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ABSITE > Fiser Chapter 37 ANAL AND RECTAL > Flashcards

Fiser Chapter 37 ANAL AND RECTAL Flashcards

1
Q

Thrombosed external hemorrhoid tx

A

< 72 hours: elliptical excision to relieve pain (can also use elliptical excision to resect external hemorrhoids)

> 72 hours: lance open

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2
Q

Surgical tx of anal fissure

A

Lateral subcutaneous internal sphincterotomy

Complication: fecal incontinence

Do NOT perform if d/t Crohn’s or UC

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3
Q

Rectal prolapse

A

Starts 6-7 cm from anal verge, involves all layers of rectum

Etiology: pudendal neuropathy and laxity of anal sphincters

Risk factors: Female, straining, chronic diarrhea, previous pregnancy, and redundant sigmoid

Tx: High-fiber diet, surgery (Altemeier or LAR)

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4
Q

Tx of anal canal adenocarcinoma

A

Usually APR, Postop chemoXRT (same as rectal cancer)

WLE if <3cm, <1/3 circumference, limited to submucosa (T1 tumors, 2-3 mm margin needed), well-differentiated, no lymphovascular invasion; needs about 1 cm margin

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5
Q

Etiologies of anal incontinence

A

Neurogenic (gaping hole): no good tx

Abdominoperineal descent: chronic damage to levator ani muscle and pudendal nerves (obesity, multiparity) and anus falls below levators; Tx high fiber diet, limit to 1 BM a day, hard to tx!

Obstetrical trauma: Tx anterior anal sphincteroplasty

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6
Q

Ulcerating, slow growing anal margin lesion

A

Anal margin squamous cell cancer

Men have better prognosis

Metastasizes to inguinal nodes

Tx: WLE for <5cm (need 0.5 cm margin)
>5 cm or involving sphincter or positive nodes, Chemo-XRT (5-FU and cisplatin), trying to preserve sphincter and avoid APR; inguinal node dissection if clinically positive

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7
Q

Anal canal lesion with pruritis, bleeding, and palpable mass

A

Squamous cell CA (e.g. epidermoid CA, mucoepidermoid CA, cloacogenic CA, basaloid CA)

-Tx: Nigro protocol (chemo-XRT with 5-FU and mitomycin), NOT surgery; cures 80%; APRT for tx failure or recurrence

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8
Q

Anal canal versus anal margin squamous cell cancer

A

Margin (below dentate line) better prognosis

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9
Q

Surgical tx of rectal prolapse

A

Perineal rectosigmoid resection (Altemeier) transanally if patient old and frail

LAR and pexy of residual colon if good condition patient

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10
Q

Anus blood supply

A

Inferior rectal artery

Internal hemorrhoid plexus (above dentate line) and external hemorrhoid plexus (below dentate line)

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11
Q

Anal margin central ulcer with raised edges

A

Basal cell CA

Rare mets

Tx: WLE usually sufficient (3 mm margins, rarely need APR unless sphincter involved)

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12
Q

AIDS patient presents with RLQ pain, fever, with shallow anorectal ulcers

A

CMV: similar presentation as appendicitis, tx Ganciclovir

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13
Q

1 rectal ulcer etiology

A

HSV, can see in AIDS patients

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14
Q

Nigro protocol

A

Anal canal SqCC: Chemo-XRT, 5-FU, mitomycin

Anal margin SqCC: Chemo-XRT, 5-FU, cisplatin

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15
Q

Tx of anal canal melanoma characteristics and tx

A

Is 3rd most common site (1. skin, 2. eyes, 3, anal canal)

1/3 has mesenteric LN spread; if symptomatic, often significantly metastatic

Hematogenous spread to liver and lungy is early and accounts for most deaths

Most common symptom rectal bleeding

Most tumors lightly pigmented or not at all

Tx: Usually APR, margin dictated by depth of lesion (standard for melanoma)

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16
Q

Hemorrhoids tx

A

Fiber

Stool softeners

Sitz baths

17
Q

AIDS patient with anal nodule and ulceration

A

Kaposi’s sarcoma, most common cancer in AIDS patients

18
Q

Internal hemorrhoid surgical tx

A

Primary and secondary can be banded

Tertiary and quaternary: 3-quadrant resection
-Resect down to internal anal sphincter (but NOT through)

Do NOT band external hemorrhoids (painful)

19
Q

Difference between internal and external hemorrhoids

A
  1. Internal hemorrhoids: cause bleeding or prolapse
    • Primary: slides below dentate with strain
    • Secondary: prolapses but reduces spontaneously
    • Tertiary: must be manually reduced
    • Quaternany: unable to reduce
  2. External hemorrhoids: distal to dentate line, covered by sensate squamous epithelium, can cause pain/swelling/itching, especially when thrombosed
20
Q

Surgical indications for hemorrhoids

A

Recurrence

Thrombosis multiple times

Large external component

21
Q

Anal margin (below dentate line) lesions

A

Squamous cell CA

Basal cell CA

22
Q

Pilonidal cyst

A

Sinus or abscess formation over sacrococcygeal junction, increased in men

Tx: Drain and pack, follow-up surgical resection of cyst

23
Q

Anal cancer associated with what

A

HPV

XRT

24
Q

Fistula-en-ano tx

A
  • Often occurs after anorectal abscess
  • Do NOT need to excise tract

Tx:
Upper 2/3 of external anal sphincter -> rectal advancement flap (incontinence most worrisome complication)

Lower 1/3 of external anal sphincter -> fustulotomy (open tract up, curettage out, let heal by secondary intention)

25
Q

Anal fissure

A

Split in anoderm (90% in posterior midline) -> pain and bleeding after defecation -> if chronic will see a sentinel pile

Medical tx: sitz baths, bulk, lidocaine jelly, stool softeners (90% heal)

Surgery: lateral subcutaneous internal sphincterotomy (do NOT perform if d/t Crohn’s or UC; higher suspicion if lateral or recurrent fissures)

26
Q

Anorectal abscess

A

Antibiotics for cellulitis, DM, immunosuppressed, or prosthetic hardware

  1. Perianal, intersphincteric, or ischiorectal: drain through skin, since are below levator muscles
    • intersphincteric and ischiorectal abscesses can form horseshoe abscess
  2. Supralevator abscess: must drain transrectally
27
Q

Anal canal and margin

A

Canal above dentate line

Margin below dentate line

28
Q

Why is fistulotomy NOT used for fistulas in upper 2/3 of external anal sphincter?

A

Risk of incontinence

29
Q

Simple and complex rectovaginal fistulas

A

Simple (low to mid-vagina)
Tx: Trans-anal rectal mucosa advancement flap
Many obstetrical fistulas heal spontaneously

Complex (high in vagina):
-Tx: abdominal or combines abdominal and perineal approach usual; resection and re-anastomosis of rectum, close hole in vagina, interpose omentum, temporary ileostomy

30
Q

AIDS patients with anorectal ulcer

A

Kaposi’s sarcoma

CMV (similar presentation as appendicitis)

HSV (#1 rectal ulcer)

B cell lymphoma (can look like abscess or ulcer)

-Need to biopsy these ulcers to r/o cancer and differentiate problems

31
Q

Hemorrhoidal plexuses

A

Left later, right anterior, right posterior

32
Q

Anorectal nodal mets

A

Superior and middle rectum -> IMA nodes

Lower rectum -> Primarily IMA nodes, but also internal iliac nodes

Upper 2/3 anal canal -> internal iliac nodes

Lower 1/3 anal canal -> inguinal nodes

33
Q

Goodsall’s rule

A

Anterior fistulas connect with anus/rectum in a STRAIGHT line

Posterior fistulas go toward a midline internal opening in the anus/rectum

34
Q

Anal canal (above dentate line) lesions

A

Squamous cell CA (e.g. epidermoid CA, mucoepidermoid CA, cloacogenic CA, basaloid CA)

Adenocarcinoma

Melanoma

35
Q

Condylomata acuminata

A

Cauliflower mass

HPV papillomavirus

Tx: laser surgery

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