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  • Question 1 - A 26 year old policewoman is admitted with bloody diarrhoea. She has been...

    Incorrect

    • A 26 year old policewoman is admitted with bloody diarrhoea. She has been passing 10 stools per day, Hb-8.1, albumin-21. Her stool culture is negative and there is evidence of colitis on endoscopy. She has been on intravenous steroids for 5 days and has now developed megacolon. Her haemoglobin is falling and inflammatory markers are static. Which of the following is the best course of action?

      Your Answer: Undertake a sub total colectomy and ileo-rectal anastomosis

      Correct Answer: Undertake a sub total colectomy and end ileostomy

      Explanation:

      The operation aims to remove most of your large bowel including the blood supply and associated lymph glands and leave the rectum behind. It is most commonly recommended for inflammatory bowel disease like ulcerative colitis and Crohn’s disease.

      It is also recommended for other bowel conditions like familial adenomatous polyposis, and when there is more than one bowel cancer.

      In inflammatory bowel disease such as ulcerative colitis the small bowel is brought out to the skin of the tummy as an ileostomy and the remaining bowel (rectum) is closed off and left inside. In other conditions where possible, the two ends of the remaining healthy bowel (small bowel to rectum) are re-joined (an anastomosis). Most
      people therefore do not require a stoma. However some people benefit from having a stoma made depending on circumstances regarding:
      1) Their general state of health (heart disease, lung disease, diabetes, vascular disease, smoking, steroid medications, being undernourished);
      2) Factors which cannot be seen until the surgeon can see inside your tummy (more extensive disease than originally thought, extensive pelvic scarring from previous surgery or other treatment, excessive bleeding).
      Temporary stomas are made to divert faeces away from the join (de-functioning) to give the best chance to heal if there is concern it may be slow to heal.

      Emergency indications for surgical intervention in severe UC include free perforation, haemorrhage or systemic instability. An urgent indication for colectomy is a severe attack that is unresponsive to medical therapy.

      In the setting of severe UC, the procedure of choice is subtotal colectomy and ileostomy. The residual rectal disease is controllable in most patients. In general, there are advantages to the subtotal colectomy approach, including a lower morbidity if pelvic dissection is not performed, preservation of the rectum so that reconstructive procedures can be performed later, and allowing the definitive procedure to be deferred to an optimal situation when the patient is off immunosuppressive medications and has improved nutritional status. Usually, the staged reconstruction with IPAA or definitive total proctocolectomy is performed several months later.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
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  • Question 2 - A 32-year-old lady presents with a six-month history of an offensive discharge from...

    Incorrect

    • A 32-year-old lady presents with a six-month history of an offensive discharge from the anus. She is otherwise well but is annoyed at the need to wear pads. On examination, she has a small epithelial defect in the five o'clock position, approximately three centimetres from the anal verge.

      Out of the following, which is the most likely cause?

      Your Answer:

      Correct Answer: Fistula-in-ano

      Explanation:

      This patient is a case of fistula-in-ano.

      A fistula-in-ano is an abnormal hollow tract or cavity that is lined with granulation tissue and that connects a primary opening inside the anal canal to a secondary opening in the perianal skin; secondary tracts may be multiple and can extend from the same primary opening. Fistulae usually occur following previous ano-rectal sepsis. The discharge may be foul smelling and troublesome.

      Fistula-in-ano is classified into two groups based on its anatomical location.
      1. Low fistula: relatively close to the skin and passes through a few or no sphincter muscle fibres, crosses <30% external sphincter
      2. High fistula: passes through a large amount of muscle

      Assessment of fistula-in-ano includes:
      1. Examination of the perineum
      2. Digital rectal examination (DRE)
      Low, uncomplicated fistulas may not require any further assessment. Other groups will usually require more detailed investigation.
      3. Endo-anal USS
      4. Ano-rectal MRI scan

      Treatment options include:
      1. Seton suture
      2. Fistulotomy: Low fistulas that are simple should be treated by fistulotomy once the acute sepsis has been controlled. Fistulotomy (where safe) provides the highest healing rates.
      3. Anal fistula plugs and fibrin glue
      4. Ano-rectal advancement flaps: primarily for high fistulae

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
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  • Question 3 - A 27-year-old male presents with altered bowel habit. He is known to have...

    Incorrect

    • A 27-year-old male presents with altered bowel habit. He is known to have familial polyposis coli. A colonoscopy shows widespread polyps, with high-grade dysplasia in a polyp removed from the rectum. What is the best course of action?

      Your Answer:

      Correct Answer: Undertake a pan proctocolectomy

      Explanation:

      Familial adenomatous polyposis (FAP) is an autosomal dominant, hereditary colon cancer syndrome that is characterized by the presence of innumerable adenomatous polyps in the colon and rectum. Gardner’s syndrome is a variant of FAP, which in addition to the colonic polyps, also presents extracolonic manifestations, including desmoid tumours, osteomas, epidermoid cysts, various soft tissue tumours, and a predisposition to the thyroid and periampullary cancers.
      Of patients with FAP, 75%-80% have a family history of polyps and/or colorectal cancer at age 40 years or younger.
      Mutations of the APC gene are thought to be responsible for the development of FAP, and the location of the mutation on the gene is thought to influence the nature of the extracolonic manifestations that a given patient might develop.
      Though patients are often asymptomatic, bleeding, diarrhoea, abdominal pain and mucous discharge frequently occur. Diagnostic tools include genetic testing, endoscopy, and monitoring for extra-intestinal manifestations.
      If left untreated, all patients with this syndrome will develop colon cancer by age 35-40 years. Besides, an increased risk exists for the development of other malignancies.
      Currently, surgery is the only effective means of preventing progression to colorectal carcinoma. Restorative proctocolectomy with ileal pouch-anal anastomosis (RPC/IPAA) with mucosectomy is the preferred surgical procedure since it attempts to eliminate all colorectal mucosa without the need for an ostomy. Periampullary carcinoma and intra-abdominal desmoid tumours are a significant cause of morbidity and mortality in these patients after colectomy. Frequent endoscopy is needed to prevent the former, while there is no definitive treatment available yet for the latter.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
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  • Question 4 - A 15 year old girl is taken to the A&E after complaining of...

    Incorrect

    • A 15 year old girl is taken to the A&E after complaining of right iliac fossa pain which started suddenly. She is well other than having some right iliac fossa tenderness but no guarding. She has no fever and the urinary dipstick result is normal. Her last menstrual cycle was 14 days ago which was also normal and the pregnancy test done is negative. What is the most likely underlying condition?

      Your Answer:

      Correct Answer: Mittelschmerz

      Explanation:

      Answer: Mittelschmerz

      Mittelschmerz is midcycle abdominal pain due to leakage of prostaglandin-containing follicular fluid at the time of ovulation. It is self-limited, and a theoretical concern is treatment of pain with prostaglandin synthetase inhibitors, which could prevent ovulation. The pain of mittelschmerz usually occurs in the lower abdomen and pelvis, either in the middle or to one side. The pain can range from a mild twinge to severe discomfort and usually lasts from minutes to hours. In some cases, a small amount of vaginal bleeding or discharge might occur. Some women have nausea, especially if the pain is very strong.
      Diagnosis of pelvic pain in women can be challenging because many symptoms and signs are insensitive and nonspecific. As the first priority, urgent life-threatening conditions (e.g., ectopic pregnancy, appendicitis, ruptured ovarian cyst) and fertility-threatening conditions (e.g., pelvic inflammatory disease, ovarian torsion) must be considered.
      Many women never have pain at ovulation. Some women, however, have mid-cycle pain every month, and can tell by the pain that they are ovulating.
      As an egg develops in the ovary, it is surrounded by follicular fluid. During ovulation, the egg and the fluid, as well as some blood, are released from the ovary. While the exact cause of mittelschmerz is not known, it is believed to be caused by the normal enlargement of the egg in the ovary just before ovulation. Also, the pain could be caused by the normal bleeding that comes with ovulation.
      Pelvic inflammatory disease can be ruled out if the patient is not sexually active.

    • This question is part of the following fields:

      • Generic Surgical Topics
      • The Abdomen
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  • Question 5 - A 30-year-old male is reviewed in the clinic. He has suffered from Crohn's...

    Incorrect

    • A 30-year-old male is reviewed in the clinic. He has suffered from Crohn's disease for many years, he has recently undergone a subtotal colectomy. However, he has residual Crohns in his rectum causing the ongoing symptoms. Medical therapy is ineffective. What is the best course of action?

      Your Answer:

      Correct Answer: Proctectomy

      Explanation:

      Treatment of Crohn’s disease is based on the disease site, pattern, activity, and severity. The general goals of treatment for Crohn’s disease are as follows:
      To achieve the best possible clinical, laboratory, and histologic control of the inflammatory disease with the least adverse effects from medication.
      To permit the patient to function as normally as possible.
      Therapy for mild Crohn’s disease is typically administered in a sequential “step-up” approach, in which less aggressive and less toxic treatments are initiated first, followed by more potent medications or procedures if the initial therapy fails.
      Patients are treated with preparations of 5-aminosalicylic acid (5-ASA), antibiotics, and nutritional therapy. However, the use of 5-ASA for the treatment of Crohn’s disease is controversial; only a small subset of patients may benefit from this agent. Although 5-ASA is effective for reducing disease activity in active Crohn’s disease, it typically has a lower efficacy for Crohn’s disease than for ulcerative colitis, and its efficacy for maintenance of remission remains unproven.

      If no response occurs or if the disease is more severe than initially thought, corticosteroids and inhibitors of DNA synthesis (i.e., immunomodulators) with 6-mercaptopurine (6-MP)/azathioprine or methotrexate are administered. Finally, biologic agents (infliximab, adalimumab, certolizumab pegol, and natalizumab) and surgical therapies can be useful.

      For the treatment of moderate to severe Crohn’s disease, current recommendations include the “top-down” approach, which differs from the conventional step-up approach in that more potent agents are administered initially. Top-down therapies include biologic agents and steroids as needed versus combination therapy with both biologic drugs and immunomodulatory agents.

      Azathioprine or 6-MP is effective for maintenance of remission in Crohn’s disease; each is effective for avoiding surgery and for preventing postoperative and endoscopic relapse. Both agents can be used in combination with infliximab.

      If medical therapy for active Crohn’s disease fails, surgical resection of the inflamed bowel, with the restoration of continuity, is indicated.

      Recommended indications for surgical intervention include the following:
      Failed medical therapy
      Persistent symptoms despite high-dose corticosteroid therapy
      Treatment-related complications, including intra-abdominal abscesses
      Medically intractable fistulae
      Fibrotic strictures with obstructive symptoms
      Toxic megacolon
      Intractable haemorrhage
      Perforation
      Cancer

      For Rectal Crohn’s: Proctectomy is appropriate, and in published series, it is required in 10 to 20% of cases. Unfortunately, proctectomy can be complicated by poor wound healing and perineal sinus formation in up to 25 to 50% of patients. A gracillis flap can be helpful.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
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  • Question 6 - A 22-year-old male is diagnosed with an intersphincteric fistula-in-ano during an examination under...

    Incorrect

    • A 22-year-old male is diagnosed with an intersphincteric fistula-in-ano during an examination under anaesthetic. Which is the most appropriate treatment?

      Your Answer:

      Correct Answer: Insertion of a ‘loose’ seton

      Explanation:

      An anal fistula is an abnormal tract between the anal canal and the skin around the anus.
      Anal fistulas can be classified according to their relationship with the external sphincter. A fistula may be complex, with several openings onto the perianal skin. Intersphincteric fistulas are the most common type and cross only the internal anal sphincter. Trans-sphincteric fistulas pass through both the internal and external sphincters.

      The aim is to drain the infected material and encourage healing.
      For simple intersphincteric and low trans-sphincteric anal fistulas, the most common treatment is a fistulotomy or laying open of the fistula tract.
      For high and complex (deeper) fistulas that involve more muscle, with a high risk of faecal incontinence or recurrence, surgery aims to treat the fistula and preserve sphincter-muscle function. Techniques include a 1‑stage or 2‑stage seton (suture material or rubber sling) either alone or in combination with fistulotomy, ligation of an intersphincteric fistula tract, creating a mucosal advancement flap, injecting glue or paste, or inserting a fistula plug .

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
      0
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  • Question 7 - A 35-year-old male presents with recurrent episodes of knife-like pain within his rectum....

    Incorrect

    • A 35-year-old male presents with recurrent episodes of knife-like pain within his rectum. On examination, there is no abnormality to find on either proctoscopy or palpation. What is the most likely diagnosis?

      Your Answer:

      Correct Answer: Proctalgia fugax

      Explanation:

      Proctalgia fugax or functional recurrent anorectal pain is part of a spectrum of functional gastrointestinal disorders defined by the Rome III diagnostic criteria as episodes of sharp fleeting pain that recur over weeks, are localized to the anus or lower rectum, and last from seconds to several minutes with no pain between episodes. There is no diurnal variation. There are numerous precipitants including sexual activity, stress, constipation, defecation and menstruation, although the condition can occur without a trigger. It should be differentiated from chronic proctalgia, a functional anorectal pain disorder with a vague, dull ache or pressure sensation high in the rectum, often worse when sitting than when standing or lying down, and lasts at least 20 minutes.
      Most treatments for proctalgia fugax (e.g., oral diltiazem, topical glyceryl nitrate, nerve blocks) act by relaxing the anal sphincter spasm, but the effectiveness of these treatments are supported only by case reports or case series, with the exception of a single randomized controlled trial of salbutamol, making the value of most treatment options, including salbutamol, difficult to judge.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
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  • Question 8 - A 40-year-old man has been diagnosed with anal fissure, which has failed to...

    Incorrect

    • A 40-year-old man has been diagnosed with anal fissure, which has failed to respond to first-line treatment.

      What should be the next most appropriate treatment?

      Your Answer:

      Correct Answer: 15–30 units of botulinum toxin injected into the internal anal sphincter

      Explanation:

      The next appropriate step would be to perform an examination under anaesthesia and inject 15–30 units of botulinum toxin into the internal anal sphincter.

      Anal fissures are commonly seen in the colorectal clinic and are a common cause of painful, bright red rectal bleeding. Most fissures are idiopathic and present as a painful mucocutaneous defect in the posterior midline (90% cases). Fissures are more likely to be anteriorly located in females, particularly if they are multiparous. Diseases associated with fissure-in-ano include:
      1. Crohn’s disease
      2. Tuberculosis
      3. Internal rectal prolapse

      Diagnostic options are as follows:
      In most cases, the defect can be visualised as a posterior midline epithelial defect. Where symptoms are highly suggestive of the condition and examination findings are unclear, an examination under anaesthesia may be helpful. Atypical disease presentation should be investigated by colonoscopy and EUA, with biopsies of the area.

      For management of anal fissure:
      1. Stool softeners are important as hard stools may tear the epithelium and result in recurrent symptoms (however, up to 25% of the patients fail to respond). The most effective first-line agents are topically applied GTN (0.2%) or Diltiazem (2%) paste.
      2. Resistant cases may benefit from injection of botulinum toxin or lateral internal sphincterotomy. Advancement flaps may be used to treat resistant cases.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
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  • Question 9 - A 41 year old lawyer presents with diarrhoea and bleeding from the rectum...

    Incorrect

    • A 41 year old lawyer presents with diarrhoea and bleeding from the rectum which has been occurring for the past 16 days. She has also noticed that she has had incontinence at night. What is her most likely diagnosis?

      Your Answer:

      Correct Answer: Inflammatory bowel disease

      Explanation:

      Answer: Inflammatory bowel disease

      Inflammatory bowel disease (IBD) is an idiopathic disease caused by a dysregulated immune response to host intestinal microflora. The two major types of inflammatory bowel disease are ulcerative colitis (UC), which is limited to the colonic mucosa, and Crohn disease (CD), which can affect any segment of the gastrointestinal tract from the mouth to the anus, involves skip lesions, and is transmural. There is a genetic predisposition for IBD, and patients with this condition are more prone to the development of malignancy.

      Generally, the manifestations of IBD depend on the area of the intestinal tract involved. The symptoms, however, are not specific for this disease. They are as follows:

      Abdominal cramping

      Irregular bowel habits, passage of mucus without blood or pus

      Weight loss

      Fever, sweats

      Malaise, fatigue

      Arthralgias

      Growth retardation and delayed or failed sexual maturation in children

      Extraintestinal manifestations (10-20%): Arthritis, uveitis, or liver disease

      Grossly bloody stools, occasionally with tenesmus: Typical of UC, less common in CD

      Perianal disease (e.g., fistulas, abscesses): Fifty percent of patients with CD

      The World Gastroenterology Organization (WGO) indicates the following symptoms may be associated with inflammatory damage in the digestive tract [1] :

      Diarrhoea: mucus or blood may be present in the stool; can occur at night; incontinence may occur

      Constipation: this may be the primary symptom in ulcerative colitis, when the disease is limited to the rectum; obstipation may occur and may proceed to bowel obstruction

      Bowel movement abnormalities: pain or rectal bleeding may be present, as well as severe urgency and tenesmus

      Abdominal cramping and pain: commonly present in the right lower quadrant in Crohn disease; occur peri umbilically or in the left lower quadrant in moderate to severe ulcerative colitis

      Nausea and vomiting: occurs more often in Crohn disease than in ulcerative colitis

      The nocturnal diarrhoea and incontinence are important symptoms in diagnosis IBD.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
      0
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  • Question 10 - A 30-year-old male presents with a discharging sinus in his nasal cleft. He...

    Incorrect

    • A 30-year-old male presents with a discharging sinus in his nasal cleft. He is found to have a pilonidal sinus. Which statement is false?

      Your Answer:

      Correct Answer: In a patient with an acute abscess the Bascoms procedure is the treatment of choice.

      Explanation:

      Typical pilonidal sinus disease (PSD) occurs in the natal cleft i.e. sacrococcygeal region.
      However, some occupation related pilonidal sinuses occurs in webs of fingers e.g. hairdresser, sheep shearer, dog groomer, slaughterman or milker.
      Other locations where pilonidal sinuses may occur include penis shaft, axilla, intermammary area, groin, nose, neck, clitoris, suprapubic area, occiput, prepuce, chin, periungual region, breast, face and umbilicus.

      Although the pilonidal disease may manifest as an abscess, a pilonidal sinus, a recurrent or chronic pilonidal sinus, or a perianal pilonidal sinus, the most common manifestation of pilonidal disease is a painful, fluctuant mass in the sacrococcygeal region.
      Initially, 50% of patients first present with a pilonidal abscess that is cephalad to the hair follicle and sinus infection. Pain and purulent discharge from the sinus tract is present 70-80% of the time and are the two most frequently described symptoms. In the early stages preceding the development of an abscess, only cellulitis or folliculitis is present. The abscess is formed when a folliculitis expands into the subcutaneous tissue or when a pre-existing foreign body granuloma becomes infected.
      The diagnosis of a pilonidal sinus can be made by identifying the epithelialized follicle opening, which can be palpated as an area of deep induration beneath the skin in the sacral region. These tracts most commonly run in the cephalad direction. When the tract runs in the caudal direction, perianal sepsis may be present.

      The ideal treatment for a pilonidal sinus varies according to the clinical presentation of the disease. First, it is important to divide the pilonidal disease into the following three categories, which represent different stages of the clinical course:
      – Acute pilonidal abscess
      – Chronic pilonidal disease
      – Complex or recurrent pilonidal disease

      Acute pilonidal abscess:
      A pilonidal abscess is managed by incision, drainage, and curettage of the abscess cavity to remove hair nests and skin debris. This can be accomplished in the surgical office or the emergency department, using local anaesthesia.
      If possible, the drainage incision should be made laterally, away from the midline. Wounds heal poorly in the deep, intergluteal natal cleft, for two reasons. The first is the frictional motion of the deep cleft, which creates continuous irritation to the healing wound; the second is the midline nature of the wound, which is a product of constant lateral traction during sitting.

      Chronic pilonidal disease is the term applied when patients have undergone at least one pilonidal abscess drainage procedure and continue to have a pilonidal sinus tract. The term also refers to a pilonidal sinus that is associated with a chronic discharge without an acute abscess. Surgical options for management of a noncomplicated chronic pilonidal sinus include the following:
      Excision and laying open of the sinus tract
      Excision with primary closure
      Wide and deep excision to the sacrum
      Incision and marsupialization
      Bascom procedure
      Asymmetrical incisions
      Skin flaps have also been described to cover a sacral defect after wide excision. Similarly, this keeps the scar off the midline and flattens the natal cleft.

    • This question is part of the following fields:

      • Colorectal Surgery
      • Generic Surgical Topics
      0
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