Q64: Surgery: PLAB/UK(MLA)/AKT Exam style question

AKT exam questions

Mar 26

Today we will discuss another Q64 Surgery PLAB 1/ UKMLA exam style question.

A 63-year-old woman comes to her GP with complaints of unintentional weight loss over the past three months, an altered bowel habit, and fatigue. She mentions intermittent episodes of blood in her stools. On examination, the GP identified a non-pulsatile, fixed mass in her left lower abdominal quadrant. There is no visible jaundice or pedal oedema. Her abdominal examination otherwise is unremarkable. Which is the SINGLE most appropriate initial step in her management?

A. Complete blood count with differential

B. Immediate referral to gastroenterology for endoscopy

C. Abdominal and pelvic CT scan with contrast

D. Urgent referral to the local colorectal service

E. Stool for occult blood test

Explanation

Answer: D. Urgent referral to the local colorectal service

This patient’s presentation is highly suggestive of colorectal carcinoma (CRC).

Key features include:

Age: She is above 60, a population at increased risk.
Symptoms: Unintentional weight loss, altered bowel habits, and blood in stools.
Physical Examination: The presence of a non-pulsatile, fixed mass in the left lower quadrant, which could indicate a tumour.

Now, let’s dissect the options:

A. Complete blood count with differential: While this can provide information on anaemia (which can result from chronic blood loss due to CRC), it does not directly address the primary concern.

B. Immediate referral to gastroenterology for endoscopy: An endoscopy can indeed visualize and biopsy potential tumours. However, given the palpable mass and the constellation of symptoms, a more comprehensive approach is required, which is usually provided by colorectal services.

C. Abdominal and pelvic CT scan with contrast: A useful investigation to delineate the anatomy and extent of a tumour, but not the first step.

D. Urgent referral to the local colorectal service: This is the best approach because CRC is suspected. A dedicated colorectal team will provide a holistic approach, including a timely diagnosis (usually via colonoscopy) and immediate management.

E. Stool for occult blood test: This test can indicate the presence of blood in the stool, which can be a sign of CRC. However, given this patient’s overt symptoms, a more definitive approach is required.

According to NICE guidelines, any individual over 40 with unexplained weight loss and abdominal pain should be referred using a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer. The guideline also states that people with a palpable rectal mass should be referred urgently (for an appointment within 2 weeks) for suspected colorectal cancer. Therefore, option D (urgent referral to the local colorectal service) is the most appropriate initial step in the management of this patient.

Additionally, NICE guidelines recommend that people with rectal bleeding and any of the following symptoms should also be referred urgently (for an appointment within 2 weeks) for suspected colorectal cancer:

A change in bowel habit lasting more than 6 weeks
A haemoglobin level below 11 g/dL in men or below 10 g/dL in women
A positive result from a faecal immunochemical test (FIT)

The guidelines also suggest that people with a change in bowel habit or abdominal pain who do not meet the criteria for a suspected cancer pathway referral should be offered a FIT, and if the FIT result is positive, they should be referred using a suspected cancer pathway referral (for an appointment within 2 weeks) for colorectal cancer.

Remember, early diagnosis and management are key in CRC, as this can significantly influence patient prognosis. A holistic approach from a dedicated colorectal team ensures this is done timely and efficiently.

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Reference:

Colorectal cancer | Guidance | NICE: This is the NICE guideline on colorectal cancer, which covers managing colorectal cancer in people aged 18 and over. It aims to improve quality of life and survival for adults with colorectal cancer through management of local disease and secondary tumours (metastatic disease). You can find the recommendations, evidence, rationale, context, and update information in this document.
Suspected cancer: recognition and referral | Guidance | NICE: This is the NICE guideline on suspected cancer, which covers identifying and referring people with suspected cancer. It aims to improve outcomes by promoting early diagnosis and reducing variation in referral practice. You can find the recommendations, evidence, rationale, context, and update information in this document.