MCQ bank · 37 questions · free
Colorectal & anal surgery MCQs with answers
37 single-best-answer questions on diverticulitis, colorectal cancer, IBD, haemorrhoids, fissure and fistula. Try each one, then open the answer to see the explanation, why the other options are wrong, and the guideline or trial behind it.
A 48-year-old, otherwise healthy woman has left iliac fossa pain. CT shows uncomplicated sigmoid diverticulitis without abscess or free gas. She is not immunosuppressed and can eat and drink. What is appropriate?
- Outpatient care; antibiotics can be used selectively rather than routinely
- Admission for intravenous antibiotics for 7 days
- Percutaneous drainage
- Colonoscopy within 48 hours
- Urgent sigmoid colectomy
Show the answer and explanation
Answer: A. Outpatient care; antibiotics can be used selectively rather than routinely. In selected immunocompetent patients with uncomplicated diverticulitis, antibiotics may be omitted, as trials showed no difference in recovery or complications. Patients who cannot tolerate oral intake, are immunosuppressed or are septic still need antibiotics and admission.
Why not the others? Colonoscopy is done after recovery (about 6–8 weeks) if the colon has not been assessed, never during the acute attack.
References
A 63-year-old man with sigmoid diverticulitis has a 5-cm pericolic abscess on CT. He is stable without generalised peritonitis. What is the best initial treatment?
- Emergency Hartmann’s procedure
- Oral antibiotics at home
- Intravenous antibiotics and CT-guided percutaneous drainage
- Colonoscopy to drain the abscess
- Laparoscopic lavage
Show the answer and explanation
Answer: C. Intravenous antibiotics and CT-guided percutaneous drainage. Abscesses larger than about 3 cm are best drained percutaneously alongside antibiotics; smaller ones often respond to antibiotics alone. Surgery is for failure of drainage or generalised peritonitis.
Why not the others? Emergency resection is not the first choice in a stable patient with a drainable abscess.
References
A 31-year-old woman has a chronic posterior anal fissure for 4 months. Eight weeks of topical diltiazem and fibre have not helped. Continence is normal. What is the most effective treatment?
- Manual anal dilatation
- Lateral internal sphincterotomy
- Fistulotomy
- Haemorrhoidectomy
- Continue diltiazem for another 6 months
Show the answer and explanation
Answer: B. Lateral internal sphincterotomy. Lateral internal sphincterotomy has the highest healing rate for chronic fissure after failed topical treatment, with a low risk of incontinence when the division is limited. Botulinum toxin is an alternative for patients who wish to avoid surgery or have risk factors for incontinence.
Why not the others? Manual dilatation causes unpredictable sphincter damage and is no longer recommended.
References
An 82-year-old man from a care home has abdominal distension and a “coffee bean” sign on X-ray. CT confirms sigmoid volvulus without ischaemia or perforation. What is the best management?
- Emergency Hartmann’s procedure
- Barium enema reduction
- Conservative treatment with laxatives
- Endoscopic detorsion and discharge without further plans
- Endoscopic detorsion, then sigmoid colectomy during the same admission if he is fit
Show the answer and explanation
Answer: E. Endoscopic detorsion, then sigmoid colectomy during the same admission if he is fit. Endoscopic detorsion treats the acute episode, but recurrence is common (often more than half), so elective sigmoid resection during the same admission is recommended for patients fit for surgery.
Why not the others? Emergency resection is for ischaemia, perforation or failed detorsion.
References
Colonoscopy in a 64-year-old man shows an adenocarcinoma 8 cm from the anal verge. CT of the chest, abdomen and pelvis shows no metastases. Which test is used for local staging?
- Barium enema
- Repeat colonoscopy
- Serum CEA alone
- PET-CT
- MRI of the pelvis
Show the answer and explanation
Answer: E. MRI of the pelvis. High-resolution pelvic MRI shows the depth of tumour spread, the circumferential resection margin, nodal disease and extramural venous invasion. These findings decide whether the patient goes straight to surgery or has neoadjuvant treatment first. Endorectal ultrasound helps for small, early tumours.
Why not the others? CEA is a baseline marker, not a staging test. PET-CT is not routine.
References
A 33-year-old man has a 3-day history of a painful, fluctuant swelling next to the anus, with no systemic illness. He is not diabetic or immunosuppressed. What is the treatment?
- Prompt incision and drainage; antibiotics are not routinely needed
- Wait for it to discharge spontaneously
- Fistulotomy and probing for a fistula at the same time in every case
- Oral antibiotics and review in 1 week
- MRI before any treatment
Show the answer and explanation
Answer: A. Prompt incision and drainage; antibiotics are not routinely needed. An anorectal abscess needs prompt drainage. Antibiotics add little after adequate drainage, and are given only for cellulitis, systemic sepsis, immunosuppression, diabetes or prosthetic valves. Patients should be told that a fistula develops later in about one-third.
Why not the others? Antibiotics alone do not treat pus and let the abscess spread. Forceful probing for a fistula during the acute stage risks false passages.
References
A 30-year-old woman has had a very painful, tense, purple lump at the anal margin for 36 hours. Examination confirms a thrombosed external haemorrhoid. What do you offer?
- Antibiotics
- Sclerotherapy
- Excision of the thrombosed haemorrhoid under local anaesthetic
- Rubber band ligation
- Emergency haemorrhoidectomy of all three columns under general anaesthesia
Show the answer and explanation
Answer: C. Excision of the thrombosed haemorrhoid under local anaesthetic. When seen early, usually within about 72 hours of onset, excision of the thrombosed external haemorrhoid gives faster relief and fewer recurrences than conservative care; the 2024 ASCRS guideline supports early excision in selected patients. Later on, the pain is already settling and conservative treatment (analgesia, stool softeners, topical treatment) is preferred.
Why not the others? Banding and sclerotherapy are for internal haemorrhoids and are very painful below the dentate line.
References
A 61-year-old woman has a 3-cm squamous cell carcinoma of the anal canal. Staging shows no nodal or distant spread. What is the first-line treatment?
- Abdominoperineal resection
- Chemotherapy alone
- Local excision
- Radiotherapy alone
- Chemoradiotherapy with fluorouracil (or capecitabine) and mitomycin
Show the answer and explanation
Answer: E. Chemoradiotherapy with fluorouracil (or capecitabine) and mitomycin. Chemoradiotherapy cures most anal squamous cancers while preserving the sphincter. Abdominoperineal resection is reserved for persistent or recurrent disease after chemoradiotherapy.
Why not the others? Local excision is only for small, well-differentiated tumours of the anal margin.
References
A fit 70-year-old has large bowel obstruction from a potentially curable cancer of the descending colon, without perforation. Which statement is correct?
- Treat with laxatives
- Colonoscopic biopsy alone will relieve the obstruction
- A stent is never appropriate in curable cancer
- A self-expanding metal stent as a bridge to elective surgery is an option, decided in a multidisciplinary discussion with an experienced team
- Emergency surgery is always contraindicated
Show the answer and explanation
Answer: D. A self-expanding metal stent as a bridge to elective surgery is an option, decided in a multidisciplinary discussion with an experienced team. In left-sided obstructing colon cancer, stenting as a bridge to surgery allows the patient to recover and be staged, and reduces the need for a stoma, but it carries a risk of perforation. Emergency resection remains a valid alternative. The choice depends on local expertise and the patient.
Why not the others? Laxatives are dangerous in complete obstruction.
References
A fit 45-year-old woman has a full-thickness rectal prolapse that comes out every time she opens her bowels. What operation gives the lowest recurrence?
- A perineal (Delorme’s) procedure
- Banding of the prolapse
- Thiersch wire
- Haemorrhoidectomy
- An abdominal (usually laparoscopic) rectopexy
Show the answer and explanation
Answer: E. An abdominal (usually laparoscopic) rectopexy. Abdominal rectopexy, often laparoscopic ventral mesh rectopexy, has lower recurrence than perineal operations and is preferred in fit patients. Perineal procedures (Delorme’s or Altemeier’s) avoid an abdominal operation and suit frail, elderly patients, accepting more recurrence.
Why not the others? Banding is for internal haemorrhoids, not full-thickness prolapse.
References
After a laparoscopic sigmoid colectomy for cancer, the pathology shows a T3 N1 (2 of 18 nodes positive) adenocarcinoma with clear margins. CT shows no metastases. What is the next step?
- Adjuvant chemotherapy with a fluoropyrimidine and oxaliplatin; 3 months of CAPOX is an option for low-risk stage III
- Radiotherapy to the pelvis
- Immunotherapy for every patient
- Repeat surgery
- Observation only
Show the answer and explanation
Answer: A. Adjuvant chemotherapy with a fluoropyrimidine and oxaliplatin; 3 months of CAPOX is an option for low-risk stage III. Stage III colon cancer has a survival benefit from adjuvant chemotherapy. The IDEA collaboration showed that 3 months of CAPOX is as good as 6 for low-risk stage III disease (T1–3 N1), with much less neuropathy.
Why not the others? Immunotherapy is used in mismatch repair-deficient tumours in specific settings, not routinely.
References
A 40-year-old woman has a recurrent anal fistula. MRI shows a high transsphincteric tract involving more than half of the external sphincter. What is the right approach?
- Fistulotomy, laying the tract open completely
- A sphincter-preserving approach: draining seton first, then a procedure such as LIFT or an advancement flap
- Leave it untreated
- Antibiotics alone
- Abdominoperineal resection
Show the answer and explanation
Answer: B. A sphincter-preserving approach: draining seton first, then a procedure such as LIFT or an advancement flap. Laying open a high fistula would divide much of the sphincter and risk incontinence, particularly in women, whose anterior sphincter is short. A loose seton controls sepsis, and a sphincter-preserving repair (ligation of the intersphincteric tract, advancement flap) is then attempted.
Why not the others? Fistulotomy is safe for low fistulas involving little sphincter.
References
A 28-year-old with acute severe ulcerative colitis has received intravenous steroids for 4 days. He still has 9 bloody stools a day, a CRP of 90 and a colon of 5 cm on X-ray. What is the next step?
- Rescue therapy (infliximab or ciclosporin) or subtotal colectomy with end ileostomy, decided jointly by the gastroenterology and surgical teams
- Colonoscopy with biopsies of the whole colon
- Emergency panproctocolectomy with ileal pouch
- Continue steroids for another 2 weeks
- Oral mesalazine only
Show the answer and explanation
Answer: A. Rescue therapy (infliximab or ciclosporin) or subtotal colectomy with end ileostomy, decided jointly by the gastroenterology and surgical teams. Failure of intravenous steroids by about day 3 should trigger rescue medical therapy or surgery. In the emergency, the operation is a subtotal colectomy with end ileostomy, leaving the rectum; a pouch can be formed later when the patient is well. Delaying surgery increases complications.
Why not the others? A full colonoscopy is dangerous in acute severe colitis because of perforation risk; a limited flexible sigmoidoscopy is used instead.
References
A 62-year-old man with a change in bowel habit has a faecal immunochemical test (FIT) result of 85 µg Hb/g. What is the next step?
- Reassure, as FIT is often falsely positive
- Repeat FIT in 1 year
- Abdominal ultrasound only
- Urgent referral for colonoscopy on a suspected colorectal cancer pathway
- Treat as haemorrhoids
Show the answer and explanation
Answer: D. Urgent referral for colonoscopy on a suspected colorectal cancer pathway. A FIT result of 10 µg Hb/g or more in a symptomatic patient warrants urgent referral and colonoscopy (or CT colonography if colonoscopy is unsuitable). FIT helps prioritise referrals because a negative result makes cancer much less likely.
Why not the others? A positive FIT must not be attributed to haemorrhoids without examining the colon.
References
A 45-year-old woman has a right hemicolectomy for colon cancer. Which test should be done on the tumour for every patient?
- No further testing
- Mismatch repair testing (immunohistochemistry or microsatellite instability) to screen for Lynch syndrome
- CA-125
- BRCA testing
- HER2 testing
Show the answer and explanation
Answer: B. Mismatch repair testing (immunohistochemistry or microsatellite instability) to screen for Lynch syndrome. All colorectal cancers should be tested for mismatch repair deficiency. It identifies Lynch syndrome (with implications for the patient and relatives, including endometrial cancer risk), and the result also affects prognosis and the choice of systemic therapy, including immunotherapy.
Why not the others? Testing only young patients or those with a family history misses many Lynch syndrome carriers.
References
After neoadjuvant chemoradiotherapy for a low rectal cancer, MRI and endoscopy show no residual tumour (a clinical complete response). The patient strongly wishes to avoid a stoma. Which option may be discussed?
- Abdominoperineal resection is the only acceptable option
- A “watch and wait” strategy with intensive surveillance in an experienced centre, with surgery if the tumour regrows
- No follow-up is needed
- Chemotherapy for life
- Radiotherapy is repeated every year
Show the answer and explanation
Answer: B. A “watch and wait” strategy with intensive surveillance in an experienced centre, with surgery if the tumour regrows. In patients with a complete clinical response, organ preservation with close surveillance avoids major surgery and a stoma for many. Around a quarter to a third have local regrowth, mostly in the first 2 years, which can usually be salvaged with surgery. This requires an expert team and a committed patient.
Why not the others? Without surveillance, regrowth would be missed.
References
A 26-year-old with Crohn’s disease has painful perianal swelling and discharge. MRI shows a complex fistula with an abscess. What is the management?
- Examination under anaesthesia, drainage of the abscess and placement of loose draining setons, then anti-TNF therapy
- Steroid enemas only
- Fistulotomy laying open all tracts
- Proctectomy as first treatment
- Antibiotics alone
Show the answer and explanation
Answer: A. Examination under anaesthesia, drainage of the abscess and placement of loose draining setons, then anti-TNF therapy. Perianal Crohn’s disease is managed jointly: sepsis is controlled surgically (drainage and setons) and the disease is treated medically, usually with anti-TNF therapy. Aggressive fistulotomy risks incontinence and non-healing wounds.
Why not the others? Antibiotics help but do not drain an abscess.
References
A 30-year-old with Crohn’s disease limited to 15 cm of terminal ileum has obstructive symptoms despite medical treatment. There is no abscess. Which option is supported by trial evidence as a reasonable alternative to escalating to biologic therapy?
- Total colectomy
- Observation
- Lifelong parenteral nutrition
- Laparoscopic ileocaecal resection
- Long-term steroids
Show the answer and explanation
Answer: D. Laparoscopic ileocaecal resection. The LIR!C trial showed that in limited, non-stricturing ileocaecal Crohn’s disease failing conventional therapy, laparoscopic ileocaecal resection gives quality of life comparable to infliximab, and many patients needed no further treatment. Fibrotic strictures respond poorly to drugs and are best treated surgically.
Why not the others? Long-term steroids are harmful and do not maintain remission.
References
A 48-year-old woman has faecal incontinence years after an obstetric tear. Diet and loperamide have helped only partly. What is the next step?
- Haemorrhoidectomy
- Specialist pelvic floor assessment with biofeedback and physiotherapy, then sacral nerve stimulation or sphincter repair if needed
- Immediate colostomy
- Antibiotics
- No treatment exists
Show the answer and explanation
Answer: B. Specialist pelvic floor assessment with biofeedback and physiotherapy, then sacral nerve stimulation or sphincter repair if needed. Faecal incontinence is managed stepwise: diet, stool modification and loperamide; then pelvic floor muscle training and biofeedback; then specialist tests (endoanal ultrasound, manometry) and procedures such as sacral nerve stimulation or sphincteroplasty. A stoma is a last resort.
Why not the others? Many patients improve with conservative measures, and asking about incontinence directly helps uncover the problem.
References
A 40-year-old man has painless bright red bleeding on the paper with grade II internal haemorrhoids (prolapse that reduces spontaneously). Fibre and fluids have not helped. What is the treatment?
- Rubber band ligation in the outpatient clinic
- Antibiotics
- Colectomy
- Lateral internal sphincterotomy
- Excisional haemorrhoidectomy
Show the answer and explanation
Answer: A. Rubber band ligation in the outpatient clinic. Office-based rubber band ligation is effective for grade I–II, and many grade III, internal haemorrhoids that fail dietary measures. Excisional haemorrhoidectomy is for larger or mixed haemorrhoids, or failure of banding. Patients over about 45–50, or with other symptoms, need the colon examined.
Why not the others? Sphincterotomy is for fissures, not haemorrhoids.
References
A 52-year-old has recovered from his second episode of uncomplicated sigmoid diverticulitis in 3 years. He asks whether he needs an operation now. What is correct?
- Surgery is never indicated
- Lifelong antibiotics are required
- Elective sigmoid colectomy is an individual decision based on symptoms and quality of life, not on the number of episodes
- Colectomy is mandatory after two episodes
- Colectomy is mandatory after the first episode in anyone under 50
Show the answer and explanation
Answer: C. Elective sigmoid colectomy is an individual decision based on symptoms and quality of life, not on the number of episodes. The old rule of operating after two attacks has been abandoned. Most recurrences are uncomplicated, and emergency surgery is rare after uncomplicated disease. Elective resection is offered for frequent or persistent symptoms, complications (fistula, stricture) or immunosuppression.
Why not the others? Complicated disease with fistula or stricture usually needs resection.
References
During an anterior resection for mid-rectal cancer, what is the key principle that reduces local recurrence?
- Removing only the visible tumour
- Blunt finger dissection of the rectum
- Leaving the mesorectum to preserve nerves
- Dividing the mesorectum close to the bowel wall
- Total mesorectal excision: sharp dissection in the plane around the intact mesorectal fascia
Show the answer and explanation
Answer: E. Total mesorectal excision: sharp dissection in the plane around the intact mesorectal fascia. Total mesorectal excision removes the rectum with its surrounding fatty envelope (mesorectum), containing the lymph nodes, in an intact package. It has greatly reduced local recurrence. The quality of the specimen and a clear circumferential margin are key measures of the operation.
Why not the others? Breaching the mesorectal fascia leaves tumour deposits behind.
References
A 2-cm pedunculated polyp removed at colonoscopy shows adenocarcinoma invading the stalk, with lymphovascular invasion, poor differentiation and a resection margin of 0.5 mm. CT shows no spread. What do you advise?
- No further treatment, because the polyp was removed
- Radiotherapy
- Surgical resection of that colonic segment with lymphadenectomy, because of high-risk features
- Repeat colonoscopy in 5 years
- Chemotherapy only
Show the answer and explanation
Answer: C. Surgical resection of that colonic segment with lymphadenectomy, because of high-risk features. A malignant polyp with high-risk features (margin under 1 mm, poor differentiation, lymphovascular invasion, tumour budding or deep submucosal invasion) carries a significant risk of residual cancer or nodal metastasis, so oncological resection is recommended for fit patients. Low-risk malignant polyps can be managed by surveillance.
Why not the others? Marking the site with a tattoo at colonoscopy helps the surgeon find it.
References
At colonoscopy, a 60-year-old has two adenomas removed completely: one is 12 mm and the other 5 mm, both with low-grade dysplasia. When should he have his next colonoscopy?
- In 3 years, because there are two premalignant polyps including one of 10 mm or more
- In 1 year
- In 6 months
- No further surveillance
- In 10 years
Show the answer and explanation
Answer: A. In 3 years, because there are two premalignant polyps including one of 10 mm or more. The 2020 BSG/ACPGBI guideline recommends a 3-year surveillance colonoscopy after either two or more premalignant polyps including at least one advanced polyp (10 mm or more, or high-grade dysplasia), or five or more premalignant polyps. Patients without these features return to national screening.
Why not the others? Surveillance that is too frequent increases risk and uses scarce resources.
References
A 16-year-old with familial adenomatous polyposis (APC mutation) has hundreds of colonic adenomas on colonoscopy. What is the definitive management?
- Prophylactic colectomy (ileorectal anastomosis or restorative proctocolectomy), usually planned in the late teens or early twenties
- Chemotherapy
- No treatment until cancer develops
- Aspirin only
- Annual polypectomy forever
Show the answer and explanation
Answer: A. Prophylactic colectomy (ileorectal anastomosis or restorative proctocolectomy), usually planned in the late teens or early twenties. Without surgery, nearly all people with classical FAP develop colorectal cancer. The choice of operation depends on rectal polyp burden. Lifelong surveillance continues for duodenal adenomas and any remaining rectum or pouch.
Why not the others? Colonoscopic polypectomy cannot keep up with hundreds of polyps.
References
A 74-year-old has large bowel obstruction from a cancer of the ascending colon, without perforation. He is stable. What is the usual operation?
- Hartmann’s procedure
- Right hemicolectomy with primary ileocolic anastomosis (or ileostomy if the patient is unstable or at high risk)
- Total colectomy
- Colonic stent for every right-sided cancer
- Loop colostomy only
Show the answer and explanation
Answer: B. Right hemicolectomy with primary ileocolic anastomosis (or ileostomy if the patient is unstable or at high risk). Right-sided obstructing cancers are usually treated by emergency right hemicolectomy with primary anastomosis, which is generally safe in stable patients. Stenting is used less often on the right because results are less reliable.
Why not the others? Hartmann’s procedure is a left-sided operation.
References
A patient with a new ileostomy after a colectomy has stoma output of 2.5 litres a day, thirst and a rising creatinine. What is the management?
- Start laxatives
- Restrict hypotonic drinks (water, tea) and use an oral rehydration solution, plus loperamide (before meals) and a PPI, while correcting dehydration
- Encourage drinking several litres of water
- Fruit juice to replace electrolytes
- Stop all fluids
Show the answer and explanation
Answer: B. Restrict hypotonic drinks (water, tea) and use an oral rehydration solution, plus loperamide (before meals) and a PPI, while correcting dehydration. High-output stomas lose sodium and water. Drinking hypotonic fluids draws more sodium into the bowel and increases output. Oral rehydration solution, restricted hypotonic fluids, antimotility drugs and PPIs reduce output. Look for causes such as infection, obstruction or drugs.
Why not the others? Plain water worsens sodium loss.
References
A 65-year-old man with diverticular disease notices air bubbles when he passes urine and has recurrent urinary infections. What is the likely diagnosis and treatment?
- Simple cystitis; antibiotics only
- Colovesical fistula; confirm with CT, exclude cancer with colonoscopy, then sigmoid resection with closure of the bladder defect
- Bladder cancer; cystectomy
- Kidney stone; lithotripsy
- Prostatitis; tamsulosin
Show the answer and explanation
Answer: B. Colovesical fistula; confirm with CT, exclude cancer with colonoscopy, then sigmoid resection with closure of the bladder defect. Pneumaturia and faecaluria indicate a colovesical fistula, most often from diverticulitis; cancer and Crohn’s disease are other causes. CT shows air in the bladder and inflammation. Treatment is sigmoid resection; the bladder side usually heals with simple repair and catheter drainage.
Why not the others? Antibiotics alone do not close a fistula.
References
A 29-year-old has had an acute posterior anal fissure for 3 weeks with pain on defaecation and bright red blood. What is the first-line treatment?
- Fibre, fluids, stool softeners and sitz baths, with topical diltiazem or GTN
- Haemorrhoidectomy
- Botulinum toxin for every patient as first-line
- Lateral internal sphincterotomy now
- Antibiotics
Show the answer and explanation
Answer: A. Fibre, fluids, stool softeners and sitz baths, with topical diltiazem or GTN. Most acute fissures heal with conservative measures and topical agents that relax the internal sphincter. Diltiazem causes fewer headaches than GTN. Surgery is for chronic fissures that fail medical treatment.
Why not the others? Fissures off the midline, or multiple fissures, suggest Crohn’s disease, infection or malignancy.
References
A 55-year-old has large grade IV mixed internal and external haemorrhoids that remain prolapsed and bleed. What is the most effective treatment?
- Rubber band ligation
- Lateral internal sphincterotomy
- Sclerotherapy
- Fibre alone
- Excisional haemorrhoidectomy
Show the answer and explanation
Answer: E. Excisional haemorrhoidectomy. Excisional haemorrhoidectomy is the most effective treatment for grade IV haemorrhoids and large external components, with the lowest recurrence, at the cost of more pain. Banding and other office procedures are for smaller internal haemorrhoids.
Why not the others? Sphincterotomy does not treat haemorrhoids.
References
A patient with high-risk locally advanced rectal cancer (threatened circumferential margin on MRI) is fit for all treatments. Which approach is supported by the RAPIDO trial?
- Immediate surgery without preoperative treatment
- Local excision
- Chemotherapy only after surgery
- Radiotherapy alone without surgery for everyone
- Total neoadjuvant therapy: short-course radiotherapy followed by chemotherapy, then total mesorectal excision
Show the answer and explanation
Answer: E. Total neoadjuvant therapy: short-course radiotherapy followed by chemotherapy, then total mesorectal excision. In high-risk rectal cancer, giving all chemotherapy and short-course radiotherapy before surgery (total neoadjuvant therapy) reduced disease-related treatment failure, mainly distant metastases, compared with standard chemoradiotherapy and adjuvant chemotherapy. It also increases complete responses.
Why not the others? Upfront surgery for a threatened margin risks an involved margin and local recurrence.
References
A 34-year-old has had extensive ulcerative colitis for 9 years. When should colonoscopic surveillance for cancer start?
- Only after age 60
- 30 years after diagnosis
- Every month
- Never, if symptoms are controlled
- About 8 years after symptom onset, with the interval (1–5 years) based on risk
Show the answer and explanation
Answer: E. About 8 years after symptom onset, with the interval (1–5 years) based on risk. Long-standing colitis increases colorectal cancer risk. Surveillance starts about 8 years after symptoms began, and the interval depends on risk factors such as extent, active inflammation, strictures, previous dysplasia, primary sclerosing cholangitis (annual from diagnosis) and family history.
Why not the others? Primary sclerosing cholangitis with colitis needs annual surveillance from diagnosis.
References
A patient with Crohn’s disease has several short fibrotic small bowel strictures and has already had two resections. Which operation preserves bowel length?
- Gastrojejunostomy
- Strictureplasty
- Extensive small bowel resection
- Ileostomy without treating the strictures
- Total colectomy
Show the answer and explanation
Answer: B. Strictureplasty. Strictureplasty widens short fibrotic strictures without removing bowel, reducing the risk of short bowel syndrome in patients with multiple strictures or previous resections. Long strictures, or those with suspected cancer, are resected.
Why not the others? Repeated resections can lead to short bowel syndrome.
References
A 62-year-old has had curative resection for stage III colon cancer and adjuvant chemotherapy. What follow-up is recommended to detect treatable recurrence?
- Annual PET-CT for 20 years
- Regular CEA and CT of the chest, abdomen and pelvis for about 3–5 years, plus colonoscopy at 1 year
- Clinical review only, with no tests
- No follow-up
- Colonoscopy every 3 months
Show the answer and explanation
Answer: B. Regular CEA and CT of the chest, abdomen and pelvis for about 3–5 years, plus colonoscopy at 1 year. Intensive follow-up with CEA and CT detects liver and lung metastases early enough for curative resection in some patients. Colonoscopy at 1 year looks for new or missed tumours. Most recurrences occur in the first 3 years.
Why not the others? PET-CT is not used for routine surveillance.
References
A frail 88-year-old with dementia and severe heart disease has a recurrent full-thickness rectal prolapse. Which operation is most suitable?
- No treatment is possible
- A perineal procedure (Delorme’s or Altemeier’s), which can be done under regional anaesthesia
- Haemorrhoidectomy
- Abdominoperineal resection
- Laparoscopic ventral mesh rectopexy under prolonged general anaesthesia
Show the answer and explanation
Answer: B. A perineal procedure (Delorme’s or Altemeier’s), which can be done under regional anaesthesia. Perineal procedures avoid an abdominal operation and can be done under spinal anaesthesia, making them suitable for frail patients, although recurrence is higher than after abdominal rectopexy.
Why not the others? Fit patients do better with abdominal rectopexy.
References
After two attacks of diverticulitis, a 66-year-old has a narrowed sigmoid segment on CT and colonoscopy cannot pass it. Biopsies are negative. What do you advise?
- Repeat biopsies every year
- Antibiotics for 3 months
- Observation only
- Sigmoid resection, because cancer cannot be reliably excluded and the stricture may obstruct
- Colonic stent permanently
Show the answer and explanation
Answer: D. Sigmoid resection, because cancer cannot be reliably excluded and the stricture may obstruct. A sigmoid stricture after diverticulitis may hide a cancer, and biopsies can miss it. Resection treats the stricture, prevents obstruction and gives a definitive diagnosis.
Why not the others? Negative biopsies do not exclude cancer in a stricture.
References
A 72-year-old has a second episode of Clostridioides difficile infection 6 weeks after treatment of the first. What is the recommended treatment?
- Oral metronidazole for 6 weeks
- Intravenous vancomycin
- No treatment
- Fidaxomicin (with bezlotoxumab where available for high-risk patients); faecal microbiota transplantation for multiple recurrences
- Loperamide
Show the answer and explanation
Answer: D. Fidaxomicin (with bezlotoxumab where available for high-risk patients); faecal microbiota transplantation for multiple recurrences. Recurrence is common after C. difficile infection. Fidaxomicin has lower recurrence rates than vancomycin. Bezlotoxumab, a monoclonal antibody against toxin B, reduces further recurrence. After two or more recurrences, faecal microbiota transplantation is highly effective. Unnecessary antibiotics should be stopped.
Why not the others? Intravenous vancomycin does not reach the colon; oral vancomycin is used.
References