37 - Anorectal

Question 1

Arterial supply to the anus

Answer 1

inferior rectal artery

Question 2

Venous drainage of the anus above and below the dentate line

Answer 2

Above the dentate line - Internal hemorrhoid plexus

Below the dentate line - External hemorrhoid plexus

Question 3

Hemorrhoid distal to dentate line, causes pain when thrombosed

Answer 3

External

Question 4

External hemorrhoids covered by what cell type

Answer 4

Squamous epithelium (sensate)

Question 5

Hemorrhoid that slides below dentate line with strain

Answer 5

Primary/Grade 1 internal hemorrhoid

Question 6

Hemorrhoid that prolapses and reduces spontaeously

Answer 6

Secondary/Grade 2 internal hemorrhoid

Question 7

Hemorrhoid that prolapses and has to manually be reduced

Answer 7

Tertiary/Grade 3 internal hemorrhoid

Question 8

Hemorrhoid that prolapses and not able to be reduced

Answer 8

Quaternary/Grade 4 internal hemorrhoid

Question 9

Tx for thrombosed external hemorrhoid

Answer 9

<72 hrs - excision

>72 hrs - lance

Question 10

Can tx _ hemorrhoids with banding

Answer 10

Grade 1/2 INTERNAL hemorrhoids

Question 11

On internal hemorrhoid resection, need to resect down to _

Answer 11

Internal anal sphincter

Question 12

Surgical tx of rectal prolapse if pt is elderly/frail

Answer 12

Perianal rectosigmoid resection (Altermeier) transanally

Question 13

Surgical tx of rectal prolapse if pt is good condition

Answer 13

LAR with pexy

Question 14

Cauliflower mass, associated with HPV

Answer 14

Condylomata Acuminata

Question 15

Chronic anal fissures are also associated with a finding of _

Answer 15

sentinel pile (anal skin tag)

Question 16

90% anal fissures location

Answer 16

Posterior midline

Question 17

Percent of anal fissure heal with medical tx

Answer 17

90%

Question 18

Surgical tx for anal fissure

Answer 18

Lateral subcutaneous internal sphincterotomy

Question 19

Lateral or recurrent anal fissures concerning for _

Answer 19

Inflammatory bowel disease (Crohn’s/UC)

Question 20

Types of anorectal abscess that can be drained through skin (3)

Answer 20

Perianal
Intersphincteric
Ischiorectal

Question 21

Types of anorectal abscess below the levator ani (3)

Answer 21

Perianal
Intersphincteric
Ischiorectal

Question 22

Types of anorectal abscess that can form horseshoe abscess

Answer 22

Ischiorectal

Intersphincteric

Question 23

Types of anorectal abscess requiring transrectal drainage

Answer 23

Supralevator

Question 24

Goodsall’s rule

Answer 24

Anterior fistulas connect in straight line

Posterior fistulas track towards a midline internal opening of anus

Question 25

When can you perform fistulotomy

Answer 25

Fistula in lower 1/3 of external anal sphincter

Question 26

MCC of simple rectovaginal fistula

Answer 26

Obstetrical trauma

Question 27

Simple rectovaginal fistula location

Answer 27

low to mid-vagina

Question 28

Complex rectovaginal fistula location

Answer 28

high in vagina

Question 29

MCC of complex rectovaginal fistula

Answer 29

Diverticulitis

Question 30

Tx of simple rectovaginal fistula

Answer 30

Rectal mucosa advancement flap

Question 31

Tx of complex rectovaginal fistula

Answer 31

Abd or perineal/abd approach with resection and anastomosis

Question 32

Chronic damage to levator ani muscle and pudendal nerves; anus falls below levators

Answer 32

Abdominoperineal descent anal incontinence

Question 33

Tx of obstetrical trauma anal incontinence

Answer 33

Anterior anal sphincteroplasty

Question 34

Most common cancer in AIDS pts, nodule with ulceration

Answer 34

Kaposi's sarcoma

Question 35

Shallow ulcers, similar presentation as appendicitis in immunocompromised pts

Answer 35

CMV (cytolomegalovirus)

Question 36

#1 rectal ulcer in immunocompromised pts

Answer 36

HSV (herpes simplex virus)

Question 37

In immunocompromised pts, cancer that can look like an abscess or ulcer

Answer 37

B-cell lymphoma

Question 38

Common associations with anal cancer (3)

Answer 38

HPV HIV XRT (radiation)

Question 39

Anal canal cancer lesions are located _

Answer 39

Above dentate line

Question 40

Anal margin cancer lesions are located _

Answer 40

Below dentate line

Question 41

Tx for anal canal squamous cell CA

Answer 41

Nigro protocol (5-FU, mitomycin C, chemo-rads)

Question 42

What is the nigro protocol

Answer 42

5-FU Mitocycin C Chemo-rads

Question 43

When can you tx anal canal adenocarcinoma with WLE

Answer 43

WLE with 2-3mm margin if <4cm, <50% circumference, limited to submucosa, well differentiate and no neurovasc invasion

Question 44

Tx for anal canal adenocarcinoma

Answer 44

Surgery (APR vs WLE) + chemo-rads

Question 45

3 most common sites for melanoma

Answer 45

1-skin 2-eyes 3-anal canal

Question 46

Most common sx for anal melanoma

Answer 46

Rectal bleeding

Question 47

Tx for anal melanoma

Answer 47

APR

Question 48

Mets of squamous cell CA of anal margin go to _

Answer 48

inguinal nodes

Question 49

Tx of anal margin squamous cell CA <5cm

Answer 49

WLE with 0.5cm margin

Question 50

Tx of anal margin squamous cell CA >5cm, involve sphincter or node involvement

Answer 50

Chemo-rads (5-FU and cisplatin)

Question 51

Cancer with central ulcer, raised edges, below dentate line

Answer 51

Basal cell CA of the anal margin

Question 52

Tx of basal cell CA of anal margin

Answer 52

WLE with 3mm margin | APR if sphincter involved

Question 53

Nodal metastases of superior and middle rectum

Answer 53

IMA nodes (inf mesenteric artery)

Question 54

Nodal metastases of lower rectum

Answer 54

IMA and internal iliac nodes

Question 55

Nodal metastases of anal canal

Answer 55

internal iliac nodes

Question 56

Nodal metastases of anal margin

Answer 56

inguinal nodes