Quality
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Benign Disease- A 23-year-old man fell off a bull while riding and later suffered an isolated injury to the left perineal region by one of the bulls’ horns. At the emergency department, he was hemodynamically intact, and had a perineal penetrating injury measuring approximately 6 × 5 cm. Abdominal examination findings were benign. Computed tomography of the abdomen and pelvis noted approximately 35% circumferential extraperitoneal rectal injury. In addition to initiating broad-spectrum antibiotics and proctoscopy, what is the next step in management?
- A 53-year-old man presents for follow-up after a screening colonoscopy. The patient was found to have a single 5-mm tubular adenoma in the descending colon that was completely removed using snare polypectomy. The patient should undergo repeat colonoscopy in:
- A 55-year-old man returns to your office after his first screening colonoscopy reveals a 15-mm pedunculated polyp in the ascending colon that was completely excised. Pathology reveals a tubular adenoma. When should he undergo his next colonoscopy?
- A 52-year-old man presents for screening colonoscopy and is found to have a 3-cm sessile polyp in the descending colon that is removed in piecemeal fashion with a snare. Pathology reveals a villous adenoma. Surveillance colonoscopy should be offered in:
- A 40-year-old man presents to the office for follow-up after an admission for diverticulitis treated with intravenous antibiotics. He reports that he has had complete resolution of his symptoms and that this was his first attack of diverticulitis. What would you recommend as the next step in his management?
- A 65-year-old woman with coronary artery disease and a history of abdominoperineal resection for a low rectal cancer 3 years ago presents with a painless peristomal bulge and an occasional appliance leak. She denies pain and reports normal colostomy output. Examination reveals a pink healthy colostomy and soft bulge medial to the stoma on application of the Valsalva maneuver. Result of recent surveillance computed tomography is available for review (Figure). What is the best management option?
- A 53-year-old male renal transplant recipient receiving tacrolimus and prednisone presents with acute sigmoid diverticulitis with specks of free air and a 5-cm pelvic abscess which is not amenable to percutaneous drainage. His vital signs are a temperature of 102.0°F (38.9°C), heart rate 105 beats/min, blood pressure 110/80 mm Hg, and white blood cell count 18,000/µL (18109/L). The best next step in management is:
- A 56-year-old woman with a history of recurrent urinary tract infections presents to the emergency department with tachycardia (heart rate 124 beats/min), hypotension (blood pressure 85/38 mm Hg), diffuse abdominal pain, and frequent watery diarrhea following a course of oral antibiotics. Her abdomen is distended and diffusely tender. Her white blood cell count is 25,000/L (25109/L) and her hemoglobin is 15.0 g/dL (150 g/L). The patient is positive for Clostridioides difficile and is not responding to treatment with 125 mg of oral vancomycin. What is the next best option for this patient?
- A 45-year-old woman with Crohn’s colitis was recently started on azathioprine to maintain clinical remission. She presents to the emergency department with sepsis and neutropenia. Her liver function test results are normal. What is the deficiency most likely associated with this clinical outcome?
- A 42-year-old asymptomatic woman has a persistent pouch vaginal fistula, as noted on a pouchogram 3 months after an ileal pouch–anal anastomosis in preparation for a diverting loop ileostomy reversal. Examination under anesthesia reveals no undrained sepsis, normal pouch mucosa, and a fistula with a discrete area of erythema at the pouch anal anastomosis. A biopsy demonstrates Paneth cell reaction, granulation tissue, and active inflammation. What is the best next step?
- A 28-year-old woman with a 12-year history of Crohn’s disease presents with cramping abdominal pain, a 15-lb (6.8-kg) unintentional weight loss, and recurrent emesis. She has been taking infliximab maintenance therapy for the last 4 years. Magnetic resonance enterography demonstrates multiple short strictures over a 15-cm portion of the mid-jejunum with decompressed distal small bowel. Colonoscopy shows no active perianal or colonic disease. What is the best definitive treatment?
- A 55-year-old woman presents to your office for surgical consultation. Colonoscopy had demonstrated hundreds of adenomas carpeting the colon and 30 polyps in the rectum. She has never had a problem with fecal incontinence. What is the best next step in management?
- A 68-year-old woman developed crampy abdominal pain with diarrhea after taking antibiotics for a dental procedure. She was treated for Clostridioides difficile infection (CDI) with oral vancomycin. Three weeks later, she developed similar symptoms and is treated for a relapse of CDI with vancomycin for 2 weeks. She now presents with her third episode of CDI 8 weeks after her initial infection. She is hemodynamically stable with minimal abdominal discomfort. She does not want to have surgery and would like to know other alternatives. What is the best next step in management?
- The quality metric for endoscopists that highly correlates with reduced interval colon cancer incidence and death is:
- Pelvic Floor
- A 64-year-old woman underwent an overlapping sphincteroplasty 3 years ago for fecal incontinence (FI). She had excellent improvement initially after surgery, but now has recurrent FI which is severely affecting her quality of life. Her Cleveland Clinic FI score is 18/20, the same as it was preoperatively. What is the most appropriate corrective surgery for this patient?
- A 33-year-old multiparous woman has complaints consistent with obstructed defecation and is scheduled for a dynamic magnetic resonance imaging defecography. What is the most concerning limitation of this diagnostic test?
- A 45-year-old woman with a history of chronic constipation is evaluated in the office. Recent transit study demonstrated retention of 16 Sitz markers scattered throughout the colon 5 days after ingesting the Sitzmark capsule. Colonoscopy findings are unremarkable. She has failed multiple medication trials. She is compliant with her dietary modifications such as fiber and fluid intake. She takes a commercial polyethylene glycol 3350 formulation as needed. What is the most appropriate next step in management?
- Malignancy
- A 25-year-old obese female patient with a known diagnosis of familial adenomatosis polyposis is preparing for prophylactic surgery. Colonoscopy reveals more than 200 small polyps in her colon with no significant polyps distal to the sigmoid. She desires to have children as soon as possible. Which surgical option will minimize her cancer risk while giving her the best chance of preserving fertility?
- A 55-year-old woman undergoes a sigmoid colectomy for microsatellite-stable sigmoid colon cancer. The final pathology demonstrates a 4-cm moderately differentiated adenocarcinoma with 2 cm proximal and distal margins negative for residual disease. A total of 12 lymph nodes were identified in the specimen, none of which were positive for adenocarcinoma. Which of the following is true regarding the quality of her resection?
- A 52-year-old current smoker undergoes colonoscopy for screening and is found to have 6 polyps in the ascending, transverse, and descending colon. The polyps are 12 mm, 12 mm, 15 mm, 6 mm, 8 mm, and 5 mm in size. All of them are completely resected. Endoscopic (Figure 1) and photomicrographic (Figure 2) images of a polyp are shown. At what interval is follow-up colonoscopy recommended?
- A 50-year-old woman was found to have a right colon adenocarcinoma on screening colonoscopy. The tumor shows a loss of MMR function. Her family history is significant for uterine and pancreatic cancer. The rest of the imaging is negative for metastatic disease. What is the most appropriate next step in treatment?
- A 56-year-old obese man with low rectal cancer is recommended to undergo a low anterior resection with diverting loop ileostomy. The best location for the ileostomy is:
- A 52-year-old man is diagnosed with a 1.5-cm anal canal squamous cell cancer. He is HIV positive and has been taking highly active antiretroviral therapy for several years; his CD4 count is 225 while his viral load is undetectable. Which of the following is the most appropriate management for this patient?
- A 67-year-old man is found to have a sigmoid adenocarcinoma with multiple metastases to the liver and lungs. He is asymptomatic and the remainder of the colon appears normal. What is your best treatment recommendation?
- A 53-year-old man has a 2-cm peripheral lung lesion on surveillance computed tomography of the chest, abdomen, and pelvis 3 years after undergoing a low anterior resection for a pT3N0 rectal cancer. No other lesion is found. Multidisciplinary evaluation concludes that this is a colorectal metastasis. What is the best treatment recommendation for this patient?
- A 62-year-old man with abdominal pain and distention presents to the emergency room. Computed tomography of the abdomen and pelvis demonstrates an obstructing mass in the upper sigmoid colon with a single right hepatic metastatic lesion. The cecum measures 8 cm in diameter, and the small bowel is decompressed. What is the best next step in treatment?
- A 68-year-old man with a history of a hemorrhoidectomy and fecal urgency presents with a T3n1m0 rectal cancer 5 cm from the anal verge. He has no family history of colorectal cancer. What is the most important consideration when counseling the patient about his surgical treatment options?
- A 25-year-old woman is referred by her gastroenterologist with innumerable adenomatous polyps covering her entire colon and rectum after colonoscopy performed for anemia. Her father died of metastatic colon cancer at age 45 years; she has 1 sibling with a presentation similar to her own. The gene most likely responsible for these findings is:
- Miscellaneous
- An 89-year-old man with multiple medical comorbidities who has been bedbound for a prolonged period is diagnosed with a large transverse colon mass that invades the pancreas. Although not obstructed, his stools are melanotic and he is anemic. The tumor is resectable but would require a distal pancreatectomy and splenectomy. It is unlikely that he would survive this extensive operation. What ethical principle helps to guide decision making in this patient?
- After performing a hemorrhoidectomy on an otherwise healthy 29-year-old woman, a recovery nurse calls to report that the patient is complaining of pain in her left buttock and involving her posterior proximal thigh. Upon examination, the patient has an area of skin discoloration described as erythema surrounding a centralized area that is pale and numb. Which measure, if used, would have avoided this complication?
- Certificate
- Perioperative
- A 26-year-old patient with Crohn’s disease who is an active smoker has terminal ileal disease and is awaiting ileocecal resection. When before surgery is the ideal time for him to stop smoking?
- A 56-year-old man undergoes a low anterior resection after neoadjuvant chemoradiation for a T3N0M0 rectal cancer located 9 cm from the anal verge. Eight days later, he presents to the emergency department with mild abdominal pain and a temperature of 102.2°F (39°C). Laboratory results are significant for a white blood cell count of 14,000/µL (14×109/L). Computed tomography of the abdomen and pelvis shows pneumoperitoneum with contrast extravasation into the pelvis. Abdominal examination shows focal peritonitis in the left lower quadrant. Intraoperative findings demonstrate a 3-mm anastomotic disruption anteriorly. In addition to abdominal washout, what is the best surgical option for this patient?
- A 42-year-old woman with Crohn’s disease is undergoing a repeat ileocolic resection for a neoterminal ileal stricture. Intraoperatively, the ileocolic anastomosis is found to be densely adherent to the retroperitoneum. After mobilizing the bowel, it was noticed that the midportion of the right ureter had been transected. The best way to repair this injury is:
- You are scheduled to perform an elective laparoscopic right hemicolectomy on a 75-year-old woman with a significant history of chronic obstructive pulmonary disease and hypertension controlled with amlodipine. She reports slow walking and unintentional weight loss. What is her most significant risk for increased postoperative morbidity and mortality utilizing the modified 5-variable fraility index?
- A 67-year-old man presents for consultation after a screening colonoscopy reveals a 3-cm sigmoid colon adenocarcinoma. The patient is not currently taking any medication and has a creatinine of 1.8 mg/dL (159.1 μmol/L). Which comorbidity in this patient would be an independent predictor of major perioperative cardiac complications?
- A 52-year-old woman underwent screening colonoscopy. No lesions were noted and the preparation was described as a Boston Bowel Preparation score of 2. When should this patient undergo a repeat colonoscopy?
- ASCRS Question Bank
- Anorectal Disease
- A 40-year-old woman with a history of Crohn's disease presents to your office with quiescent proctitis and a 4-mm rectovaginal fistula just above the anorectal ring. There is no appreciable sphincter defect. What is your best recommendation for repair?
- A 35-year-old man is seen in consultation in the emergency department (ED) after several unsuccessful attempts by the ED physician to extract a foreign body in the rectum. The patient is hemodynamically stable but very uncomfortable with severe lower abdominal cramping. Abdominal and pelvic radiography demonstrates a 7-cm cylindrical foreign body above the sacral promontory, without evidence of free intra-abdominal air. What is the best next step in management?