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Surgery > Reading around cases > Flashcards

Reading around cases Flashcards

1
Q

What do you need to do if pt comes in with rectal bleeding?

A

r/o colon CA: don’t just assume hemorrhoids (history, Ix)

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2
Q

What is a hemorrhoid?

A

normal vascular structures in anal canal: helps anus form seal
Common for them to become enlarged and inflamed

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3
Q

What are external hemorroids

A

Below dentate line

Somatic sensory innvervation

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4
Q

What are internal hemorroids?

A

Above dentate line (no somatic sensation)

Columns of rectal mucosa

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5
Q

What are the standard positions of hemorrhoids?

A

Right anterior, right posterior,

3, 7, 11

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6
Q

What is the clock orientation?

A

Lithotomy position

12 is anterior, 3 is pt left, 9 is pt right

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7
Q

What is the presentation of hemorrhoids?

A

Pain, bleeding, prolapse, itch [though Paun says itch is not a symptom]

External: Present as bulge or mass below dentate line
Internal: bleeding, protrusion

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8
Q

What history is important for hemorrhoids?

A
  • nature of bleeding (surface, mixed, dripping)
  • FHx colon CA
  • constipation Hx (fibre, stooling, straining)
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9
Q

What are the grades of hemorrhoids?

A

1: bleeding, no prolapse
2: prolapse, spontaneously reduce
3: prolapse, need to be reduced manually
4: prolapse, incarcerated, cannot be reduced

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10
Q

What is the Exam for hemorrhoids?

A

Differentiate: Internal vs external
(Can you feel finger above hemorrhoid cushion? – can with external, can’t usually with internal)

Consider scope (rigid, or colonoscopy)

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11
Q

How are external hemorrhoids managed?

A

External: depends on duration

  • manage pain and Sx (ice, NSAIDs, laxatives); if skin tag develops, can excise later
  • can lance, if thrombosed and w/in 24h (unusual)
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12
Q

How are internal hemorrhoids managed?

A

Internal:
Grade 1-2: non-op. Increase dietary fibre
“Constipation is the enemy” – water, fibre, avoid straining
If symptoms resolve, leave

Procedures:

  • banding
  • injection
  • photocoagulation
  • hemorrhoidectomy
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13
Q

How is banding done, and what are the complications?

A

Banding: only for internal. Band around hemorrhoid. Can be outpt – minimal discomfort (test with suction on mucosa first to ensure above lined).

Complications:

  • pain
  • urinary retention
  • perianal sepsis (rare)
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14
Q

What are the indications for hemorrhoidectomy? Pros/cons?

A

Rare.

  • persistent prolapsing hemorrhoids (perineum looks like a bunch of grapes – so many skin tags etc)
  • uncontrolled bleeding (eg young man with Hb of 60)

Overall, very painful, but very effective.

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15
Q

What is an anal fissure?

A

split or tear in anoderm (sensitive skin below dentate line)

Likely due to tear with constipation

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16
Q

What is the clinical presentation of anal fissure?

A

bleeding (BRBPR, on TP or in bowel, not mixed in stool, usually immediately after BM; like with hemorrhoids)

  • *pain**
  • defining characteristic
  • burning, at time of BM, can last for minutes to hours after
  • pt may fear BM – even stop eating to prevent BM

Chronic: most marked in 1st wk or two; chronic, pain becomes duller.

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17
Q

What is the natural history of most anal fissures?

A

w/ proper treatment, acute anal fissure will heal within a few weeks (1-2w)

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18
Q

What is the history of chronic anal fissure?

A

Doesn’t heal, pain & inflammation continues, and internal sphincter spasms

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19
Q

What will you find on exam?

A

DRE exquisitely painful (tell pt you know it will be sore but you won’t hurt them)

Inspection:

  • sphincter spasm
  • may see sentinel tag
  • may see fissure (post midline, or anywhere)

DRE:

  • may feel spasm
  • may feel specific area of tenderness

If you can do a full rectal exam on someone, with no pain, pretty good indication they don’t have an anal fissure!

20
Q

What is the DDx from fissure?

A
  • Hemorrhoids
  • Anal or low rectal CA
    NOT: anal fistula!
21
Q

What is the difference in clinical presentation between anal fissure and anal fistula?

A

Fissure: pain, bleeding
fistula: swelling, discharge

Remember that these are very different: some med students mix them up!

22
Q

What is the management of acute anal fissure?

A

Acute:

  • relieve pain
  • treat constipation (get soft BM)
  • get fissure to heal

so:

  • analgesics
  • stool softeners, laxatives
  • Sitz baths
23
Q

What is the management of acute anal fissure?

A

Key: spasm (which stops normal healing)
So: make it relax.

Chemical, neurological, and __ sphincterotomy
Chem: induces muscle to relax. Topical. App 6-8x /d
- glyceril trinitrate (0.1%), diltiazem (2%)

24
Q

What is the difference between internal and external anal sphincters?

A

Internal sphincter spasms. Involuntary. Always on, unless having BM
(External: voluntary – so eg to stop self from having BM)

25
Q

What is a chemical anal sphincterotomy?

A

Chemical: 1st line.
Induces muscle to relax. Topical. App 6-8x /d
- glyceril trinitrate (0.1%), diltiazem (2%)

a/e:
- h/a, lightheadness (better with diltiazem)

6w-3mo
Should see some response

26
Q

What is a neurological anal sphincterotomy?

A

2nd line (though could be 1st)
Botulinum toxin in intersphinctery groove
Very effective – also temporary (wears off after 2-3mo)
May be incontinent to gas or even liquid in first few days

27
Q

What is a surgical anal sphincterotomy sphincterotomy?

A

Third line:
Lateral internal sphincterotomy
cut in anoderm laterally
Forces sphincter to relax

Can –> incontinence (frank incontinence rare, but some impairment common-ish). Pros: relief is immediate.

28
Q

What should you do after treating for fissure?

A

See the pt in follow up!

Want to avoid: Treat for fissure …. never see again … and turns out they had anal CA

Also, want to remind them to avoid constipation! Bc that can –> fissure again.

29
Q

What is an anal fistula?

A

Classic story:
- swelling, redness, around anal canal; ED Dx as abscess
- red fluctuant mass, I&D, home with dressings
If abscess: heals. If not: wound gets smaller, starts to close, but doesn’t all the way

Swelling and drainage
Sometimes pain with infection

Pain, swelling, and discharge

Classic picture really is swelling and draining

30
Q

What is a fistula?

A

Abnormal communication between two epithelialized surfaces

31
Q

Where does a naturally arising anal fistula start?

A

The dentate line

32
Q

What is the most common type of anal fistula?

A

Inter-sphincteric fistula (approx 40%)

Goes between internal and external sphincters, and exits medial to external sphincter, near anus

33
Q

What is the second-most-common type of anal fistula?

A

Trans-sphincteric fistula (approx 30%)

Goes through both sets of sphincter muscles

34
Q

What is the third-most-common type of anal fistula?

A

Supra-sphincteric fistula (approx 20%)

Goes through internal sphincter, tracks along external, then exits out above puborectalis

35
Q

What is the least common type of anal fistula?

A

Extrasphincteric fistula
Not naturally occurring (10%)
May be due to radiation, or Crohn’s
This 10% may not have opening on dentate line

36
Q

What is Goodsall’s rule?

A

Fissures that begin anteriorly will have straight course and exit anteriorly (run radially). Fissures that begin posteriorly will begin in the midline and have a curved tract (arcing from midline more laterally)

(Med students get asked this a lot!)

37
Q

What is the basic anatomy of an anal fistula?

A

Internal opening, tract, external opening.

38
Q

What history should you ask when assessing anal fistula?

A 
History to ask:
- bowel habit
- bleeding 
- previous surgery in the area
- PMHX of bowel issues or IBD, Crohns; also FHx
(want to know if eg radiation)

Typical: normal bowel habit, no bleeding, no previous Hx of problems, just this swelling that’s draining fluid

39
Q

What should you look for in a pt with ?anal fistula on exam?

A
  • WL, anemia (r/o CA, bleed)
  • abdo exam
  • locate external opening (likely site with some drainage)
  • assess for active infection (fluctuant, inflammatory signs)
  • rectal exam (assess for induration – can palpate tract, potentially abscess)
40
Q

What characterizes simple vs complex anal fistulas?

A

Simple:

  • 1st time, no prev surgery
  • 1 ext opening, low in anal canal, no signs of sepsis

Complex:

  • previous operations, multiple external openings (multiple tracts), previous disease
  • if sepsis: OR ASAP, to drain
  • if not: MRI ( + St Mark’s diagram – draw out tracts)
41
Q

What is the first step in performing surgery for anal fistula?

A

Run probe through tract. Estimate how much muscle is above the fistula tract.

42
Q

How big are the anal sphincter muscles?

A

4cm in man, 3cm in women

larger at back, smaller at front

43
Q

What is a Seton suture?

A

Suture that loops through fistula and is left temporarily. Allows it to drain. (Buys some time.)

44
Q

What is the biggest risk of fistula surgery?

A

Incontinence

Consider asking pt in initial assessment about whether they are continent to gas (more sensitive)

45
Q

What is one non-operative option for management of anal fistula?

A

Indwelling seton: stays, facilitates drainage

46
Q

What is the operative management of

A 
low lying (does not involve external sphincter): primary fistulotomy
high lying (involves external sphincter): 
- staged fistulotomy, with Seton. Spares muscle.
- new: LIFT (ligation of intersphincteric fistula tract)

Surgery (11 decks)

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