3.

Which of the following statements about hemorrhoids is/are not true?

A. Hemorrhoids are specialized cushions present in everyone that aid continence.
B. External hemorrhoids are covered by skin whereas internal hemorrhoids are covered by mucosa.
C. Pain is often associated with uncomplicated hemorrhoids.
D. Hemorrhoidectomy is reserved for third- and fourth-degree hemorrhoids.
Answer: C
DISCUSSION: Hemorrhoids are specialized, highly vascularized cushions in the anal canal that aid
continence. The cause of hemorrhoids is unknown, but they may represent nothing more than the
downward sliding of anal cushions associated with straining and irregular bowel habits. They are classified
and treated according to the severity of symptoms. External hemorrhoids are covered with anoderm and are
distal to the dentate line. Internal hemorrhoids are covered by the mucosal lining of the anal canal proximal
to the dentate line. They can cause painless bleeding, usually in association with defecation. Uncomplicated
hemorrhoids usually are not associated with pain, but fissures more often are. Hemorrhoidectomy is
reserved for third-degree (bleeding with prolapse requiring manual reduction) and fourth-degree
(permanently prolapsed with or without bleeding) hemorrhoids.

4.
Which statement(s) is/are true about hidradenitis suppurativa?
A. It is a disease of the apocrine sweat glands.
B. It causes multiple perianal and perineal sinuses that drain watery pus.
C. The sinuses do not communicate with the dentate line.
D. The treatment is surgical.
E. All of the above.
Answer: E
DISCUSSION: Hidradenitis suppurativa is an inflammatory process of the sweat glands characterized by
abscess and sinus formation. The disease may involve other areas where apocrine glands are present, such
as the axilla, mammary, inguinal, and genital regions. The affected areas have a blotchy, purplish
appearance with numerous sinuses draining watery pus. The condition must be differentiated from
cryptoglandular fistulas, which communicate with the dentate line, and Crohn's disease, which may track to
the anorectum proximal to the dentate line. Treatment consists of unroofing sinuses for limited disease and
wide local excision for more advanced disease.
5.

Which of the following statement(s) relating to anal sphincteric function is/are correct?

a. When the rectum is distended, the internal anal sphincter relaxes and the external anal sphincter
contracts
b. When the rectum is distended, the internal anal sphincter contracts and the external anal sphincter
relaxes
c. The external anal sphincter is responsible for resting anal pressure
d. The internal anal sphincter is responsible for resting anal pressure
Answer: a, d
The internal sphincter, because it is innervated by the autonomic nervous system, is not subject to voluntary
control. This powerful muscle exists in a continuously tonic state, and is responsible for maintaining
closure of the resting anal canal. The high-pressure zone of the anal canal at rest is due to the actions of the
internal sphincter. The external sphincter contributes to anal pressure only when a bolus of stool is present
within the anal canal. The increase in pressure during voluntary contraction (squeeze pressure) is
exclusively due to the activity of the external sphincter. The high resting pressure in the anal canal acts as a
barrier to prevent leakage of mucus and gas.
When the rectum is distended, the internal sphincter relaxes. This relaxation allows the rectal content to
move down to the anal canal. In contrast, when the rectum is distended, the external sphincter contracts.
Reflex contraction of the external sphincter prevents rectal content from leaking through the anus. Although

volitional contraction of the external sphincter can only be sustained for short periods, it is the most
important mechanism of voluntary continence.
6.

The most common complication after hemorrhoidectomy is which of the following?

a. Urinary retention
b. Rectal bleeding
c. Incontinence
d. Wound infection
Answer: a
Hemorrhoidectomy should be considered when the hemorrhoids are severely prolapsed through the anus,
requiring manual replacement, or in hemorrhoids complicated with associated pathology, such as
ulceration, fissure, fistula, large hypertrophied anal papilla, or extensive skin tags. An elliptic excision starts
at the perianal skin, includes external and internal hemorrhoids, and ends at the anorectal ring. The mucosa
and submucosa are dissected off the underlying internal sphincter muscle. Unless there is an associated anal
stenosis or chronic anal fissure, internal sphincterotomy is not performed. The entire wound is closed with
running absorbable suture. The largest and the most redundant hemorrhoid should be excised first. No
packing is placed in the anal canal. Urinary retention is the most common complication of
hemorrhoidectomy, and can be avoided if intravenous fluids are restricted during the procedure and
minimized for the next 6 to 8 hours.
7.
A 65-year-old man presents with complaints of mucous discharge and perianal discomfort.
Physical examination reveals a fistulous opening lateral to the anus. Anoscopic examination permits
passage of a probe through the fistula tract. The fistula traverses the internal anal sphincter, the
intersphincteric plane, and a portion of the external anal sphincter. The fistula is categorized as which
type?
a. Intersphincteric
b. Transsphincteric
c. Suprasphincteric
d. Extrasphincteric
Answer: b
There are four main forms of fistula-in-ano, based on the relation of the fistula to the sphincter muscles. An
intersphincteric fistula tract is in the intersphincteric plane. The external opening is usually in the perianal
skin close to the anal verge. A transsphincteric fistula starts in the intersphincteric plane or in the deep
postanal space. The fistulous track traverses the external sphincter, with the external opening at the
ischioanal fossa. Horseshoe fistulas are in this category. Suprasphincteric fistulas start in the
intersphincteric plane in the mid-anal canal and then pass upward to a point above the puborectalis. The
fistula passes laterally over this muscle and downward between the puborectalis and the levator ani muscle
into the ischioanal fossa. An extrasphincteric fistula passes from the perineal skin through the ischioanal
fossa, the levator ani muscle, and finally penetrates the rectal wall. Extrasphincteric fistulas may arise from
cryptoglandular origin, trauma, foreign body, or pelvic abscess.
8.
For the patient in the preceding question, appropriate management includes which of the
following?
a. Division of the tissues over the probe with electrocautery, leaving the wound open to heal by
secondary intention
b. Division of the tissues over the probe with electrocautery, closing the wound using a pedicled skin
flap

c. Division of the internal anal sphincter using electrocautery, encircling the external sphincter with a
seton
d. Proximal diverting colostomy and antibiotics
Answer: c
In young patients, transection of internal and external sphincter muscles in the posterior half, when
performed in the course of a fistulotomy, does not always jeopardize anal continence. In older patients and
in women, however, transection of the external sphincter muscle, particularly in the anterior half, risks
incontinence. When external sphincter transection appears likely, some authors recommend the use of a
seton. A seton is a suture that is drawn through a fistula. The rationale for using a seton is to create fibrosis.
The seton is threaded through the fistulous track and tied over the muscles. In the second stage (average
interval, 6 to 8 weeks), fistulotomy is performed. Incontinence after the proper use of seton is uncommon,
even when the fistula is deep.

1)

What 16 years old female presented with pinkish streaks in the

stool, and it was painless, mostly its due to
a) Hemorrhoids
b) Fistula in ano

2)

What is the wrong answer

a) Anal fistula is a common cause for malignancy
b) Multiple fissures arise the suspicion of secondary cause
c) AIDS is a secondary cause

most common presentation of internal :hemorrhoids

Passing fresh blood after defecation.
11- True about anal fissures:
a) Usually don't respond to medical treatment
b) Usually located above the dentate line
c) There's a hypertonic sphinctor
d) Rarely located in the midline
e) Sentinel pile is found in acue fissure
84- True about anal hemorrhoids:

a) Part of the continence mechanism

11. The following symptoms are common in anal problems, except:

a. Perianal discharge
b. Perianal itching and irritation
c. Pain
d. Nausea and vomiting
e. Anal bleeding D
12. The following statement regarding Haemorrhoids are true,
except:
a. They are dilatation of the inferior haemorrhoidal vein only
b. They can present with fresh bleeding per rectum.
c. May be caused by chronic constipation
d. May develop secondary to pregnency
e. May be caused by carcinoma of the rectum A
13. The following statement regarding Anal Fissure are true, except:
a. longitudinal tear in the mucosa and skin of the anal canal
b. commonly situated at the lateral side of the anal canal
c. lateral fissures suggested specific lesions such as Ulcerative
colitis or Maligancy
d. The chronic anal fissure can form A sentinel pile
e. lateral internal sphincterotomy one option of surgical treatment
B
77. The proper treatment of a patient with a peri-anal abscess is;
a. Incision and drainage as soon as fluctuation develops
b. Incision and drainage with excision of the internal opening
c. Prompt incision and drainage
d. Use of antibiotics and sitz bath
e. None of the above C

29. Which of the followings is true?

A. Anal fistula is an abnormal connection between the epithelialized
surface of
the anal canal and the perianal skin
B. Antibiotics alone may be sufficient in the treatment of an anorectal
abscess
C. Traumatic fistulae are usually intersphincteric
D. Setons have an increased risk of incontinence

83- One of the following is true about management of perianal

suuparation:

a) Surgery is needed in most cases

84- True about anal hemorrhoids:

a) Part of the continence mechanism