1. The most prevalent species of bacteria in the colon are:
A. Proteus spp.
B. Escherichia spp.
C. Bacteroides spp.
D. Campylobacter spp.
2. The short-chain fatty acid produced in the greatest quantity by colonic bacterial fermentation that is used in cholesterol synthesis is:
A. Butyrate B. Acetate C. Propionate D. Linolenic acid
3. The principal secretory cation in the colon is:
A. Sodium B. Potassium C. Hydrogen D. Chloride
4. The most appropriate management of diverticulitis with an associated 3-cm pelvic abscess is:
A. Hartmann procedure
B. Sigmoid resection with primary anastomoses C. Parenteral antibiotics
D. Percutaneous drainage
5. The best modality to detect the most common fistula complicating diverticulitis in women is:
A. Cystoscopy
B. Tampon detection with rectal methylene blue C. CT scan
D. Physical examination
6. The most common cause for recurrent diverticulitis after sigmoid resection is believed to be due to:
A. Pancolonic diverticular disease B. Inadequate distal resection margin C. Use of a side-to-end stapled technique D. Dietary indiscretion
7. The internal anal sphincter is most closely related embryologically to:
A. Embryologic ectoderm B. Embryologic endoderm
C. Longitudinal muscle layer of the rectum D. Circular muscle layer of the rectum
8. What are the most common location and position of the tip of the appendix?
A. Retroperitoneally; retrocecal B. Retroperitoneally; retroileal C. Intraperitoneally; pelvic D. Intraperitoneally; pericecal
9. The primary blood supply to the midtransverse colon derives from the:
A. Celiac axis
B. Superior mesenteric artery C. Ileocolic artery
D. Marginal artery of Drummond
10. Which pelvic floor muscle provides an important function in maintaining the rectal angle?
A. Pubococcygeus B. Iliococcygeus C. Puboiliacus D. Puborectalis
11. The most common neurologic complication that may be caused during IMA ligation is:
A. Sympathetic dysfunction—bladder dysfunction and retrograde ejaculation B. Sympathetic dysfunction—bladder dysfunction and impotence
C. Parasympathetic dysfunction—cutaneous anesthesia and retrograde ejaculation D. Sympathetic dysfunction—cutaneous anesthesia and impotence
12. A 70-year-old man from a nursing home admitted with obstructive symptoms is found to have a cecal volvulus. The most appropriate management of this entity includes:
A. Right colectomy with end ileostomy
B. Right hemicolectomy with primary anastomosis C. Cecopexy
D. Tube cecostomy
13. A 63-year-old woman is postoperative day 3 after a total knee arthroplasty and has symptoms of large bowel obstruction. She is in minimal distress, and her WBC count is 7.8.
The most appropriate initial step in management is:
A. Neostigmine
B. Hartmann procedure C. Epidural anesthesia D. Gastrografin enema
14. A 50-year-old man with a 20-year history of quiescent ulcerative colitis undergoes surveillance endoscopy and is found to have a focus of low-grade dysplasia on random colonic biopsy in the transverse colon. The most appropriate next step in management is:
A. Transverse colectomy
B. Extended right hemicolectomy
C. Total proctocolectomy with end ileostomy
D. Total proctocolectomy with immediate J-pouch construction
15. A 55-year-old woman with a prior diagnosis of quiescent ulcerative colitis, who is receiving no medication, undergoes a surveillance colonoscopy. She has had no prior operations, and she has never been pregnant. She is found to have a normal rectum to 25 cm and moderate colitis extending from 25 cm to the mid-descending colon. She had a cecal polyp removed, which showed a 0.2-cm focus of intramucosal carcinoma. She desires to avoid an ostomy. The most appropriate step in operative management is:
A. Right hemicolectomy B. Subtotal colectomy
C. Total proctocolectomy with end ileostomy
D. Total proctocolectomy with J-pouch reconstruction
16. A 70-year-old man with significant coronary artery disease undergoes an abdominal aortic reconstruction. On postoperative day 2, he presents with worsening abdominal pain and bloody diarrhea. He is hemodynamically stable and has a serum lactate level of 0.7. He undergoes flexible endoscopy, which shows mucosal sloughing of the sigmoid colon. The most appropriate next step in management is:
A. Emergent laparotomy with sigmoid resection and primary anastomoses B. Emergent laparotomy with sigmoid resection and end colostomy C. Angiography with intravascular papaverine injection
D. Angiography with sigmoid arterial embolization E. Fluid resuscitation and expectant management.
17. A 55-year-old healthy man with rectal bleeding undergoes colonoscopy, which shows an ulcerated mass in the midrectum, 10 cm from the anal verge. A 2-cm cecal polyp is
removed en bloc with snare polypectomy, which shows a 0.4-cm focus of high-grade dysplasia. The margins are grossly negative, with the closest margin being 4 mm.
Endorectal ultrasound shows focal invasion through the submucosa with focal invasion of the muscularis propria. No enlarged lymph nodes are seen. The most appropriate next step in surgical management is:
A. Synchronous right colectomy and low anterior resection B. Low anterior resection
C. Total proctocolectomy with J-pouch reconstruction D. Neoadjuvant chemoradiation
18. A 60-year-old woman undergoes a left colectomy for a near-obstruction descending colon cancer. Pathology shows a poorly differentiated tumor invading through the wall of the colon into the serosa. Six lymph nodes are identified in the specimen, none of which contain metastatic tumor. Microscopic evaluation of the specimen reveals lymph vascular invasion. The most appropriate next step in management is:
A. No adjuvant treatment; serial CEA every 3 months for 2 years B. No adjuvant treatment; serial CT scans every 3 months
C. Adjuvant radiation; serial colonoscopy every 6 months for 2 years D. Adjuvant chemotherapy; serial CEA every 3 months for 2 years
19. A 73-year-old woman is admitted with a high-grade large bowel obstruction. CT scan indicates a proximal rectal cancer with invasion into the pelvic sidewall and left
hydroureter. The most appropriate operation is:
A. Proctectomy and primary anastomoses
B. Proctectomy and end colostomy (Hartmann procedure) C. Loop ileostomy
D. Diverting loop sigmoid colostomy
Chapter 53: Anus
1. Optimal results for rectocele treatment can be expected from:
A. Biofeedback and medical management of constipation B. Surgical correction of rectoceles <2 cm
C. Surgical correction of rectoceles requiring digital evacuation
D. Medical plus surgical management of rectoceles associated with anismus
2. All of the following statements are true regarding acute anal fissures except:
A. They produce pain and bleeding with defecation.
B. Women typically have anterior fissures.
C. They result from sphincter hypertonia and mucosal ischemia.
D. They can be treated successfully with medical therapies.
3. Anorectal abscesses are infections that typically:
A.Originate within anal crypt glands
B. Resolve completely without sequelae after incision and drainage C. Form horseshoe extensions
D. Occur in patients who are immunocompromised E. Can be treated early with antibiotics
4. Which of the following statements is true regarding fistula in ano?
A. Most are intersphincteric.
B. They usually follow a curvilinear course to the midline if arising in the anterior anal crypts.
C. Persistent drainage after fistulotomy indicates the presence of Crohn's disease.
D. Seton placement should rarely be required.
5. Which of the following statements is true regarding pilonidal infections except:
A. Acute drainage should be over the point of maximal fluctuance.
B. Removal of the entire cyst is required for complete healing.
C. Midline congenital defects are the basis of the disease.
D. The presence of hair perpetuates the infection.
6. All the following are true regarding rectovaginal fistula except:
A. Causes include congenital and acquired conditions.
B. They are often diagnosed based on symptoms alone.
C. For a high rectovaginal fistula, rectal resection is almost always necessary.
D. Successful repair of a low rectovaginal fistula requires maximal resolution of inflammatory diseases
7. When a patient with Crohn's disease presents with anorectal problems:
A. Usually a proctectomy is required.
B. Conservative management is best.
C. The anal conditions are always related to Crohn's disease.
D. The patient should not be considered for sphincterotomy.
8. Wide local excision is least likely to be indicated in which of the following?
A.Bowen's disease B. Paget's disease
C. Squamous cell of the anal margin D. Squamous cell of the anal canal E. Basal cell of the anus
9. Verrucous carcinomas are:
A. Often fast-growing B. Are always invasive C. Rarely metastasize
D. Are essentially the same as squamous cell carcinomas
10. For melanoma of the anal canal, all of the following statements are true except:
A. They are often amelanotic.
B. Abdominoperineal resection is the procedure of choice.
C. Five-year survival rates are poor, at 10% to 17%.
D. Survival rates are stage-dependent.