Anorectal Flashcards
Paget Disease of Anus
erythematous, eczematous rash
severe, intractable pruritus
Anal Squamous Cell Carcinoma
Painful, tender, ulcerated lesion
Condyloma Lata
flat, smooth, pale lesion
Condyloma Acuminata
perianal growth, cauliflower-like shape
Lymphogranuloma venereum
multiple small, shallow ulcers
Inguinal lymphadenopathy
Fissures
Pain w/ defecation, blood on toilet paper, assoc w/ hard stools. 2/2 hypertonic sphincter
hypotonic sphincter (previous anorectal surgery, obstetrical trauma) tx w/ fissurectomy + anocutaneous advancement flap
Don’t need a digital and proctoscopy exam to dx. Should evaluate via endoscopy within 4-6 weeks.
sentinel pile or tag externally, enlarged anal papilla internally
Usually located in posterior commissure in midline
Lateral issues -> w/up for inflammatory causes/STDs
tx: lateral internal sphincterotomy
Perianal sepsis
Occurs after hemorrhoid ligation. Requires emergent tx. I&D, Abx
Criteria for transanal excision of rectal adeno
Lesion < 3cm in size, <30% circumference, w/in 10cm from anal verge, negative high risk features
Anorectal abscesses
Perianal - MC; Tx: I&D
Ischiorectal - I&D
Supralevator - Depends on extension
Intersphincteric - Tx: internal drainage internal sphincter muscle
Anal melanoma
3rd MC site following skin & eyes MC in women ~60s MC sxs: BPR Pigmented, polypoid or ulcerated w/ raised edges Important prognostic factor: perineurial invasion \+S-100, HMB-45, Melan A Resistant to chemo, immunotherapy, rads Tx: wide local excision
Simple Fistulas vs Complex Fistulas
Complex: >30% sphincter complex, anterior in women, multiple or recurrent, pts w/ Hx of incontinence, pelvic radiation, Crohn’s.
Tx: simple fistula w/ fistulotomy. Complex fistula w/ draining seton to mature fistula tract followed by definitive repair later
Goodsall’s rule
Describes the path of anal fistula
Anterior fistula have straight path to anal canal
Posterior fistula have curved path to posterior midline
Exception: fistula > 3cm go posterior no matter what
Anal fistula tx
MC arise from cryptoglandular infection
Previous history of abscess that was probs drained
Types: submucosal, intersphincteric, transsphincteric, suprasphincteric, extrasphincteric
Simple intersphincteric/low transsphincteric: fistulotomy or cutting seton (except in IBD)
High transsphincteric/suprasphincteric/extrasphincteric (involve large portion of anal sphincter): draining seton
Condyloma acuminate of anus
MCC: HPV, sexually transmitted
High-grade squamous intraepithelial lesions (HSILs) - AIN 2 & 3
Low-graded squamous intraepithelial lesions (LSILs) - include perianal condyloma & anal intra-epithelial neoplasia 1 (AIN 1)
Tx of perianal condyloma: sharp excision or fulguration of gross disease. vaccination against HPV
W/u of fecal incontinence
incompetent anal sphincter (trauma/surgery, etc.)
Assess sphincters w/ DRE -> endoanal US
Rectal cancer treatment
CT scan shows mets -> palliation
No mets -> MRI/EUS +/-FNA of LNs
T1/2: resection first -> adjuvant chemorads
T1 (mucosal dz): EMR or transanal excision
T1 (submucosal dz): transanal excision or surgery
T2: surgery
N1/N2/T3/T4: neoadjuvant chemorads -> surgery -> chemo
neoadjuvant chemorads: 25-45 Gy rads + 5-FU/capecitabine based chemo
Adjuvant chemo for stage III (T2N1M0)
Management of small (<5cm) rectal prolapse in elderly, frail, patient
Delorme - circumferential mucosal incision 1cm above dentate line. mucosa is excised off underlying muscularis propria to proximal to prolapse. longitudinal plication of muscularis propria done, mucosa repaired by bringing intact edges together w/ suture
Management of large (>5cm) rectal prolapse in elderly, frail patient
Altemeier - rectosligmoidectomy. prolapse exteriorized, circumferential full-thickness incision made 1cm above dentate line. redundant sigmoid extracted transanally & resected, stapled or hand-sewn anastomosis done
Fecal incontinence
Find the cause.
If external anal sphincter injury -> diet and lifestyle changes first. then sphincteroplasty. if refractory –> sacral neuromodulation (implant device to stimulate sacral nerve)
if all else fails, fecal diversion
AAST rectal injury scale
Grade I: contusion/hematoma without devascularization, partial thickness lac
Grade II: lac <=50% circumference
Grade III: lac >=50% circumference
Grade IV: Full-thickness lac, extension into perineum
Grade V: devascularized segment
Intraperitoneal rectal injury management
ex lap, washout, resection, closure of defect and +/- proximal diversion
Extraperitoneal rectal injury management
Drainage and diversion, unless >50% luminal circumference involved where you resect and perform end colostomy
Management of rectal carcinoids
<1.0cm: endoscopic removal/local excision
1-1.9cm: full-thickness excision (if invades muscularis or LN mets -> surgical resection + TME)
>=2.0cm: surgical resection
Abdominal approach of rectal prolapse management
Low midline incision or laparoscopic
rectosigmoid mobilization, sigmoid resection and colorectal anastomosis is done, rectopexy to presacral fascia
superior rectal artery is preserved - main blood supply to anastomosis
mobilization done medial to lateral to preserve ureter (laterally) and pelvic nerves (posterolaterally)
Hemorrhoid vs prolapse
Hemorrhoid - starburst patter
prolapse - concentrate circles
Verrucous carcinoma
Variety of squamous cell carcinoma
large, cauliflower-like anal mass
histo: mild atypia, pushing margins
type of giant condyloma acuminatum arising from anal canal or anal margin
assoc w/ HPV (sexually transmitted)
Tx: wide local excision
Soave technique
submucosal endorectal dissection within aganglionic distal rectum. ganglionic colon pulled through remnant muscular cuff. coloanal anastomosis is done
avoids risk of injury to pelvic structures (as in Swenson)
Swenson procedure
Removal of aganglionic colon, with end-to-end anastomosis above anal sphincter
Duhamel procedure
bringing the normal colon down through retrorectal space
Martin procedure
side-to-side anastomosis between normally innervated small bowel and aganglionic left colon
Kimura procedure
staged procedure where right colon is anastomosed side-to-side ileum
Grading of hemorrhoids
Grade I: Prominent hemorrhoidal vessels, no prolapse
Grade II: prolapse w/ Valsalva, spontaneous reduction
Grade III: prolapse w/ Valsalva, requires manual reduction
Grade IV: chronically prolapse, manual reduction ineffective
Grade I - III: rubber band ligation (most effective; CI w/ coag disorders, anticoagulation, anti platelet therapy) or sclerotherapy (useful in patients w/ bleeding tendencies or who are therapeutically anticaogulated)
Grade IV: surgical hemorrhoidectomy
