Anal Flashcards
Arterial supply to anus
Inferior rectal artery
Venous drainage of anus
Above dentate – internal hemorrhoid plexus; below external hemorrhoid plexus
Cause of hemorrhoids
Straining
External hemorrhoids cause pain when…
They thrombose
Distal to dentate line, hemorrhoids are covered by
Sensate squamous epithelium; pain/swelling/itching
Internal hemorrhoids cause…
Bleeding/prolapse
Primary through Quarternary hemorrhoids
Primary: slide below dentate with strain
Secondary: reduces spontaneously
Tertiary: manual reducation
Quarternary: Not able to reduce
Treatment of hemorrhoids
Fiber and stool softeners; Sitz, fluids
Treatment of thrombosed external hemorrhoid based on 72 hour time mark
> 72 hours; lance open
< 72 hours: elliptical excision
Should you band external hemorrhoids
No
T/F A three quadrant resection is needed for 3ary/4ary hemorrhoids
Need to resect down to internal anal sphincter
- Sitz, stool softener, high fiber
Where does rectum begin from the anal verge?
6-7 cm
Why does rectum prolapse?
Pudendal neuropathy, laxity of anal sphincters
Increased risk of rectal prolapse
Females, straining, diarrhea, previous rpregnancy, redundant sigmoid colon
Medial treatment of rectal prolapse
High fiber diet
Surgical treatments of rectal prolapse
Old and frail: perineal recto-sigmoid resection
Young: LAR/Pexy
Cause and treatment of anal condylomata acuminata
HPV
* Laser surgery
Anal fissure is caused by
Straining bowel movements; constipation; split in anoderm
- 90% posterior midline
First-line treatment of anal fissure
Sitz, bulk, lido jelly, stool softeners, NG cream
Surgical tx of anal fissure
Lateral subcutaneous internal sphincterotomy
Most serious complication of anal fissure surgery
Fecal incontinence
For lateral or recurrent anal fissures, the main worry is
IBD
What types of anal absecesses need to be drained transrectally?
Supra-levator abscesses
When do you provide Abx for ano-rectal abscesses?
cellulitis, DM, IS, prosthetic hardware
What is a pilonidal cyst?
Sinus/abscess formation over sacrococcygeal junction
Do you excise tract of a fistula-in-ano?
No
What is Goodsall’s rule?
Anterior fistulas connect with anus/rectum in straight line; posterior fistulas go toward a midline internal opening in anus/rectum
Treatment of lower 1/3 external anal sphincter fistula
Draining seton stitch; possible fistulotomy; heal by secondary intention
Treatment of upper 2/3 external anal sphincter fistula
Draining seton stitch; +/- rectal advancement flap
Most worrisome complication following anal fistula repair
Incontinence; no fistulotomy above the lower 1/3 of external anal sphincter
MCC simple recto-vaginal fistula
OB trauma; treatment – trans-anal rectal mucosa advancement flap
MCC complex recto-vaginal fistula
Diverticulitis; resection and re-anastamosis of rectum, close hold in vagina, interpose omentum, ileostomy
MCC cancer in AIDS patients
Kaposi’s sarcoma; nodule with ulceration
1 rectal ulcer in AIDS
HSV
Shallow ulcers in AIDS rectum
CMV
T/F B cell lymphoma can look like rectal/anal abscess or ulcer
True
Anal canal vs anal margin
Anal canal: above dentate
Anal margin: below dentate
Anal cancer is a/w this virus and XRT
HPV
Anal canal lesions include
SCC, AC, Melanoma
Anal margin lesions include
SCC, basal cell ca
Nodal mets following ano-recal cancer
Superior, middle rectum: IMA
Lower rectum: IMA, II nodes
Anal canal: Int iliac nodes
Anal margin: Inguinal nodes
Anal canal SCC
Pruritis, bleeding, palpable mass
What is Nigro protocol?
For anal canal SCC
- Chemo-XRT with 5-Fu and mitomycin; not surgery (cures 80%; APR for treatment failure, or recurrent cancer)
Treatment for anal canal adenocarcinoma
APR, WLE if < 4 cm, < 1/2 circumference limited to submucosa; T1, 2-3mm margins
Top 3 sites for melanoma
Skin, eyes, Anal canal
What accounts for most anal melanoma early deaths
Heme spread to liver, lung
Most common symptoms of anal melanoma
Rectal bleeding
Treatment, usual for anal canal melanoma
APR
Which have better prognosis: anal margin or anal canal?
Anal margin
Anal margin SCC
WLE for lesions < 5 cm
5-FU and cisplatin
Treatment for anal BCC
Central ulcer, raised edges, rare mets; 3-mm margins; rare need for APR unless spinchter involved
