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ABSITE > Anal Disease > Flashcards

Anal Disease Flashcards

1
Q

How do you identify the dentate/pectinate line? Above = internal hem, Below = external hem

A

Anal valves and bases of anal columns. Microscopically, transitions from mucocutaneous junction between nonkeratinizing squamous mucosa and keratinizing squamous epithelium.

Innervation: SOMATIC below, AUTONOMIC above.

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2
Q

What is the arterial blood supply to the anal region?

A

Proximal (above dentate) = superior rectal artery / superior rectal vein (IMV) and middle rectal vein (iliacs)
Distal = inferior rectal branch of PUDENDAL artery / inferior hemorrhoidal vessels (iliac)

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3
Q

What is the lymphatic drainage of the anal region?

A

Proximal (above dentate) = mesorectal, internal iliac, inferior mesenteric nodes
Distal = inguinal nodes

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4
Q

What is the incidence of anal cancer?

A

2.6% of GI malignancies.

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5
Q

Histologic variants of anal squamous neoplasms?

A

Cloacogenic
Basaloid
Epidermoid
Mucoepidermoid

All need Nigro.

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6
Q

Main HPV variants that cause anal squamous cell carcinoma?

A

16 and 18.

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7
Q

What is condyloma acuminata?

A

Anal warts. Mostly 6 and 11. Flesh colored papules that itch.

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8
Q

How do you treat condyloma acuminata?

A

Imiquimod cream, podophyllotoxin, 5-FU, sinecatechins clear to 40-60% especially in smaller lesions.
If fails, try 80-90% trichoroacetic acid TCA (in office), cryotherapy, or fulguration/excision.
If very large, surgical excision.
if > 50% circumference, need to stage to avoid stenosis

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9
Q

What is the recurrence rate of condyloma after treatment?

A

20-40%.

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10
Q

What is Buschke-Lowenstein tumor?

A

Verrucous carcinoma or giant condyloma acuminatum; with very high risk of fistula/abscess formation. Spreads laterally (doesn’t really metastasize). HPV 6, 11. Treat with WLE.

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11
Q

What is the Bethesda classification in the setting of AIN?

A

ASCUS, LSIL (AIN I), HSIL (AIN II/III), atypical squamous cells that cannot exclude HSIL.

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12
Q

What cyclin dependent kinase inhibitor is overexpressed in HPV associated carcinogenesis?

A

P16

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13
Q

How do you screen for anal SCC in high risk population?

A

Annual anal pap smear with high resolution anoscopy (with 3% acetic acid solution or Lugol’s) for ASCUS or dysplasia.

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14
Q

How do you treat LSIL?

A

Nothing, can just surveillance q3-6 mos with pap +/- HRA

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15
Q

How do you treat HSIL?

A

Topical 5% Imiquimod
Topical 5% 5-FU
TCA
should be adjuncts to photodynamic therapy, RF ablation, infrared coagulation, electrocautery.

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16
Q

What is superficially invasive squamous cell carcinoma of the anus?

A

Minimally invasive SCC that is completely excised with 3mm or less basement membrane invasion and 7mm or less horizontal spread.

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17
Q

How often does anal SCC spread?

A

32% nodal, 13% metastatic.

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18
Q

Workup of anal mass?

A

DRE/anoscopy/BIOPSY, FNA of lymphadenopathy, CT CAP for staging, MRI for locoregional disease

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19
Q

What is the Nigro protocol?

A

5-FU , mitomycin C, 30 Gray radiation x 3 weeks.

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20
Q

How successful is Nigro protocol?

A

80-90% for locoregional disease.

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21
Q

What chemotherapeutic do you consider to add to 5-FU for metastatic anal SCC?

A

Cisplatin.

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22
Q

When is surgery indicated for anal SCC?

A

Locoregional recurrence/persistence after Nigro protocol, after 6 months. Surgery of choice is salvage APR (5 yr overall survival 25-60% compared to 3%)

23
Q

What is the surveillance after Nigro protocol?

A

DRE/anoscopy q3-6 months x 5 years; add panscan if nodal disease present or above T3 primary lesion.

24
Q

How to treat T1 well-differentiated perianal SCC that you can pull out of anus easily ?

A

WLE 1 cm margins alone.

25
Q

anal SCC (but of anal margin, not canal) mgmt

A

WLE < 5 cm with 5m margin
otherwise > 5cm gets chemoXRT 5FU cisplatin (not mitomycin) or if involving sphincter or positive nodes

26
Q

How to treat anal adenocarcinoma?

A

WLE w/ 2-3 mm margins for T1 (<4cm, <1/2 circumference) well differentiated. Or APRO with adjuvant chemoXRT like rectal ca

27
Q

What glands are anal adenocarcinomas from?

A

Upper glandular anal cells like columnar epithelium (like low rectal adenocarcinoma), anal glands, chronic fistula tracts.

28
Q

What kind of cells are malignant in extramammary Paget’s disease of the perianal region?

A

Large rounded vacuolated Paget cells (arising from apocrine glands or metachronous lesion from another site) causing an intraepithelial adenocarcinoma. Look for concurrent CRC or GU malignancy.

29
Q

How to treat extramammary Paget’s disease?

A

WLE 1 cm margin with (myo)cutaneous flaps; if locally invasive may need neoadjuvant chemoradiation with APR.

30
Q

How does anal melanoma present?

A

Bleeding and pain. Pigmented lesions may look like thrombosed hemorrhoids. (30% amelanotic)

31
Q

Is the prognosis good or bad for anal melanoma?

A

Bad.

32
Q

How to treat anal melanoma?

A

WLE, or if extensive sphincter involvement will need APR.

33
Q

How to treat anal NET?

A

WLE, or if very large locally advanced tumors will need radical resection.

34
Q

How to treat anal lymphoma (HL and NHL)?

A

Chemoradiation (usually high grade B cell lymphoma).

35
Q

perianal nerve block

A

ischioanal fossa -
ischial spine is palpated, needle is advanced towards the ischial spine.

Local anesthetic is administered about 2.5 cm posteromedial to the ischial tuberosity

36
Q

fissure tx

A
  1. NOM: fiber, sitz, topic anesthetic > nitrates (AE: HA), CCB (no HA - similar efficacy)
  2. Botox (AE: incontinence//CI!)
  3. LIS (CI: childbearing, prior OB injury, IBD, hx incontinence) vs anocutaneous flap (+/- LIS, botox)

LIS = laternal internal sphincterotomy; along entire length of the FISSURE

37
Q

incont after lat int sphincteroyomy?

A

8-30% will have

38
Q

hemorrhoid mgmt

A

int:
conservative first
banding I & II
sclerotherapy if bleeding risk (on AC) I & II
excisional III & IV

ext thrombosed:
<72 hrs - excise
>72 hrs - conservative (or lance open)

39
Q

perianal I&D target

A

as close to anal verge as possible

40
Q

incont 2/2 sphincter thinness post vag delivery ie

A

get endoanal us to dx then:
phincter overlp or sacral N stim

41
Q

heomorrhoidal plexuses

A
  1. left lateral
  2. right anterior
  3. right posterior
42
Q

anorectal abscess location

A
  1. perianal MC
  2. intersphincteric
  3. ischiorectal
  4. supralevator abscess (transrectal)
  5. Submucosal
  6. Deep posterior
43
Q

indications after I&D anal absess for Abx

A

DM, cellulitis, immunosuppressed, prosthetic hardware

44
Q

goodsalls rule anal fistula

A

ANTERIOR fistula connect with anus/rectum in straight line
POSTERIOR (or >3cm anterior) go toward midline internal opening in anus/rectum

45
Q

mgmt anal fistula

A

If <25% sphincter and superficial: fistulotomy at time of drainage
If > 25% sphincter: drain abscess and place SETON

If simple fistulotomy cannot be done: LIFT (ligation of intersphincteric fistula tract) +/- anorectal advancement flap

46
Q

rectovaginal fistula mgmt

A

HIGH: (form diverticulitis) needs abdominal approach, resection, close vaginal hole, temporaroy ileostomy
MID/LOW VAGINA: (obstetrical) transanal rectal mucosa advancment lap (leave vagina open)

47
Q

Anal Abscess Treatment

A
  1. DRAIN:
    Superficial perianal and ischiorectal: external I&D
    Deeper intersphincteric/supralevator: internal transanal I&D
  2. Abx if cellulitis/SIRS/immunosuppressed
  3. LOOK FOR FISTULAS. (1/3 will develop FIA)
48
Q

Anal fistula types (5)

A

INTERsphincteric: MC.
TRANSsphincteric: across BOTH sphincter muscles (HIGH >1/3rd of complex or LOW <1/3rd of complex)
SUPRAsphincteric: between then UP AND OVER external
EXTRAsphincteric: runs OVER AND ABOVE the sphincter complex totally
Submucosal

49
Q

Purpose of seton

A

Induce fibrosis
Convert HIGH fistula to LOW fistula for later procedures

50
Q

Internal hemorrhoid grading.

A

I: internal only
II: Prolapse and spontaneously reduce
III: Manually reduce
IV: Not reducible

51
Q

repair of imperforate anu

A

staged: 1. end colostomy with mucus fistula

  1. definitive: get contrast study through mucus fistula to see if there is a urinary fistula
52
Q

approach to imperforate repair of fistula to bladdder

A

bladder fistula: abdominal approach

rectobulbar urethral fistula: perineal (posterior sagittal)

rectoprostatic urethral: abdominal

53
Q
A

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