Anal and rectal

Question 1

arterial supply to the anus

Answer 1

inferior rectal artery

Question 2

venous drainage form the anus

Answer 2

above dentate line- internal hemorrhoid plexus

below dentate line- external hemorrhoid plexus

Question 3

external hemorrhoids

Answer 3

painful
squamous sensate epithelium
TX: lance when thrombosed to relieve pain

Question 4

internal hemorrhoids

Answer 4

primary - slides below dentate line
secondary- prolapse that reduces spontaneously
tertiary- prolapse that has to be reduced manually
Quaternary - not able to reduce

TX: band,
quternanry - 3 quadrant resection, down to the internal sphincter

Question 5

rectal prolapse

Answer 5

starts 6-7 cm from anal verge
secondary to pudendal neuropathy and laxity of anal sphincters
involves all layers of the rectum
TX: perineal rectosigmoidectomy

Question 6

anatomic defects in pts with chronic rectal prolpase

Answer 6

abnormally deep rectovaginal or rectovesical pouch
lax and atonic musculature of the pelvic floor
lack of normal fixation of the rectum and an elongated mesorectum
redundant sigmoid colon
lax and atonic anal sphincter

Question 7

condylomata acuminata

Answer 7

HPV

TX laser surgery

Question 8

anal fissure

Answer 8

90% posterior midline
pain and bleeding after defecation, chronic ones will see a sentinel pile
TX sitz baths, lidocaine jellly, stool oftners
internal sphincterotomy (EXCEPT IN setting of crohns or UC)
lateral or recurrent fissurres - think inflammatory disease

Question 9

anorectal abscess

Answer 9

below levator muscles ( perianal, intersphinteric, ischiorectal) drain through skin
supralevator - drain transrectally, abx

Question 10

pilonidal cyst

Answer 10

abscess of sinus fromation over the sacrococcygeal junction

drain and pack - resect cyst

Question 11

fistula in ano

Answer 11

unroof and eliminate the primary opening with rectal advancement flap

Question 12

Goodsalls rule

Answer 12

anterior fistulas connect with rectum in a straight lines

posterior fistulas go toward midline internal opening in the rectum

Question 13

Simple rectovaginal fistula

Answer 13

secondary to infection or obstetrical trauma, low to midvagina < 2.5 cm
TX: transanally unroof and place rectal muscosa advancement flap

Question 14

complex rectovaginal fistula

Answer 14

secondary to imflammatory bowel disease, XRT, neoplasm or high in vagina > 2.5 cm
TX: abdominal approach or combine approach usual; resection and re-anastamosis with placement of colostomy

Question 15

anal incontinence

Answer 15

neurogenic- no good tx
abdominoperineal descent - damage to levator ani muscle and anus falls below levators, also stretches the pudendal nerves
TX high - fiber diet, limit to 1 bowel movement a day, sphincteroplasty if related to trauma

Question 16

squamous cell ca of anal canal

Answer 16

above dentate line

chemotherapy first line TX (nigro protocol)

Question 17

nigro protocol

Answer 17

anal squamous cell cancer

mitomycin C and 5 FU

Question 18

anal canal melanoma

Answer 18

3rd most common site for melanome
1/3 lymphatic spread to mesenteric lymph nodes
most common symptom - rectal bleeding
TX: APR

Question 19

anal margin squamous cell

Answer 19

ulcerating, slow growing
mets to inguinal nodes
TX WLE lesions < 3 cm

Question 20

qnal margin basal cell ca

Answer 20

central ulcer, raised edges, rare mets

TX WLE

Question 21

Bowens disease

Answer 21

intraepidermal squamous cell CA
malignant, will develop primary cancer of skin
TX local therapy WLE

Question 22

Pagets disease

Answer 22

intraepidermal apocrine gland ca
slow growing
positive RAS stain
TX WLE, check for other malingnancies

Question 23

lymphatic drainage superior and middle rectum

Answer 23

IMA nodes

Question 24

lymphatic drainage lower rectum

Answer 24

IMA nodes, internal iliac nodes

Question 25

lymphatic drainage upper 2/3 anal canal

Answer 25

internal iliac and pelvic nodes

Question 26

lymphatic drainage lower 1/3 anal canal

Answer 26

inguinal nodes