rectum and anal disease Flashcards
rectal carcinoma
-adenocarcinoma!
-fulguration?
-adjuvant chemotherapy
-the rectum is aserosal (lacking a serosal layer) in its lower portion -> difficult to suture
-!!abdominal perineal resection (APR)- GOLD standard tx
-APR- removal of left sigmoid colon, anus, and rectum with permanent colostomy!
anal carcinoma
-squamous cell type (SCC)!!
-very aggressive, poor prognosis
-nigro protocol for tx is comparable to APR -> 5FU, mitomycin
-HPV is risk facotr
-pts who have anal sex
-external beam radiation 45-50 Gy
lower anterior resection (LAR)
-preserves ability to go to bathroom still (anal sparing)
-Laser or electrocautery → not cure just palliative if can’t treat!
-metastatic/ advanced
miscellaneous conditions
-volvulus
-ischemic colitis- thumbprinting
-rectal prolapse- need to have it reduced or surgically repaired
-anal fissure
-rectovaginal fistula
-pruritis ani
-hemorrhoids
redundant sigmoid colon
-older pts
-colonoscopy or sigmoidoscopy
-put rectal tube past point of occlusion to allow gas out and decompress
ischemic colitis
-watershed areas
-sudden onset, usually LLQ
-blood diarrhea within 24 hours
-bowel wall thickening
-thumbprinting
-abd pain out of proportion to physical findings, leukocytosis, + lactic acidosis
-CT with contrast scan to show pneumatosis intestinal (air within bowel) → pt needs to be taken to OR
-dead bowel gets resected, black gangrene
-if they are viable, wrap around warm pads and wait to see if it turns pink
-if questionable areas → leave open for 24 hrs and put on heparin drip to see if its dead or viable
-colonoscopy- mild to moderate
-IV fluids for mild
-IV antibiotics, colonic resection for severe
non-occlusive mesenteric ischemia (NOMI)
-hypoperfusion
-first areas to lose will be watershed
-volvulus
-causes obstruction and can plug the mesenteric arteries -> gangrenous bowel
-dx- flat plate
-tx- barium enema to decompress (put stent in)
-coffee bean appearance
hemorrhoids grading
-First degree - No prolapse
-Second degree - Prolapse with spontaneous reduction
-Third degree - Reduces with manual reduction
-Fourth degree - Permanently prolapsed
anal fissure
-increased anal sphincter tone!
-anal pain, during/after bowel movement
-Ulcer in the lower portion of the anal canal
-Acute vs. chronic: primary vs. secondary
-Can be traced to passage of large, hard stool or explosive diarrhea, trauma to anus, or tearing during vaginal delivery
-~100% men posterior midline,
-~10% women anterior midline
-higher internal sphincter tone -> resulting in poor anodermal perfusion to the posterior
-Sx: Anal pain, during and after BM’s
-Dx: Inspection, usually increased anal tone can be appreciated on rectal exam if tolerated
-Acute fissure: tx with bulking agents, local anesthetic, cleansing measures (baby fresh wipes) typically resolve in 6 weeks without surgical intervention
chronic fissure-In-Ano
- sentinel tag, ulcer (transverse fibers of the internal sphincter may be exposed), hypertrophied anal papilla.
-Form because of swelling, edema, and low-grade inflammation
-may go on to develop fibrosis.
-Extends from the dentate line to the anal verge
tx- chronic fissure
-Topical Nifedipine (4-weeks) or
-Nitroglycerin ointment 0.2% - 0.4% BID (50%-75% resolution at 6 weeks with 50% later recurrence).
-topical diltiazem
-Botulinum toxin A injection – 42% recurrence at 42 months – side effects (transitory incontinence).
-Surgery: Lateral internal sphincterotomy (ONLY IF ABOVE TX FAILS)
secondary anal fissure
-Crohn disease.
-Non-midline or abnormal appearing fissure should undergo margin biopsy.
-Avoid surgery in neutropenic patients – treat with perineal hygiene and pain relief
anorectal abscesses
-swollen tender mass
-severe pain aggravated by walking
-obese, DM (look everywhere for source of infection), bad hygiene
-infection of anal glands in the wall of the canal.
-Sx: Severe pain (aggravated by walking, straining)
-Rx: Drainage, surgical debridement, avoid packing, no abx typically?
-if not drained -> fournier’s grangrene -> spreading gangrene through perineum
-Crohn disease- oral metronidazole or ciprofloxacin seems to have a mitigating effect
fistula
-Unroofing the fistula, eliminating the internal opening, and establishing adequate drainage.
-Older pts have increased risk of incontinence associated with transection of the external sphincter– use loosely tied setons to allow for adequate drainage (to resolve infection) -> wait 6 – 8 weeks prior to fistulotomy!
pilonidial disease
-truck drivers disease- obese pts with prolonged sitting
-Believed to start with infection of the hair follicle in the sacrococcygeal area.
-painful fluctuant mass
-if fluctuant (boggy, pus) -> ready to be drained with I&D
-if just indurated and firm = not ready
-Hirsute, moderately obese men 15 – 25 yo.
-Presentation: painful fluctuant mass (early).
-Chronic with sinus presentation 5 cm above the anus.
-Differential: furuncles of the skin, anal fistula, syphilitic or tuberculous granulomas, and osteomyelitis
pilonidal disease tx
-drainage with a longitudinal incision made lateral to the midline in the coccygeal area
-Deepened into the abscess cavity
-Remove all hair and pack gauze.
-Daily wet to dry (pull out when its dry) -> No abx
-closed by secondary
-Chronic pilonidal sinus – open cavity lateral to midline -> Lay open the sinus tract and curette
-surgical debridement and local wound care- packing, cleaning, changing
-Pack with wet to dry
-let it heal by tertiary intention
-chronic pilonidal sinus can lead to SCC
-Wound typically heals in 4 weeks. (primary closure associated with non-healing and recurrence)
hemorrhoids
-Varices of hemorrhoidal plexus.
-A-V communication in anal mucosa .
-Vascular cushions – thick submucosa with blood vessels, smooth muscle, elastic and connective tissue = downward displacement of cushions.
-5% of people symptomatic with hemorrhoids.
-Low fiber diets leads to constipation = hemorrhoids.
-Sx: Painless red rectal bleeding associated with bowel movement
-MCC OF LOWER GI BLEED
-Dx: Anoscopy - determine internal or external
-colonoscopy
hemorrhoid classification
-External skin tags.
-External hemorrhoids (below the dentate line).
-Internal hemorrhoids.
Degree of prolapse:
-first – bulging; painless bleeding, no prolapse
-second – protrude with BM; reduce spontaneously.
-third – spontaneous protrusion with manual reduction.
-fourth – irreducible to manual reduction, painful, thrombosis -> surgery
internal hemorrhoids
-Bleeding.
-Prolapse.
-Pain – usually associated with other anal disease (fissure, abscess, etc)
rx- internal hemorrhoids
-Bulking agents for first and second degree hemorrhoids.
-Sclerotherapy (1 – 2 mL of the agent in the submucosal space proximal to the hemorrhoid).
-Infrared Photocoagulation .
-Banding à 2 – 3 ligations at 4 to 6 week intervals 2.8% bleeding rate, 0.09% bacteremia.
-Recurrence 20% à 5% require surgery.
-tx- Hemorrhoidectomy -> gold standard
-Stapled Circular Hemorrhoidectomy -> for prolapsed hemorrhoids
-first and second degree tx= bulking agents
anal condylomata acuminata
-HPV 6 and 11
-Warts involve perianal skin, anal verge and anoderm
-high recurrence rate
-1-to-3-month incubation period
-malignant transformation to squamous carcinoma (16 and 18)!
-increased risk if immunocompromised
-nigro procedure will be useful
-small -> podophyllin solution
-extensive -> excision and fulguration with electrocautery
-Rx:
-Small -> podophyllin solution.
-Extensive -> excision and fulguration with electrocautery.
-Recurrence rate > than 65%.
-Malignant transformation to squamous CA rare (higher in immunocompromised pts) but associated with serotypes 16 and 18.
