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Flashcards in Anus Deck (78):
1

What is the most common carcinoma of the anus?

Squamous cell carcinoma (80%)

2

What cell types are found in carcinomas of the anus?

1. Squamous cell carcinoma
2. Cloacogenic (transitional cell)
3. Adenocarcinoma, melanoma, mucoepidermal

3

What is the incidence of anal carcinoma?

Rare

4

What is anal Bowen's disease?

Squamous cell carcinoma in situ

5

How is anal Bowen's disease treated?

Local wide excision

6

What is Paget's disease of the anus?

Adenocarcinoma in situ of the anus

7

How is Paget's disease of the anus treated?

Local wide excision

8

What are the risk factors for anal cancer?

HPV, condyloma, HSV, HIV, chronic inflammation, immunosuppression, homosexuality in males, cervical or vaginal cancer, STDs, smoking

9

What is the most common symptom of anal carcinoma?

Anal bleeding

10

What are the other signs and symptoms of anal carcinoma?

Pain, mass, mucus per rectum, pruritus

11

What percentage of patients with anal cancer is asymptomatic?

25%

12

To what locations do anal canal cancers metastasize?

Lymph nodes, liver, bone, lung

13

What is the lymphatic drainage below the dentate line?

Below to inguinal lymph nodes (above to pelvic chains)

14

Are most patients with anal cancer diagnosed early or late?

Late

15

What is the workup of a patient with suspected anal carcinoma?

H&P; DRE; proctoscopic exam; colonoscopy; biopsy; abdominal and pelvic CT; transanal U/S; CXR; LFTs

16

What is anal margin cancer?

Anal verge out 5 cm onto the perianal skin

17

What is anal canal cancer?

Proximal to anal verge up to the border of the internal sphincter

18

How is an anal canal epidermal carcinoma treated?

NIGRO protocol:
1. Chemotherapy (5-FU, mitomycin C)
2. Radiation
3. Post-radiation therapy scar biopsy (6-8 weeks post-XRT)

19

What percentage of patients with anal canal epidermal carcinoma have a complete response with the NIGRO protocol?

90%

20

What is the 5-year survival for anal canal epidermal carcinoma with the NIGRO protocol?

85%

21

What is the treatment for local recurrence of anal cancer after the NIGRO protocol?

May repeat chemotherapy/XRT or salvage APR

22

How is a small (< 5 cm) anal margin cancer treated?

Surgical excision with 1-cm margins

23

How is a large (> 5 cm) anal margin cancer treated?

Chemoradiation

24

What is the treatment of anal melanoma?

Wide excision or APR (especially if tumor is large) +/- XRT, chemotherapy

25

What is the 5-year survival rate with anal melanoma?

< 10%

26

How many patients with anal melanoma have an amelanotic anal tumor?

Approximately 33%, thus making diagnosis difficult without pathology

27

What is fistula in ano?

Anal fistula, from rectum to perianal skin

28

What are the causes of fistula in ano?

Usually anal crypt/gland infection (usually perianal abscess)

29

What are the signs and symptoms of fistula in ano?

Perianal drainage, perirectal abscess, recurrent perirectal abscess, "diaper rash", itching

30

What disease should be considered with fistula in ano?

Crohn's disease

31

How is the diagnosis of fistula in ano made?

Exam, proctoscope

32

What is Goodsall's rule?

Fistulas originating anterior to a transverse line through the anus will course straight ahead and exit anteriorly, whereas those exiting posteriorly have a curved tract

33

What is the management of anorectal fistulas?

1. Define the anatomy
2. Marsupialization of fistula tract
3. Wound care: routine Sitz baths and dressing changes
4. Seton placement if fistula is through the sphincter muscle

34

What is a seton?

Thick suture placed through fistula tract to allow slow transection of sphincter muscle.
Scar tissue formed will hold the sphincter muscle in place and allow for continence after transection

35

What percentage of patients with a perirectal abscess develop a fistula in ano after drainage?

50%

36

How do you find the internal rectal opening of an anorectal fistula in the OR?

Inject H2O2 (or methylene blue) in external opening, then look for bubbles (or blue dye) coming out of internal opening

37

What is a sitz bath?

Sitting in a warm bath (usually done after bowel movement and TID)

38

What is a perirectal abscess?

Abscess formation around the anus/rectum

39

What are the signs and symptoms of perirectal abscess?

Rectal pain, drainage of pus, fever, perianal mass

40

How is the diagnosis of perirectal abscess made?

PE, DRE: perianal/rectal submucosal mass/fluctuance

41

What is the cause of a perirectal abscess?

Crypt abscess in dentate line with spread

42

What is the treatment for a perirectal abscess?

Drainage, sitz bath, anal hygiene, stool softeners

43

What is the indication for postoperative IV antibiotics for drainage of a perirectal abscess?

Cellulitis, immunosuppression, diabetes, heart valve abnormality

44

What percentage of patients develops a fistula in ano during the 6 months after perirectal abscess surgery?

50%

45

What is an anal fissure?

Tear or fissure in the anal epithelium

46

What is the most common site of an anal fissure?

Posterior midline (comparatively low blood flow)

47

What is the cause of an anal fissure?

Hard stool passage, constipation, hyperactive sphincter, disease process (e.g. Crohn's disease)

48

What are the signs and symptoms of an anal fissure?

Pain the anus, painful (can be excruciating) bowel movement, rectal bleeding, blood on toilet tissue after bowel movement, sentinel rage, tear in the anal skin, extremely painful rectal exam, sentinel pile, hypertrophic papilla

49

What is a sentinel pile?

Thickened mucosa/skin at the distal end of an anal fissure that is often confused with a small hemorrhoid

50

What is the anal fissure triad for a chronic fissure?

1. Fissure
2. Sentinel pile
3. Hypertrophied anal papilla

51

What is the conservative treatment for an anal fissure?

Sitz baths, stool softeners, high fiber diet, excellent anal hygiene, topical nifedipine, Botox

52

What disease processes must be considered with a chronic anal fissure?

Crohn's disease, anal cancer, STDs, UC, AIDS

53

What are the indications for surgery for an anal fissure?

Chronic fissure refractory to conservative treatment

54

What is one surgical option for an anal fissure?

Lateral internal sphincterotomy:
Cut the internal sphincter to release it from spasm

55

What is the "rule of 90%" for anal fissures?

90% occur posteriorly
90% heal with medical treatment alone
90% of patients who undergo an LIS heal successfully

56

What are perianal warts?

Warts around the anus/perineum

57

What is the cause of perianal warts?

Condyloma acuminatum (HPV)

58

What is the major risk with perianal warts?

Squamous cell carcinoma

59

What is the treatment if perianal warts are small?

Topical podophyllin, imiquimod

60

What is the treatment if perianal warts are large?

Surgical resection or laser ablation

61

What are hemorrhoids?

Engorgement of the venous plexuses of the rectum, anus, or both, with protrusion of the mucosa, anal margin, or both

62

Why do we have "healthy" hemorrhoidal tissue?

Thought to be involved with fluid/air continence

63

What are the signs and symptoms of hemorrhoids?

Anal mass/prolapse, bleeding, itching, pain

64

Which type of hemorrhoids, internal or external, is painful?

External below the dentate line

65

If a patient has excruciating anal pain and history of hemorrhoids, what is the likely diagnosis?

Thrombosed external hemorrhoid (treat by excision)

66

What are the causes of hemorrhoids?

Constipation, portal hypertension, pregnancy

67

What is an internal hemorrhoid?

Hemorrhoid above the dentate line

68

What is an external hemorrhoid?

Hemorrhoid below the dentate line

69

What are the 3 hemorrhoid quadrants?

1. Left lateral
2. Right posterior
3. Right anterior

70

What is a 1st degree internal hemorrhoid?

Hemorrhoid that does not prolapse

71

What is a 2nd degree internal hemorrhoid?

Prolapses with defecation, but returns on its own

72

What is a 3rd degree internal hemorrhoid?

Prolapses with defecation or any type of Valsalva maneuver and requires active manual reduction

73

What is a 4th degree internal hemorrhoid?

Prolapsed hemorrhoid that cannot be reduced

74

What is the treatment for hemorrhoids?

High-fiber diet, anal hygiene, topic steroids, sits baths, rubber band ligation, surgical resection for large refractory hemorrhoids, infrared coagulation, harmonic scalpel

75

What is a closed vs. open hemorrhoidectomy?

Closed (Ferguson): closes the mucosa with sutures after hemorrhoid tissue removal.
Open (Milligan-Morgan): leaves mucosa open.

76

What are the dreaded complications of hemorrhoidectomy?

Exsanguination, pelvic infection, incontinence, anal stricture

77

What condition is a contraindication for hemorrhoidectomy?

Crohn's disease

78

What must be ruled out with lower GI bleeding believed to be caused by hemorrhoids?

Colon cancer