A 32-year-old woman has had severe pain during and after defecation, with bright red streaks of blood on the stool, for 4 months. Examination shows a posterior midline fissure with a sentinel tag and exposed internal sphincter fibres in its base. Eight weeks of fibre, sitz baths and topical diltiazem have not helped. What is the treatment of choice now?

Lateral internal sphincterotomy

Posterior midline sphincterotomy

A 26-year-old woman has had sharp pain on passing hard stools, with a streak of fresh blood, for 10 days. Gentle parting of the buttocks shows a fresh split in the anoderm in the posterior midline, with no skin tag. What is the first-line treatment?

Fibre, laxatives and sitz baths

Fissurectomy and advancement flap

Lateral internal sphincterotomy

A 58-year-old man has rectal bleeding and tenesmus. Colonoscopy shows an ulcerated adenocarcinoma 6 cm from the anal verge. CT of the chest and abdomen shows no metastases. Which investigation best stages the local tumour, including the circumferential resection margin?

High-resolution MRI of the pelvis

A 34-year-old man has had painless bright red bleeding after defecation for 3 months. Proctoscopy shows internal haemorrhoids that prolapse on straining and reduce by themselves; there are no red-flag features. A month of fibre and fluids has not stopped the bleeding. What is the next step?

Rubber band ligation in the OPD

Lateral internal sphincterotomy

Colorectal cancer, anorectal disease and hernias

37 NEET-PG practice questions on Colorectal cancer, anorectal disease and hernias, part of General Surgery. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

Question 1 · Medium
A 32-year-old woman has had severe pain during and after defecation, with bright red streaks of blood on the stool, for 4 months. Examination shows a posterior midline fissure with a sentinel tag and exposed internal sphincter fibres in its base. Eight weeks of fibre, sitz baths and topical diltiazem have not helped. What is the treatment of choice now?
1. ALateral internal sphincterotomy
2. BPosterior midline sphincterotomy
3. CManual anal dilatation
4. DRubber band ligation
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Answer: A · Lateral internal sphincterotomy
A fissure lasting over 6 weeks with a sentinel tag and visible sphincter fibres is chronic, kept open by internal sphincter spasm and poor blood flow at the posterior midline. When topical calcium-channel blockers or GTN fail, lateral internal sphincterotomy divides part of the internal sphincter and heals over 90% of chronic fissures. The cut is made laterally to avoid a keyhole deformity and limited to the fissure length to keep the risk of incontinence low. A fissure off the midline should raise suspicion of Crohn disease, TB, HIV or carcinoma.
- B: A posterior midline cut leaves a keyhole deformity with soiling.
- C: Uncontrolled stretching tears the sphincter and causes incontinence; it is abandoned.
- D: Banding treats internal haemorrhoids, not a fissure.
Question 2 · Easy
A 26-year-old woman has had sharp pain on passing hard stools, with a streak of fresh blood, for 10 days. Gentle parting of the buttocks shows a fresh split in the anoderm in the posterior midline, with no skin tag. What is the first-line treatment?
1. AFissurectomy and advancement flap
2. BLateral internal sphincterotomy
3. CBotulinum toxin injection
4. DFibre, laxatives and sitz baths
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Answer: D · Fibre, laxatives and sitz baths
A painful posterior midline split of short duration without a sentinel tag is an acute anal fissure. Most heal with conservative care: dietary fibre and fluids, stool softeners or bulk laxatives, warm sitz baths and a topical anaesthetic, with topical diltiazem or GTN if needed. Surgery is considered only for chronic fissures that fail medical treatment.
- A: Advancement flaps are for chronic fissures in patients at risk of incontinence.
- B: Sphincterotomy is for chronic fissures that fail medical therapy.
- C: Botulinum toxin is a second-line option for chronic fissures.
Question 3 · Medium
A 58-year-old man has rectal bleeding and tenesmus. Colonoscopy shows an ulcerated adenocarcinoma 6 cm from the anal verge. CT of the chest and abdomen shows no metastases. Which investigation best stages the local tumour, including the circumferential resection margin?
1. AHigh-resolution MRI of the pelvis
2. BDouble-contrast barium enema
3. CPET-CT
4. DCT of the pelvis
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Answer: A · High-resolution MRI of the pelvis
High-resolution pelvic MRI shows the depth of spread into the mesorectum, mesorectal nodes, extramural vascular invasion and, above all, the distance of the tumour from the mesorectal fascia (the circumferential resection margin). These findings decide whether neoadjuvant therapy is needed before total mesorectal excision. Endorectal ultrasound helps mainly for small early tumours.
- B: Barium enema shows luminal outline only, not depth of spread or margins.
- C: PET-CT is for doubtful metastases, not local staging of the rectum.
- D: CT shows distant spread but cannot assess the mesorectal fascia accurately.
Question 4 · Easy
A 40-year-old shopkeeper has bright red bleeding after defecation. On proctoscopy the internal haemorrhoids come out on straining and go back by themselves afterwards. What degree are these haemorrhoids?
1. AThird degree
2. BSecond degree
3. CFourth degree
4. DFirst degree
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Answer: B · Second degree
Internal haemorrhoids are graded by prolapse (Goligher): first degree bleed but do not prolapse, second degree prolapse and reduce spontaneously, third degree prolapse and need manual reduction, and fourth degree stay prolapsed. First and second degree are usually treated by diet and office procedures such as banding. Third and fourth degree more often need haemorrhoidectomy.
- A: Third-degree haemorrhoids must be pushed back by hand.
- C: Fourth-degree haemorrhoids remain prolapsed and cannot be reduced.
- D: First-degree haemorrhoids do not prolapse at all.
Question 5 · Medium
A 34-year-old man has had painless bright red bleeding after defecation for 3 months. Proctoscopy shows internal haemorrhoids that prolapse on straining and reduce by themselves; there are no red-flag features. A month of fibre and fluids has not stopped the bleeding. What is the next step?
1. ALateral internal sphincterotomy
2. BOpen haemorrhoidectomy
3. CStapled haemorrhoidopexy
4. DRubber band ligation in the OPD
Show answerHide answer
Answer: D · Rubber band ligation in the OPD
Grade I-II haemorrhoids that keep bleeding despite diet are treated in the OPD by rubber band ligation, which strangles the redundant mucosa so it sloughs and leaves a fixing scar. Bands are placed above the dentate line, where pain fibres are absent. Haemorrhoidectomy is kept for grade III-IV haemorrhoids or failure of office procedures.
- A: Sphincterotomy treats chronic fissure, not haemorrhoids.
- B: Excisional surgery is too much for grade II haemorrhoids that have not yet had banding.
- C: Stapled haemorrhoidopexy is for larger prolapsing haemorrhoids.
Question 6 · Medium
A 66-year-old retired teacher from Thrissur is referred from a PHC with tiredness. Haemoglobin is 8.1 g/dL, MCV 68 fL and serum ferritin 6 ng/mL. He has no visible bleeding, no change in bowel habit and no abdominal pain; a vague mass is felt in the right iliac fossa. Upper GI endoscopy is normal. What is the next best investigation?
1. AStool for occult blood
2. BBarium meal follow-through
3. CUltrasound of the abdomen
4. DColonoscopy with biopsy
Answer and explanation in LearnFree account
Question 7 · Easy
After a curative right hemicolectomy for stage II colon cancer, a 59-year-old man is enrolled in a follow-up programme. What is the main use of serum CEA in his care?
1. ADetecting recurrence after resection
2. BScreening his siblings for colon cancer
3. CDiagnosing cancer in place of biopsy
4. DDeciding the extent of colectomy
Answer and explanation in LearnFree account
Question 8 · Hard
A 72-year-old woman is admitted with 3 days of vomiting and a tender, irreducible lump below and lateral to the right pubic tubercle. She is still passing flatus and stools, and the abdomen is not distended. At surgery, the sac contains only part of the antimesenteric wall of the ileum, which is dusky. What type of hernia is this?
1. AAmyand hernia
2. BMaydl hernia
3. CRichter hernia
4. DLittre hernia
Answer and explanation in LearnFree account
Question 9 · Medium
A 50-year-old farmer has a reducible, primary, unilateral indirect inguinal hernia. He prefers open surgery under local anaesthesia so that he can go home the same day. What is the preferred repair?
1. AMcVay (Cooper ligament) repair
2. BBassini herniorrhaphy
3. CLichtenstein tension-free mesh repair
4. DHerniotomy alone
Answer and explanation in LearnFree account
Question 10 · Medium
A 30-year-old auto-rickshaw driver comes to the surgical OPD 24 hours after he felt a sudden, very painful lump at the anal margin while straining at stool. There is a tense, tender, bluish 1.5 cm swelling covered by skin at the anal verge. What is the best treatment?
1. ARubber band ligation of the swelling
2. BEvacuation of the clot under local anaesthesia
3. CEmergency open haemorrhoidectomy
4. DInjection sclerotherapy of the swelling
Answer and explanation in LearnFree account
Question 11 · Medium
Pelvic MRI in a 61-year-old woman with adenocarcinoma of the mid-rectum shows a T3 tumour with three enlarged mesorectal lymph nodes and a threatened circumferential resection margin. CT of the chest and abdomen shows no metastases. What is the next step?
1. ATransanal local excision of the tumour
2. BImmediate anterior resection with total mesorectal excision
3. CPalliative colostomy and chemotherapy
4. DNeoadjuvant chemoradiotherapy, then total mesorectal excision
Answer and explanation in LearnFree account
Question 12 · Medium
A 45-year-old man feels almost nothing when a rubber band is applied to his internal haemorrhoid 1.5 cm above the dentate line, but a band placed accidentally at the dentate line causes severe pain and has to be removed. What explains this difference?
1. AAbove the line, the inferior rectal nerve supplies it
2. BAbove the line, the lining is keratinised squamous
3. CAbove the line, lymph drains to inguinal nodes
4. DAbove the line, innervation is autonomic
Answer and explanation in LearnFree account
Question 13 · Medium
A surgery tutor asks interns about anal fissures. Consider these statements: 1. Most fissures lie in the posterior midline. 2. Manual anal dilatation is the preferred operation for a chronic fissure. 3. Topical GTN or diltiazem works by relaxing the internal sphincter. 4. A lateral fissure in a young man with diarrhoea should prompt a search for Crohn's disease. Which are correct?
1. A2, 3 and 4 only
2. B1, 3 and 4 only
3. C3 and 4 only
4. D1 and 2 only
Answer and explanation in LearnFree account
Question 14 · Medium
At examination under anaesthesia in the OT, a 30-year-old man with normal continence is found to have a low intersphincteric fistula, with the internal opening at the dentate line and the track passing below almost all of the external sphincter. What is the treatment of choice?
1. ADiverting loop colostomy
2. BAbdominoperineal excision
3. CFistulotomy (laying open)
4. DLoose draining seton for 6 months
Answer and explanation in LearnFree account
Question 15 · Easy
During an open repair of a right inguinal hernia in a 62-year-old man, the sac is found bulging through the posterior wall of the inguinal canal, medial to the inferior epigastric vessels. What type of hernia is this?
1. AIndirect inguinal hernia
2. BDirect inguinal hernia
3. CSpigelian hernia
4. DFemoral hernia
Answer and explanation in LearnFree account
Question 16 · Medium
A 33-year-old woman's perianal fistula has been operated on twice and has recurred, now with two external openings and induration on both sides of the anus. Which investigation best maps the tracks and any hidden abscess before the next operation?
1. AMRI of the pelvis
2. BSigmoidoscopy
3. CContrast CT of the pelvis
4. DFistulogram
Answer and explanation in LearnFree account
Question 17 · Hard
A 60-year-old woman who had an anterior resection for rectal cancer 2 years ago has a rising CEA. CT and liver MRI show two metastases in the right lobe of the liver and no other disease, and the future liver remnant will be adequate. She is fit. What offers the best chance of long-term survival?
1. APalliative systemic chemotherapy alone
2. BWhole-liver radiotherapy
3. CLiver transplantation
4. DResection of the liver metastases
Answer and explanation in LearnFree account
Question 18 · Medium
A healthy 3-year-old boy is brought to the surgical OPD with a reducible right inguinal hernia noticed by his mother two weeks ago. What is the appropriate operation?
1. ABassini herniorrhaphy
2. BLichtenstein mesh repair
3. CHerniotomy
4. DLaparoscopic TEP repair
Answer and explanation in LearnFree account
Question 19 · Easy
A 35-year-old man in the surgical OPD has a discharging opening in the perianal skin 2 cm from the anal verge at the 5 o'clock position, with the patient in lithotomy. Where is the internal opening of this fistula most likely to be?
1. APosterior midline, 6 o'clock
2. B5 o'clock, by a straight radial track
3. CAnterior midline, 12 o'clock
4. D3 o'clock, by a lateral track
Answer and explanation in LearnFree account
Question 20 · Hard
A 55-year-old woman living with HIV, on antiretroviral therapy, has a 3 cm ulcerated mass in the anal canal. Biopsy shows squamous cell carcinoma, and FNAC of a 1.5 cm right inguinal node is positive. CT shows no distant spread. What is the first-line treatment?
1. AInguinal block dissection alone
2. BAbdominoperineal resection
3. CChemoradiotherapy with 5-FU and mitomycin
4. DWide local excision
Answer and explanation in LearnFree account
Question 21 · Hard
A 74-year-old man reaches casualty with 4 days of absolute constipation, distension and vomiting. CT shows an obstructing sigmoid tumour with a caecum of 11 cm. At emergency laparotomy the sigmoid colon has perforated above the tumour, with faecal peritonitis, and he needs vasopressors. What is the most appropriate operation?
1. AInsertion of a colonic stent
2. BResection with primary anastomosis alone
3. CHartmann's procedure
4. DLoop transverse colostomy only
Answer and explanation in LearnFree account
Question 22 · Medium
During an open repair of a large, long-standing left inguinal hernia in a 70-year-old man, the surgeon finds that the posterior wall of the sac is formed by a segment of bowel. Which part of the bowel is it most likely to be?
1. AVermiform appendix
2. BSigmoid colon
3. CTransverse colon
4. DCaecum
Answer and explanation in LearnFree account
Question 23 · Medium
A 21-year-old woman with genetically confirmed familial adenomatous polyposis has more than 1,000 adenomas carpeting the colon and rectum, one of them with high-grade dysplasia. What is the operation of choice?
1. ASegmental resection of the dysplastic segment
2. BRestorative proctocolectomy with ileal pouch-anal anastomosis
3. CTotal colectomy with ileorectal anastomosis
4. DRepeated endoscopic polypectomy
Answer and explanation in LearnFree account
Question 24 · Medium
A 24-year-old software engineer from Hyderabad seeks advice. His father had colon cancer at 45, his paternal aunt endometrial cancer at 50 and his paternal grandfather colon cancer at 62. His father's tumour showed loss of MLH1 and PMS2 on immunohistochemistry. What is the most appropriate advice?
1. AOne colonoscopy at age 40, then every 10 years
2. BProphylactic total colectomy now
3. CFaecal immunochemical test yearly from age 45
4. DGenetic counselling and colonoscopy every 1-2 years from now
Answer and explanation in LearnFree account
Question 25 · Hard
A 58-year-old man had an open Lichtenstein mesh repair of a right inguinal hernia 3 years ago. He now has a recurrent right inguinal hernia and a new left inguinal hernia, both reducible, and he is fit for general anaesthesia. What is the preferred repair?
1. ABilateral Bassini repair
2. BBilateral open Lichtenstein repair
3. CLaparoscopic (TEP or TAPP) mesh repair
4. DObservation with a truss
Answer and explanation in LearnFree account

12 more Colorectal cancer, anorectal disease and hernias questions

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Study General Surgery

Colorectal cancer, anorectal disease and hernias

A 26-year-old woman has had sharp pain on passing hard stools, with a streak of fresh blood, for 10 days. Gentle parting of the buttocks shows a fresh split in the anoderm in the posterior midline, with no skin tag. What is the first-line treatment?

A 58-year-old man has rectal bleeding and tenesmus. Colonoscopy shows an ulcerated adenocarcinoma 6 cm from the anal verge. CT of the chest and abdomen shows no metastases. Which investigation best stages the local tumour, including the circumferential resection margin?

A 40-year-old shopkeeper has bright red bleeding after defecation. On proctoscopy the internal haemorrhoids come out on straining and go back by themselves afterwards. What degree are these haemorrhoids?

A 34-year-old man has had painless bright red bleeding after defecation for 3 months. Proctoscopy shows internal haemorrhoids that prolapse on straining and reduce by themselves; there are no red-flag features. A month of fibre and fluids has not stopped the bleeding. What is the next step?

After a curative right hemicolectomy for stage II colon cancer, a 59-year-old man is enrolled in a follow-up programme. What is the main use of serum CEA in his care?

A 50-year-old farmer has a reducible, primary, unilateral indirect inguinal hernia. He prefers open surgery under local anaesthesia so that he can go home the same day. What is the preferred repair?

A 30-year-old auto-rickshaw driver comes to the surgical OPD 24 hours after he felt a sudden, very painful lump at the anal margin while straining at stool. There is a tense, tender, bluish 1.5 cm swelling covered by skin at the anal verge. What is the best treatment?

Pelvic MRI in a 61-year-old woman with adenocarcinoma of the mid-rectum shows a T3 tumour with three enlarged mesorectal lymph nodes and a threatened circumferential resection margin. CT of the chest and abdomen shows no metastases. What is the next step?

A 45-year-old man feels almost nothing when a rubber band is applied to his internal haemorrhoid 1.5 cm above the dentate line, but a band placed accidentally at the dentate line causes severe pain and has to be removed. What explains this difference?

At examination under anaesthesia in the OT, a 30-year-old man with normal continence is found to have a low intersphincteric fistula, with the internal opening at the dentate line and the track passing below almost all of the external sphincter. What is the treatment of choice?

During an open repair of a right inguinal hernia in a 62-year-old man, the sac is found bulging through the posterior wall of the inguinal canal, medial to the inferior epigastric vessels. What type of hernia is this?

A 33-year-old woman's perianal fistula has been operated on twice and has recurred, now with two external openings and induration on both sides of the anus. Which investigation best maps the tracks and any hidden abscess before the next operation?

A 60-year-old woman who had an anterior resection for rectal cancer 2 years ago has a rising CEA. CT and liver MRI show two metastases in the right lobe of the liver and no other disease, and the future liver remnant will be adequate. She is fit. What offers the best chance of long-term survival?

A healthy 3-year-old boy is brought to the surgical OPD with a reducible right inguinal hernia noticed by his mother two weeks ago. What is the appropriate operation?

A 35-year-old man in the surgical OPD has a discharging opening in the perianal skin 2 cm from the anal verge at the 5 o'clock position, with the patient in lithotomy. Where is the internal opening of this fistula most likely to be?

A 55-year-old woman living with HIV, on antiretroviral therapy, has a 3 cm ulcerated mass in the anal canal. Biopsy shows squamous cell carcinoma, and FNAC of a 1.5 cm right inguinal node is positive. CT shows no distant spread. What is the first-line treatment?

During an open repair of a large, long-standing left inguinal hernia in a 70-year-old man, the surgeon finds that the posterior wall of the sac is formed by a segment of bowel. Which part of the bowel is it most likely to be?

A 21-year-old woman with genetically confirmed familial adenomatous polyposis has more than 1,000 adenomas carpeting the colon and rectum, one of them with high-grade dysplasia. What is the operation of choice?

A 24-year-old software engineer from Hyderabad seeks advice. His father had colon cancer at 45, his paternal aunt endometrial cancer at 50 and his paternal grandfather colon cancer at 62. His father's tumour showed loss of MLH1 and PMS2 on immunohistochemistry. What is the most appropriate advice?

A 58-year-old man had an open Lichtenstein mesh repair of a right inguinal hernia 3 years ago. He now has a recurrent right inguinal hernia and a new left inguinal hernia, both reducible, and he is fit for general anaesthesia. What is the preferred repair?