Exam (elaborations)
Surgical-Specialities
- Course
- Institution
Surgical-Specialities
[Show more]
Seller
Follow
Lansky
Content preview
MyPasTest: MRCS A Online - Jan Exam 201526. Surgical Specialities; General Surgery; Colorectal Surgery (36Qs)
01. A 46-year-old man attends colorectal clinic presenting with a 4 month history of a change in bowel
habit with blood mixed with stool. He has no relevant past medical history. What is the most appropriate
investigation? Single best answer - select one answer only.
Barium enema« YOUR ANSWER
Capsule endoscopy
Page
Colonoscopy« CORRECT ANSWER
CT scan
1541
Oesphagoduodenoscopy.
This 46-year-old male requires a lower GI endoscopy for his red flag symptoms of change in bowel habit
associated with PR bleeding. This test is the best investigation as it allows inspection of the bowel
mucosa, biopsy if required and is potentially even therapeutic, for example, if a polyp is seen this can be
removed by snare and sent for histology. It is an invasive test, requiring bowel preparation prior to the
procedure but he is otherwise well and there are no contradindications in undertaking colonoscopy. A
barium enema, though it could be useful, is not the best test for this patient. It may give an impression of
a lesion in the bowel wall but does not give such accurate information as colonoscopy in this case.
Furthermore he would still require an endoscopic biopsy if a lesion was seen. CT scans maybe useful for
detecting gross bowel pathology and staging for cancers but would not be as useful as colonoscopy here
as commented above. Oesphagoduodenoscopy (OGD) is useful if an upper GI source is suspected but
this patient has lower GI symptoms. Capsule endoscopy is an expensive test and not readily available. It
is useful for looking for a source of GI bleeding that occurs in the small bowel beyond the scope of the
OGD and proximal to the caecum/Terminal ileum which can be accessed by colonoscopy.
02. Theme: Abdominal system investigations
A Colonoscopy
B CT
C Endoanal ultrasound
D Evacuation proctogram
E Flexible sigmoidoscopy enema
F Mesenteric angiogram
G MRI
H Red cell scan
I Single contrast gastrografin.
For each of the following scenarios, select the most likely answer from
the above list. Each option may be used once, more than once, or not at all.
Scenario 1
Local invasiveness of rectal cancer in the pelvis.
A - Colonoscopy « YOUR ANSWER
G - MRI« CORRECT ANSWER.
G – MRI:
Tissue invasion within the pelvis by rectal cancer is best assessed with MRI as this modality gives the
best contrast resolution. MRI can identify whether the fascial envelope in which the rectum lies has been
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
26. Surgical Specialities; General Surgery; Colorectal Surgery (36Qs)
breached, or has a margin which may be threatened with tumour during surgical resection. With this
technique, MRI can predict if neoadjuvant chemoradiotherapy needs to be given.
Scenario 2
Evidence of secondary spread to the liver.
B - CT« CORRECT ANSWER.
Page
B – CT:
Hepatic metastases can be visualised by both MRI and CT. CT has better spatial resolution whereas MRI
1542
has superior contrast resolution.
Scenario 3
A 35-year-old lady with passive and urge faecal incontinence following obstetric injury.
C - Endoanal ultrasound « CORRECT ANSWER.
C – Endoanal ultrasound:
The most suitable investigation here would be an endoanal ultrasound to visualise the internal and
external anal sphincters. Other investigations that need to be requested in such a patient would be
anorectal manometry (to measure resting and squeeze anal pressures) and rectal sensory thresholds.
03. Theme: Diarrhoea
A Amoebic dysentery
B Bacterial enterocolitis
C Colonic carcinoma
D Crohn’s disease
E Diabetes
F Irritable bowel disease
G Giardiasis
H Malabsorption
I Neuro-endocrine tumour
J Overflow (faecal impaction)
K Pancreatic exocrine insufficiency
L Pseudomembranous colitis
M Thyrotoxicosis
N Ulcerative colitis.
The following scenarios describe patients with diarrhoea. From the above list choose the most
appropriate cause. Each item may be used once, more than once, or not at all.
Scenario 1
A 35-year-old woman presents with a 1-month history of passing bloody diarrhoea/mucus up to seven times per
day and lower abdominal pain. She was previously fit and well and her problems started following an episode of
food poisoning in Thailand. She has associated lethargy and weight loss. On examination, she appears pale and
abdominal examination reveals some lower abdominal tenderness. Haemoglobin 9.8 g/dl, mean corpuscular
volume 60, white cell count 13 x 109/litre, erythrocyte sedimentation rate 65, C-reactive protein 130. A stool
culture is negative. Sigmoidoscopy demonstrates active proctitis.
A - Amoebic dysentery« YOUR ANSWER
N - Ulcerative colitis« CORRECT ANSWER.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
26. Surgical Specialities; General Surgery; Colorectal Surgery (36Qs)
N – Ulcerative colitis:
Interestingly, both ulcerative colitis and irritable bowel syndrome (IBS) appear to be triggered in a
proportion of patients following acute enteritis (the entity of post-infectious IBS is well established). The
symptoms and signs are those of an acute attack of colitis confirmed by sigmoidoscopy. Clearly, before
steroids are administered, stool culture must be performed, however, as in this case.
Scenario 2 Page
A 24-year-old man presents to clinic with a few months of diarrhoea and abdominal pain. At colonoscopy, there is
patchy active inflammation affecting the transverse and right colon. Biopsies are reported as indeterminate colitis.
1543
B - Bacterial enterocolitis« YOUR ANSWER
D - Crohn’s disease« CORRECT ANSWER.
D – Crohn’s disease:
This patient (on balance) has evidence of Crohn’s colitis. This is supported by rectal sparing and skip
lesions within the colon. It is not infrequent for biopsies to have insufficient findings to conclusively
support a diagnosis either of Crohn’s disease or ulcerative colitis and these are usually described as
indeterminate.
04. Theme: Treatments for anal pain
A Anal canal carcinoma
B Fissure in ano
C Low subcutaneous anal fistula (below the dentate line)
D Perianal abscess
E Perianal haematoma with supralevator extension
F Proctitis secondary to Crohn’s disease
G Radiation proctitis
H Solitary rectal ulcer syndrome
I Transphincteric anal fistula.
For each of the treatment options, select the most likely answer from the above list. Each option may be
used once, more than once, or not at all.
Scenario 1
Biofeedback
A - Anal canal carcinoma « YOUR ANSWER
H - Solitary rectal ulcer syndrome« CORRECT ANSWER.
H – Solitary rectal ulcer syndrome:
Solitary rectal ulcer syndrome is a relatively common cause of bright red rectal bleeding. It classically
produces an ulcer on the anterior wall of the rectum, but may also have a polypoid appearance. The
aetiology of the condition is incompletely understood but is thought to be a combination of internal
intussusception/anterior wall prolapse and increased intrarectal pressure. The resultant symptoms are
that of rectal evacuatory difficulty. Surgical treatment (abdominal rectopexy) is often unsatisfactory and
the first line management is biofeedback.
Scenario 2
4% Formalin (topical)
B - Fissure in ano « YOUR ANSWER
G - Radiation proctitis« CORRECT ANSWER.
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
, MyPasTest: MRCS A Online - Jan Exam 2015
26. Surgical Specialities; General Surgery; Colorectal Surgery (36Qs)
G – Radiation proctitis:
Radiation proctitis following treatment for cervical or prostatic cancer is a troublesome condition that is
difficult to treat. Topical application of 4% formalin can help the bleeding. Other options include Nd: YAG
laser, and surgery in the form of a coloanal sleeve anastamosis.
Scenario 3
Insertion of seton Page
C - Low subcutaneous anal fistula (below the dentate line)« YOUR ANSWER
I - Transphincteric anal fistula« CORRECT ANSWER.
1544
Treatment of anal fistula is complex when the tract extends high to involve a considerable portion of the
external anal sphincter. The danger of laying open too much external anal sphincter is to render the
patient incontinent. The difficulty in decision-making lies in estimating the ‘safe’ amount of sphincter to
divide and thus how much sphincter is left behind. The decision varies according to the sex of the patient,
the presence of sphincter defects, colonic and rectal function and also the patient. A low anal fistula,
below the dentate line is usually safe to lay open; however, if there is concern regarding continence a
seton (suture material: ethibond, nylon, silastic slings have all been used) can be placed through the tract
to allow drainage and reassessment of treatment options.
Scenario 4
2% Diltiazem ointment
D - Perianal abscess « YOUR ANSWER
B - Fissure in ano « CORRECT ANSWER.
B – Fissure in ano:
Diltiazem is a calcium antagonist that reduces the resting pressure of the internal anal sphincter muscle
(smooth muscle). Trials have shown this to be an effective treatment for acute and chronic anal fissures
(65% healing rates).
Scenario 5
Botulinum toxin
E - Perianal haematoma with supralevator extension« YOUR ANSWER
B - Fissure in ano « CORRECT ANSWER.
B – Fissure in ano:
Botulinum toxin has also been demonstrated to be an effective treatment for chronic anal fissure (73%
efficacy). The precise mechanism of action is unclear, but reduced myogenic tone and contractile
response to sympathetic stimulation by directly acting on its smooth muscle or indirectly on the nerves
through inhibition of acetylcholine release are possibilities.
05. A 27-year-old female presents with severe pain during defecation. She also reports a small amount of
blood on the toilet paper following defecation, and her only past medical history is constipation which
has become worse because of the pain. What is the most likely diagnosis? Select one answer only.
Anal fissure« YOUR ANSWER
Anal fistula
Haemorrhoids
Perianal abscess
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Dr Mohammed Shamsul Islam Khan, Medical Officer, Clinical Neuro-Surgery, National Institute of Neuro-Sciences and Hospital
Sher-E-Bangla Nagar, Dhaka-1207, Bangladesh. Mobile: +880 1713 455 662, +880 1685 811979. E-mail: drsikhan@gmail.com
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller Lansky. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $15.49. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
79976 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now