100+ Free AOBPr Proctology Practice Questions

Hemorrhoidal Disease

Internal hemorrhoids above dentate line (visceral innervation, painless bleeding), external below dentate (somatic, painful when thrombosed). Goligher I (no prolapse) -> rubber band ligation/sclerotherapy/IRC; II (prolapse, reduces spontaneously) -> RBL; III (manual reduction) -> RBL or excisional hemorrhoidectomy; IV (irreducible) -> excisional hemorrhoidectomy (Ferguson closed, Milligan-Morgan open). Stapled hemorrhoidopexy (PPH) for circumferential disease. Thrombosed external hemorrhoid within 72 hours -> excision; after 72 hours -> conservative.

Anal Fissure and Anorectal Abscess/Fistula

Acute fissure (<6 weeks) — sitz baths, fiber, topical nifedipine or diltiazem first-line. Chronic posterior midline fissure (sentinel pile, hypertrophied papilla) — lateral internal sphincterotomy (LIS) is gold standard (risk of minor incontinence). Anterior or lateral fissure — rule out Crohn's, HIV, TB, syphilis, leukemia. Perianal abscess — incision and drainage (do NOT delay for imaging in simple disease). Goodsall rule: anterior external opening -> radial straight tract; posterior -> curved tract to posterior midline crypt. Simple low fistula — fistulotomy; complex/high or Crohn's — non-cutting seton, LIFT, advancement flap, fibrin glue/plug.

Inflammatory Bowel Disease (Crohn's, UC)

Crohn's disease — transmural, skip lesions, perianal disease (fistula, abscess, stricture). EUA + drainage + non-cutting seton for fistulizing perianal Crohn's, then biologics (infliximab, adalimumab, ustekinumab, vedolizumab). Avoid sphincterotomy and aggressive fistulotomy in Crohn's. Ulcerative colitis — mucosal, continuous from rectum proximally. Severity Truelove-Witts (severe = >=6 bloody stools/day + 1 systemic feature). Severe UC — IV steroids day 3 -> if no response, infliximab or cyclosporine rescue or colectomy. Definitive surgery — total proctocolectomy with IPAA (J-pouch). Pouchitis — ciprofloxacin/metronidazole.

Colorectal Cancer Screening and Management

USPSTF: average-risk screening starts at age 45. Colonoscopy q10y; FIT annually; FIT-DNA (Cologuard) q3y; CT colonography q5y. Polyp surveillance (USMSTF) — 1-2 small tubular adenomas -> 7-10y; 3-4 adenomas -> 3-5y; 5-10 or >=10 mm or villous/HGD -> 3y; >10 adenomas -> 1y. Lynch syndrome (MSH2/MLH1/MSH6/PMS2, EPCAM) — colonoscopy q1-2y starting 20-25. FAP (APC) — total proctocolectomy by 20s. Rectal cancer staging — MRI pelvis, EUS, CT C/A/P. Locally advanced rectal cancer (T3-4 or N+) -> total neoadjuvant therapy (TNT) -> TME with sphincter-preserving LAR if margin allows, APR if tumor at sphincter. Watch-and-wait for clinical complete response (cCR) selectively. Adjuvant FOLFOX/CAPOX for stage III colon.

Anal Cancer and Anal Dysplasia

Anal squamous cell carcinoma — strongly associated with HPV 16/18, HIV, MSM, immunosuppression. Standard first-line treatment is the Nigro protocol — concurrent chemoradiation with 5-fluorouracil + mitomycin C plus pelvic radiation (45-59 Gy). Achieves ~70-90% complete response without surgery, preserving sphincter. Salvage APR reserved for persistent or recurrent disease. Anal HSIL (precursor) — high-resolution anoscopy (HRA) and ablation (ANCHOR trial in HIV+). Anal adenocarcinoma is treated like rectal cancer (neoadjuvant CRT + TME or APR).

Pelvic Floor and Functional Disorders

Fecal incontinence — assess sphincter integrity (endoanal ultrasound), anal manometry, pudendal nerve terminal motor latency. First-line — fiber + loperamide + biofeedback (pelvic floor PT). Sacral nerve stimulation (SNS, InterStim) for refractory FI with intact sphincter. Sphincteroplasty for obstetric or traumatic sphincter defect (results deteriorate at 5 years). Constipation — slow-transit (Sitz marker) vs outlet obstruction (dyssynergic defecation — balloon expulsion, defecography, biofeedback first-line). Rectal prolapse — full-thickness procidentia — perineal (Altemeier, Delorme) for high-risk frail patient; transabdominal ventral mesh rectopexy (D'Hoore) for fit patient.

Diverticular Disease

Diverticulosis — most common in sigmoid in Western countries. Uncomplicated diverticulitis (Hinchey 0/Ia) — CT diagnosis; selective antibiotics in mild cases (DIABOLO/AVOD/STAND-DIVA support no antibiotics in mild). Complicated — Hinchey II (pericolic/pelvic abscess >3-4 cm) — percutaneous drainage; Hinchey III (purulent peritonitis) and IV (feculent peritonitis) — emergent surgery (Hartmann classically vs primary anastomosis with diverting loop in selected stable patients per LADIES/DIVERTI). Elective resection — individualized after recurrent episodes, immunosuppression, fistula, stricture. Colovesical fistula — most common diverticular fistula. Diverticular bleeding — usually right-sided, painless hematochezia; colonoscopy with clip/cautery first-line.

Ostomies and Postoperative Care

End colostomy (often Hartmann) vs end ileostomy vs loop ileostomy (diverting). Stoma siting preoperatively by enterostomal therapist — through rectus, away from belt line, skin folds, scars. High-output ileostomy (>1.5 L/day) — fluid + electrolytes (oral rehydration), loperamide titration, codeine, octreotide, omeprazole; address dehydration and AKI risk. Parastomal hernia — repair with mesh (Sugarbaker, keyhole). Stoma reversal — diverting loop ileostomy typically reversed ~8-12 weeks after low anastomosis confirmed intact by Gastrografin enema.

Anorectal Anatomy, Physiology, and Diagnostics

Dentate (pectinate) line — embryologic junction; above is endodermal (columnar/cuboidal, visceral innervation, painless), below is ectodermal (squamous, somatic innervation via inferior rectal/pudendal). Internal anal sphincter — involuntary smooth muscle (continuation of circular rectal muscle). External anal sphincter — voluntary skeletal (deep, superficial, subcutaneous). Pudendal nerve S2-4 — motor and sensory below dentate. Arterial — superior rectal (IMA), middle rectal (internal iliac), inferior rectal (internal pudendal). Anorectal manometry — resting (IAS) and squeeze (EAS) pressures, RAIR (rectoanal inhibitory reflex — absent in Hirschsprung).

Endoscopy and Polypectomy

Colonoscopy quality metrics — ADR >=25% (>=30% men, >=20% women), cecal intubation >=95% (screening), withdrawal time >=6 min, adequate prep (Boston >=6, >=2 each segment). Polyp histology — tubular adenoma (low risk), tubulovillous, villous (higher HGD/cancer risk); sessile serrated lesion (BRAF, MSI, right-sided, serrated pathway); hyperplastic (rectosigmoid, generally benign). Polypectomy — cold snare for <10 mm sessile/pedunculated (preferred over hot biopsy forceps), hot snare for pedunculated >10 mm, EMR (lift sign) for sessile >=10 mm, ESD for large laterally spreading. Post-polypectomy bleeding — clips, cautery, epinephrine injection.

Osteopathic Principles & Practice (OMM/OMT)

Sacral counterstrain and pelvic diaphragm release for pelvic floor dysfunction. Abdominal lymphatic pump for postoperative ileus and improved peristalsis. Mesenteric lift and visceral release techniques. Chapman reflexes — colon (anterior — IT band; posterior — T11-L1 transverse processes), rectum (anterior — superior border of pubic ramus near symphysis; posterior — lateral aspect of sacrum). Suboccipital release and rib raising for autonomic balance (parasympathetic via vagus, sympathetic via T11-L2 to colon). Five osteopathic models integrated into surgical recovery and chronic pelvic pain management.