Anorectal

Question 1

Paget Disease of Anus

Answer 1

erythematous, eczematous rash

severe, intractable pruritus

Question 2

Anal Squamous Cell Carcinoma

Answer 2

Painful, tender, ulcerated lesion

Question 3

Condyloma Lata

Answer 3

flat, smooth, pale lesion

Question 4

Condyloma Acuminata

Answer 4

perianal growth, cauliflower-like shape

Question 5

Lymphogranuloma venereum

Answer 5

multiple small, shallow ulcers

Inguinal lymphadenopathy

Question 6

Fissures

Answer 6

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

Question 7

Perianal sepsis

Answer 7

Occurs after hemorrhoid ligation. Requires emergent tx. I&D, Abx

Question 8

Criteria for transanal excision of rectal adeno

Answer 8

Lesion < 3cm in size, <30% circumference, w/in 10cm from anal verge, negative high risk features

Question 9

Anorectal abscesses

Answer 9

Perianal - MC; Tx: I&D
Ischiorectal - I&D
Supralevator - Depends on extension
Intersphincteric - Tx: internal drainage internal sphincter muscle

Question 10

Anal melanoma

Answer 10

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

Question 11

Simple Fistulas vs Complex Fistulas

Answer 11

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

Question 12

Goodsall’s rule

Answer 12

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

Question 13

Anal fistula tx

Answer 13

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

Question 14

Condyloma acuminate of anus

Answer 14

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

Question 15

W/u of fecal incontinence

Answer 15

incompetent anal sphincter (trauma/surgery, etc.)

Assess sphincters w/ DRE -> endoanal US

Question 16

Rectal cancer treatment

Answer 16

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)

Question 17

Management of small (<5cm) rectal prolapse in elderly, frail, patient

Answer 17

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

Question 18

Management of large (>5cm) rectal prolapse in elderly, frail patient

Answer 18

Altemeier - rectosligmoidectomy. prolapse exteriorized, circumferential full-thickness incision made 1cm above dentate line. redundant sigmoid extracted transanally & resected, stapled or hand-sewn anastomosis done

Question 19

Fecal incontinence

Answer 19

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

Question 20

AAST rectal injury scale

Answer 20

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

Question 21

Intraperitoneal rectal injury management

Answer 21

ex lap, washout, resection, closure of defect and +/- proximal diversion

Question 22

Extraperitoneal rectal injury management

Answer 22

Drainage and diversion, unless >50% luminal circumference involved where you resect and perform end colostomy

Question 23

Management of rectal carcinoids

Answer 23

<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

Question 24

Abdominal approach of rectal prolapse management

Answer 24

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)

Question 25

Hemorrhoid vs prolapse

Answer 25

Hemorrhoid - starburst patter

prolapse - concentrate circles

Question 26

Verrucous carcinoma

Answer 26

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

Question 27

Soave technique

Answer 27

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)

Question 28

Swenson procedure

Answer 28

Removal of aganglionic colon, with end-to-end anastomosis above anal sphincter

Question 29

Duhamel procedure

Answer 29

bringing the normal colon down through retrorectal space

Question 30

Martin procedure

Answer 30

side-to-side anastomosis between normally innervated small bowel and aganglionic left colon

Question 31

Kimura procedure

Answer 31

staged procedure where right colon is anastomosed side-to-side ileum

Question 32

Grading of hemorrhoids

Answer 32

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