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37 Anal and Rectal Flashcards

1
Q

arterial supply

A

inferior rectal artery

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2
Q

venous drainage

A

above dentate line is internal hemorrhoid plexus … below dentate is external hemorrhoid plexus

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3
Q

hemorrhoids: list plexi

A

left lateral, right anterior, right posterior hemorrhoidal plexi

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4
Q

hemorrhoids: external vs internal

A

external painful vs internal cause bleeding and prolapse

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5
Q

hemorrhoids: external - describe

A

cause pain when they thrombose, distal to the dentate line, covered by sensate squamous epithelium, can cause pain, swelling, itching

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6
Q

hemorrhoids: internal - describe, types

A

cause bleeding or prolapse … primary = slides below dentate with strain … secondary = prolapse that reduces spontaneously … tertiary = prolapse that has to be manually reduced …. quaternary = not able to reduce

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7
Q

hemorrhoids: tx

A

fiber, stool softeners (prevent straining), sitz baths

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8
Q

hemorrhoids: mgmt of thrombosed external hemorrhoids

A

lance open (if >72 hours) or elliptical excision (if <72 hours) to relieve pain

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9
Q

hemorrhoids: surgical indications

A

recurrence, thrombosis multiple times, large external component

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10
Q

hemorrhoids: surgery of external vs internal

A

external = can be resected with elliptical excision (can NOT band, would be painful) … primary or secondary internal = band …. tertiary or quaternary internal = 3 quadrant resection, need to resect down to the internal anal sphincter (do NOT go through it), postop w sitz baths, stool softener, high-fiber diet

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11
Q

rectal prolapse: location

A

6-7cm from anal verge

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12
Q

rectal prolapse: cause

A

pudendal neuropahy and laxity of anal sphincters

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13
Q

rectal prolapse: inc risk

A

F gender, straining, chronic diarrhea, previous pregnancy, reducdant sigmoid colons

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14
Q

rectal prolapse: layers

A

prolapse involves all layers of the recum

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15
Q

rectal prolapse: medical tx

A

high-fiber diet

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16
Q

rectal prolapse: surgical tx

A

perineal rectosigmoid resection (Altemeier) transanally if pt is older and frail … low anterior resection and pexy of residual colon if good condition patient

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17
Q

condylomata acuminata: px, cause, tx

A

cauliflower mass, papillomavirus (HPV), tx w laser surgery

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18
Q

anal fissure: caused by what?

A

split in anoderm

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19
Q

anal fissure: location

A

90% in posterior midline

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20
Q

anal fissure: causes what

A

pain and bleeding after defecation, chronic ones will see a sentinel pile (skin tag)

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21
Q

anal fissure: medical tx

A

sitz bath, bulk, lidocaine jelly, stool softener … 90% heal

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22
Q

anal fissure: surgical tx

A

lateral subcutaneous internal sphincterotomy

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23
Q

anal fissure: MC complication of surgery

A

fecal incontinence

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24
Q

anal fissure: contraindications to surgery

A

do NOT perform if 2/2 crohn’s or UC

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25
anal fissure: lateral or recurrent
worry about IBD
26
anorectal abscess: px
can cause severe pain
27
anorectal abscess: mgmt of different locations
perianal, intersphincteric, ischiorectal = drain through the skin (all are below the levator muscles) ... supralevator = drain transrectally .... intersphincteric, ischiorectal = can form horseshoe abscess
28
anorectal abscess: assoc w
abx cellulitis, DM, immunocompromised, prosthetic hardware
29
pilonidal cysts: describe, MC in which gender, tx
sinus or abscess formation over the sacrococcygeal junction ... inc in M ... tx w drainage and pakcing, f/u surgical resection of cyst
30
fistula-in-ano: occurs after what
anorectal abscess formation
31
fistula-in-ano: goodsall's rule
anterior fistulas connect with anus/rectum in straight line ... posterior fistulas go toward a midline internal opening in the anus/rectum
32
fistula-in-ano: tx
do NOT need to excise the tract ... lower 1/3 of the external anal sphincter --> fistulotomy (open tract up, curettage out, let it heal by secondary intention) .... upper 2/3 of the external anal sphincter --> rectal advancement flap
33
fistula-in-ano: complication
most concerning is risk of incentinence, you want to avoid damage to external anal sphincter so fistulotomy is not used for fistulas above the lower 1/3 of the external anal sphincter
34
fistula-in-ano: simple
low to mid vagina .... tx = trans-anal rectal mucosa advancement flap .... manu obstetrical fistulas heal spontaneously
35
fistula-in-ano: complex
high in vagina .... tx = abdominal or combined abdominal and perineal approach usual, resection and re-anastomosis of rectum, close hole in vagina, interpose omentum, temporary ileostomy
36
anal incontinence: neurogenic
gaping hole ... no good treatment
37
anal incontinence: abdominoperineal descent
chronic damage to levator ani muscle and pudendal nerves (obesity, multiparous women) and anus falls below levators ... tx = high-fiber diet, limit to 1 bowel movement a day, hard to treat
38
anal incontinence: tx 2/2 obstetrical trauma
anterior anal sphincteroplasty
39
AIDS anorectal problems: list
Kaposi's sarcoma, CMV, HSV, B cell lymphoma
40
AIDS anorectal problems: Kaposi's
see nodule with ulceration, C cancer in pts w AIDS
41
AIDS anorectal problems: CMV
see shallow ulcers, similar presentation as appendicitis, tx w ganciclovir
42
AIDS anorectal problems: HSV
#1 rectal ulcer
43
AIDS anorectal problems: B cell lymphoma
can look like ulcer or abscess
44
AIDS anorectal problems: workup
bx to r/o cancer and make dx
45
AIDS anorectal problems: present as nodule w ulceration vs shallow ulcers / appendicitis vs ulcer vs ulcer or abscess
nodule w ulceration = Kaposis shallow ulcer = CMV #1 rectal ulcer = HSV ulcer or abscess = B cell lymphoma need bx to differentiate
46
anal cancer: assoc with what
HPV and XRT
47
anal cancer: anal canal vs anal margin
canal = above dentate line = squamous cell CA, adenocarcinoma, melanoma ... margin = below dentate line = squamous cell CA, basal cell CA .... anal margin have better prognosis with anal canal lesions
48
anal cancer: anal canal lesions - squamous cell CA - types
above dentate line, epidermoid CA, mucoepidermoid CA, cloacogenic CA, basaloid CA
49
anal cancer: anal canal lesions - squamous cell CA - sx
pruritis, bleeding, palpable mass
50
anal cancer: anal canal lesions - squamous cell CA - tx
nigro protocol - chemo-XRT with 5FU and mitomycin, NOT surgery .... cures 80% .... APR for failures or recurrence cancer
51
anal cancer: anal canal lesions - adenocarcinoma tx
APR usual, WLE if <3cm, <1/3 circumference, limited to submucosa (T1 tumors, 2-3mm margin needed), well-differentiated, no vascular/lymphatic invasion .... need about 1cm margin ... postop chemo/XRT same as rectal CA
52
anal cancer: anal canal lesions - melanoma - rate
3rd most common site for melanoma, skin and eyes are #1 and #2
53
anal cancer: anal canal lesions - melanoma - spread to lymph nodes
1/3 has spread to mesenteric lymph nodes
54
anal cancer: anal canal lesions - melanoma - hematogenous spread
to liver and the lung is early and accounts for most deaths
55
anal cancer: anal canal lesions - melanoma - sx disease
often assoc w significant met disease
56
anal cancer: anal canal lesions - melanoma - MC sx
rectal bleeding
57
anal cancer: anal canal lesions - melanoma - appearance of most lesions
lightly pigmented or lack pigmentation
58
anal cancer: anal canal lesions - melanoma - tx
APR usual, margin dictated by depth of lesion standard for melanoma
59
anal cancer: anal margin lesions - prognosis
better prognosis than anal canal lesions
60
anal cancer: anal margin lesions - squamous cell CA - describe
ulcerating, slow growing, M with better prognosis
61
anal cancer: anal margin lesions - squamous cell CA - mets
go to inguinal nodes
62
anal cancer: anal margin lesions - squamous cell CA - tx
WLE for lesions <5cm (need 0.5 cm margin) ... chemo-XRT (5FU and cisplatin), primary tx for lesions >5cm, if involving sphincter or if positive nodes (trying to preserve the sphincter here and avoid APR) ... need inguinal node dissection if clinically positive
63
anal cancer: anal margin lesions - basal cell CA - describe, tx
central ulcer, raised edges, rare mets ... tx = WLE usually sufficient, only need 3mm margina, rare need for APR unless sphincter involved
64
nodal mets: superior and middle rectum
IMA nodes
65
nodal mets: lower rectum
primarily IMA nodes, also to internal iliac nodes
66
nodal mets: upper 2/3 of anal canal
internal iliac nodes
67
nodal mets: lower 1/3 of anal canal
inguinal nodes

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