Which patient would be best managed with a fistulotomy?

A 50-year-old man presents to the emergency department with a 3-day history of perianal pain and swelling. His history and physical examination are consistent with an uncomplicated, superficial perianal abscess located at the anal verge on the right side. You are preparing to assist a junior resident in a bedside drainage procedure. Where should you teach the junior resident to make an incision in the perianal skin?

A 28-year-old man presents for follow-up after undergoing excision of an anal lesion. Pathology was consistent with anal condyloma without evidence of dysplasia. The man asks about the implications of this diagnosis. Your counseling of this patient should include which of the following?

A 20-year-old man has familial adenomatous polyposis and is undergoing screening colonoscopy. He is found to have about 100 colonic polyps along with 8 to 10 small rectal polyps. A right-sided colon polyp is too large for endoscopic removal, and biopsies reveal tubular adenoma with high-grade dysplasia. Which of the following is the most appropriate treatment?

A 36-year-old man with a history of ulcerative colitis presents to the hospital with increasing diarrhea that occurs upwards of eight times daily, severe cramping, temperature of 38.4ºC, heart rate of 110 beats/min, hemoglobin of 10.2 g/dL, and an erythrocyte sedimentation rate (ESR) of 37 mm/hr. He is admitted to the internal medicine department and started on methylprednisolone and broad-spectrum antibiotics. Abdominal plain film on admission shows transverse colon dilation to 5.2 cm. His diarrhea, fever, and cramping persist, and he is started on infliximab. Forty-eight hours later he continues to have abdominal pain, plain film shows transverse colon dilation to 6.7 cm, and his hemoglobin is 8.8 g/dL. Which portion of this patient's history indicates he should go to the operating room urgently for a total abdominal colectomy?

A 65-year-old man presents to the emergency department with sudden onset abdominal pain and bloody diarrhea. An abdominal examination demonstrates mild abdominal tenderness but no peritoneal signs. A CT demonstrates diffuse thickening of the descending colon and splenic flexure without free air. A colonoscopy demonstrates erythematous and edematous mucosa with small ulcerations. What is the next step in management?

A 65-year-old man presents to the ED with sudden onset abdominal pain and bloody diarrhea. He is diagnosed with ischemic colitis and hospitalized and treated with intravenous fluids, bowel reset, and broad-spectrum antibiotics. His symptoms resolve, and he is discharged home, tolerating a diet after 6 days. Two months later, he returns reporting 2 weeks of intermittent, crampy abdominal pain and constipation alternating with diarrhea. What is the likely diagnosis?

A 32-year-old man presents with increasing severe, unrelenting pain and swelling near his anus of 36 hours' duration. He has a history of hemorrhoids that he has managed conservatively. On examination, he has a single large thrombosed external hemorrhoid. What is the best management?

A 75-year-old woman with a history of HTN and DM arrives in the ED reporting sudden onset abdominal pain and bloody diarrhea for the past 12 hours. An abdominal examination reveals that the patient is mildly tender in the left lower quadrant, but she does not have peritonitis. A CT scan demonstrates thickening of the left colon. After initial resuscitation, what is the next appropriate step?

A 66-year-old woman returns to your outpatient clinic for follow-up 2 weeks after you performed a laparoscopic abdominoperineal resection of the rectum. She had previously completed neoadjuvant chemoradiotherapy. The final pathology shows a T3 lesion with 1 of the 12 lymph nodes you removed involved with cancer. What is the most appropriate next step in this patient's management?

A 76-year-old woman presents with newly diagnosed ascending colon adenocarcinoma. In addition to ensuring that she has undergone a full colonoscopic examination, what additional staging workup is required?

A 52-year-old man with abdominal pain undergoes a CT scan and is found to have sigmoid colon wall thickening. He is treated with oral antibiotics for 7 days, and his abdominal pain resolves. What is the most appropriate next treatment step?

On postoperative day 1 after an abdominoperineal resection, you are called to the bedside to evaluate the colostomy because the nurse believes it appears black. You see dusky mucosa and with test-tube evaluation, the mucosa is pink and viable just below skin level. What is the appropriate management?

A 53-year-old man with long-standing ulcerative colitis presents to your office to discuss a total abdominal colectomy. He has been on and off steroid tapers and has tried multiple biologic agents without good control of his symptoms. Unfortunately, he also has multiple extra colonic manifestations of his disease, including uveitis, anemia, arthritis, pyoderma gangrenosum, and primary sclerosing cholangitis. You counsel the patient that many of his colonic and other symptoms will improve with surgery. You should also inform him that which symptom only improves about 50% of the time following a total abdominal colectomy in patients with ulcerative colitis?

Which individual is considered to be at highest risk of developing colorectal cancer?

A 25-year-old woman with familial adenomatous polyposis (FAP) and rectal sparing is trying to decide which operative procedure to pursue. You counsel her on total proctocolectomy with ileal pouch anal anastomosis (IPAA) compared with total abdominal colectomy (TAC) with ileorectal anastomosis. What does TAC with ileorectal anastomosis offer for this patient?

A 57-year-old woman presents with a large-bowel obstruction. Computed tomographic (CT) scan shows obstruction at the level of the midrectum with no dilated small intestine, and with suspicious lymph nodes in the mesorectum. What is the appropriate management?

During a laparoscopic appendectomy, you visualize a 10-mm mass at the tip of the appendix. Which action is indicated?

A 62-year-old man with localized colon cancer undergoes a laparoscopic partial colectomy. Compared to open partial colectomy, laparoscopic partial colectomy is associated with which of the following?

A 35-year-old immunocompetent man is diagnosed with anal intraepithelial neoplasia, grade 1. What is the current recommended management for this lesion?

An 82-year-old woman presents to the emergency department reporting bright red blood from her rectum for the last 2 days. She also reports experiencing intense fatigue, and she has noticed black stools intermittently over last 6 months. She is not on any anticoagulation medications. The patient has stable vital signs, and a physical examination reveals grade 3 prolapsing hemorrhoids in the right anterior and right posterior location. Laboratory testing reveals a hemoglobin of 6.9 and microcytic anemia. She does not recall ever having a screening colonoscopy. What is the best next step in management of this patient?

A 71-year-old woman is currently admitted to the ICU with Clostridioides difficile colitis that developed after a course of antibiotics for pneumonia. She has been on PO vancomycin and IV metronidazole for 3 days; however, she has continued to have multiple watery bowel movements per day. Physical examination shows a temperature of 39.1°C, heart rate of 105 beats/min, and blood pressure of 109/73 mm Hg, supported with norepinephrine drip. Laboratory tests are significant for a white blood cell count of 19,000/µL and a creatinine level of 1.7 mg/dL, both of which are essentially unchanged despite therapy. She is not able to be taken to the CT scanner, but plain film of the abdomen shows colonic dilation to 8 cm. Which of the following is an absolute indication to take this patient to the operating room?

A 45-year-old man presents with rectal pain without any evidence of external erythema, induration, or fluctuance. His digital rectal examination is notable for bulging of the anal canal that is painful to palpation. What does appropriate management of this patient include?

A 46-year-old man with chronic alcoholism presents to the emergency department with severe abdominal pain. Abdominal CT imaging reveals Hinchey stage III perforated diverticulitis. He is hemodynamically stable. A decision is made to proceed to the operating room. Which procedure is indicated for this patient?

You are performing a total proctocolectomy on a patient with familial adenomatous polyposis (FAP) and a distal sigmoid colon cancer. Which vessel would most conclusively perform a high ligation?

A 66-year-old man presents with biopsy-proven rectal cancer at 6 cm from the anal verge. Staging shows that the cancer is in an early stage. When considering this patient for transanal resection, you review the inclusion criteria, which are primarily assessing his risk for what?

A 60-year-old man presents to the emergency department reporting several days of obstipation and abdominal pain. CT imaging reveals a moderately dilated colon and no evidence of metastatic disease. Flexible sigmoidoscopy reveals an upper rectal cancer at approximately 17 cm from the anal verge that is almost completely occluding the lumen. The patient is taken to the operating room for resection of the cancer. The pathology comes back T4aN0 adenocarcinoma. What are the recommendations for postoperative therapy?

A 62-year-old man with a T2N0M0 squamous cell carcinoma of the anal canal receives the modified Nigro protocol (mitomycin, 5-fluorouracil, and 45 Gy of radiation). He presents to the clinic 8 weeks after treatment. On physical examination, a residual tumor is evident. What is the next best step?

A 58-year-old man presents to the emergency department with vomiting and abdominal pain. A CT of the chest, abdomen, and pelvis shows a large mass in the distal rectum with dilation of the proximal small and large bowel. On examination, you identify an obstructing and malignant-appearing lesion 2 cm from the anal verge that is overlying the anal sphincters. What is the most appropriate next step in this patient's treatment?