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ABSITE 2019-RM > chapter 37: anal and rectal > Flashcards

chapter 37: anal and rectal Flashcards

1
Q

arterial supply to the anus

A

inferior rectal artery

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2
Q

venous drainage of the anus

A

above the dentate is internal hemorrhoid plexus and below the dentate is external hemorrhoid plexus

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3
Q

hemorrhoidal plexuses

A
  • left lateral
  • right anterior
  • right posterior
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4
Q
  • can pain when the thrombosis

- distal to the dentate line, covered by sensate squamous epithelium; can cause pain, swelling and itching

A

external hemorrhoids

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5
Q

cause bleeding or prolapse

A

internal hemorrhoids

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6
Q

internal hemorrhoids: slides below dentate with strain

A

primary

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7
Q

internal hemorrhoids: prolapse that reduces spontaneously

A

secondary

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8
Q

internal hemorrhoids: prolapse that has to be manually reduced

A

tertiary

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9
Q

internal hemorrhoids: not able to reduce

A

quaternary

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10
Q

tx: hemorrhoids

A

fiber and stool softeners (prevent straining); sitz baths

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11
Q

tx: thromboses external hemorrhoid

A

lance open (if > 72 hours) or elliptical excision (if

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12
Q

surgical indications for hemorrhoids:

A

recurrence, thrombosis multiple times, large external component

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13
Q

hemorrhoids: can be resected with elliptical excision

A

external hemorrhoids

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14
Q

type of internal hemorrhoids that can be banded

A

can band primary and secondary internal hemorrhoids

- do not band external hemorrhoids (painful)

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15
Q

surgery required for what type of internal hemorrhoids

A

surgery for tertiary and quaternary internal hemorrhoids - 3 quadrant resection
- need to resect down to the internal anal sphincter (do not go through it)

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16
Q

post op management of tertiary and quaternary internal hemorrhoids

A

sitz baths, stool softener, high-fiber diet

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17
Q

where does rectal prolapse start?

A

starts 6-7 cm form anal verge

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18
Q

what causes rectal prolapse?

A

secondary to pudendal neuropathy and laxity of the anal sphincters

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19
Q

risk factors for rectal prolapse

A

increased with female gender, straining, chronic diarrhea, previous pregnancy, and redundant sigmoid colons

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20
Q

what layers of the rectum are involved in rectal prolapse?

A

prolapse involves all layers of the rectum

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21
Q

medical treatment: rectal prolapse

A

high-fiber diet

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22
Q

surgical tx: rectal prolapse

A
  • perineal rectosigmoid resection (altemeier) transanally if patient is older and frail
  • low anterior resection and pexy of residual colon if good condition patient
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23
Q

caused by a split in the anodrem

  • 90% in posterior midline
  • causes pain and bleeding after defection; chronic ones will see a sentinel pile
A

anal fissure

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24
Q

medical tx: anal fissure

A

sitz baths, lidocaine jelly, and stool softeners (90% heal)

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25
Q

surgical tx: anal fissure

A

lateral subcutaneous internal sphincterotomy

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26
Q

most serious complication of surgery for anal fissure

A

fecal incontinence

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27
Q

what do you worry about with lateral or recurrent anal fissures?

A

worry about inflammatory bowel disease

28
Q

can cause severe pain

- risk factors: antibiotics, cellulitis, DM, immunosuppressed or prosthetic hardware

A

anorectal abscess

29
Q

anorectal abscess: can be drained through the skill (all are below the elevator muscles)

A

perianal, intersphincteric, and ischiorectal abscesses

30
Q

anorectal abscess: can form horseshoe abscess

A

intersphincteric and ischiorectal abscesses

31
Q

anorectal abscess: need to be drained transrectally

A

supralevator abscesses

32
Q
  • sinus or abscess formation over the sacrococcygeal junction; increased incidence in men
  • tx?
A

pilonidal cysts

tx: drainage and packing; follow-up surgical resection of cyst

33
Q

do not need to excise the tract

- often occurs after anorectal abscess formation

A

fistula-in-ano

34
Q

what is goodsall’s rule for fistula-in-ano?

A
  • anterior fistulas connect with anus/rectum in a straight line
  • posterior fistulas go toward a midline internal opening in the anus/rectum
35
Q

tx: fistula-in-ano (lower 1/3 of the external anal sphincter)

A

fistulotomy (open tract up, curettage out, let it heal by secondary intention)

36
Q

tx: fistula-in-ano (upper 2/3 of the external anal sphincter)

A

rectal advancement flap

37
Q

most worrisome complication of treatment for fistula in ano

A

risk of incontinence - you want to avoid damage to the external anal sphincter so fistulotomy is not used for fistulas above the 1/3 of the external anal sphincter

38
Q

tx -> rectovaginal fistulas:

- simple (low to mid-vagina)

A

tx: trans-anal rectal mucosa advancement flap

- many obstetrical fistulas heal spontaneously

39
Q

tx -> rectovaginal fistulas:

- complex (high in vagina)

A

abdominal or combined abdominal and perineal approach usual; resection and reanastomosis of rectum, close hole in vagina, interpose omentum, temporary ileostomy

40
Q

tx: neurogenic anal incontinence (gaping hole)

A

no good treatment

41
Q

chronic damage to levator ani muscle and pudendal nerves (obesity, multiparous women) and anus falls below levators

A

abdominoperineal descent

42
Q

tx: abdominoperineal descent

A

high-fiber diet, limit to 1 bowel movement a day; hard to treat

43
Q

tx: obstetrical trauma leading to anal incontinence

A

anterior anal sphincteroplasty

44
Q

what is anal cancer associated with?

A

xrt and hpv

45
Q

above dentate line

A

anal canal

46
Q

below dentate line

A

anal margin

47
Q

what are the different types of squamous cell carcinoma in the anal canal?

A

epidermoid CA
mucoepidermoid CA
cloacogenic CA
basaloid CA

48
Q

anal cancer:

- symptoms: pruritus, bleeding, and palpable mass

A

squamous cell CA

49
Q

tx: squamous cell CA - anal cancer

A

nigro protocol (chemo-XRT with 5FU and mitomycin), not surgery

  • cures 80%
  • APR for treatment failures or recurrent cancer
50
Q

tx: adenocarcinoma - anal cancer

A

APR usual; WLE if

51
Q

3rd most common site for melanoma

A

anal cancer (skin and eyes #1 and #2)

52
Q

how does melanoma spread?

A

1/3 has spread to mesenteric lymph nodes

- hematogenous spread to the liver and the lung is early and accounts for most deaths

53
Q

what is symptomatic melanoma of the anal cancer associated with?

A

significant metastatic disease

54
Q

anal melanoma: most common symptom

A

rectal bleeding

55
Q

anal melanoma: appearance

A

lightly pigmented or not pigmented at all

56
Q

tx: anal melanoma

A

APR usual; margin dictated by depth of lesion standard for melanoma

57
Q

anal cancer below dentate line - have better prognosis than anal canal lesions

A

anal margin lesions (below dentate line)

58
Q
  • ulcerating, slow growing; men with better prognosis

- metastases: go to inguinal nodes

A

squamous cell cancer - anal margin lesions

59
Q

sx: anal margin lesions (squamous cell CA)

A

WLE for lesions

60
Q

anal margin lesions: squamous cell CA - primary tx for lesions > 5cm, if involving sphincter or if positive nodes

A

chemo-XRT (5-FU and cisplatin) - try to preserve the sphincter here and avoid APR

61
Q

anal cancer: central ulcer, raised edges, rare metastases

A

basal cell CA

62
Q

tx: anal cancer - basal cell CA

A

WLE usually sufficient, only need 3-mm margins; rare need for APR unless sphincter involved

63
Q

nodal metastases: superior and middle rectum

64
Q

nodal metastases: lower rectum

A

primarily IMA nodes, also to internal iliac nodes

65
Q

nodal metastases: upper 2/3 of anal canal

A

internal iliac nodes

66
Q

nodal metastases: lower 1/3 of anal canal

A

inguinal nodes

ABSITE 2019-RM (33 decks)

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