Anorectal Flashcards
Grading of internal hemorrhoids
I slides below dentate w/ strain, II prolapse that reduces spontaneously, III prolapse that has to be manually reduced, IV not able to reduce
surgical treatment for rectal prolapse (what are the options)
abdominal approach (rectopexy +/- bowel resection) - only for young/low risk, otherwise perineal resection (Altemeier - full thickness excision of excess rectum/colon with colo-anal anastomosis; Delorme - mucosa/submucosa excised, muscularis plicated
What is Goodsall’s rule?
anterior fistulas connect with anus/rectum in a straight line, posterior fistulas go towards a midline internal opening
Most common cancer in patients with AIDS?
Kaposi’s sarcoma
Treatment of anal canal squamous cell cancer?
associated with HPV - Nigro protocol - chemo-XRT with 5FU and mitomycin – otherwise APR for treatment failures / recurrence
Treatment for anal canal adenocarcinoma cancer?
treat as a low rectal Ca – usually APR, consider WLE if small (<3 cm, T1 status (only submucosa), <1/3 circumference, no lymphatic invasion), post-op chemo XRT same as rectal ca
Treatment for anal margin squamous cell cancer?
WLE for lesions <5 cm (need 5mm margins), chemo-XRT (5FU and cisplatin) primary tx for lesions >5 cm (preserving sphincter, avoiding APR)
T and N staging for anal cancer?
T1 <2 cm, T2 >2 cm <5 cm, T3 >5 cm, T4 involves adj organ, N1 perirectal lymph nodes, N2 unilateral internal iliac/inguinal nodes, N3 perirectal/inguinal nodes or bilateral inguinal/internal iliac nodes
Indication for neoadjuvant chemoradiation in rectal cancer?
locally advanced disease (T3 - into serosa/through muscularis, or T4 through serosa / adjacent organ) – other indications still being studied, to possible allow LAR vs APR, or achieve a better tumor-free margin in cT1/T2 node positive rectal cancers
Which patients with colon cancer benefit most from adjuvant chemo? What type?
stage 3 (node positive dz), oxaliplatin based regimen
What is Waldeyer’s fascia? what is the clinical significance?
Waldeyer’s fascia is the presacral fascia (between rectum and sacrum), separates rectum from presacral venous plexus and pelvic nerves
What marks the transition from the rectum to the anal canal?
Levator ani
Describe the lymphatic drainage of the rectum
Upper and middle rectum drain only into the inferior mesenteric nodes, lower rectum drains into both inferior mesenteric nodes and internal iliac nodes
what is the initial treatment of anal cancer melanoma?
wide local excision - no benefit to lymph node dissection, consider rads/chemo as adjuvant therapy
management of perianal pain in a neutropenic patient?
exam under anesthesia to rule out abscess, areas of induration should be incised/drained and biopsy to exclude leukemia infiltrate and cultured to help with antibiotic choices
Describe the arterial supply of the rectum?
superior rectal artery (IMA), middle rectal artery / inferior rectal artery (internal iliac artery / pudendal artery) – Superior Rectal think Sudak’s (Superior rectal artery middle rectal)
Describe the venous supply of the rectum?
superior rectal vein (IMV - portal vein), middle / inferior rectal artery (internal iliac veins / IVC)
Treatment of chronic radiation proctitis?
First line treatment is sucralfate enemas (steroids, 5-aminosalicylic acid not effective), if sucralfate enemas fail, then argon plasma coagulation > formalin (may have association w/ stricturing)
pt s/p hemorrhoidal banding presents w/ rectal/abdominal pain, inability to urinate, febrile/tachycardic - dx/tx?
pelvic sepsis - usually presents in first 12 hrs, tx w/ broad-spectrum abx, exam under anesthesia to rule out necrotizing infection
5-fluorouracil and mitomycin C
Nigro protocol
Management of thrombosed external hemorrhoid?
For duration <72 hours, consider incision and drainage (Not stab incision) of the thrombosed hemorrhoid under local anesthesia
HPV subtypes - benign warts? assoc. w/ dysplasia?
6 and 11 are benign, 16 and 18 are more aggressive, gardasil targets 6, 11, 16, 18
Most common cause of bacterial proctitis
N. Gonorrhea > Chlamydia
adult-onset Hirschsprung disease – genetic associations? presentation? treatment?
associated with RET (like children), presents with short segment aganglionosis, barium enema can show extremely dilated proximal colon, however typically will need rectal mucosal biopsy – tx short segment aganglionosis with anorectal myomectomy (as opposed to Soave/Duhamel operation)
What is the pathophysiolgoy of “solitary rectal ulcer syndrome”?
Benign process caused by chronic straining, leads to internal intussuception and repetitive mucosal trauma, dx w/ anorectal manometry/defecography, tx is non-operative, high fiber diet, defecation training, surgical tx would be similar to rectal prolapse (abdominal/perineal repair)
