1 - Which of the following statements is correct?

a. The anal sphincter complex comprises the mesoderm-related external anal sphincter muscle and the ectoderm-related internal anal sphincter muscle.b. The anal sphincter complex comprises the endoderm-related levator ani and external anal sphincter muscle.c. The anal sphincter complex comprises endodermal as well as ectoderm-related muscles.d. The levator ani muscle consists of supportive and sphincteric components.e. The internal anal sphincter muscle belongs to the bilaterally organized mesoderm-related portion of the anal sphincter complex.

Dr. M. Al-Shobaki

Answer: D

Comment: The internal anal sphincter muscle forms a continuation of the circular layer of the muscular coat of the rectum and therefore belongs to the unilaterally organized, endoderm-related components of the anal sphincter complex. The striated external anal sphincter and levator ani muscles form the bilaterally organized, mesoderm-related part of the anal sphincter complex.

Dr. M. Al-Shobaki

2 - Which of the following statements regarding the rectogenital septum is Incorrect?

a. The rectogenital septum consists of dense connective tissue and longitudinal smooth muscle fibers.b. The rectogenital septum develops locally when the density of mesenchymal tissue increases between the urogenital organs and the anorectum.c. The rectogenital septum is attached to the lateral pelvic wall and prevents prolapse of the anorectum.d. The rectogenital septum is an important landmark structure for the pelvic surgeon during low anterior resection of the rectum.e. Groups of parasympathetic ganglia can be found within the lateral borders of the rectogenital septum and indicate intrinsic innervation of the septum for defecation.

Dr. M. Al-Shobaki

Answer: C

Comment: The rectogenital septum is easily separated from the muscular components of the rectovesical/rectouterine pouch cranially. A close relationship between the fascial structuresof the lateral pelvic wall is not demonstrable at any level. The density of these collagenous fibers increases through fetal development, and smooth muscle cells are integrated into the coronal plate at the rectal wall.

Dr. M. Al-Shobaki

3 - Lesions of the cauda equina cause:

a. Increased rectal toneb. Reduced rectal reflex activity and tonec. Reduced rectal complianced. Paradoxical puborectalis contractione. No clinically significant changes in anorectal function

Dr. M. Al-Shobaki

Answer: B

Comments: Lesions of the cauda equina or the conus medullaris interrupt the reflex arch between the left colon and rectum, and the sacral spinal cord segments 2–4. This interrupts parasympathetic stimuli, thereby reducing rectal (and left colonic) reflex activity and tone (answer b). This usually leads to severely compromised rectosigmoid emptying at defecation

Dr. M. Al-Shobaki

4 - Which of the following are NOT physiological functions of the colon:

a. Providing nutrition for itselfb. Fluid balancec. Electrolyte homeostasisd. Thermoregulatione. Releasing anti-inflammatory cytokines

Dr. M. Al-Shobaki

Answer: D

Dr. M. Al-Shobaki

5 - Massive hemorrhage of the distal gastrointestinal tract:

a. Is commonb. Is seen mainly in elderly patientsc. Is due to a usually easy-to-discover etiologyd. Is never related to angiodysplasiae. Always ceases spontaneously

Dr. M. Al-Shobaki

Answer: B

Comments: Massive colorectal bleeding is seen mainly in elderly patients. The etiology and location of hemorrhage are usually difficult to establish. Bleeding may cease spontaneously and the site of origin remain unknown. The phenomenon is most frequently due to angiodysplasia, diverticular disorder, inflammatory conditions, ischemia, tumors or hematologic disorders

Dr. M. Al-Shobaki

Dr. M. Al-Shobaki

6 - Regarding malignant polyps, which of the following statements is true?

a. Ulceration is uncharacteristic.b. They should be removed in a piecemeal fashion where possible.c. Lifting with submucosal injection of saline is a poor prognostic sign.d. They usually have a type I pit pattern.e. Endoscopic ultrasound can be useful for assessing invasion.

Dr. M. Al-Shobaki

Answer: E

Comments: Compared with benign lesions, malignant tissue is more likely to be indurated, ulcerated, friable and vascular. Pit pattern type I is the normal mucosal pattern of colonic mucosa , a disrupted type V pattern being more typical of malignancy. Lesions that have invaded into the submucosal tissues tend not to lift with submucosal injection and can be further evaluated by endoscopic ultrasound, if it is available.

Dr. M. Al-Shobaki

7 - Which tumour stage is correct, referring to an anterior resection specimen containing an adenocarcinoma that has invaded through the muscularis propria by 10 mm and is within 1 mm of the mesorectal margin posteriorly; the tumour has invaded 4/32 lymph nodes and the high tie node is not invaded by tumour?

a. Dukes B, pT3c, N2, Mx, R1.b. Dukes C2, pT3b, N2, Mx, R0.c. Dukes C1, pT3c, N2, Mx, R1.d. Dukes C1, pT3a, N1, Mx, R1.e. Dukes C1, pT3c, N1, Mx, R0.

Dr. M. Al-Shobaki

Answer: C

The tumour has spread beyond the outermost border of the muscularis propria and is therefore stage pT3. This tumour stage can be subdivided into pT3a (<1 mm beyond the border of the muscularis propria), pT3b (1–5 mm beyond the border of the muscularis propria), pT3c (>5–15 mm beyond the border of the muscularis propria) and pT3d (>15 mm beyond the border of the muscularis propria). The minimum distance between the tumour and circumferential margin in this case is ≤ 1 mm so the surgical margin is regarded as being involved. This can be annotated as R1, which is defined as tumour left behind microscopically at a resection margin (R0 would denote no tumour left at the resection margins; R2 would denote macroscopic tumour left at the surgical margins). Since four or more nodes are involved by tumour the nodal status is annotated as N2. The high tie node remains uninvolved, making the tumour Dukes C1 regardless of the extent of local tumour spread. Finally, as no tissue has been submitted by the surgeon to establish distant metastasis, the annotation Mx is used.

Dr. M. Al-Shobaki

8 - Which of the following statements regarding abdominal radiographs is true?

a. At least 10 ml must be present for the detection of free gas.b. Normal jejunal diameter can be up to 4 cm.c. A caecal volvulus classically points towards the right upper quadrant.d. The presence of mucosal islands in acute colonic inflammation is associated with an increased requirement for surgery.e. A transverse colonic diameter of up to 8 cm is normal.

Dr. M. Al-Shobaki

Answer: D

The abdominal X-ray is sensitive in detecting free gas, having the ability to identify as little as 2 ml. The normal jejunal diameter should be less than 2.5 cm, and 4 cm would be considered to be pathological. Similarly, a transverse colonic diameter of up to 6 cm is considered the norm, and 8 cm pathological. A caecal volvulus classically points to the left upper quadrant, with the apex of mesentery fixed in the right iliac fossa.

Dr. M. Al-Shobaki

9 - With respect to Positron Emission Tomography (PET)/ CT imaging, which of the following is correct?

a. PET scanning does not rely on ionising radiation.b. The most commonly incorporated substrate for PET scanning is heavy water.c. Preparation for a PET scan requires the patient to refrain from physical activity for 1 h prior to the examination.d. The main role for PET/CT is currently T staging.e. Optimal tumour demonstration requires the rapid injection of tracer and a rapid acquisition of images.

Dr. M. Al-Shobaki

Answer: C

Excessive muscle activity during the incorporation phase of 18fluorodeoxyglucose will promote increased uptake of the tracer into skeletal muscle rather than the target area, thus decreasing the sensitivity of the examination.

Dr. M. Al-Shobaki

10 - Which of the following is not an indication for a defunctioning ileostomy?

a. Severe ulcerative colitis after failed medical therapyb. Severe Crohn’s colitis after failed medical therapyc. Before a long course of downsizing chemoradiotherapy for locally advanced rectal carcinomad. After ileoanal pouch reconstruction for familial adenomatous polyposise. After low anterior resection

Dr. M. Al-Shobaki

Answer: A

Comment: Severe ulcerative colitis does not respond to defunctioning, unlike severe Crohn’s colitis

Dr. M. Al-Shobaki

11 - Management of a high-output ileostomy may include all of the following except?

a. Loperamideb. H2 blockersc. Magnesium replacementd. Increased oral hypotonic fluidse. Intravenous potassium replacement

Dr. M. Al-Shobaki

Answer: D

Comment: Increased hypotonic fluids is contraindicated in the management of a high-output stoma. Oral fluids should be restricted in severe cases to less than 500 ml/day. Isotonic fluids with a high sodium concentration should be used.

Dr. M. Al-Shobaki

12 - Which of the following mechanisms does not play a role in the pathophysiology of hemorrhoids?

a. Insufficient blood return through the superior rectal veinsb. Increased intra-abdominal pressurec. High anal resting pressured. Incomplete relaxatione. Portal hypertension

Dr. M. Al-Shobaki

Answer: E

Comments: The first four of these mechanisms have been shown to play a role in the pathophysiology of hemorrhoids. Portal hypertension does not seem to increase the risk of hemorrhoidal disease, but is responsible for the development of rectal varicoseveins

Dr. M. Al-Shobaki

13 - Glyceryl trinitrate acts on the internal sphincter by:

a. Calcium channel blockadeb. Blocking acetylcholine release in the sympathetic relay ganglionc. Phosphodiesterase-5 inhibitiond. Acting as a nitric oxide donore. Reducing sympathetic tone

Dr. M. Al-Shobaki

Answer: D

Dr. M. Al-Shobaki

14 - Extrasphincteric fistulas:

a. Are caused by Neisseria gonorrhoeab. Are most often caused by a rectal cancerc. Are related to immune deficiencyd. Need a search for Crohn’s diseasee. Are the second most frequent type of fistula

Dr. M. Al-Shobaki

Answer: D

Comments: Gonorrhoea causes an inflammation of the anal canal and proctitis. Perineal fistulas originate from the urethra and not the intestinal tract.

Dr. M. Al-Shobaki

15 - Lymph-node and distant metastasis in anal cancer:

a.Almost 5% of patients with anal cancer have lymphnode involvement on presentation.b. Sentinel lymph-node biopsy is the gold standard to assess nodal involvement in anal cancer.c. Superior rectal nodes are usually the lymph nodes to metastasise.d. Lymph-node involvement does not depend on the size of the tumour.e. Visceral involvement is seen in 30% of patients on diagnosis.

Dr. M. Al-Shobaki

Answer: C

Comments: The first group of lymph nodes that metastasise is the superior rectal, followed by the inguinal and lateral pelvic nodes. Lymph-node spread is seen in around 30% of patients.

Dr. M. Al-Shobaki

16 - Paget’s disease of the anus:

a. Is an intraepithelial adenocarcinoma arising from dermal apocrine sweat glandsb. Has a very low incidence of associated malignancyc. Has a higher incidence in femalesd. Is rarely associated with local recurrencee. Progresses to an invasive carcinoma in more than 95% of untreated lesions

Dr. M. Al-Shobaki

Answer: A

Comments: Sir James Paget described this lesion in breast tissue in 1874; it is an intraepithelial adenocarcinoma arising from dermal apocrine sweat glands. The incidence of associated malignancy is very high, in the region of 50–73%. It has an equal gender distribution

Dr. M. Al-Shobaki

17 - Which of the following features does NOT apply to the external anal sphincter?

a. Innervated by the pudendal nerveb. Under voluntary controlc. Innervation from the dorsal horn of S2d. No anatomical distinction at surgery from the puborectalis musclee. Disruption most frequently due to childbirth

Dr. M. Al-Shobaki

Answer: C

Comments: Innervation from the ventral horn of S2 .

Dr. M. Al-Shobaki

18 - Proctalgia fugax is caused by smooth muscle spasms and therefore calls for:

a. Immediate injection of Botox into the sphincter muscle to avoid muscular necrosisb. No active therapy, as a general rule, since it rarely occurs over long intervalsc. Enhancement of sphincter tone, making sphincterotomy the therapy of choiced. Psychological therapye. Long-acting methadone to ensure pain relief

Dr. M. Al-Shobaki

Answer: B

Comments: Proctalgia fugax is defined as a sudden, severe pain in the anal area lasting several seconds or minutes, which subsequently disappears altogether. Attacks are infrequent, occurring less than five times a year . For most patients, episodes of pain are so brief that treatment consists only of reassurance and explanation

Dr. M. Al-Shobaki

19 - In fistula surgery:

a. Sphincter-sparing treatment of an anterior transsphincteric fistula in a woman is advisable whatever the level of the track.b. Goodsall’s rule is a sensitive indicator of fistula track anatomy.c. Fistulectomy is more effective than fistulotomy in the treatment of low transsphincteric fistula.d. Marsupialisation after fistulotomy increases the incidence of recurrence.e. A course of infliximab will heal over 80% of Crohn’s fistulae.

Dr. M. Al-Shobaki

Answer: A

Comment: The anterior sphincter is narrow, particularly in a woman. Even cutting a small proportion may result in incontinence .

Dr. M. Al-Shobaki

20 - Accurate staging of depth of penetration of the rectal wall by tumours is best performed by:

a. Computed tomography (CT) scanningb. Magnetic resonance imaging (MRI)c. Endorectal ultrasoundd. A combination of CT scanning and MRIe. Positron emission tomography scanning

Dr. M. Al-Shobaki

Answer: C

Dr. M. Al-Shobaki

21 - After resection of S3–S5 nerve roots unilaterally for a chordoma, which deficit is more likely to be found?

a. No deficitb. Neurogenic bladder and fecal incontinencec. Normal urinary and fecal continence with male impotenced. Hemisensory loss and leg weakness with preservation of urinary and fecal continencee. Fecal incontinence alone

Dr. M. Al-Shobaki

Answer: D

Comments: At least one S3 nerve root is required to preserve normal continence and defecation. Hemisensory loss and leg weakness result in injury to branches of the sacral plexus, which becomes the sciatic nerve with its cutaneous and muscular branches.

Dr. M. Al-Shobaki

22 - Which of the following is not true?

a. CCK affects gallbladder motilityb. gallbladder volume decreases following truncal vagatomyc. sympathetic stimulation causes gallbladder relaxationd. patients on total parenteral nutrition may have defective gallbladder motilitye. gallbladder motility can be correlated with migratory motor complex of the gut during the interdigestive period

Dr. M. Al-Shobaki

Answer : B

Dr. M. Al-Shobaki

23 - Which is the first line imaging modality of choice in a patient with suspected “sclerosing cholangitis”?

a. transcutaneous ultrasoundb. multidetector CTc. endoscopic retrograde cholangiographyd. T1-weighted magnetic resonance imaginge. magnetic resonance cholangiography

Dr. M. Al-Shobaki

Answer : E

Dr. M. Al-Shobaki

24 - Which of the following statements about ERCP is true?

a. all patients undergoing laparoscopic cholecystectomy should have oneb. all patients who have had acute pancreatitis should have onec. all patients with severe acute hemolysis should have oned. all patients with acute pancreatitis and evidence of cholangitis should have onee. all patients with post-cholecystectomy pain should have one

Dr. M. Al-Shobaki

Answer : D

Dr. M. Al-Shobaki

25 - Which of the following statements about bile leak after cholecystectomy is false?

a. bilomas do not require drainageb. the ususal site of leakage is the cystic duct stumpc. transpapillary stenting and biliary sphincterotomy are about equally effective in treating the leakd. leaks from accessory bile ducts may not improve with stenting or sphincterotomye. usually, the serum bilirubin is mildly elevated when a significant biloma is present in the abdomen

Dr. M. Al-Shobaki

Answer : A