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ABSITE > 37 Anal and Rectal > Flashcards

37 Anal and Rectal Flashcards

1
Q

arterial supply

A

inferior rectal artery

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2
Q

venous drainage

A

above dentate line is internal hemorrhoid plexus … below dentate is external hemorrhoid plexus

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3
Q

hemorrhoids: list plexi

A

left lateral, right anterior, right posterior hemorrhoidal plexi

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4
Q

hemorrhoids: external vs internal

A

external painful vs internal cause bleeding and prolapse

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5
Q

hemorrhoids: external - describe

A

cause pain when they thrombose, distal to the dentate line, covered by sensate squamous epithelium, can cause pain, swelling, itching

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6
Q

hemorrhoids: internal - describe, types

A

cause bleeding or prolapse … primary = slides below dentate with strain … secondary = prolapse that reduces spontaneously … tertiary = prolapse that has to be manually reduced …. quaternary = not able to reduce

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7
Q

hemorrhoids: tx

A

fiber, stool softeners (prevent straining), sitz baths

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8
Q

hemorrhoids: mgmt of thrombosed external hemorrhoids

A

lance open (if >72 hours) or elliptical excision (if <72 hours) to relieve pain

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9
Q

hemorrhoids: surgical indications

A

recurrence, thrombosis multiple times, large external component

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10
Q

hemorrhoids: surgery of external vs internal

A

external = can be resected with elliptical excision (can NOT band, would be painful) … primary or secondary internal = band …. tertiary or quaternary internal = 3 quadrant resection, need to resect down to the internal anal sphincter (do NOT go through it), postop w sitz baths, stool softener, high-fiber diet

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11
Q

rectal prolapse: location

A

6-7cm from anal verge

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12
Q

rectal prolapse: cause

A

pudendal neuropahy and laxity of anal sphincters

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13
Q

rectal prolapse: inc risk

A

F gender, straining, chronic diarrhea, previous pregnancy, reducdant sigmoid colons

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14
Q

rectal prolapse: layers

A

prolapse involves all layers of the recum

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15
Q

rectal prolapse: medical tx

A

high-fiber diet

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16
Q

rectal prolapse: surgical tx

A

perineal rectosigmoid resection (Altemeier) transanally if pt is older and frail … low anterior resection and pexy of residual colon if good condition patient

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17
Q

condylomata acuminata: px, cause, tx

A

cauliflower mass, papillomavirus (HPV), tx w laser surgery

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18
Q

anal fissure: caused by what?

A

split in anoderm

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19
Q

anal fissure: location

A

90% in posterior midline

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20
Q

anal fissure: causes what

A

pain and bleeding after defecation, chronic ones will see a sentinel pile (skin tag)

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21
Q

anal fissure: medical tx

A

sitz bath, bulk, lidocaine jelly, stool softener … 90% heal

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22
Q

anal fissure: surgical tx

A

lateral subcutaneous internal sphincterotomy

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23
Q

anal fissure: MC complication of surgery

A

fecal incontinence

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24
Q

anal fissure: contraindications to surgery

A

do NOT perform if 2/2 crohn’s or UC

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25
Q

anal fissure: lateral or recurrent

A

worry about IBD

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26
Q

anorectal abscess: px

A

can cause severe pain

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27
Q

anorectal abscess: mgmt of different locations

A

perianal, intersphincteric, ischiorectal = drain through the skin (all are below the levator muscles) … supralevator = drain transrectally …. intersphincteric, ischiorectal = can form horseshoe abscess

28
Q

anorectal abscess: assoc w

A

abx cellulitis, DM, immunocompromised, prosthetic hardware

29
Q

pilonidal cysts: describe, MC in which gender, tx

A

sinus or abscess formation over the sacrococcygeal junction … inc in M … tx w drainage and pakcing, f/u surgical resection of cyst

30
Q

fistula-in-ano: occurs after what

A

anorectal abscess formation

31
Q

fistula-in-ano: goodsall’s rule

A

anterior fistulas connect with anus/rectum in straight line … posterior fistulas go toward a midline internal opening in the anus/rectum

32
Q

fistula-in-ano: tx

A

do NOT need to excise the tract … lower 1/3 of the external anal sphincter –> fistulotomy (open tract up, curettage out, let it heal by secondary intention) …. upper 2/3 of the external anal sphincter –> rectal advancement flap

33
Q

fistula-in-ano: complication

A

most concerning is risk of incentinence, you want to avoid damage to external anal sphincter so fistulotomy is not used for fistulas above the lower 1/3 of the external anal sphincter

34
Q

fistula-in-ano: simple

A

low to mid vagina …. tx = trans-anal rectal mucosa advancement flap …. manu obstetrical fistulas heal spontaneously

35
Q

fistula-in-ano: complex

A

high in vagina …. tx = abdominal or combined abdominal and perineal approach usual, resection and re-anastomosis of rectum, close hole in vagina, interpose omentum, temporary ileostomy

36
Q

anal incontinence: neurogenic

A

gaping hole … no good treatment

37
Q

anal incontinence: abdominoperineal descent

A

chronic damage to levator ani muscle and pudendal nerves (obesity, multiparous women) and anus falls below levators … tx = high-fiber diet, limit to 1 bowel movement a day, hard to treat

38
Q

anal incontinence: tx 2/2 obstetrical trauma

A

anterior anal sphincteroplasty

39
Q

AIDS anorectal problems: list

A

Kaposi’s sarcoma, CMV, HSV, B cell lymphoma

40
Q

AIDS anorectal problems: Kaposi’s

A

see nodule with ulceration, C cancer in pts w AIDS

41
Q

AIDS anorectal problems: CMV

A

see shallow ulcers, similar presentation as appendicitis, tx w ganciclovir

42
Q

AIDS anorectal problems: HSV

A

1 rectal ulcer

43
Q

AIDS anorectal problems: B cell lymphoma

A

can look like ulcer or abscess

44
Q

AIDS anorectal problems: workup

A

bx to r/o cancer and make dx

45
Q

AIDS anorectal problems: present as nodule w ulceration vs shallow ulcers / appendicitis vs ulcer vs ulcer or abscess

A

1 rectal ulcer = HSV

nodule w ulceration = Kaposis

shallow ulcer = CMV

ulcer or abscess = B cell lymphoma

need bx to differentiate

46
Q

anal cancer: assoc with what

A

HPV and XRT

47
Q

anal cancer: anal canal vs anal margin

A

canal = above dentate line = squamous cell CA, adenocarcinoma, melanoma … margin = below dentate line = squamous cell CA, basal cell CA …. anal margin have better prognosis with anal canal lesions

48
Q

anal cancer: anal canal lesions - squamous cell CA - types

A

above dentate line, epidermoid CA, mucoepidermoid CA, cloacogenic CA, basaloid CA

49
Q

anal cancer: anal canal lesions - squamous cell CA - sx

A

pruritis, bleeding, palpable mass

50
Q

anal cancer: anal canal lesions - squamous cell CA - tx

A

nigro protocol - chemo-XRT with 5FU and mitomycin, NOT surgery …. cures 80% …. APR for failures or recurrence cancer

51
Q

anal cancer: anal canal lesions - adenocarcinoma tx

A

APR usual, WLE if <3cm, <1/3 circumference, limited to submucosa (T1 tumors, 2-3mm margin needed), well-differentiated, no vascular/lymphatic invasion …. need about 1cm margin … postop chemo/XRT same as rectal CA

52
Q

anal cancer: anal canal lesions - melanoma - rate

A

3rd most common site for melanoma, skin and eyes are #1 and #2

53
Q

anal cancer: anal canal lesions - melanoma - spread to lymph nodes

A

1/3 has spread to mesenteric lymph nodes

54
Q

anal cancer: anal canal lesions - melanoma - hematogenous spread

A

to liver and the lung is early and accounts for most deaths

55
Q

anal cancer: anal canal lesions - melanoma - sx disease

A

often assoc w significant met disease

56
Q

anal cancer: anal canal lesions - melanoma - MC sx

A

rectal bleeding

57
Q

anal cancer: anal canal lesions - melanoma - appearance of most lesions

A

lightly pigmented or lack pigmentation

58
Q

anal cancer: anal canal lesions - melanoma - tx

A

APR usual, margin dictated by depth of lesion standard for melanoma

59
Q

anal cancer: anal margin lesions - prognosis

A

better prognosis than anal canal lesions

60
Q

anal cancer: anal margin lesions - squamous cell CA - describe

A

ulcerating, slow growing, M with better prognosis

61
Q

anal cancer: anal margin lesions - squamous cell CA - mets

A

go to inguinal nodes

62
Q

anal cancer: anal margin lesions - squamous cell CA - tx

A

WLE for lesions <5cm (need 0.5 cm margin) … chemo-XRT (5FU and cisplatin), primary tx for lesions >5cm, if involving sphincter or if positive nodes (trying to preserve the sphincter here and avoid APR) … need inguinal node dissection if clinically positive

63
Q

anal cancer: anal margin lesions - basal cell CA - describe, tx

A

central ulcer, raised edges, rare mets … tx = WLE usually sufficient, only need 3mm margina, rare need for APR unless sphincter involved

64
Q

nodal mets: superior and middle rectum

A

IMA nodes

65
Q

nodal mets: lower rectum

A

primarily IMA nodes, also to internal iliac nodes

66
Q

nodal mets: upper 2/3 of anal canal

A

internal iliac nodes

67
Q

nodal mets: lower 1/3 of anal canal

A

inguinal nodes

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