for a confirmed case of anorectal melanoma? A. Wide local excision B. Chemoradiation C. APR (abdominoperineal resection) D. Imatinib therapy

Answer 29

A. Wide local excision ✅ High-Yield Rationale: Anorectal melanoma responds poorly to chemo/radiation. Surgical excision with negative margins is the mainstay of treatment. Wide local excision balances oncologic control and quality of life.

Question 30

A patient is diagnosed with anal cancer. What factor primarily determines whether local excision or chemoradiation is the initial treatment? A. Tumor grade only B. Patient age C. Tumor location (above vs. below dentate line) D. Family history of cancer

Answer 30

C. Tumor location (above vs. below dentate line) ✅ High-Yield Rationale: Tumors below dentate line (anal margin): Often squamous cell and may be treated with local excision if margins are clear and sphincter is not involved. Tumors above dentate line (anal canal): Typically require chemoradiation due to proximity to the sphincter complex and deeper invasion risk.

Question 31

In stage IV anal cancer (with distant metastasis), what is the mainstay of treatment? A. Local excision B. Chemoradiation C. Systemic chemotherapy ± radiation D. Prophylactic APR

Answer 31

C. Systemic chemotherapy ± radiation ✅ High-Yield Rationale: Stage IV disease is treated with systemic chemotherapy, sometimes with palliative radiation for bleeding or pain. Surgery is palliative only unless there is obstruction or hemorrhage.

Question 32

When is local excision considered for anal cancer? A. In all anal cancers B. Only for tumors involving rectum C. For tumors below the dentate line that are resectable with free margins D. For T4 tumors with metastasis

Answer 32

C. For tumors below the dentate line that are resectable with free margins ✅ High-Yield Rationale: Anal margin tumors (below dentate line) can be managed with wide local excision if: Small and well-marginated No sphincter involvement Negative margins are achievable