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Surgery > colon, rectum, anus > Flashcards

colon, rectum, anus Flashcards

1
Q

parts of the large intestine

A
  • cecum is largest part and where small bowel joins colon (no distinct division between cecum and ascending colon which is retroperitoneal)
  • hepatic flexure (inf to liver) bend in asc colon where it becomes transverse colon
  • transverse colon suspends freely in peritoneal cavity by transverse mesocolon
  • splenic flexure is where transverse colon bends at the spleen and is retroperitoneal
  • descending colon is retorter down to sigmoid colon which is loop of redundant colon in llq
  • distal colon is intraperi becomes the rectum at the sacrum then cont. to anal sphincters that form short (3cm) anal canal
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2
Q

rectum anatomy

A
  • 15cm long
  • teniae coli disperse and disappear at level of sacral promontory resulting in longitudinal muscle layer that becomes continuous homogeneous layer
  • prox rectum covered by peritoneum ant not post to 10cm above anal verge
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3
Q

importance of knowing what part of the rectum is intraperitoneal

A

full thickness rectal bx taken from higher than 8-9cm above anal verge carries risk of free perf into peritoneal cavity

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4
Q

where does the anal canal extend from

A

anorectal junction (dentate/pectinate line) to anal verge

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5
Q

what does the dentate one mark

A

junction between columnar rectal epithelium (insensate) and the squamous anal epithelium (richly innervated by somatic sensory nerves)

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6
Q

columns of Morgagni (rectal columns)

A
  • immediately proximal to dentate line

- where perianal glands discharge secretions, level of anal crypts

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7
Q

where do perirectal abscesses usually originate

A

columns of morgagni (anal crypts)

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8
Q

what is the blood supply of ascending colon and prox half of transverse colon

A

branches of sma

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9
Q

what is the blood supply of distal half of transverse colon, descending colon, and sigmoid colon

A

infer mesenteric artery

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10
Q

importance of understanding arterial blood supply in certain areas of colon

A

-junction of two separate blood vessel systems, blood supply is poor so anastomoses in this region would carry higher risk of ischemic complications

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11
Q

marginal artery of drummond

A

vessel runs parallel to about 2-3cm from descending colon wall and is a collateral that connects the middle colic and left colic systems
-provides adequate blood supply to descending colon even if left colic artery has to be sacrificed during sigmoid or distal descending colon surgery

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12
Q

venous drainage of large bowel

A
  • most branches accompany the arteries and eventually drain into portal system
  • inf mesenteric vein drains into splenic vein which joins w super mesenteric vein to form portal vein
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13
Q

arterial supply of rectum

A

branch of inf mesenteric artery (sup hemorrhoidal artery) for upper rectum and from branches of internal iliac arteries (middle hemorrhoidal arteries) and internal pudendal arteries (inf hem arteries) for the middle and lower rectum

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14
Q

venous supply of rectum

A

veins from upper rectum drain into portal system through inf mes vein; middle and inf rectal veins drain into systemic circulation through the internal iliac and pudendal veings

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15
Q

what are hemorrhoids

A

physiologic venous cushions that connect the two systems

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16
Q

lymphatic drainage of large intestine

A

parallels arterial blood supply w several levels of lymph nodes between periaortic plexus and parabolic lymph nodes

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17
Q

order of tumor metastases of lymph nodes

A

paracolic lymph nodes then middle tier of lymph nodes then periaortic lymph nodes

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18
Q

layers of bowel wall of colon

A

mucosa, submucosa, muscularis and serosa

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19
Q

what is the major histologic difference between colon and small intestine

A
  • colon has no villi
  • outer longitudinal smooth muscle layer is separated into 3 bands (teniae coli) that cause out pouching of bowel between teniae (haustra)
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20
Q

internal sphincter

A

continuation of the circular muscular layer of the rectum; invol sphincter made of smooth muscle

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21
Q

external sphincter

A
  • striated voluntary muscle
  • 3 parts: subq, superficial and deep portions
  • deep portion is continuity w legator ani muscles (base of pelvic floor)
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22
Q

most important control of colon activity

A

mediated by regional reflex activity that occurs in submucosal plexuses

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23
Q

3 ways colon and rectum play role in maintaining hemeostasis

A
  1. absorb water and electrolytes from liquid stool
  2. through fermentation, help digest some starches and protein that are resistant to digestion and absorption by small bowel
  3. serve as storage for feces
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24
Q

mc anaerobic colonic organism

A

bacteroides fragilis

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25
Q

mc aerobic colonic organisms

A

e coli and enterococci

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26
Q

function of colonic bacteria

A
  • degradation of bile pigments
  • production of vitamin k
  • fermentation of undigested starches and proteins
  • produce short chain fatty acids that are absorbed by the colon
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27
Q

does a resection of entire colon and rectum impact a person’s capacity to maintain normal nutrition

A

no

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28
Q

what many L of chyme does the small bowel deliver to the cecum each day

A

1-2L

most is absorbed in ascending and transverse colon leaving

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29
Q

what does the colon absorb and secret

A

absorbs sodium and chloride

secretes bicarb and potassium

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30
Q

what regulates the final evacuation of solid stool

A

anorectum

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31
Q

how many ml/day of colonic gas does bacterial fermentation produce

A

800-900mL/day

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32
Q

what gives colonic gas its odor

A

indole and skatole

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33
Q

dx evaluation of colon and rectum

A
  • DRE
  • rigid sigmoidoscopy which been replaced by fiberoptic flexible sigmoidoscopy
  • fiberoptic colonoscopy (most accurate)
  • abd series (flat plate and upright radiograph)
  • barium enema
  • virtual colonoscopy or ct colography
  • technetium labeled rbi scanning
  • angiography
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34
Q

what should a sigmoidoscopy be performed

A

pts >50yr and performed every 3-5yrs

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35
Q

double contrast barium enema

A

using air insufflation while some intraluminal barium remains in the colon is particularly sensitive in detecting polyps and small lesions

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36
Q

what is a barium enema helpful in dx

A

tumors
diverticulosis
volvulus
obstruction

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37
Q

what is technetium labeled rbc scanning used

A

eval of lower gi bleeding (less rapid and pt stable)

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38
Q

what is angiography useful for

A

moderate or rapid colonic bleeding

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39
Q

what is a colostomy

A

surgical procedure in which the colon is divided and the proximal end is brought through a surgically created defect in abd wall and distal end is either overseen and placed in peritoneal vanity as a blind limb (Hartmann’s procedure) or brought out inferiorly to colostomy through abd wall as mucous fistula

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40
Q

what is the purpose of a colostomy

A

divert stool from a diseased segment distally in the colon or rectum or to protect a distal anastomosis

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41
Q

how is a loop colostomy created

A

bringing a loop of colon through a defect in abd wall, placing a rod underneath, and making a small hole in the loop to allow stool to exit into colostomy bag

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42
Q

what is an ileostomy

A

similar to colostomy in which the ileum is brought through the abd wall to divert its contents from distal ds or in proctocolectomy, to serve as permanent stoma

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43
Q

why are stomas created

A

(1) to allow healing from a distal anastomosis before bowel continuity is restored; (2) the ends of the bowel are not suitable for an immediate anastomosis after resection (e.g., severely inflamed bowel, questionable vascular supply); (3) when the conditions are not right for proceeding (e.g., severe fecal peritonitis, patient too unstable or too sick to tolerate the procedure); and (4) when there is not enough bowel left for reanastomosis (abdominoperineal resection [APR]).

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44
Q

proctocolectomy

A

operative removal of entire colon and rectum (ulcerative colitis or polyposis syndromes)

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45
Q

abdominoperineal resection

A

surgical tx of very low rectal cancers; removal of lower sigmoid colon and entire rectum and anus leaving a permanent proximal sigmoid colostomy

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46
Q

low anterior resection

A

tx cancers of middle and upper sections of rectum; removal of distal sigmoid colon and apporx one half of rectum w primary anastomosis of prox sigmoid to distal rectum

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47
Q

what are the white lines of toldt

A

lateral peritoneal reflections of the ascending and descending colon

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48
Q

what parts of gi tract do not have serosa

A

esophagus, middle and distal rectum

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49
Q

major differences between colon and small bowel

A

colon has taeniae coli, haustra, and appendices epiploicae (fat appendages) whereas the small intestine is smooth

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50
Q

blood supply of proximal rectum and venous drainage

A

superior hemorrhoidal (superior rectal) from IMA

imv to splenic vein then to portal vein

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51
Q

blood supply of middle rectum

A

middle hemorrhoidal (midde rectal) from hypogastric (internal iliac)

iliac vein to ivc

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52
Q

blood supply of distal rectum

A

inf hemorrhoidal (inf rectal) from pudendal artery (branch of hypogastric artery)

iliac vein to ivc

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53
Q

what is the mc gi cancer

A

colorectal carcinoma

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54
Q

risk factors for colorectal carcinoma

A

diet- low fiber, high fat
genetic- famhx, FAP, lynch syndrome
IBD- UC > crohns, age, prev colon cancer

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55
Q

what is lynch’s syndrome

A

HNPCC= Hereditary NonPolyposis Colon Cancer

autosomal dominant inheritance of high risk for dev of colon cancer

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56
Q

ACS recommendations for polyp/colorectal screening in asymp pts without 1st degree fam hx of colorectal cancer

A

starting age 50:

  • colonoscopy q 10yrs
  • double contrast barium enema (DCBE) q 5yrs
  • flex sigmoidoscopy q 5yrs
  • Ct colonography q5yrs
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57
Q

ACS recommendations for polyp/colorectal screening in asymp pts with 1st degree fam hx of colorectal cancer

A

colonoscopy at age 40 or 10 years before age at dx of youngest 1st deg relative and every 5 yrs thereafter

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58
Q

s/sx assoc w right sided lesions

A

r side of bowel has lg luminal diameter so tumor may attain a lg size before causing problems

microcytic anemia, occult/melena more than hematochezia PR, postprandial discomfort, fatigue

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59
Q

s/sx assoc w left sided lesions

A

left side fo bowel small lumen and semisolid contents

change in bowel habits (small caliber stools), colicky pain, signs of obstruction, abd mass, +heme, or gross red blood

n,v,constipation

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60
Q

from which site is melena more common

A

right sided colon cancer

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61
Q

which site is hematochezia more common

A

left sided colon cancer

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62
Q

s/sx of rectal cancer

A

mc is hematochezia or mucus

tenesmus, feeling of incomplete evacuation of stool, rectal mass

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63
Q

dx tests for colorectal cancer

A 
hx/pe
heme occult
cbc
barium enema
colonoscopy
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64
Q

what ds does microcytic anemia signify until proven otherwise in man or postmenopausal woman

A

colon cancer

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65
Q

preop w/u for colorectal cancer

A 
hx
pe
lfts
cea
cbc
chem 10
pt/ptt
type/cross 2u
prbcs
cxr
ua
abdominopelvic ct
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66
Q

means by which cancer spreads

A

direct extension-circumferentially and through bowel wall to later invade other abdominoperineal organs

hematogenous- portal circulation to liver; lumbar/vertebral veins to lungs

lymphogenous-regional lymph nodes

transperitoneal

intraluminal

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67
Q

what unique dx test is helpful in pts w rectal cancer

A

endorectal US

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68
Q

tnm stages

A

stage1- invades submucosa or muscularis propria (T1-2 N0 M0)

stage2- invades through muscularis propria or surrounding structures but w negative nodes (t3-4, N0, M0)

stage3- positive nodes, no distant metastasis (any T, N1-3, M0)

stage4- positive distant metastasis (any T, any N, M1)

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69
Q

preop bowel prep

A
  1. golytely colonic lavage or fleets phospho-soda until clear effluent per rectum
  2. PO abx (1g neomycin and 1g erythromycin x3doses)

pt should also receive preop and 24hr IV abx

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70
Q

common preop IV abx

A

cefoxitin (mefoxin), carbapenem

if alx- IV cipro and flagyl (metronidazole)

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71
Q

what determines low ant resection (LAR) vs abd perineal resection (APR)

A

distance from anal verge, pelvis size

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72
Q

what do all rectal cancer operations include

A

total mesorectal excision- remove rectal mesentery, including lymph nodes

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73
Q

what surgical margins are needed for colon cancer

A

traditionally >5cm; margins must be at least 2cm

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74
Q

how many lymph nodes should be resected w colon cancer mass

A

12min= for stage and may improve prognosis

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75
Q

adjuvant tx stage 3 colon cancer

A

5fu and leucovorin chemo

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76
Q

adjuvant tx for t3-4 rectal cancer

A

preop radiation therapy and 5fu chemo

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77
Q

mc site distant metastasis from colorectal cancer

A

liver

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78
Q

surveillance regimen of colorectal cancer

A 
pe
stool guaiac
cbc
cea
lfts- every 3m for 3y then every 6m for 2y
cxr every 6m for 2yr then yearly
colonoscopy at yrs 1 and 3 postop
ct scans directed by exam
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79
Q

mc causes of colonic obstruction in adult population

A

colon cancer
diverticular ds
colonic volvulus

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80
Q

what are colonic and rectal polps

A

tissue growth into bowel lumen usually consisting of mucosa, submucosa or both

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81
Q

how are colonic and rectal polyps anatomically classified

A

sessile=flat

pedunculated= on a stalk

82
Q

histologic classifications of inflammatory (pseudopolyp) colonic/rectal polyps

A

crohns or ulcerative colitis

83
Q

histologic classifications of hamartomatous colonic/rectal polyps

A

normal tissue in abn configuration

84
Q

histologic classifications of hyperplastic colonic/rectal polyps

A

benign-normal cells, no malignant potential

85
Q

histologic classifications of neoplastic colonic/rectal polyps

A

proliferation of undifferentiated cells; premalignant or malignant cells

86
Q

subtypes of neoplastic polyps

A 
tubular adenomas (pedunculated)
tubulovillous adenomas
villous adenomas (sessile and look like broccoli heads)
87
Q

what determines malignant potential of an adenomatous polyp

A

size
histologic type
atypia of cells

88
Q

mc type of adenomatous polyp

A

tubular

89
Q

correlation between size and malignancy of polyps

A

polyps larger than 2cm higher risk

90
Q

what about histology and cancer potential of an adenomatous polyp

A

villous > tubovillous > tubular

villous=villain

91
Q

where are most polyps found

A

rectosigmoid

92
Q

s/sx of polyp

A 
bleeding
change in bowel habits
mucus per rectum
electrolyte loss
totally asyptomatic
93
Q

dx tests for polyps

A

colonoscopy*

barium enema and sigmoidoscopy

94
Q

tx polyp

A

endoscopic resection (snared)

if lg sessile villous adenomas - removed w bowel resection and lymph node resection

95
Q

familial polyposis (familial adenomatous polyposis=FAP)

A

hundreds of adenomatous polyps within the rectum and colon that begin developing at puberty

untx develop cancer by ages 40-50

96
Q

inheritance pattern of FAP and genetic defect

A

autosomal dominant

adenomatous polyposis coli= APC gene

97
Q

tx FAP

A

total proctocolectomy and ileostomy

total colectomy and rectal mucosal removal (musosal proctectomy) and ileoanal anastomosis

98
Q

what other tumor must be looked for with FAP

A

duodenal tumors

99
Q

Gardner’s syndrome

A

neoplastic polyps of small bowel and colon

cancer by age 40 if undx

100
Q

assoc findings of gardners syndrome

A 
desmoid tumors (abd wall or cavity)
osteomas of skull
sebaceous cysts
adrenal and thyroid tumors
retroperitoneal fibrosis
duodenal and periampullary tumors
101
Q

what is a desmoid tumor

A

tumor of musculoaponeurotic sheath, usually of abd wall

benign but grows locally

tx w wide resection

102
Q

what meds can slow growth of desmoid tumor

A

tamoxifen, sulindac, steroids

103
Q

what is peutz jeghers syndrome

A

hamartomas throughout the GI tract (jejunum/ileum >colon > stomach)

assoc w ovarian cancer

auto dom

104
Q

s/sx and tx peutz jeghers syndrome

A

melanotic pigmentation (black/brown) of buccal mucosa, lips, digits, palms, feet

Peutz=pigmented

removal of polyps if symp or large (>1.5cm)

105
Q

what are juvenile polyps

A

benign hamartomas in small bowel and colon, not premalig

“retention polyps”

106
Q

Cronkhite Canada syndrome

A

diffuse GI hamartoma polyps assoc w malabsorption/wl, diarrhea, and loss of electrolytes/protein

signs- alopecia, nail atrophy, skin pigmentation

107
Q

turcot’s syndrome

A

colon polyps w malignant CNS tumors

108
Q

tx diverticulitis

A

acute- admit to hospital, IV hydration, NPO, IV abx for 5-7d

recurrent- sigmoid colectomy

109
Q

operation w diverticular ds w acute perf or obstruction

A

segment resected, diverting colostomy brought to abd wall and distal rectal stump oversewn (Hartmann)

then colostomy takedown and anastomosis to rectal stump (3months)

110
Q

tx for colovesical fistula

A

surgery- primary closure of bladder and resection of sigmoid colon w primary anastomosis

111
Q

what is considered massive bleeding related to diverticular bleeding

A

bleeding that is sufficient to warrant transfusion of more than 4units of blood in 24hr to maintain normal hemodynamics

rapid colonic bleeding= rate of 0.5mL/min

112
Q

dx procedure of choice to rule out lower GI sources of bleeding

A

colonoscopy

113
Q

tx diverticular bleeding

A

most stop on own

id of site allows surgical resection of colon

vasopressin through angiography (temporary)

coil emobolization (temp)

114
Q

what is ulcerative colitis

A

IBD that involves mucosa and submucosa of large bowel and rectum

ages 15-30 then >55

115
Q

what is crohns ds

A

transmural ds that can involve any portion of the alimentary canal

116
Q

UC vs crohns

A

crohns- rectal sparing, skip lesions, aphthous sores, linear ulcers, thickening, strictures, string sign,fibrosis

UC-diarrhea severe, bloody, rectum/terminal ileum, continuous, friable, exudates, lead pipe, foreshortening, crypt abscesses

117
Q

what leads to pseudo polyp formation assoc w UC

A

coalescing of crypt abscess (Lieberkuhn) and erosion of mucosa

118
Q

s/sx UC

A

watery diarrhea that contains blood, pus and mucus

cramping

abd pain

tenesmus

urgency

varying- wl, dehydration, pain, fever

119
Q

dx UC

A

endoscopy w bx- friable, reddish mucosa w no normal intervening areas, mucosal exudates, and pseudopolyposis

barium enema

shortening of colon, loss of normal austral markings and lead pipe appearance

120
Q

tx UC and crohns

A

initial is medical therapy- antidiarrheal agents (loperamide) and bulking agents (psyllium)

moderate- sulfasalazine or mesalamine

severe- steroid

crohns- infliximab (remicade)

uc- surgery, total colectomy w proctectomy and ileoanal pull through

121
Q

mc site of colonic obstruction

A

sigmoid colon

122
Q

mc causes of colonic obstruction

A

adenocarcinoma

scarring assoc w diverticulitis

volvulus

123
Q

s/sx colonic obstruction

A

abd distension, cramping abd pain, n, v, obstipation

pe- abd distention, tympany, high pitched metallic rushes, gurgles, localized tender palpable mass ( indicates strangulated closed loop or diverticular ds)

124
Q

radiologic and ct findings colonic obstruction

A

proximal colon, air fluid levels, no distal rectal air

125
Q

dx colonic obstruction

A

axr

water soluble contrast enema

barium enema

colonoscopic esp w Ogilvie’s syndrome (localized paralytic ileus of colon without mechanical obstruction)

126
Q

why should barium never be given orally w colonic obstruction

A

accumulates proximal to the obstruction and cause a barium impaction

127
Q

tx large bowel obstruction

A

IV fluids,NG suction, continuous observation

emergency lap for acute w cecal distention >12cm, severe tenderness, evidence of peritonitis, generalized sepsis

perf from volvulus/cancers/diver-lap w resection and diverting colostomy

cancer wout peritonitis-colonic stent placement allows decompression

Ogilvie’s- IV neostigmine

128
Q

complications of lg bowel obstruction

A

perforation, peritonitis, sepsis

129
Q

what is a volvulus

A

rotation of a segment of the intestine on axis formed by mesentery

stretching and elongation w age

hypermobile cecum

130
Q

mc site of volvulus lg bowel

A

sigmoid and cecum

131
Q

s/sx volvulus

A

abd distention, v, abd pain, obstipation, tachypnea

pe-distention, tympany, high pitched tinkling sounds, rushes

132
Q

dx volvulus

A

axr

water soluble contrast enema- funnel narrowing resembles birds beak or ace of spades

ct scan

133
Q

tx volvulus

A

sigmoidoscopy w rectal tube insertion to decompress sigmoid volvulus

cecal volvulus- cecopexy (suturing the cecum to parietal peritoneum) or w right hemicolectomy w ileotransverse colostomy

134
Q

tx tubular polyp

A

endoscopic excision

135
Q

tx villous polyp

A

surgical removal

136
Q

tx of hamartoma polyp

A

excise for bleeding or obstruction

137
Q

tx inflammatory polyp

A

observation

138
Q

tx hyperplastic polyp

A

observation

139
Q

where do most large bowel cancers occur

A

lower left side of colon near rectum

140
Q

mild risk factors for colorectal cancer

A 
age
diet
physical inactivity
obesity
smoking
race
alcohol
141
Q

screening guidelines for polyps and cancer

A
  1. flex sigmoid every 5yr
  2. colonoscopy ever 10yr
  3. double contrast barium enema every 5yr
  4. ct colonography every 5 yr

all start at age 50 unless fhx or higher risk then age 40 or 10yr before person with cancer age

higher risk also do every 3-5yr instead of 10yr

142
Q

symptoms assoc w cancer of right colon

A
  • exophytic lesions
  • occult blood loss=fe def anemia
  • weight loss
  • mass
  • virchows node
  • blunder’s shelf
143
Q

symptoms assoc w cancer of left colon

A
  • +/- weight loss
  • rectal bleeding
  • blunder’s shelf
  • obstruction
144
Q

symptoms assoc w cancer of rectum

A

-rectal bleeding
-tympany
-obstruction
+/- alt diarrhea/constipation

145
Q

tx for colorectal cancer

A

resection including lymph nodes

146
Q

mc organ involved in distant colorectal metastases

A

liver

147
Q

how are tumors of cecum and ascending colon tx

A

right hemicolectomy that includes resection of distal portion of ileum and colon to mid transverse colon with an ileo mid transverse colon anastomosis

148
Q

tx cancers to right and left middle colic artery

A

right- extended right hemicolectomy

left-partial left colectomy

149
Q

tx hepatic flexure lesions

A

extended right colectomy that includes resection to or beyond level ofmidtransverse colon

150
Q

tx splenic flexure and left sided lesions

A

left hemicolectomy thats includes resection from level of mid transverse colon to sigmoid

151
Q

tx sigmoid colon lesions

A

sigmoid resection

152
Q

tx obstructing or perf tumors

A

resection, diverting colostomy, and hartmann’s pouch or mucous fistula

153
Q

what is folfox and what is it used for

A
  • 5fu, leucovorin, oxaliplatin

- tx metastatic colorectal cancer

154
Q

tx rectal tumors

A

resection + radiation + 5fu

155
Q

what is used to stage the depth of penetration of the tumor in the rectal wall

A

endorectal us or mri

156
Q

TNM staging

A 
tx= primary tumor not assessed
to= no evidence prim tumor
tis= carcinome in situ; intraepithelial tumor or invasion of lamina propria
t1= submucosa
t2= muscularis propria
t3= muscularis propria into subserosa or into nonperitonealized pericolic or perirectal tissues
t4= organs or structures or perf visceral peritoneum
nx= nodes not assessed
no=no regional nodes
n1= 1-3 pericolic or perirectal nodes
n2=>4 pericolic or perirectal nodes
n3= any node along course of vascular trunk or to >1 apical node
mx= no distant metastasis assessed
mo= no distant metastasis
m1= distant metastasis
157
Q

frequent follow up visits

A

3m for 2 yrs then 6m for 3 yrs then yearly until 10yr post resection

colonoscoy 1-2 yr postop then every 2-3yr

158
Q

when do most recurrences happen

A

18-24 months

159
Q

what is the most sensitive test to detect widespread metastases in colorectal cancer

A

positron emission tomography (PET)

160
Q

rectal prolapse

A

intussessception of a full thickness portion of rectum through the anal opening

161
Q

mucosal prolapse

A

eversion of 2-3cm of rectal mucosa through anal opening but which is not full thickness

162
Q

difference between rectal prolapse and mucosal/hemorrhoidal prolapse

A

rectal has concentric, circumferential mucosal folds where mucosal has radial pattern of folds

163
Q

rectal pain/pressure with mild bleeding, incontinence, mucous discharge and wet anus

A

rectal prolapse

164
Q

tx rectal prolapse

A

intra abdominal procedure including sigmoid resection (redundant bowel) w rectopexy (suturing the bowel wall to the pre sacral fascia to immobilize it)

165
Q

tx mucosal or hemorrhoidal prolapse

A

three column hemorrhoidectomy

166
Q

what are the 3 positions in which hemorrhoids are normally found

A

left lateral

right anterior

right posterior

167
Q

location of internal vs external hemorrhoids

A

internal- originate above dentate line

ext- below dentate line

168
Q

degree of internal hemorrhoidal prolapse

A

1st- int hem do not prolapse

2nd- int hem prolapse w defecation and return spont. to anatomic position

3rd- int hem prolapse w defecation and require manual reduction

4th- not reducible

169
Q

what is recommended in tx of hemorrhoids

A

bulk forming agents (psyllium derivatives) and avoidance of constipation

170
Q

1st degree int hem def and tx

A
  • bulge in anal canal lumen; doesn’t protrude outside of lumen
  • asym= bulking agents, no constipation, inc water intake
  • symp= same asym, rubber band ligation, infrared coag
171
Q

2nd degree int hem def and tx

A
  • protrudes w defecation reduces spont

- conservative man or rubber band ligation

172
Q

3rd degree int hem def and tx

A
  • selected cases= rubber band ligation

- mixed= surgical hemorrhoidectomy

173
Q

4th degree int hem def and tx

A
  • protrudes, permanently incarcerated

- surgical hemorrhoidectomy

174
Q

how long do thromboses ext hem last

A

self limited and resolves progressively over 7-10d

175
Q

how are most anorectal abscesses start

A

obstruction of the perianal glands located between internal and external sphincters; as it inc in size and spreads it becomes a perianal abscess

176
Q

what are the mc perirectal abscesses

A

perianal and ischiorectal

177
Q

tx of rectal abscess

A

drainage

178
Q

after drainage of a perirectal abscess what does a pt have a 50% chance of having

A

chronic fistula-in-anu- abnorm communication between anus at level of dentate line and perirectal skin through the bed of previous abscess

179
Q

intersphincteric fistulae is result of

A

perianal abscess

180
Q

transsphincteric fistulae is result of

A

ischiorectal abscess

181
Q

supresphincteric fistulae result of

A

suprelevator abscess

182
Q

chronic drainage of pus and sometimes stool from the skin opening

A

fistula

183
Q

Goodsall’s rule

A

imaginary line drawn from right lateral to left lateral position at level of anus

184
Q

tx of fistula

A

fistulotomomy- unroofing the fistula tract, allowing to heal slowly by secondary intention

185
Q

mc cause of severe localized anorectal pain

A

anal fissure- linear tears in lining of anal canal below level of dentate line

186
Q

where do most anal fissures occur

A

posteroanterior plane because pelvic muscular support is weakest along axis

187
Q

classic triad assoc w anal fissures

A
  • ext skin tag
  • fissure exposing internal sphincter fibers
  • hypertrophied anal papilla at level of dentate line
188
Q

tx anal fissures

A
  • acute= conservative tx, avoid d/c, bulk laxatives, mild nonnarcotic analgesic; sits baths; topical agents (procainamide, nitroglycerin) relax sphincter
  • fails or is chronic=surgery= partial lateral internal sphincterotomy
189
Q

two types of anal cancers

A
  • epidermoid carcinoma (generic type includes squamous cells, basaloid, cloacogenic, mucoepidermoid, transitional carcinomas)
  • malignant melanoma
190
Q

tx anal cancers

A

chemo and radiation using protocol of pelvic radiation w infusion of 5fu and mitomycin c

191
Q

mc anorectal infx affecting homosexual men

A

anal condylomas- pink/white papillary lesions, cauliflower like, bleed easily, pain

192
Q

tx anal condylomas

A
  • topical= bichloracetic acid, poco-phyllin

- local destructive= electrocoag, cryo, laser

193
Q

rectal symptoms including tenesmus and pain, hematochezia, ulcer

A

chlamydia- friable, ulcerating erythematous mucosa

194
Q

tx chlyamydia

A

tetracycline or doxycycline

195
Q

pruritus, tenesmus, hematochezia w thick yellow mucopurulent discharge

A

neisseria gonorrhea

196
Q

tx n gonorrhea

A

ceftriaxone w tx for chlamydia (tetra or doxy)

197
Q

A 57-year-old man comes to clinic with complaints of foul-smelling urine and two urinary tract infections treated with antibiotics by his primary care physician over the past 6 weeks. He has no pain at this time. Two months ago, he was seen in the emergency department with 2 days of left lower quadrant pain and constipation and was treated with oral antibiotics for diverticulitis. His past history is otherwise negative. His only medication Is ciprofloxacin. He is afebrile and vital signs are normal. A urine sample is cloudy with sediment. What is the next best step In diagnosis?

A

CT scan remains the most sensitive test for diagnosis of enterovesical fistula and location of the portion of the intestinal tract involved. Plain radiographs may show air in the bladder, but not the etiology. Ultrasound has no role. Barium enema Identifies the fistula

198
Q

A 62-year-old woman is seen in the emergency department with dark red rectal bleeding and hypotension. Initial hemoglobin is 7.2. She is given intravenous fluids and two units of packed red blood cells but continues to have large amounts of bloody stools. Nasogastric tube effluent is clear bilious fluid. The best choice for Identification of the bleeding site at this time is .

A

mesenteric angiography

While rigid proctoscopy may be done, it Is unlikely to identify a source of massive bleeding. The patient is unlikely to be sufficiently stable for the colonoscopy prep or the time required for it. Tagged RBC scan Is more sensitive than angiography for Identifying active bleeding, but much less specific for identifying the source of bleeding and is not as useful in massive bleeds. Diagnostic laparoscopy would not elucidate the bleeding source. Mesenteric angiography Is much more specific for identifying the source and offers the potential for therapy (angiographic embolization) to control bleeding as well in selected cases.

199
Q

An 85-year-old male nursing home resident is brought to the emergency department with 3 days of painless abdominal distention and obstipation. He appears to be in no pain, but his abdomen is massively distended and tympanitic. Plain abdominal films show a kidney-bean-shaped air-filled structure suspicious for cecal volvulus. The best management at this point is .

A

right colon resection

Observation occurs In Ogllvle’s, not volvulus. Contrast enema decompression Is not useful in cecal volvulus. Colonoscopic detorsión is useful for sigmoid volvulus, but considered unwise in cecal volvulus due to associated risks. Cecopexy carries a high rate of revolvulus.

200
Q

A 41 -year-old man Is seen In clinic with bright red rectal bleeding, seen on the toilet tissue intermittently over the last several months. He is an insurance agent, exercises regularly, and eats a well-balanced diet. He denies changes In bowel habits. Family history is unremarkable. His vital signs are normal. His abdomen exam is normal. Digital rectal exam is normal, and blood is Identified on the examining finger. Anoscopy shows no other pathology. What is the next best step in diagnosis?

A

colonoscopy

In the absence of an obvious source in the anus or distal rectum, further evaluation of the colon Is needed. Fecal occult blood test (FOBT) Is irrelevant with a history of visible rectal bleeding. CBC is unlikely to be helpful. Flexible sigmoidoscopy only examines part of the colon. While barium enema may Identify an abnormality anywhere In the colon, It Is not as specific as colonoscopy.

201
Q

A 24-year-old woman is seen In clinic with anal pain. Examination shows a fissure in the anterior midline of the anal canal. Digital rectal exam cannot be performed due to pain. The next step in management should be .

A

sitz baths, bulking agents, reassurance

The presentation is classic for traumatic anal fissure. Fissures off the midline generally prompt evaluation for other etiologies.

Surgery (21 decks)

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