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Question 1
Correct
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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: 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 muscleAssessment 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 scanTreatment 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 2
Incorrect
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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: Treatment involves excising or laying open the sinus tract.
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 diseaseAcute 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
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Question 3
Incorrect
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A 25 year old man presents to the A&E department with bloating, alternating constipation/diarrhoea and colicky abdominal pain. Family history shows that his grandfather died from colon cancer at the age of 84 years. The physical examination and digital rectal examination are normal. Which of the following is the best course of action?
Your Answer: Undertake a colonoscopy
Correct Answer: Measurement of faecal calprotectin
Explanation:Answer: Measurement of faecal calprotectin
Based on Rome criteria, this patient has Irritable Bowel Syndrome (IBS). Irritable bowel syndrome (IBS) is a group of symptoms—including abdominal pain and changes in the pattern of bowel movements without any evidence of underlying damage. These symptoms occur over a long time, often years. It has been classified into four main types depending on whether diarrhoea is common or constipation is common, or both are common, or neither occurs very often (IBS-D, IBS-C, IBS-M, or IBS-U respectively). IBS negatively affects quality of life and may result in missed school or work. Disorders such as anxiety, major depression, and chronic fatigue syndrome are common among people with IBS.
The recommendations for physicians are to minimize the use of medical investigations. Rome criteria are usually used. They allow the diagnosis to be based only on symptoms, but no criteria based solely on symptoms is sufficiently accurate to diagnose IBS. Worrisome features include onset at greater than 50 years of age, weight loss, blood in the stool, iron-deficiency anaemia, or a family history of colon cancer, celiac disease, or inflammatory bowel disease. The criteria for selecting tests and investigations also depends on the level of available medical resources.
Rome criteria
The Rome IV criteria includes recurrent abdominal pain, on average, at least 1 day/week in the last 3 months, associated with two or more of the following criteria:Related to defecation
Associated with a change in frequency of stool
Associated with a change in form (appearance) of stool.
Physicians may choose to use one of these guidelines or may simply choose to rely on their own anecdotal experience with past patients. The algorithm may include additional tests to guard against misdiagnosis of other diseases as IBS. Such red flag symptoms may include weight loss, gastrointestinal bleeding, anaemia, or nocturnal symptoms. However, red flag conditions may not always contribute to accuracy in diagnosis; for instance, as many as 31% of people with IBS have blood in their stool, many possibly from hemorrhoidal bleeding.The diagnostic algorithm identifies a name that can be applied to the person’s condition based on the combination of symptoms of diarrhoea, abdominal pain, and constipation. For example, the statement 50% of returning travellers had developed functional diarrhoea while 25% had developed IBS would mean half the travellers had diarrhoea while a quarter had diarrhoea with abdominal pain. While some researchers believe this categorization system will help physicians understand IBS, others have questioned the value of the system and suggested all people with IBS have the same underlying disease but with different symptoms
The main diseases that cause an increased excretion of faecal calprotectin are inflammatory bowel diseases, coeliac disease, infectious colitis, necrotizing enterocolitis, intestinal cystic fibrosis and colorectal cancer.
Although a relatively new test, faecal calprotectin is regularly used as indicator for inflammatory bowel diseases (IBD) during treatment and as diagnostic marker. IBD are a group of conditions that cause a pathological inflammation of the bowel wall. Crohn’s disease and ulcerative colitis are the principal types of inflammatory bowel disease. Inflammatory processes result in an influx of neutrophils into the bowel lumen. Since calprotectin comprises as much as 60% of the soluble protein content of the cytosol of neutrophils, it can serve as a marker for the level of intestinal inflammation. Measurement of faecal calprotectin has been shown to be strongly correlated with 111-indium-labelled leucocytes – considered the gold standard measurement of intestinal inflammation. Levels of faecal calprotectin are usually normal in patients with irritable bowel syndrome (IBS). In untreated coeliac disease, concentration levels of faecal calprotectin correlate with the degree of intestinal mucosal lesion and normalize with a gluten-free diet.
Faecal calprotectin is measured using immunochemical techniques such as ELISA or immunochromatographic assays. The antibodies used in these assays target specific epitopes of the calprotectin molecule.
Gallbladder ultrasonography should be considered if the patient has recurrent dyspepsia or characteristic postprandial pain.
Abdominal computed tomography (CT) scanning is appropriate to screen for tumours, obstruction, and pancreatic disease if these are diagnostic possibilities.
CT and magnetic resonance (MR) enterography or wireless capsule endoscopy are employed if red flags exist to suggest enteritis (small bowel inflammation) or a tumour.
Colonoscopy is appropriate if alarm symptoms are present and in patients who otherwise qualify for screening colonoscopy.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 4
Incorrect
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A 20-year-old woman presents with a posteriorly-sited anal fissure. Treatment with stool softeners and topical GTN have failed to improve the condition. Which of the following would be the most appropriate next step of management?
Your Answer: Endoanal advancement flap
Correct Answer: Injection of botulinum toxin
Explanation:The most appropriate management option to consider, after GTN or other topical nitrates have failed, is botulinum toxin injection. In males, a lateral internal sphincterotomy would be an acceptable alternative. In a female who has yet to conceive, this may predispose to an increased risk of sphincter dysfunction. Moreover, division of the external sphincter would result in faecal incontinence and is not a justified treatment for anal fissure.
Anal fissures 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 prolapseDiagnostic 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. 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 5
Incorrect
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A 31 year old detective has been having symptoms of post-defecation bleeding over the past 6 years. She visits her doctor and on examination, large prolapsed haemorrhoids were seen. A colonoscopy was done and it showed no other disease. Which of the following options is the best course of action?
Your Answer: Haemorrhoidal artery ligation
Correct Answer: Excisional haemorrhoidectomy
Explanation:The American Society of Colon and Rectal Surgeons (ASCRS) states that clinicians should typically offer haemorrhoidectomy to patients with symptomatic disease from external haemorrhoids or combined internal/external haemorrhoids with prolapse. For those who undergo surgical haemorrhoidectomy, a multimodality pain regimen is recommended to reduce use of narcotics and promote a faster recovery.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 6
Incorrect
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A 32 year old man is suffering from recurrent bouts of severe pain that is localized to the anus. The pain lasts momentarily for a few seconds and completely resolves between attacks. Which of the following would be the most suitable approach to this patient's management?
Your Answer:
Correct Answer: Reassurance
Explanation:Proctalgia fugax (PF) is a benign painful rectal condition that is defined as intermittent, recurring, and self-limiting pain in the anorectal region in the absence of organic pathology. The pain of proctalgia fugax is sharp or gripping and severe. Similar to other urogenital focal pain syndromes, such as vulvodynia and proctodynia, the causes remain obscure. Stress and sitting for prolonged periods often increase the frequency and intensity of attacks of proctalgia fugax. Patients often feel an urge to defecate with the onset of the paroxysms of pain . Depression often accompanies the pain of proctalgia fugax but is not thought to be the primary cause. The symptoms of proctalgia fugax can be so severe as to limit the patient’s ability to perform activities of daily living. Reassurance has proven to help in many cases as the condition has been linked to stress.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 7
Incorrect
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A 35 year old woman presents to her family physician complaining of perianal discomfort. She is diagnosed with pruritis ani. Which of the following would not be associated with this condition?
Your Answer:
Correct Answer: Tuberculosis
Explanation:Tuberculosis is least likely to be associated with this condition. Anal pruritus affects up to 5% of the population. It is often persistent and the constant urge to scratch the area can cause great distress. Although usually caused by a combination of irritants, particularly faecal soiling and dietary factors, it can be a symptom of serious dermatosis, skin or generalised malignancy or systemic illness.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 8
Incorrect
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A 25-year-old male is found to have a 5cm carcinoid tumour of the appendix. Imaging and diagnostic workup show no distant diseases. What is the best course of action?
Your Answer:
Correct Answer: Right hemicolectomy
Explanation:Carcinoid tumours are of neuroendocrine origin and derived from primitive stem cells in the gut wall, especially the appendix.
Signs and symptoms of carcinoid tumours vary greatly. Carcinoid tumours can be non-functioning presenting as a tumour mass or functioning. The sign and symptoms of a non-functioning tumour depend on the tumour location and size as well as on the presence of metastases. Therefore, findings range from no tumour-related symptoms (most carcinoid tumours) to full symptoms of carcinoid syndrome (primarily in adults).
– Periodic abdominal pain: Most common presentation for a small intestinal carcinoid; often associated with malignant carcinoid syndrome
– Cutaneous flushing: Early and frequent (94%) symptom
– Diarrhoea and malabsorption (84%)
– Cardiac manifestations (60%): Valvular heart lesions, fibrosis of the endocardium; may lead to heart failure with tachycardia and hypertension
– Wheezing or asthma-like syndrome (25%)
– Pellagra
– Carcinoid crisis can be the most serious symptom of carcinoid tumours and can be life-threatening. It can occur suddenly, after stress, or following chemotherapy and anaesthesia.Two surgical procedures can be applied to treat appendiceal Neuroendocrine Neoplasm (NEN): simple appendicectomy and oncological right-sided hemicolectomy.
– For T1 (ENETS) or T1a (UICC/AJCC) NEN (i.e. <1 cm), generally simple appendicectomy is curative and sufficient.
– For NEN >2 cm with a T3 stage (ENETS) or higher and T2 (UICC/AJCC) or higher respectively, a right-sided hemicolectomy is advised due to the increased risk of lymph node metastasis and long-term tumour recurrence and/or distant metastasis. The right-sided hemico- lectomy should be performed either as the initial surgical intervention should the problem be overt at that time, or during a second intervention. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 9
Incorrect
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A 57 year old male is diagnosed with carcinoma of the caecum. A CT scan is performed and it shows a tumour invading the muscularis propria with some regional lymphadenopathy. What is the best initial treatment?
Your Answer:
Correct Answer: Right hemicolectomy
Explanation:Open right hemicolectomy (open right colectomy) is a procedure that involves removing the caecum, the ascending colon, the hepatic flexure (where the ascending colon joins the transverse colon), the first third of the transverse colon, and part of the terminal ileum, along with fat and lymph nodes. It is the standard surgical treatment for malignant neoplasms of the right colon; the effectiveness of other techniques are measured by the effectiveness of this technique.
The caecum is a short, pouch-like region of the large intestine between the ascending colon and vermiform appendix. It is located in the lower right quadrant of the abdominal cavity, inferior and lateral to the ileum.
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This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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Question 10
Incorrect
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A 32 year old man has a perianal abscess at 6 o'clock position. Which of the following is the most appropriate step in the management of this patient?
Your Answer:
Correct Answer: Examination under anaesthetic and drainage of sepsis
Explanation:Optimal physical assessment of an anorectal abscess may require anaesthesia to alleviate patient discomfort that would otherwise limit the extent of the examination.
Drainage should be carried out promptly to prevent the sepsis worsening. Perianal incisions to allow drainage of pus should be circumanal, thus reducing the likelihood of damage to the sphincters and thereby preventing faecal incontinence. -
This question is part of the following fields:
- Colorectal Surgery
- Generic Surgical Topics
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