37 Anal and Rectal Flashcards
arterial supply
inferior rectal artery
venous drainage
above dentate line is internal hemorrhoid plexus … below dentate is external hemorrhoid plexus
hemorrhoids: list plexi
left lateral, right anterior, right posterior hemorrhoidal plexi
hemorrhoids: external vs internal
external painful vs internal cause bleeding and prolapse
hemorrhoids: external - describe
cause pain when they thrombose, distal to the dentate line, covered by sensate squamous epithelium, can cause pain, swelling, itching
hemorrhoids: internal - describe, types
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
hemorrhoids: tx
fiber, stool softeners (prevent straining), sitz baths
hemorrhoids: mgmt of thrombosed external hemorrhoids
lance open (if >72 hours) or elliptical excision (if <72 hours) to relieve pain
hemorrhoids: surgical indications
recurrence, thrombosis multiple times, large external component
hemorrhoids: surgery of external vs internal
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
rectal prolapse: location
6-7cm from anal verge
rectal prolapse: cause
pudendal neuropahy and laxity of anal sphincters
rectal prolapse: inc risk
F gender, straining, chronic diarrhea, previous pregnancy, reducdant sigmoid colons
rectal prolapse: layers
prolapse involves all layers of the recum
rectal prolapse: medical tx
high-fiber diet
rectal prolapse: surgical tx
perineal rectosigmoid resection (Altemeier) transanally if pt is older and frail … low anterior resection and pexy of residual colon if good condition patient
condylomata acuminata: px, cause, tx
cauliflower mass, papillomavirus (HPV), tx w laser surgery
anal fissure: caused by what?
split in anoderm
anal fissure: location
90% in posterior midline
anal fissure: causes what
pain and bleeding after defecation, chronic ones will see a sentinel pile (skin tag)
anal fissure: medical tx
sitz bath, bulk, lidocaine jelly, stool softener … 90% heal
anal fissure: surgical tx
lateral subcutaneous internal sphincterotomy
anal fissure: MC complication of surgery
fecal incontinence
anal fissure: contraindications to surgery
do NOT perform if 2/2 crohn’s or UC
anal fissure: lateral or recurrent
worry about IBD
anorectal abscess: px
can cause severe pain
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
anorectal abscess: assoc w
abx cellulitis, DM, immunocompromised, prosthetic hardware
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
fistula-in-ano: occurs after what
anorectal abscess formation
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
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
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
fistula-in-ano: simple
low to mid vagina …. tx = trans-anal rectal mucosa advancement flap …. manu obstetrical fistulas heal spontaneously
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
anal incontinence: neurogenic
gaping hole … no good treatment
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
anal incontinence: tx 2/2 obstetrical trauma
anterior anal sphincteroplasty
AIDS anorectal problems: list
Kaposi’s sarcoma, CMV, HSV, B cell lymphoma
AIDS anorectal problems: Kaposi’s
see nodule with ulceration, C cancer in pts w AIDS
AIDS anorectal problems: CMV
see shallow ulcers, similar presentation as appendicitis, tx w ganciclovir
AIDS anorectal problems: HSV
1 rectal ulcer
AIDS anorectal problems: B cell lymphoma
can look like ulcer or abscess
AIDS anorectal problems: workup
bx to r/o cancer and make dx
AIDS anorectal problems: present as nodule w ulceration vs shallow ulcers / appendicitis vs ulcer vs ulcer or abscess
1 rectal ulcer = HSV
nodule w ulceration = Kaposis
shallow ulcer = CMV
ulcer or abscess = B cell lymphoma
need bx to differentiate
anal cancer: assoc with what
HPV and XRT
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
anal cancer: anal canal lesions - squamous cell CA - types
above dentate line, epidermoid CA, mucoepidermoid CA, cloacogenic CA, basaloid CA
anal cancer: anal canal lesions - squamous cell CA - sx
pruritis, bleeding, palpable mass
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
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
anal cancer: anal canal lesions - melanoma - rate
3rd most common site for melanoma, skin and eyes are #1 and #2
anal cancer: anal canal lesions - melanoma - spread to lymph nodes
1/3 has spread to mesenteric lymph nodes
anal cancer: anal canal lesions - melanoma - hematogenous spread
to liver and the lung is early and accounts for most deaths
anal cancer: anal canal lesions - melanoma - sx disease
often assoc w significant met disease
anal cancer: anal canal lesions - melanoma - MC sx
rectal bleeding
anal cancer: anal canal lesions - melanoma - appearance of most lesions
lightly pigmented or lack pigmentation
anal cancer: anal canal lesions - melanoma - tx
APR usual, margin dictated by depth of lesion standard for melanoma
anal cancer: anal margin lesions - prognosis
better prognosis than anal canal lesions
anal cancer: anal margin lesions - squamous cell CA - describe
ulcerating, slow growing, M with better prognosis
anal cancer: anal margin lesions - squamous cell CA - mets
go to inguinal nodes
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
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
nodal mets: superior and middle rectum
IMA nodes
nodal mets: lower rectum
primarily IMA nodes, also to internal iliac nodes
nodal mets: upper 2/3 of anal canal
internal iliac nodes
nodal mets: lower 1/3 of anal canal
inguinal nodes
