Anorectal

Question 1

Grading of internal hemorrhoids

Answer 1

I slides below dentate w/ strain, II prolapse that reduces spontaneously, III prolapse that has to be manually reduced, IV not able to reduce

Question 2

surgical treatment for rectal prolapse (what are the options)

Answer 2

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

Question 3

What is Goodsall’s rule?

Answer 3

anterior fistulas connect with anus/rectum in a straight line, posterior fistulas go towards a midline internal opening

Question 4

Most common cancer in patients with AIDS?

Answer 4

Kaposi’s sarcoma

Question 5

Treatment of anal canal squamous cell cancer?

Answer 5

associated with HPV - Nigro protocol - chemo-XRT with 5FU and mitomycin – otherwise APR for treatment failures / recurrence

Question 6

Treatment for anal canal adenocarcinoma cancer?

Answer 6

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

Question 7

Treatment for anal margin squamous cell cancer?

Answer 7

WLE for lesions <5 cm (need 5mm margins), chemo-XRT (5FU and cisplatin) primary tx for lesions >5 cm (preserving sphincter, avoiding APR)

Question 8

T and N staging for anal cancer?

Answer 8

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

Question 9

Indication for neoadjuvant chemoradiation in rectal cancer?

Answer 9

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

Question 10

Which patients with colon cancer benefit most from adjuvant chemo? What type?

Answer 10

stage 3 (node positive dz), oxaliplatin based regimen

Question 11

What is Waldeyer’s fascia? what is the clinical significance?

Answer 11

Waldeyer’s fascia is the presacral fascia (between rectum and sacrum), separates rectum from presacral venous plexus and pelvic nerves

Question 12

What marks the transition from the rectum to the anal canal?

Answer 12

Levator ani

Question 13

Describe the lymphatic drainage of the rectum

Answer 13

Upper and middle rectum drain only into the inferior mesenteric nodes, lower rectum drains into both inferior mesenteric nodes and internal iliac nodes

Question 14

what is the initial treatment of anal cancer melanoma?

Answer 14

wide local excision - no benefit to lymph node dissection, consider rads/chemo as adjuvant therapy

Question 15

management of perianal pain in a neutropenic patient?

Answer 15

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

Question 16

Describe the arterial supply of the rectum?

Answer 16

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)

Question 17

Describe the venous supply of the rectum?

Answer 17

superior rectal vein (IMV - portal vein), middle / inferior rectal artery (internal iliac veins / IVC)

Question 18

Treatment of chronic radiation proctitis?

Answer 18

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)

Question 19

pt s/p hemorrhoidal banding presents w/ rectal/abdominal pain, inability to urinate, febrile/tachycardic - dx/tx?

Answer 19

pelvic sepsis - usually presents in first 12 hrs, tx w/ broad-spectrum abx, exam under anesthesia to rule out necrotizing infection

Question 20

5-fluorouracil and mitomycin C

Answer 20

Nigro protocol

Question 21

Management of thrombosed external hemorrhoid?

Answer 21

For duration <72 hours, consider incision and drainage (Not stab incision) of the thrombosed hemorrhoid under local anesthesia

Question 22

HPV subtypes - benign warts? assoc. w/ dysplasia?

Answer 22

6 and 11 are benign, 16 and 18 are more aggressive, gardasil targets 6, 11, 16, 18

Question 23

Most common cause of bacterial proctitis

Answer 23

N. Gonorrhea > Chlamydia

Question 24

adult-onset Hirschsprung disease – genetic associations? presentation? treatment?

Answer 24

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)

Question 25

What is the pathophysiolgoy of “solitary rectal ulcer syndrome”?

Answer 25

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)