Chapter 37 - Anal & Rectal

Question 1

What is the arterial supply to the anus?

Answer 1

Inferior rectal artery

Question 2

What is the venous drainage above the dentate line? Below?

Answer 2

Above: Internal hemorrhoid plexus
Below: External hemorrhoid plexus

Question 3

Hemorrhoid plexus locations?

Answer 3

Left lateral, right anterior, right posterior

Question 4

Symptoms of external hemorrhoids?

Answer 4

Pain when they thrombose, swelling, itching

Question 5

Symptoms of internal hemorrhoids?

Answer 5

Bleeding or prolapse

Question 6

Grades of prolapse of internal hemorrhoids?

Answer 6

Primary: slides below dentate w/ strain
Secondary: prolapse that reduces spontaneously
Tertiary: Prolapse that has to be manually reduced
Quaternary: not able to reduce

Question 7

Treatment for hemorrhoids?

Answer 7

Stool softeners, fiber, sitz baths

Question 8

Surgical indications for hemorrhoids?

Answer 8

Recurrent disease (bleeding), thrombosis, large external component

Question 9

Banding for internal or external hemorrhoids?

Answer 9

Internal only

Question 10

Rectal prolapse begins how far from the anal verge?

Answer 10

6-7cm

Question 11

What causes rectal prolapse? Risk factors?

Answer 11

Pudendal neuropathy and laxity of the anal sphincters; increased with females, straining, diarrhea, previous pregnancy, redundant sigmoid colons

Question 12

Treatment for rectal prolapse?

Answer 12

High-fiber diet
Rectosigmoid resection (Altmier) transanally
LAR or rectopexy

Question 13

Virus associated with condylomata acuminata?

Answer 13

HPV

Laser surgery

Question 14

What causes anal fissure?

Answer 14

Split in the anoderm

Question 15

Where are anal fissures located?

Answer 15

90% in posterior midline

Question 16

Symptoms of anal fissure?

Answer 16

Pain and bleeding after defecation; chronic ones will see a sentinel pile

Question 17

Medical treatment for anal fissure? Surgical?

Answer 17

Medical: sitz baths, bulk, lidocaine jelly, stool softeners
Surgical: lateral subcu internal sphincterotomy

Question 18

Most serious complication of anal fissure surgery?

Answer 18

Fecal incontinence

Question 19

Contraindications to surgery for anal fissure?

Answer 19

If secondary to Crohn’s or UC

Question 20

Drainage procedure for perianal, intersphincteric, and ischiorectal abscesses?

Answer 20

Through skin (all below the levator muscles)

Question 21

Drainage for supralevator abscesses?

Answer 21

Transrectally

Question 22

Treatment for pilonidal cyst?

Answer 22

Drainage and packing; follow0up surgical resection of cyst

Question 23

Treatment for fistula in ano?

Answer 23

Unroof fistula and eliminate the primary opening with rectal advancement flap; do not need to excise the tract

Question 24

What is Goodsall’s rule?

Answer 24

Anterior fistulas connect with rectum in straight line; posterior fistulas go toward midline internal opening in rectum

Question 25

Definition of simple rectovaginal fistula?

Answer 25

Secondary to infection or obstetrical trauma, low to midvagina, <2.5cm

Question 26

Treatment for simple rectovaginal fistula?

Answer 26

Many heal spontaneously; transanally unroof and place rectal mucosa advancement flap

Question 27

Definition of complex rectovaginal fistula?

Answer 27

Secondary to inflammatory bowel disease, XRT, neoplasm, or high in vagina, or >2.5cm

Question 28

Treatment for complex rectovaginal fistula?

Answer 28

Abdominal or combined approach; resection and reanastomosis with placement of colostomy, need good tissue for anastamosis

Question 29

Types of anal incontinence? Treatment?

Answer 29

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)

Question 30

Anorecatal problems associated with AIDS? Characteristics?

Answer 30

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

Question 31

What type cancer found in the anal canal (above dentate line)?

Answer 31

Squamous cell CA, basaloid, mucoepidermoid, adenocarcinoma, melanoma

Question 32

Treatment for squamous cell CA of anal canal?

Answer 32

Chemo: Nigro protocol, chemo - 5FU and mitomycin, XRT) NOT surgery

Question 33

Cure rate for anal squamous cell CA?

Answer 33

80%

Question 34

Treatment for adenocarcinoma of the anal canal?

Answer 34

APR; WLE if <1/3 circumference, limited to submucosa, well differentiated, no vascular/lymphatic invasion; needs 1cm margin; postop chemo/XRT

Question 35

Treatment for melanoma of the anal canal?

Answer 35

APR; margin dictated by depth of lesion standard for melanoma

Question 36

What accounts for most deaths due to anal canal melanoma?

Answer 36

Hematogenous spread to the liver and lung early

Question 37

Most common symptom of melanoma of anal canal?

Answer 37

Rectal bleeding

Question 38

What type of cancers are found in anal verge (below dentate line)?

Answer 38

Squamous cell CA, basal cell CA, Bowen's disease, Paget's disease

Question 39

What is the treatment for squamous cell CA of the anal verge?

Answer 39

WLE for lesions <3cm, can get 0.5cm margin; APR for larger lesions or if sphincter involved

Question 40

Treatment for basal cell CA of anal verge?

Answer 40

WLE usually sufficient; need 3mm margins; rare need for APR

Question 41

What is Bowen's disease?

Answer 41

Intraepidermal squamous cell CA

Question 42

Associated conditions with Bowen's disease?

Answer 42

1 or more primary internal malignancy or primary cancer of the skin with internal mets

Question 43

Treatment for Bowen's disease?

Answer 43

Local therapy, WLE with clear margins

Question 44

What is Paget's disease of anal verge?

Answer 44

Intraepidermal apocrine gland CA, slow growing, positive PAS stain

Question 45

Treatment for Paget's disease?

Answer 45

WLE with clear margins; groin dissection for positive nodes

Question 46

Where do nodal mets from anal/rectal cancer go?

Answer 46

Superior and middle rectum: IMA nodes Lower rectum: primarily IMA nodes, internal iliac nodes Upper 2/3 of anal canal: internal iliac and pelvic nodes Lower 1/3 of anal canal: inguinal nodes