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  • Question 1 - An 88-year-old man presents to the Emergency Department with diffuse abdominal pain and...

    Correct

    • An 88-year-old man presents to the Emergency Department with diffuse abdominal pain and one episode of dark rectal bleeding. He is noticed to be in fast atrial fibrillation. He is an ex-smoker and drinks three pints of beer per week. On examination, he is not peritonitic, but his pain is generalised and only temporarily alleviated by opioid analgesia. His bloods show: white blood count 14 (4.5 to 11.0 × 109/l), c-reactive protein 23 (normal: Less than 10 mg/L) and arterial lactate 4.8 (normal 1 ± 0.5 mmol/l4). Abdominal and chest X-rays are unremarkable.
      What is the most likely diagnosis?

      Your Answer: Bowel ischaemia

      Explanation:

      When a patient presents with consistent abdominal pain, bowel ischaemia should be considered as a possible cause. This is especially true for elderly patients who experience crampy abdominal pain followed by dark rectal bleeding. Bowel ischaemia occurs when the bowel mucosa becomes necrotic due to a lack of blood flow. Atrial fibrillation increases the risk of mesenteric artery embolisation, which can lead to bowel ischaemia. A raised lactate level is also indicative of bowel ischaemia. Haemorrhoids, on the other hand, would not cause an acute abdomen and typically present as bright red blood on wiping stool. Ulcerative colitis is more common in younger patients and is characterised by episodes of bloody diarrhoea. It is not associated with smoking and acute exacerbations are characterised by many episodes of diarrhoea, some of which may be bloody, and fever. Bowel volvulus, which is twisting of the bowel leading to obstruction, would cause abdominal distension, pain, constipation, and bloody stool. However, this patient’s normal appearance on plain film X-rays makes bowel obstruction or volvulus unlikely. Diverticulitis, which is inflammation of outpouchings of the large bowel, usually presents with gradual onset of left iliac fossa pain, loose stools, and fever. It is associated with more episodes of loose stools and fever and can progress to shock.

    • This question is part of the following fields:

      • Colorectal
      62.2
      Seconds
  • Question 2 - A 60-year-old diabetic arrives at the Emergency Department complaining of severe abdominal pain....

    Incorrect

    • A 60-year-old diabetic arrives at the Emergency Department complaining of severe abdominal pain. The pain started suddenly and he has been experiencing bloody diarrhoea for the past six hours. Despite his discomfort, his physical examination does not reveal any significant findings. The patient has a notable medical history, having previously suffered a myocardial infarction that necessitated the placement of a pacemaker.
      What test is most likely to confirm a diagnosis of mesenteric ischemia?

      Your Answer: Magnetic resonance angiography (MRA)

      Correct Answer: Abdominal computed tomography (CT)

      Explanation:

      Diagnostic Imaging Techniques for Mesenteric Ischaemia

      Mesenteric ischaemia is a condition that occurs when there is a lack of blood flow to the intestines, which can lead to serious complications. There are several diagnostic imaging techniques that can be used to identify mesenteric ischaemia, including abdominal computed tomography (CT), abdominal ultrasound, abdominal X-ray, colonoscopy, and magnetic resonance angiography (MRA).

      Abdominal CT is often the first-line investigation used to rule out other causes and can identify signs of mesenteric ischaemia, such as gas in the intestinal wall and portal vein. Abdominal ultrasound is not useful in assessing bowel lesions but may indicate perforation and free fluid in the abdomen. Abdominal X-ray findings are non-specific and may not be helpful in narrowing down the differential. Colonoscopy can be helpful in looking at mucosal lesions of the bowel but carries a risk of perforation. MRA can be useful in assessing vascular pathology but is not recommended for patients with pacemakers.

      In conclusion, a combination of diagnostic imaging techniques may be necessary to accurately diagnose mesenteric ischaemia and determine the appropriate treatment plan.

    • This question is part of the following fields:

      • Colorectal
      71
      Seconds
  • Question 3 - A 32-year-old man with inflammatory bowel disease undergoes emergency surgery involving resection of...

    Correct

    • A 32-year-old man with inflammatory bowel disease undergoes emergency surgery involving resection of a portion of his bowel. At the clinico-pathological conference, the histological findings of the operative sample are discussed.
      Which of the following features is most indicative of Crohn’s disease?

      Your Answer: Transmural inflammation

      Explanation:

      Distinguishing Between Crohn’s Disease and Ulcerative Colitis: Histopathological Features

      Inflammatory bowel disease (IBD) is a term used to describe two conditions: Crohn’s disease and ulcerative colitis. While both conditions share some similarities, they have distinct differences that can be identified through histopathological examination of surgical specimens.

      Transmural inflammation, which affects all layers of the intestinal wall, is a hallmark feature of Crohn’s disease. This type of inflammation is not typically seen in ulcerative colitis. Additionally, Crohn’s disease often presents as skip lesions, meaning that affected areas are separated by healthy tissue. In contrast, ulcerative colitis typically presents as continuous disease limited to the large bowel.

      Crypt abscesses, which are collections of inflammatory cells within the crypts of the intestinal lining, are more commonly seen in ulcerative colitis. Mucosal inflammation, which affects only the surface layer of the intestinal lining, is more typical of ulcerative colitis as well.

      Other histopathological features that can help distinguish between Crohn’s disease and ulcerative colitis include the presence of rose thorn ulcers (deep ulcers with a characteristic appearance) in Crohn’s disease and lymphoid aggregates in Crohn’s disease but not in ulcerative colitis.

      In summary, while Crohn’s disease and ulcerative colitis share some similarities, histopathological examination of surgical specimens can help differentiate between the two conditions based on the presence or absence of certain features.

    • This question is part of the following fields:

      • Colorectal
      42.5
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  • Question 4 - A 28-year-old gardener who is typically healthy and in good shape visits his...

    Correct

    • A 28-year-old gardener who is typically healthy and in good shape visits his doctor complaining of worsening abdominal pain that has been present for two days. He also reports feeling nauseous and experiencing loose bowel movements. During the examination, the patient's temperature is found to be 37.9 °C, and he has a heart rate of 90 bpm and a blood pressure of 118/75 mmHg. The doctor notes that the patient's abdomen is tender to the touch and that he has a positive Rovsing sign. What is the most probable diagnosis for this patient?

      Your Answer: Appendicitis

      Explanation:

      Physical Signs and Symptoms of Abdominal Conditions

      Abdominal conditions can present with a variety of physical signs and symptoms that can aid in their diagnosis. Here are some common signs and symptoms associated with different abdominal conditions:

      Appendicitis: A positive Rovsing sign, psoas sign, and obturator sign are less commonly found symptoms of appendicitis. More common signs include rebound tenderness, guarding, and rigidity.

      Splenic rupture: A positive Kehr’s sign, which is acute shoulder tip pain due to irritation of the peritoneum by blood, is associated with a diagnosis of splenic rupture.

      Pyelonephritis: Positive costovertebral angle tenderness, also known as the Murphy’s punch sign, may indicate pyelonephritis.

      Abdominal aortic aneurysm: A large abdominal aortic aneurysm may present with a pulsatile abdominal mass on palpation of the abdomen. However, the Rovsing sign is associated with appendicitis, not an abdominal aneurysm.

      Pancreatitis: A positive Grey Turner’s sign, which is bruising/discoloration to the flanks, is most commonly associated with severe acute pancreatitis. Other physical findings include fever, abdominal tenderness, guarding, Cullen’s sign, jaundice, and hypotension.

      Knowing these physical signs and symptoms can aid in the diagnosis and treatment of abdominal conditions.

    • This question is part of the following fields:

      • Colorectal
      48
      Seconds
  • Question 5 - A 28-year-old woman with Crohn's disease undergoes a resection of her terminal ileum....

    Correct

    • A 28-year-old woman with Crohn's disease undergoes a resection of her terminal ileum. What is her greatest risk?

      Your Answer: Macrocytic normochromic anaemia

      Explanation:

      Gastrointestinal Disorders and Associated Nutritional Deficiencies

      The gastrointestinal tract plays a crucial role in the absorption of essential nutrients, and any disruption in this process can lead to various nutritional deficiencies. Here are some common gastrointestinal disorders and their associated nutritional deficiencies:

      1. Macrocytic normochromic anaemia: This type of anaemia is caused by vitamin B12 deficiency, which is absorbed in the terminal ileum. Without adequate B12, megaloblasts form in the bone marrow, leading to macrocytic normochromic anaemia. B12 supplements are necessary to prevent this condition.

      2. Osteomalacia: Reduced vitamin D absorption can cause osteomalacia, a condition where bones become soft and weak. Vitamin D is absorbed in the jejunum, so an ileal resection would not affect absorption. Crohn’s disease may also cause osteomalacia, but it typically affects the terminal ileum and proximal colon.

      3. Microcytic hypochromic anaemia: Iron deficiency is the most common cause of microcytic anaemia. Iron is absorbed in the duodenum and jejunum, so deficiency leading to microcytic normochromic anaemia is less likely. However, iron deficiency may occur secondary to internal bleeding or extensive small bowel disease.

      4. Angular stomatitis: This condition is commonly caused by Candida or staphylococcal infection. Iron deficiency, vitamin B12 deficiency, or dermatitis may also be causes. Patients with B12 deficiency may develop angular stomatitis, but not all patients with B12 deficiency develop this condition.

      5. Wernicke’s encephalopathy: Reduced thiamine (B1) absorption can cause Wernicke’s encephalopathy, a neurological disorder. Thiamine is absorbed in the upper small intestine.

    • This question is part of the following fields:

      • Colorectal
      782
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  • Question 6 - You are the F2 in the Surgical Outpatient Clinic and have been asked...

    Incorrect

    • You are the F2 in the Surgical Outpatient Clinic and have been asked to see Mrs Jones by the consultant. Mrs Jones is a 56-year-old lady who presents with trouble defecating, and although she still passes her motions normally, over the past month, she has noticed the uncomfortable feeling of still wanting to defecate after passing her motions. During the past 2 weeks, she has noticed she has been passing mucous and some blood but no change in colour. Examination is unremarkable.
      Which of the following does the National Institute for Health and Care Excellence (NICE) guidance recommend as an initial investigation?

      Your Answer: Rigid sigmoidoscopy

      Correct Answer: Colonoscopy

      Explanation:

      Choosing the Right Investigation for Bowel Habit Changes: A Guide

      When a patient experiences changes in bowel habit, it is important to choose the right investigation to determine the underlying cause. In this scenario, the patient is having difficulty defecating, feels incomplete emptying, and is passing mucous per rectum. The main differential diagnoses include colorectal cancer, colorectal polyps, and diverticular disease. Here are some options for investigations and their appropriateness:

      Colonoscopy: NICE recommends colonoscopy as the initial investigation for those without major co-morbidities. If a lesion is visualized, it can be biopsied, allowing for a diagnosis of colon cancer. Flexible sigmoidoscopy, followed by barium enema, can be offered in those with major co-morbidities.

      Barium enema: This may be considered in patients for whom colonoscopy is not suitable. However, it would not be the first investigation of choice in this patient without major co-morbidities.

      Faecal occult blood testing: This is a screening test offered to men and women aged 60-74 in the general population. It would not be appropriate to request this test in the above scenario, as it is not specific and would not offer any extra information for diagnosis. Plus, the patient already has signs of bleeding.

      Rigid sigmoidoscopy: This would be a valid option in the outpatient setting, as it allows quick visualization of the anorectal region. However, NICE guidance recommends colonoscopy as first line as it allows visualization of a much greater length of the bowel.

      Computerized tomography (CT) abdomen: For patients who present as emergencies, this may be more appropriate. However, in this case, in the outpatient setting, this is unlikely to be the investigation of choice.

      In summary, choosing the right investigation for bowel habit changes depends on the patient’s individual circumstances and the suspected underlying cause. Colonoscopy is often the first line investigation recommended by NICE, but other options may be appropriate in certain situations.

    • This question is part of the following fields:

      • Colorectal
      25.1
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  • Question 7 - A 65-year-old man presents to the clinic with three positive faecal occult blood...

    Correct

    • A 65-year-old man presents to the clinic with three positive faecal occult blood specimens. He has had no significant symptoms, apart from mild fatigue over the past few months.
      On examination, he has pale conjunctiva, but there are no other specific findings.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 105 g/l 135–175 g/l
      Mean corpuscular volume (MCV) 79 fl 76–98 fl
      White cell count (WCC) 4.5 × 109/l 4–11 × 109/l
      Platelets 275 × 109/l 150–400 × 109/l
      Erythrocyte sedimentation rate (ESR) 11 mm/hour 0–10mm in the 1st hour
      Sodium (Na+) 139 mmol/l 135–145 mmol/l
      Potassium (K+) 4.5 mmol/l 3.5–5.0 mmol/l
      Creatinine 100 μmol/l 50–120 µmol/l
      Alanine aminotransferase (ALT) 35 IU/l 5–30 IU/l
      Alkaline phosphatase 46 IU/l 30–130 IU/l
      Flexible colonoscopy: abnormal vessels visualised on the right side of the colon
      Which of the following is the initial therapy of choice?

      Your Answer: Endoscopic ablation of abnormal vessels

      Explanation:

      Management of Angiodysplasia of the Colon

      Angiodysplasia of the colon is a condition that commonly affects individuals over the age of 60 and presents with chronic hypochromic microcytic anemia or massive bleeding with hemodynamic instability in 15% of patients. The treatment of choice for this condition is endoscopic ablation of abnormal vessels. Surgery may be considered for those who do not respond to ablation therapy. A review colonoscopy in 6 months would not be appropriate as management is required for the observed angiodysplasia. Blood transfusion is not indicated unless there are signs of acute large-volume blood loss. Iron sulfate supplementation may not be necessary if the underlying condition is treated, as the iron deficiency should correct itself with adequate dietary intake.

    • This question is part of the following fields:

      • Colorectal
      48
      Seconds
  • Question 8 - A 73-year-old woman with a history of diverticular disease undergoes emergency abdominal surgery....

    Correct

    • A 73-year-old woman with a history of diverticular disease undergoes emergency abdominal surgery. When examining this patient after her surgery, you notice she has an end colostomy.
      What feature in particular will suggest that this patient has had a Hartmann’s procedure and not an abdominoperineal (AP) resection?

      Your Answer: Presence of rectum

      Explanation:

      The patient has a presence of rectum, indicating that they have undergone a Hartmann’s procedure, which is commonly performed for perforated diverticulitis or to palliate rectal carcinoma. This involves resecting the sigmoid colon and leaving the rectal stump, which is oversewn. An end colostomy is created in the left iliac fossa, which can be reversed later to restore intestinal continuity. The midline scar observed is not exclusive to a Hartmann’s procedure, as AP resections and other abdominal surgeries can also be carried out via a midline incision. The presence of an end colostomy confirms that a Hartmann’s procedure has been performed. The Rutherford-Morison scar, a transverse scar used for colonic procedures and kidney transplants, is not unique to either an AP resection or a Hartmann’s procedure. The presence of solid faeces in the stoma bag is expected for a colostomy, while ileostomies typically contain liquid faeces and are usually located in the right lower quadrant.

    • This question is part of the following fields:

      • Colorectal
      23.1
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  • Question 9 - A 65 year old man arrives at the emergency department complaining of abdominal...

    Incorrect

    • A 65 year old man arrives at the emergency department complaining of abdominal pain and distension. He reports not having a bowel movement in 4 days and is now experiencing vomiting. An abdominal X-ray reveals enlarged loops of the large intestine. The patient has no history of surgery and a physical examination shows a soft, tender abdomen without palpable masses. A rectal exam reveals an empty rectum. What is the probable cause of the obstruction?

      Your Answer: Sigmoid volvulus

      Correct Answer: Sigmoid carcinoma

      Explanation:

      Causes of Large Bowel Obstruction: Differential Diagnosis

      Large bowel obstruction can be caused by various conditions, and a proper diagnosis is crucial for appropriate management. The following are some possible causes of large bowel obstruction and their distinguishing features:

      1. Sigmoid Carcinoma: Colorectal cancer is a common cause of large bowel obstruction, with the sigmoid colon being the most commonly affected site. Patients may present with abdominal pain, distension, and constipation. Treatment usually involves emergency surgery.

      2. Sigmoid Volvulus: This occurs when the sigmoid colon twists on itself, leading to obstruction. The classic coffee bean sign may be seen on abdominal X-ray. Treatment involves endoscopic or surgical decompression.

      3. Incarcerated Inguinal Hernia: This occurs when a portion of the intestine protrudes through the inguinal canal and becomes trapped. Patients may present with a palpable mass in the groin, which is not described in the case history above. Treatment involves surgical repair.

      4. Adhesions: Adhesions are bands of scar tissue that can form after abdominal surgery. They can cause bowel obstruction by kinking or compressing the intestine. Adhesions usually affect the small bowel, but they can also involve the large bowel. Treatment involves surgery.

      5. Constipation: Chronic constipation can cause pseudo-obstruction, which mimics mechanical obstruction. However, the finding of an empty rectum on digital rectal examination makes constipation unlikely as the sole cause of large bowel obstruction.

      In conclusion, large bowel obstruction can have various causes, and a thorough evaluation is necessary to determine the underlying condition and appropriate treatment.

    • This question is part of the following fields:

      • Colorectal
      89.7
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  • Question 10 - A 20-year-old man presents with a 3-week history of left groin pain, associated...

    Correct

    • A 20-year-old man presents with a 3-week history of left groin pain, associated with a lump that seems to come and go.
      Following examination, the clinician deduces that the swelling is most likely to be an indirect inguinal hernia.
      Indirect inguinal hernias can be controlled at:

      Your Answer: 1.3 cm above the mid-point of the inguinal ligament

      Explanation:

      Understanding Inguinal Hernias: Key Landmarks and Assessment Techniques

      Inguinal hernias are a common condition that can cause discomfort and pain. Understanding the key landmarks and assessment techniques can aid in the diagnosis and management of this condition.

      Deep Inguinal Ring: The location of the deep inguinal ring is 1.3 cm above the midpoint of the inguinal ligament. Indirect hernias originate from this area.

      Pubic Tubercle: The pubic tubercle is a landmark that distinguishes between inguinal hernias and femoral hernias. Inguinal hernias emerge above and medial to the tubercle, while femoral hernias emerge below and lateral.

      Hasselbach’s Triangle: This is the area where direct hernias protrude through the abdominal wall. The triangle consists of the inferior epigastric vessels superiorly and laterally, the rectus abdominis muscle medially, and the inguinal ligament inferiorly.

      Inferior Epigastric Vessels: Direct hernias are medial to the inferior epigastric vessels, while indirect hernias arise lateral to these vessels. However, this assessment can only be carried out during surgery when these vessels are visible.

      Scrotum: If a lump is present within the scrotum and cannot be palpated above, it is most likely an indirect hernia.

      By understanding these key landmarks and assessment techniques, healthcare professionals can accurately diagnose and manage inguinal hernias.

    • This question is part of the following fields:

      • Colorectal
      50.7
      Seconds
  • Question 11 - A 17-year-old man presents to the Emergency Department with a lump in his...

    Correct

    • A 17-year-old man presents to the Emergency Department with a lump in his groin that he noticed while lifting weights. Upon examination, a soft palpable mass is found in the scrotum that can be reduced with gentle massage. What structure is most likely ascending along the deep inguinal ring through which this mass has passed?

      Your Answer: Inferior epigastric artery and vein

      Explanation:

      Anatomy Landmarks in Inguinal Hernias

      Inguinal hernias are a common condition that occurs when abdominal contents protrude through the inguinal canal. Understanding the anatomy landmarks involved in inguinal hernias is crucial for diagnosis and treatment. Here are some important landmarks to consider:

      1. Inferior epigastric artery and vein: These vessels lie immediately medial to the deep inguinal ring and are important landmarks when performing laparoscopic indirect inguinal hernia repair.

      2. Rectus abdominis muscle: This muscle forms the medial border of a spigelian hernia and also a direct inguinal hernia.

      3. Inguinal ligament: This represents the inferior limit of the deep inguinal ring.

      4. Femoral artery and vein: These vessels lie inferior to the inguinal ligament which forms the inferior boundary on the deep inguinal ring.

      5. Superficial inguinal ring: This lies medial to the deep inguinal ring but is not considered to form its medial border. Indirect hernias then travel through the inguinal canal after passing through the deep inguinal ring.

      In conclusion, understanding the anatomy landmarks involved in inguinal hernias is crucial for proper diagnosis and treatment.

    • This question is part of the following fields:

      • Colorectal
      17.4
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  • Question 12 - A 25-year-old medical student presents with a 2-month history of abdominal pain and...

    Incorrect

    • A 25-year-old medical student presents with a 2-month history of abdominal pain and diarrhoea. She has no family history of bowel conditions, has not traveled recently, and has no sick contacts. During colonoscopy, seven polyps measuring <5 mm in diameter are found proximal to the sigmoid colon and removed for further analysis. Which of the following conditions linked to bowel polyps is considered non-hereditary?

      Your Answer: Familial adenomatous polyposis (FAP)

      Correct Answer: Serrated polyposis syndrome

      Explanation:

      Overview of Hereditary Colorectal Polyp Disorders

      Hereditary colorectal polyp disorders are a group of genetic conditions that increase the risk of developing colorectal cancer. These disorders are caused by various genetic defects and are inherited in different patterns. Here are some of the most common hereditary colorectal polyp disorders:

      1. Serrated Polyposis Syndrome: This condition is characterized by the presence of numerous serrated and/or hyperplastic polyps in the colon and rectum. It is not associated with any specific genetic defect and is linked to an increased risk of colorectal cancer.

      2. Familial Adenomatous Polyposis (FAP): FAP is an autosomal dominant condition that causes the development of hundreds or thousands of adenomatous polyps in the colon. These polyps have a high risk of malignant transformation, and patients with FAP are likely to develop colorectal cancer if left untreated.

      3. Lynch Syndrome: Also known as hereditary non-polyposis colorectal cancer, Lynch syndrome is an autosomal dominant condition that increases the risk of developing colorectal cancer and other malignancies, including breast, stomach, endometrial, and urinary tract cancers.

      4. Peutz-Jeghers Syndrome: This autosomal dominant condition is characterized by the development of gastrointestinal hamartomatous polyps and mucocutaneous hyperpigmentation. Patients with Peutz-Jeghers syndrome have an increased risk of developing colorectal, breast, liver, and lung cancers.

      5. Gardner Syndrome: Gardner syndrome is a subtype of FAP that is inherited in an autosomal dominant pattern. It is characterized by the development of numerous colorectal polyps and extracolonic manifestations such as desmoids, osteomas, and epidermoid cysts. Prophylactic surgery is the mainstay of treatment for patients with Gardner syndrome.

      In conclusion, hereditary colorectal polyp disorders are a group of genetic conditions that increase the risk of developing colorectal cancer. Early detection and management are crucial in preventing the development of cancer in these patients.

    • This question is part of the following fields:

      • Colorectal
      21.9
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  • Question 13 - A 12-year-old girl presents to the General Practitioner (GP) with a 2-day history...

    Correct

    • A 12-year-old girl presents to the General Practitioner (GP) with a 2-day history of abdominal pain and fever, associated with vomiting. Following examination, the GP suspects a diagnosis of acute appendicitis and refers the patient to the surgical assessment unit at the local hospital. With regard to acute appendicitis, which one of the following statements is correct?

      Your Answer: It can result in thrombosis of the appendicular artery (endarteritis obliterans)

      Explanation:

      Appendicitis is a common condition that occurs when the appendix becomes inflamed and infected. It can be caused by obstruction of the appendix, usually by a faecolith, leading to the build-up of mucinous secretions and subsequent infection. Alternatively, pressure within the closed system can compress the superficial veins and eventually lead to thrombosis of the appendicular artery, resulting in ischaemic necrosis and gangrene. Appendicitis is most common between the ages of 10 and 30 years, and conservative management is rarely effective. Without treatment, appendicitis can progress to perforation and generalised peritonitis, which can be life-threatening. The pain associated with appendicitis is initially referred to the epigastric region and later localises to the right iliac fossa. Surgical intervention is almost always required, except in the case of an appendix mass or abscess, where removal is advised after an interval of 6-8 weeks.

    • This question is part of the following fields:

      • Colorectal
      32.9
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  • Question 14 - You are asked to see a 43-year-old man with a stoma in the...

    Correct

    • You are asked to see a 43-year-old man with a stoma in the right lower quadrant of his abdomen. It is sprouted and produces a liquid, light brown fluid.
      What form of stoma is this likely to be?

      Your Answer: Ileostomy

      Explanation:

      Types of Stomas: Ileostomy, Colostomy, Enterocutaneous Fistula, Mucous Fistula, and Urostomy

      Stomas are surgical openings created in the abdomen to allow for the elimination of waste products from the body. There are different types of stomas, each with its unique characteristics and functions.

      An ileostomy is a stoma created from the small intestine. The stool from an ileostomy is looser and more acidic, making it more likely to cause skin damage. To prevent this, ileostomies are fashioned with a spout for better delivery of the stoma content into the stoma bag.

      A colostomy, on the other hand, is a stoma created from the large intestine. Colostomies are generally flat and placed in the left iliac fossa, although this can vary.

      An enterocutaneous fistula is an abnormal passage between the gastrointestinal tract and the skin. It is not a stoma.

      A mucous fistula is a stoma that allows the collection of mucous associated with inflammatory bowel disease.

      Finally, a urostomy is formed as a result of bladder excision. Urostomies are created by anastomosis of the ureters and drainage into a segment of the small bowel, which has been resected and used to form an ileal conduit. This conduit delivers urine to the skin in the form of a spouted stoma. Urostomies can be differentiated from ileostomies by their output (urine vs. feces).

    • This question is part of the following fields:

      • Colorectal
      24
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  • Question 15 - A 21-year-old student presents to his General Practitioner with intermittent watery diarrhoea and...

    Correct

    • A 21-year-old student presents to his General Practitioner with intermittent watery diarrhoea and lower colicky abdominal pain. He has experienced these symptoms for two years and during this time has lost over a stone in weight. Recently he has noticed a strange red rash on his shins. Past medical history includes a diagnosis of a fissure-in-ano three years ago.
      What is the most likely diagnosis?

      Your Answer: Crohn’s disease

      Explanation:

      Diagnosis of Crohn’s Disease: Clinical Picture and Differential Diagnosis

      The clinical presentation of a patient with weight loss and a red rash on the shins suggests a possible diagnosis of Crohn’s disease. This condition typically affects individuals between the ages of 15-30 and is characterized by symptoms such as diarrhea, abdominal pain, and weight loss.

      A history of fissure-in-ano further supports the possibility of Crohn’s disease, as this condition is commonly associated with perianal disease. To confirm the diagnosis, a full blood count and colonoscopy with biopsy are necessary. Crohn’s disease is transmural and can affect any part of the gastrointestinal tract, leading to the formation of skip lesions between inflamed and unaffected bowel.

      Other conditions that may present with similar symptoms include infective colitis, ulcerative colitis, irritable bowel syndrome, and appendicitis. However, infective colitis typically has a shorter duration of symptoms, while ulcerative colitis presents with bloody diarrhea and mucous discharge. Irritable bowel syndrome is a diagnosis of exclusion, and a 2-year history effectively rules out appendicitis.

    • This question is part of the following fields:

      • Colorectal
      22.9
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  • Question 16 - A 68-year-old man presents to the General Surgical Outpatient Clinic with a 4-week...

    Correct

    • A 68-year-old man presents to the General Surgical Outpatient Clinic with a 4-week history of altered bowel habit. There is no history of rectal bleeding, although faecal occult blood testing is positive. He denies any other symptoms from the abdominal point of view, and his general examination is otherwise unremarkable.
      You discuss this case with the patient and agree that the next best step would be to undergo a colonoscopy and some blood tests. The results are shown below:
      Bloods:
      Investigation Result Normal value
      Haemoglobin 112g/l 135–175 g/l
      White cell count (WCC) 7.2 × 109/l 4–11 × 109/l
      Platelets 205 × 109/l 150–400 × 109/l
      Urea 4.5 mmol/l 2.5–6.5 mmol/l
      Creatinine 71 mmol/l 50–120 μmol/l
      Sodium (Na+) 135 mmol/l 135–145 mmol/l
      Potassium (K+) 4.1 mmol/l 3.5–5.0 mmol/l
      Endoscopy Report:
      The endoscope was passed to the caecum without complication. The caecum was identified with confidence as the ileocaecal valve and appendicular orifice were seen and also confirmed with transillumination. There are multiple diverticulae seen in the sigmoid colon. A large ulcerated and haemorrhagic lesion resembling a tumour was found at the splenic flexure. Multiple biopsies were taken and sent for histology. Small polyp found in ascending colon, snared without complication.
      Follow-up with histology results in General Surgery Clinic in one week. Histology to be discussed at the next gastrointestinal multidisciplinary meeting.
      The histology results come back as adenocarcinoma of the colon involving the splenic flexure. Further staging reveals no initial metastatic disease.
      Which of the following is the next best course of action?

      Your Answer: Proceed to left hemicolectomy

      Explanation:

      Surgical Options for Bowel Carcinoma: Choosing the Right Procedure

      When it comes to resecting bowel carcinoma, the location of the tumor and the blood supply to the bowel are the primary factors that determine the appropriate operation. It’s crucial to ensure that the remaining bowel has a good blood supply after the resection.

      For tumors in the splenic flexure or descending colon, a left hemicolectomy is the most suitable procedure. This operation involves removing part of the transverse colon, descending colon, and sigmoid up to the upper rectum, which are supplied by the left colic artery and its branches.

      If the tumor is located in the transverse colon, a transverse colectomy may be performed. An extended right hemicolectomy is necessary for tumors in the hepatic flexure.

      For non-metastatic bowel cancer, surgical removal of the tumor and a portion of the bowel is the primary treatment. However, if the patient refuses surgery, chemotherapy alone can be used, but the prognosis may vary.

      Preoperative neoadjuvant chemotherapy and surgery are not recommended at this point since there are no identifiable metastases, and the histology results are not yet available to determine the grade of the tumor and the number of mesenteric lymph nodes affected.

    • This question is part of the following fields:

      • Colorectal
      152.8
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  • Question 17 - A 32-year-old man comes to the Emergency Department complaining of lower abdominal pain....

    Correct

    • A 32-year-old man comes to the Emergency Department complaining of lower abdominal pain. He reports that the pain began 6 hours ago as a vague discomfort around his belly button, but has since become a sharp pain in the right iliac fossa, which worsens when he walks or coughs. He has lost his appetite and has vomited twice. The examining surgeon suspects that he may have appendicitis.
      Which dermatome level in the spinal cord receives afferent signals from the periumbilical pain in this condition?

      Your Answer: T10

      Explanation:

      Sensory Levels and Pain Localization in Appendicitis

      Appendicitis is a common condition that causes inflammation of the appendix. The initial pain associated with this condition is vague and poorly localized, and it is felt in the periumbilical region. However, as the inflammation progresses and the parietal peritoneum adjacent to the appendix becomes inflamed, the pain becomes sharp and localizes to the right iliac fossa.

      The sensory level for visceral afferents from the appendix is at the 10th thoracic segment, which is the same level as the somatic afferents from the anterior abdominal wall in the region of the umbilicus. This is why the initial pain is felt in the periumbilical region.

      The hip girdle and groin area are innervated by the cutaneous dermatome representing L1 spinal cord. However, T6 to T12 affect abdominal and back muscles, and T8 and T12 are not the correct sensory levels for appendicitis pain localization. Understanding the sensory levels and pain localization in appendicitis can aid in its diagnosis and treatment.

    • This question is part of the following fields:

      • Colorectal
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  • Question 18 - A 70-year-old woman presents to the Emergency Department with severe lower abdominal pain....

    Correct

    • A 70-year-old woman presents to the Emergency Department with severe lower abdominal pain. The pain started yesterday and is increasing in intensity. She has had loose stools for a few days and has been feeling nauseated. She has not vomited. There is no past medical history of note. On examination, there is tenderness and guarding in the left iliac fossa. Bloods: haemoglobin (Hb) 116 g/l; white cell count (WCC) 15 × 109/l.
      What is the most likely diagnosis?

      Your Answer: Diverticulitis

      Explanation:

      Diverticulitis is a condition where small pouches in the bowel wall become inflamed, often due to blockages. This is more common in older individuals and can cause symptoms such as fever, nausea, and abdominal pain. Treatment typically involves antibiotics and rest, but surgery may be necessary in severe cases. It is important to confirm the diagnosis and rule out other conditions, such as colorectal cancer, with lower gastrointestinal endoscopy. In contrast, Crohn’s disease and ulcerative colitis are less likely diagnoses in a 75-year-old patient without prior gastrointestinal history. Diverticulosis, the presence of these pouches without inflammation, is often asymptomatic and more common in the elderly.

    • This question is part of the following fields:

      • Colorectal
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  • Question 19 - A 35-year-old woman is experiencing constipation and undergoes diagnostic imaging, which reveals a...

    Correct

    • A 35-year-old woman is experiencing constipation and undergoes diagnostic imaging, which reveals a sigmoid volvulus. What are the most likely direct branches of the arteries that supply blood to this part of the colon?

      Your Answer: Inferior mesenteric artery

      Explanation:

      Arteries Involved in Sigmoid Colon Volvulus

      Sigmoid colon volvulus is a condition where a part of the colon twists and rotates, causing obstruction and ischemia. The following arteries are involved in this condition:

      1. Inferior mesenteric artery: The sigmoid colon is directly supplied by the sigmoid arteries, which branch directly from the inferior mesenteric artery.

      2. Ileocolic artery: The ileocolic artery is the terminal branch of the superior mesenteric artery and supplies the ileum, caecum, and ascending colon.

      3. Left common iliac artery: The left common iliac artery branches into the left external and internal iliac arteries, which supply the lower limbs and pelvis, including the rectum.

      4. Superior mesenteric artery: The superior mesenteric artery originates from the abdominal aorta and supplies the caecum, ascending colon, and transverse colon. However, the sigmoid colon is supplied by the inferior mesenteric artery.

      While the inferior mesenteric artery is the most specific artery involved in sigmoid colon volvulus, understanding the other arteries can also aid in diagnosis and treatment.

    • This question is part of the following fields:

      • Colorectal
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  • Question 20 - A 65-year-old male patient is admitted with severe abdominal pain and is diagnosed...

    Incorrect

    • A 65-year-old male patient is admitted with severe abdominal pain and is diagnosed with mesenteric vascular occlusion. The small bowel becomes gangrenous and requires resection. What is a potential complication of this surgical procedure?

      Your Answer: Constipation

      Correct Answer: Nephrolithiasis

      Explanation:

      Complications of Short Bowel Syndrome

      Short bowel syndrome refers to clinical problems that arise from the removal of varying lengths of the small bowel. One common complication is nephrolithiasis, which is caused by enteric hyperoxaluria resulting from increased absorption of oxalate in the large intestine. Bile acids and fatty acids increase colonic mucosal permeability, leading to increased oxalate absorption. Steatorrhoea is also common due to fat malabsorption in the small bowel. Weight loss, not weight gain, is a complication of this syndrome. Diarrhoea is a severe complication, especially after ileal resection, which results in malabsorption of bile acid and stimulates fluid secretion in the intestinal lumen. Nutritional deficiencies of vitamins A, D, E, K, folate, and B12 are also seen. Gastric hypersecretion is common, but achlorhydria is not a complication of small bowel resection.

    • This question is part of the following fields:

      • Colorectal
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  • Question 21 - A 21-year-old student presents to the General Practitioner with complaints of passing bright...

    Correct

    • A 21-year-old student presents to the General Practitioner with complaints of passing bright red blood during bowel movements. The patient experiences severe pain each time they open their bowels, which has been ongoing for the past two weeks. The patient is now very anxious and avoids opening their bowels whenever possible, but this seems to worsen the pain symptoms. Rectal examination is not possible due to the patient's inability to tolerate the procedure because of pain.
      What is the recommended treatment for the most likely diagnosis?

      Your Answer: Nitroglycerin ointment

      Explanation:

      Anal Fissure: Causes, Symptoms, and Treatment Options

      An anal fissure is a common condition that can occur at any age, but is most common in individuals aged 15-40. It can be primary, without underlying cause, or secondary, associated with conditions such as inflammatory bowel disease or constipation. Symptoms include severe anal pain during and after bowel movements, bleeding, and itching.

      Treatment options include managing pain with simple analgesia and topical anesthetics, regular sitz baths, increasing dietary fiber and fluid intake, and stool softeners. Topical glyceryl trinitrate ointment may also be used to promote relaxation of the anal sphincter and aid healing. If the fissure remains unhealed after 6-8 weeks, surgical management options such as local Botox injection or sphincterotomy may be considered.

      Antibiotic therapy does not have a role in the management of anal fissures, and band ligation is a secondary care option for the treatment of hemorrhoids, not anal fissures. Incision and drainage would only be indicated if the patient presented with a perianal abscess. Simple analgesia can be offered to manage pain symptoms, but opioid-containing preparations should be avoided to prevent further constipation and worsening of symptoms.

    • This question is part of the following fields:

      • Colorectal
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  • Question 22 - A 35-year-old woman with Crohn's disease presents with severe abdominal pain. Upon investigation,...

    Correct

    • A 35-year-old woman with Crohn's disease presents with severe abdominal pain. Upon investigation, a small intestinal obstruction is discovered, and during surgery, a large stricture is found in the terminal ileum. As a result, approximately 90 cm of the terminal ileum had to be resected. What is the most common complication in this scenario?

      Your Answer: Vitamin B12 deficiency

      Explanation:

      Complications of Terminal Ileum Resection

      When the terminal ileum is lost due to resection, there can be various complications depending on the length of the resection. One such complication is D-lactic acidosis, which occurs after the intake of refined carbohydrates. Gallstones may also form due to interruption in the enterohepatic circulation of bile acids. Patients with a short bowel are encouraged to eat more to replenish the different vitamins and minerals. They may also be at risk of developing calcium oxalate kidney stones. However, they are not at increased risk of uric acid stones unless they have coexisting conditions such as gout. It is important to note that iron deficiency may not be affected by ileal pathology, while vitamin K and D deficiencies are not common complications of terminal ileum resection.

    • This question is part of the following fields:

      • Colorectal
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  • Question 23 - A 67-year-old man presents with severe left lower abdominal pain, his third attack...

    Correct

    • A 67-year-old man presents with severe left lower abdominal pain, his third attack in the past 2 years. He admits to intermittent dark red blood loss per rectum (PR) and diarrhoea. He generally has a poor diet and dislikes fruit and vegetables. On examination, he has a temperature of 38.2 °C and a tachycardia of 95 bpm, with a blood pressure of 110/70 mmHg; his body mass index is 32. There is well-localised left iliac fossa tenderness.
      Investigations:
      Investigation Result Normal value
      Haemoglobin 110 g/l 135–175 g/l
      White cell count (WCC) 14.5 × 109/l (N 11.0) 4–11 × 109/l
      Platelets 280 × 109/l 150–400 × 109/l
      Sodium (Na+) 141 mmol/l 135–145 mmol/l
      Potassium (K+) 4.9 mmol/l 3.5–5.0 mmol/l
      Urea 10.0 mmol/l 2.5–6.5 mmol/l
      Creatinine 145 μmol/l 50–120 µmol/l
      C-reactive protein (CRP) 64 mg/l 0–10 mg/l
      Which of the following is the most likely diagnosis?

      Your Answer: Diverticulitis

      Explanation:

      Differentiating Diverticulitis from Other Colonic Conditions in Older Adults

      Diverticulitis is a common condition in older adults, characterized by recurrent attacks of lower abdominal pain, fever, and tenderness in the left lower quadrant. It is associated with increasing age and a diet poor in soluble fiber. Left-sided involvement is more common due to increased intraluminal pressures. Management is usually conservative with antibiotics, but surgery may be necessary in 15-25% of cases. Complications include bowel obstruction, perforation, fistula formation, and abscess formation.

      Colonic cancer, on the other hand, presents with insidious symptoms such as loss of appetite, weight loss, and rectal bleeding, especially if left-sided. Late presentations may cause bowel obstruction or disseminated disease. Inflammatory bowel disease is less common in older adults and would present differently. Irritable bowel syndrome does not cause periodic fevers and has a different pattern of pain. Gastroenteritis is usually viral and self-limiting, unlike diverticulitis. It is important to differentiate these conditions to provide appropriate management and prevent complications.

    • This question is part of the following fields:

      • Colorectal
      73.6
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  • Question 24 - You are asked to see an elderly patient who has not opened their...

    Correct

    • You are asked to see an elderly patient who has not opened their bowels for several days. Their abdomen is distended, and they describe cramping abdominal pain that comes and goes. A supine abdominal X-ray is performed to identify features of bowel obstruction and suggest the location of the obstruction.
      Which of the following is more characteristic of the large bowel, rather than the small bowel, on an abdominal X-ray?

      Your Answer: Haustral folds

      Explanation:

      Characteristics of Small and Large Bowel Anatomy

      The human digestive system is composed of various organs that work together to break down food and absorb nutrients. Two important parts of this system are the small and large bowel. Here are some characteristics that differentiate these two structures:

      Haustral Folds and Valvulae Conniventes
      Haustral folds are thick, widely separated folds that are characteristic of the large bowel. In contrast, valvulae conniventes are thin mucosal folds that pass across the full width of the small bowel.

      Location
      The small bowel is located towards the center of the abdomen, while the large bowel is more peripheral and frames the small bowel.

      Diameter
      The normal maximum diameter of the small bowel is 3 cm, while the large bowel can have a diameter of up to 6 cm. The caecum, a part of the large bowel, can have a diameter of up to 9 cm.

      Air-Fluid Levels in Obstruction
      The appearance of air-fluid levels is characteristic of small bowel obstruction.

      Remembering the 3/6/9 Rule
      To help remember the normal diameters of the small and large bowel, use the 3/6/9 rule: the small bowel has a diameter of 3 cm, the large bowel can have a diameter of up to 6 cm, and the caecum can have a diameter of up to 9 cm.

      Understanding the Differences Between Small and Large Bowel Anatomy

    • This question is part of the following fields:

      • Colorectal
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  • Question 25 - A 72-year-old man is undergoing open surgery to repair a direct inguinal hernia....

    Incorrect

    • A 72-year-old man is undergoing open surgery to repair a direct inguinal hernia. In theatre, the hernial sac is noted to lie medial to the inferior epigastric artery.
      To weakness of which of the following structures can the hernia best be attributed?

      Your Answer: Muscular fibres of transversus abdominis

      Correct Answer: Conjoint tendon

      Explanation:

      Types of Abdominal Hernias and Their Characteristics

      Abdominal hernias occur when an organ or tissue protrudes through a weak point in the abdominal wall. There are different types of abdominal hernias, each with its own characteristics and symptoms.

      Direct Inguinal Hernia

      A direct inguinal hernia occurs medial to the inferior epigastric vessels. The bowel sac is pushed directly through a weak point in the conjoint tendon, which is formed by the aponeurosis of the internal oblique and transversus abdominis muscles. This type of hernia is more common in men and worsens with exercise, coughing, or straining.

      Aponeurosis of External Oblique

      In a direct inguinal hernia, the bowel sac does not push through the aponeurosis of the external oblique muscle.

      Muscular Fibres of Internal Oblique

      A ventral hernia occurs through the muscular fibres of the anterior abdominal muscles, such as the internal oblique. It can be incisional or occur at any site of muscle weakening. Epigastric hernias occur above the umbilicus, and hypogastric hernias occur below the umbilicus.

      Muscular Fibres of Transversus Abdominis

      Another type of ventral hernia occurs through the muscular fibres of the transversus abdominis. It becomes more prominent when the patient is sitting, leaning forward, or straining. Ventral hernias can be congenital, post-operative, or spontaneous.

      Superficial Inguinal Ring

      An indirect inguinal hernia is the most common type of abdominal hernia. It occurs in men and children and arises lateral to the inferior epigastric vessels. The bowel sac protrudes through the deep inguinal ring into the inguinal canal and then through the superficial inguinal ring, extending into the scrotum. It may be asymptomatic but can also undergo incarceration or strangulation or lead to bowel obstruction.

      Understanding the Different Types of Abdominal Hernias

    • This question is part of the following fields:

      • Colorectal
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  • Question 26 - A 45-year-old man is admitted to the Surgical Unit with colicky central abdominal...

    Correct

    • A 45-year-old man is admitted to the Surgical Unit with colicky central abdominal pain. He has been vomiting for 6 hours and has not passed any stools for over 24 hours. On examination, he is in obvious discomfort; his abdomen is distended, and his pulse is 90 bpm, respiratory rate 18 breaths per minute and blood pressure 90/55 mmHg. A supine radiograph film confirms small bowel obstruction.
      What is the most common cause of small bowel obstruction in the United Kingdom (UK)?

      Your Answer: Adhesions

      Explanation:

      Causes and Management of Small Bowel Obstruction

      Small bowel obstruction is a common surgical condition that can be caused by various factors. The most common cause in the UK is adhesions, accounting for 50-70% of cases. Other causes include volvulus, hernia, malignancy, and foreign bodies. The obstruction can be classified based on its location, whether it is intraluminal, intramural, or extramural.

      The typical presentation of small bowel obstruction includes pain, vomiting, and failure to pass stool or gas. Abdominal distension and tinkling bowel sounds may also be observed, along with tachycardia and hypotension. Diagnosis is made through plain abdominal X-ray, which may show distended bowel loops in the center.

      Management of small bowel obstruction involves fluid resuscitation and prompt correction of the underlying cause. Conservative treatment, such as intravenous fluids and regular aspiration through a nasogastric tube, may be used initially. However, operative intervention is necessary for suspected strangulation, irreducible hernias, and cases that do not resolve with conservative management.

      In summary, small bowel obstruction can have various causes and presentations, but early diagnosis and appropriate management are crucial for successful outcomes.

    • This question is part of the following fields:

      • Colorectal
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  • Question 27 - A 42-year-old woman comes to her General Practitioner complaining of severe pain during...

    Correct

    • A 42-year-old woman comes to her General Practitioner complaining of severe pain during bowel movements and passing fresh red blood while opening her bowels for the past 2 weeks. She is experiencing slight constipation but is otherwise healthy and has no significant medical history.

      What would be the most suitable course of action for her management?

      Your Answer: Prescribe GTN cream and laxatives

      Explanation:

      Management of Anal Fissure: Laxatives and GTN Cream

      An anal fissure is often the cause of pain during defecation and fresh red blood per rectum. To diagnose the fissure, a full blood count and digital examination per rectum may be necessary. However, initial management should involve a combination of laxatives to soften the stool and glyceryl trinitrate (GTN) cream. Drinking plenty of fluids is also advised. These measures are effective in 80% of cases. Surgery may be considered if medical management fails. Colonoscopy is not necessary in this scenario. Co-codamol is not recommended as it may worsen constipation and aggravate the fissure. While dietary advice is helpful, prescribing laxatives and GTN cream is the best course of action for healing the fissure.

    • This question is part of the following fields:

      • Colorectal
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  • Question 28 - What is the correct statement regarding the greater omentum when asked to identify...

    Incorrect

    • What is the correct statement regarding the greater omentum when asked to identify it during an open repair of a perforated gastric ulcer by the operating surgeon, as observed by a medical student?

      Your Answer: It is two layers thick

      Correct Answer: It provides a route of access to the lesser sac

      Explanation:

      The Greater Omentum: An Integral Structure with Surgical Importance

      The greater omentum, also known as the gastrocolic omentum, is a double sheet of peritoneum that hangs down like an apron overlying loops of intestine. It is made up of four layers, two of which descend from the greater curvature of the stomach and are continuous with the peritoneum on the anterior and posterior surfaces of the stomach. The other two layers run between the anterior layers and the transverse colon, loosely blending with the peritoneum on the anterior and posterior surfaces of the colon and the transverse mesocolon above it.

      Contrary to the belief that it has no surgical importance, the greater omentum is of paramount surgical importance. Surgeons use it to buttress an intestinal anastomosis or in the closure of a perforated gastric or duodenal ulcer. It also attempts to limit the spread of intraperitoneal infections, earning it the nickname great policeman of the abdomen. The greater omentum is supplied by the right and left gastric arteries, and its blood supply may be cut off if it undergoes torsion.

      Furthermore, the greater omentum is often found plugging the neck of a hernial sac, preventing the entry of coils of the small intestine and strangulation of the bowel. In an acutely inflamed appendix, the omentum adheres to the appendix and wraps itself around the infected organ, localizing the infection to a small area of the peritoneal cavity. However, in the first two years of life, the greater omentum is poorly developed and less protective in young children.

      In conclusion, the greater omentum is an integral structure with significant surgical importance, providing access to the lesser sac and attempting to limit the spread of intraperitoneal infections.

    • This question is part of the following fields:

      • Colorectal
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  • Question 29 - A 40-year-old man with a chronic bowel condition presents with severe pain on...

    Correct

    • A 40-year-old man with a chronic bowel condition presents with severe pain on defecation, which has lasted over two months despite increasing fluid intake and stool softeners. He has had anal fissures in the past, as well as a previous perianal abscess. On examination, the anal area is inflamed, with evidence of a deep anal fissure with an associated large sentinel tag.
      The doctor explains that this is a symptom of active perianal disease secondary to this patient’s chronic bowel condition.
      With which of the following conditions is perianal disease most commonly associated?

      Your Answer: Crohn’s disease

      Explanation:

      Perianal Manifestations in Inflammatory Bowel Disease: A Comparison

      Inflammatory bowel disease (IBD) is a chronic condition that affects the digestive tract. Two main types of IBD are Crohn’s disease and ulcerative colitis. Both conditions can cause perianal manifestations, but the prevalence and severity differ.

      Crohn’s disease is commonly complicated by perianal abscesses, fistula-in-ano, anal fissures, and skin tags. Up to 80% of patients with Crohn’s disease may suffer from perianal disease, which can significantly impair their quality of life. In contrast, perianal disease is far less common in patients with ulcerative colitis.

      Coeliac disease, another digestive disorder, is not associated with perianal disease. However, it is linked to an increased risk of other autoimmune disorders such as type 1 diabetes and autoimmune thyroid disease.

      Diverticular disease, which causes abdominal pain, bloating, constipation, and diarrhea, is also not associated with an increased risk of perianal disease.

      Irritable bowel syndrome (IBS) is a functional disorder that causes symptoms such as bloating, cramping, abdominal pain, and constipation or diarrhea. Unlike IBD, IBS is not associated with an increased risk of perianal disease.

      In summary, perianal manifestations are more commonly seen in Crohn’s disease than ulcerative colitis or other digestive disorders. A multidisciplinary approach may be required to manage severe cases of perianal Crohn’s disease.

    • This question is part of the following fields:

      • Colorectal
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  • Question 30 - A 43-year-old man comes to the clinic complaining of colicky abdominal pain and...

    Correct

    • A 43-year-old man comes to the clinic complaining of colicky abdominal pain and vomiting. His medical history shows that he has had previous abdominal surgery. During the examination, you notice that his abdomen is distended, and upon auscultation, you hear 'tinkling' bowel sounds. An abdominal radiograph reveals multiple loops of dilated bowel centrally, with valvulae conniventes present. What is the most probable cause of his symptoms?

      Your Answer: Adhesions

      Explanation:

      Causes of Bowel Obstruction: Understanding the Symptoms and Differential Diagnosis

      Bowel obstruction is a serious medical condition that requires prompt diagnosis and treatment. In young patients, adhesions secondary to previous surgery are the most common cause of bowel obstruction, particularly in the small intestine. The four classical features of bowel obstruction are abdominal pain, vomiting, abdominal distension, and absolute constipation. It is important to differentiate between small bowel and large bowel obstruction, with age being a helpful factor in determining the latter.

      While colorectal carcinoma is a significant cause of large bowel obstruction, it only accounts for about 5% of cases in the UK. Hernias are the second most common cause of small bowel obstruction, but adhesions are more likely in patients with a history of abdominal surgery. Crohn’s disease typically presents with diarrhea, abdominal pain, and weight loss, while diverticulitis is more common in older patients and is unlikely to cause the symptoms described.

      In conclusion, understanding the various causes of bowel obstruction and their associated symptoms is crucial for accurate diagnosis and effective treatment.

    • This question is part of the following fields:

      • Colorectal
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SESSION STATS - PERFORMANCE PER SPECIALTY

Colorectal (23/30) 77%
Passmed