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Section II General Surgery P203Surgical Recall Sixth > Anus, C49 P325-334 > Flashcards

Anus, C49 P325-334 Flashcards

1
Q

ANATOMY
Identify the following:
P325 (picture)

A
  1. Anal columns
  2. Dentate line
  3. Rectum
  4. External sphincter
  5. Internal sphincter
  6. Levator ani muscle
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2
Q

ANAL CANCER
What is the most common
carcinoma of the anus?
P326

A

Squamous cell carcinoma (80%)

Think: ASS = Anal Squamous Superior

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3
Q

ANAL CANCER
What cell types are found in
carcinomas of the anus?
P326

A
  1. Squamous cell carcinoma (80%)
  2. Cloacogenic (transitional cell)
  3. Adenocarcinoma/melanoma/
    mucoepidermal
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4
Q

ANAL CANCER
What is the incidence of
anal carcinoma?
P326

A

Rare (1% of colon cancers incidence)

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5
Q

ANAL CANCER
What is anal Bowen’s disease?
P326

A

Squamous cell carcinoma in situ

Think: B.S. = Bowen Squamous

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6
Q

ANAL CANCER
How is Bowen’s disease
treated?
P326

A

With local wide excision

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7
Q

ANAL CANCER
What is Paget’s disease of
the anus?
P326

A

Adenocarcinoma in situ of the anus

Think: P.A. = Paget’s Adenocarcinoma

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8
Q

ANAL CANCER
How is Paget’s disease
treated?
P326

A

With local wide excision

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9
Q

ANAL CANCER
What are the risk factors for
anal cancer?
P326

A 
Human papilloma virus, condyloma,
herpes, HIV, chronic inflammation
(fistulae/Crohn’s disease) immunosuppression,
homosexuality in males, cervical/
vaginal cancer, STDs, smoking
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10
Q

ANAL CANCER
What is the most common
symptom of anal carcinoma?
P326

A

Anal bleeding

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11
Q 
ANAL CANCER
What are the other
signs/symptoms of anal
carcinoma?
P326
A

Pain, mass, mucus per rectum, pruritus

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12
Q 
ANAL CANCER
What percentage of patients
with anal cancer is
asymptomatic?
P326
A

≈25%

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13
Q

ANAL CANCER
To what locations do anal
canal cancers metastasize?
P326

A

Lymph nodes, liver, bone, lung

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14
Q 
ANAL CANCER
What is the lymphatic
drainage below the dentate
line?
P327
A

Below to inguinal lymph nodes (above to

pelvic chains)

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15
Q 
ANAL CANCER
Are most patients with anal
cancer diagnosed early or
late?
P327
A

Late (diagnosis is often missed)

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16
Q 
ANAL CANCER
What is the workup of a
patient with suspected anal
carcinoma?
P327
A 
History
Physical exam: digital rectal exam,
    proctoscopic exam, and colonoscopy
Biopsy of mass
Abdominal/pelvic CT scan, transanal U/S
CXR
LFTs
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17
Q

ANAL CANCER
Define:
Margin cancer
P327

A

Anal verge out 5 cm onto the perianal skin

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18
Q

ANAL CANCER
Define:
Canal cancer
P327

A

Proximal to anal verge up to the border

of the internal sphincter

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19
Q 
ANAL CANCER
How is an anal canal
epidermal carcinoma
treated?
P327
A 
NIGRO protocol:
1. Chemotherapy (5-FU and mitomycin C)
2. Radiation
3. Postradiation therapy scar biopsy
    (6–8 weeks post XRT)
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20
Q 
ANAL CANCER
What percentage of patients
have a “complete” response
with the NIGRO protocol?
P327
A

90%

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21
Q

ANAL CANCER
What is the 5-year survival
with the NIGRO protocol?
P327

A

85%

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22
Q 
ANAL CANCER
What is the treatment for
local recurrence of anal
cancer after the NIGRO
protocol?
P327
A

May repeat chemotherapy/XRT or

salvage APR

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23
Q

ANAL CANCER
How is a small (<5 cm) anal
margin cancer treated?
P327

A

Surgical excision with 1-cm margins

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24
Q

ANAL CANCER
How is a large (>5 cm) anal
margin cancer treated?
P327

A

Chemoradiation

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25
Q

ANAL CANCER
What is the treatment of
anal melanoma?
P328

A

Wide excision or APR (especially if
tumor is large) +-/ XRT, chemotherapy,
postoperatively

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26
Q

ANAL CANCER
What is the 5-year survival
rate with anal melanoma?
P328

A

<10%

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27
Q 
ANAL CANCER
How many patients with
anal melanoma have an
amelanotic anal tumor?
P328
A

Approximately one third, thus making

diagnosis difficult without pathology

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28
Q

ANAL CANCER
What is the prognosis of
anal melanoma?
P328

A

<5% 5-year survival rate

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29
Q

FISTULA IN ANO
What is it?
P328

A

Anal fistula, from rectum to perianal skin

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30
Q

FISTULA IN ANO
What are the causes?
P328

A

Usually anal crypt/gland infection (usually

perianal abscess)

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31
Q

FISTULA IN ANO
What are the signs/symptoms?
P328

A

Perianal drainage, perirectal abscess,
recurrent perirectal abscess, “diaper
rash,” itching

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32
Q 
FISTULA IN ANO
What disease should be
considered with fistula in
ano?
P328
A

Crohn’s disease

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33
Q

FISTULA IN ANO
How is the diagnosis made?
P328

A

Exam, proctoscope

34
Q

FISTULA IN ANO
What is Goodsall’s rule?
P328 (picture)

A

Fistulas originating anterior to a transverse
line through the anus will course straight
ahead and exit anteriorly, whereas those
exiting posteriorly have a curved tract

35
Q

FISTULA IN ANO
How can Goodsall’s rule be
remembered?
P329 (picture)

A

Think of a dog with a straight nose

anterior) and curved tail (posterior

36
Q

FISTULA IN ANO
What is the management of
anorectal fistulas?
P329

A
  1. Define the anatomy
  2. Marsupialization of fistula tract
    (i.e., fillet tract open)
  3. Wound care: routine Sitz baths and
    dressing changes
  4. Seton placement if fistula is through
    the sphincter muscle
37
Q

FISTULA IN ANO
What is a seton?
P329 (picture)

A 
Thick suture placed through fistula tract
to allow slow transection of sphincter
muscle; scar tissue formed will hold the
sphincter muscle in place and allow for
continence after transection
38
Q 
FISTULA IN ANO
What percentage of patients
with a perirectal abscess
develop a fistula in ano after
drainage?
P330
A

≈50%

39
Q 
FISTULA IN ANO
How do you find the
internal rectal opening of an
anorectal fistula in the O.R.?
P330
A 
Inject H(2)O(2) (or methylene blue) in external
opening—then look for bubbles (or blue
dye) coming out of internal opening!
40
Q

FISTULA IN ANO
What is a sitz bath?
P330

A

Sitting in a warm bath (usually done after

bowel movement and TID

41
Q

PERIRECTAL ABSCESS
What is it?
P330

A

Abscess formation around the anus/rectum

42
Q

PERIRECTAL ABSCESS
What are the signs/symptoms?
P330

A

Rectal pain, drainage of pus, fever,

perianal mass

43
Q

PERIRECTAL ABSCESS
How is the diagnosis made?
P330

A

Physical/digital exam reveals perianal/

rectal submucosal mass/fluctuance

44
Q

PERIRECTAL ABSCESS
What is the cause?
P330

A

Crypt abscess in dentate line with spread

45
Q

PERIRECTAL ABSCESS
What is the treatment?
P330

A

As with all abscesses (except simple liver
amebic abscess) drainage, sitz bath,
anal hygiene, stool softeners

46
Q 
PERIRECTAL ABSCESS
What is the indication for
postoperative IV antibiotics
for drainage?
P330
A

Cellulitis, immunosuppression, diabetes,

heart valve abnormality

47
Q 
PERIRECTAL ABSCESS
What percentage of patients
develops a fistula in ano
during the 6 months after
surgery?
P330
A

≈50%

48
Q

ANAL FISSURE
What is it?
P330

A

Tear or fissure in the anal epithelium

49
Q

ANAL FISSURE
What is the most common
site?
P330

A 
Posterior midline (comparatively low
blood flow)
50
Q

ANAL FISSURE
What is the cause?
P330

A

Hard stool passage (constipation),
hyperactive sphincter, disease process
(e.g., Crohn’s disease)

51
Q

ANAL FISSURE
What are the signs/symptoms?
P331

A

Pain in the anus, painful (can be
excruciating) bowel movement, rectal
bleeding, blood on toilet tissue after
bowel movement, sentinel tag, tear in the
anal skin, extremely painful rectal exam,
sentinel pile, hypertrophic papilla

52
Q

ANAL FISSURE
What is a sentinel pile?
P331

A

Thickened mucosa/skin at the distal end
of an anal fissure that is often confused
with a small hemorrhoid

53
Q

ANAL FISSURE
What is the anal fissure triad
for a chronic fissure?
P331 (picture)

A
  1. Fissure
  2. Sentinel pile
  3. Hypertrophied anal papilla
54
Q

ANAL FISSURE
What is the conservative
treatment?
P331

A

Sitz baths, stool softeners, high fiber diet,
excellent anal hygiene, topical nifedipine,
Botox®

55
Q 
ANAL FISSURE
What disease processes must
be considered with a chronic
anal fissure?
P331
A

Crohn’s disease, anal cancer, sexually
transmitted disease, ulcerative colitis,
AIDS

56
Q

ANAL FISSURE
What are the indications for
surgery?
P331

A

Chronic fissure refractory to conservative

treatment

57
Q

ANAL FISSURE
What is one surgical option?
P331

A

Lateral internal sphincterotomy (LIS)—
cut the internal sphincter to release it
from spasm

58
Q

ANAL FISSURE
What is the “rule of 90%”
for anal fissures?
P331

A

90% occur posteriorly
90% heal with medical treatment alone
90% of patients who undergo an LIS heal
successfully

59
Q

PERIANAL WARTS
What are they?
P332

A

Warts around the anus/perineum

60
Q

PERIANAL WARTS
What is the cause?
P332

A 
Condyloma acuminatum (human
papilloma virus)
61
Q

PERIANAL WARTS
What is the major risk?
P332

A

Squamous cell carcinoma

62
Q

PERIANAL WARTS
What is the treatment if
warts are small?
P332

A

Topical podophyllin, imiquimod (Aldara®)

63
Q

PERIANAL WARTS
What is the treatment if
warts are large?
P332

A

Surgical resection or laser ablation

64
Q

HEMORRHOIDS
What are they?
P332

A

Engorgement of the venous plexuses of
the rectum, anus, or both; with protrusion
of the mucosa, anal margin, or both

65
Q

HEMORRHOIDS
Why do we have “healthy”
hemorrhoidal tissue?
P332

A

It is thought to be involved with fluid/air

continence

66
Q

HEMORRHOIDS
What are the signs/
symptoms?
P332

A

Anal mass/prolapse, bleeding, itching, pain

67
Q

HEMORRHOIDS
Which type, internal or
external, is painful?
P332

A

External, below the dentate line

68
Q 
HEMORRHOIDS
If a patient has excruciating
anal pain and history of
hemorrhoids, what is the
likely diagnosis?
P332
A

Thrombosed external hemorrhoid

treat by excision

69
Q

HEMORRHOIDS
What are the causes of
hemorrhoids?
P332

A

Constipation/straining, portal

hypertension, pregnancy

70
Q

HEMORRHOIDS
What is an internal
hemorrhoid?
P332

A

Hemorrhoid above the (proximal)

dentate line

71
Q

HEMORRHOIDS
What is an external
hemorrhoid?
P332

A

Hemorrhoid below the dentate line

72
Q

HEMORRHOIDS
What are the three
“hemorrhoid quadrants”?
P332

A
  1. Left lateral
  2. Right posterior
  3. Right anterior
73
Q

Classification by Degrees
Define the following terms for internal hemorrhoids:
First-degree hemorrhoid
P333 (picture)

A

Hemorrhoid that does not prolapse

74
Q

Classification by Degrees
Define the following terms for internal hemorrhoids:
Second-degree hemorrhoid
P333 (picture)

A

Prolapses with defecation, but returns on

its own

75
Q

Classification by Degrees
Define the following terms for internal hemorrhoids:
Third-degree hemorrhoid
P333 (picture)

A 
Prolapses with defecation or any type of
Valsalva maneuver and requires active
manual reduction (eat fiber!)
76
Q

Classification by Degrees
Define the following terms for internal hemorrhoids:
Fourth-degree hemorrhoid
P334

A

Prolapsed hemorrhoid that cannot be

reduced

77
Q

Classification by Degrees
What is the treatment?
P334

A 
High-fiber diet, anal hygiene, topical
    steroids, sitz baths
Rubber band ligation (in most cases
    anesthetic is not necessary for internal
    hemorrhoids)
Surgical resection for large refractory
    hemorrhoids, infrared coagulation,
    harmonic scalpel
78
Q

Classification by Degrees
What is a “closed” vs. an
“open” hemorrhoidectomy?
P334

A

Closed (Ferguson) “closes” the mucosa with
sutures after hemorrhoid tissue removal
Open (Milligan-Morgan) leaves mucosa
“open”

79
Q 
Classification by Degrees
What are the dreaded
complications of
hemorrhoidectomy?
P334
A 
Exsanguination (bleeding may pool
    proximally in lumen of colon without
    any signs of external bleeding)
Pelvic infection (may be extensive and
    potentially fatal)
Incontinence (injury to sphincter complex)
Anal stricture
80
Q 
Classification by Degrees
What condition is a
contraindication for
hemorrhoidectomy?
P334
A

Crohn’s disease

81
Q 
Classification by Degrees
Classically, what must be
ruled out with lower GI
bleeding believed to be
caused by hemorrhoids?
P334
A

Colon cancer (colonoscopy)

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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