Chapter 37 - Anal & Rectal++ Flashcards
What is the arterial supply to the anus?
Inferior rectal artery
What is the venous drainage above the dentate line? Below?
Above: Internal hemorrhoid plexus (prolapse)
Below: External hemorrhoid plexus (painful thrombosis)
Hemorrhoid plexus locations?
Left lateral, right anterior, right posterior.
Symptoms occur after venous congestions results in hypertrophy. Constipation and diarrhea over time will exacerbate this process.
Symptoms of external hemorrhoids?
Pain when they thrombose (excise if < 3 days; nonop mgmt can be done if > 4 days), swelling, itching
Symptoms of internal hemorrhoids?
Bleeding (needs colonoscopy) or prolapse (refer to surgery if doesn’t reduce spontaneously)
Grades of prolapse of internal hemorrhoids?
Primary: slides below dentate w/ strain
Secondary: prolapse that reduces spontaneously
Tertiary: Prolapse that has to be manually reduced
Quaternary: not able to reduce
Treatment for symptomatic hemorrhoids?
Every patient, every time: stool softeners, fiber, avoid straining, sitz baths, topical pain relievers.
Prolapse requiring manual reduction (grade III): surgical referral.
Thrombosed external hemorrhoids < 3 days: office excision.
Bleeding: outpatient colonoscopy.
Surgical indications for hemorrhoids?
Sx I or II dz refractory to conservative tx (6-8wks). Sx III (band vs -ectomy) or IV dz (-ectomy). Thrombosed external hemorrhoids if < 3 days (excision).
Banding for internal or external hemorrhoids?
Internal only. Best for grade I, II, or III.
IV requires hemorrhoidectomy.
Rectal prolapse begins how far from the anal verge?
6-7cm
What causes rectal prolapse? Risk factors?
Pudendal neuropathy and laxity of the anal sphincters; increased with females, straining, diarrhea, previous pregnancy, redundant sigmoid colons
Treatment for rectal prolapse?
High-fiber diet.
Transanal rectosigmoid resx (only if contraindx for OR)
LAR or rectopexy (low recurrence, for young/healthy).
Virus associated with condylomata acuminata?
Psx, Tx?
HPV (6 and 11), most common STD in colorectal office
Psx: raised cauliflower appearance on anus, itching; promiscuous patient
Tx: Can attempt pt applied imiquimod, podophyllotoxin vs clinician applied cryo, TCA. Can elect for surgical/laser/electrosurgical removal of macroscopic dz, no margins necessary (does not decrease recurrence rate), no LADx. Can combine if single tx fails.
Ppx: HPV vaccine
What causes anal fissure?
Split in the anoderm from straining
Where are anal fissures located?
90% in posterior midline. Odd/multiple locations or refractory dz can occur w/ Crohn’s.
Symptoms of anal fissure?
Pain and some bright red bleeding after defecation; chronic ones will see a sentinel pile.
Dx is clinical w/o DRE or scope (defer). Usually posterior midline, so lateral location should trigger evaluation for inflammatory diseases.
Medical treatment for anal fissure? Surgical?
Medical (1st line): sitz baths, bulk, lidocaine, softeners
Surgical (for chronic): lateral internal sphinctx for young and healthy; LIFT and/or advancement flap if pt is at high-risk for incontinence issues
Most serious complication of anal fissure surgery?
Fecal incontinence
What disease processes are contraindications to surgery for anal fissure?
If secondary to Crohn’s or UC
Drainage procedure for perianal, ischiorectal, and intersphincteric abscesses?
Perianal/ischiorectal - incision and drainage through skin if below the levator muscles.
Intersphincteric - EUA and internal drainage with division of the mucosa and internal sphincter muscle along length of fluctuance to allow free drainage
Drainage for supralevator abscesses?
Transrectally incision and drainage (no packing needed)
Treatment for pilonidal cyst?
Drainage and packing; follow up surgical resection of cyst
Treatment for fistula in ano?
3 main categories, each with different treatment.
The questions needing to be answered: Is a lot of the sphincter involved (are you gonna cause incontinence)? Can the patient tolerate a procedure?
1) If not much external sphincter (inter/transsphincteric) involvement and no incontinence: unroof fistula (fistulotomy) w/ curettage; do not need to excise the tract.
2) If complex, extensive sphincter involvement (>30%), high transsphincteric, suprasphincteric, extrasphincteric, horseshoe, recurrent: need sphincter-sparing procedure - do partial fistulotomy, draining seton placement, and future LIFT/advancement flap.
3) If complex and cannot tolerate surgery: do cutting seton.
What is Goodsall’s rule?
Anterior fistulas connect with rectum in straight line; posterior fistulas go toward midline with internal opening in rectum
Definition of simple rectovaginal fistula?
Secondary to infection or obstetrical trauma, low to midvagina, <2.5cm
Treatment for simple rectovaginal fistula?
Many heal spontaneously; transanally unroof and place rectal mucosa advancement flap
Definition of complex rectovaginal fistula?
Secondary to inflammatory bowel disease, XRT, neoplasm, or high in vagina, or >2.5cm
Treatment for complex rectovaginal fistula?
Abdominal or combined approach; resection and reanastomosis with placement of colostomy, need good tissue for anastamosis
Types of anal incontinence? Treatment?
Neurogenic: no good treatment
Abdominoperineal descent: damage to levator ani muscle and anus falls below levators, stretches the pudendal nerves; high fiber diet, limit to 1 bm/day, sphincteroplasty if related to trauma (childbirth)
Anorecatal problems associated with AIDS? Characteristics?
Kaposi’s sarcoma: nodule with ulceration
CMV: shallow ulcers, similar presentation as appendicitis
HSV: #1 rectal ulcer
B cell lymphoma: can look like abscess or ulcer
What type cancer found in the anal canal (above dentate line)?
Squamous cell CA: basaloid, mucoepidermoid, epidermoid, cloacogenic.
Adenocarcinoma.
Melanoma.
