Anus, C49 P325-334 Flashcards by Tiggee R

ANATOMY
Identify the following:
P325 (picture)

Anal columns
Dentate line
Rectum
External sphincter
Internal sphincter
Levator ani muscle

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ANAL CANCER
What is the most common
carcinoma of the anus?
P326

Squamous cell carcinoma (80%)

Think: ASS = Anal Squamous Superior

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ANAL CANCER
What cell types are found in
carcinomas of the anus?
P326

Squamous cell carcinoma (80%)
Cloacogenic (transitional cell)
Adenocarcinoma/melanoma/
mucoepidermal

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ANAL CANCER
What is the incidence of
anal carcinoma?
P326

Rare (1% of colon cancers incidence)

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ANAL CANCER
What is anal Bowen’s disease?
P326

Squamous cell carcinoma in situ

Think: B.S. = Bowen Squamous

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ANAL CANCER
How is Bowen’s disease
treated?
P326

With local wide excision

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ANAL CANCER
What is Paget’s disease of
the anus?
P326

Adenocarcinoma in situ of the anus

Think: P.A. = Paget’s Adenocarcinoma

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ANAL CANCER
How is Paget’s disease
treated?
P326

With local wide excision

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ANAL CANCER
What are the risk factors for
anal cancer?
P326

Human papilloma virus, condyloma,
herpes, HIV, chronic inflammation
(fistulae/Crohn’s disease) immunosuppression,
homosexuality in males, cervical/
vaginal cancer, STDs, smoking

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ANAL CANCER
What is the most common
symptom of anal carcinoma?
P326

Anal bleeding

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ANAL CANCER
What are the other
signs/symptoms of anal
carcinoma?
P326

Pain, mass, mucus per rectum, pruritus

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ANAL CANCER
What percentage of patients
with anal cancer is
asymptomatic?
P326

≈25%

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ANAL CANCER
To what locations do anal
canal cancers metastasize?
P326

Lymph nodes, liver, bone, lung

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ANAL CANCER
What is the lymphatic
drainage below the dentate
line?
P327

Below to inguinal lymph nodes (above to

pelvic chains)

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ANAL CANCER
Are most patients with anal
cancer diagnosed early or
late?
P327

Late (diagnosis is often missed)

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ANAL CANCER
What is the workup of a
patient with suspected anal
carcinoma?
P327

History
Physical exam: digital rectal exam,
    proctoscopic exam, and colonoscopy
Biopsy of mass
Abdominal/pelvic CT scan, transanal U/S
CXR
LFTs

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ANAL CANCER
Define:
Margin cancer
P327

Anal verge out 5 cm onto the perianal skin

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ANAL CANCER
Define:
Canal cancer
P327

Proximal to anal verge up to the border

of the internal sphincter

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ANAL CANCER
How is an anal canal
epidermal carcinoma
treated?
P327

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

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ANAL CANCER
What percentage of patients
have a “complete” response
with the NIGRO protocol?
P327

90%

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ANAL CANCER
What is the 5-year survival
with the NIGRO protocol?
P327

85%

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ANAL CANCER
What is the treatment for
local recurrence of anal
cancer after the NIGRO
protocol?
P327

May repeat chemotherapy/XRT or

salvage APR

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ANAL CANCER
How is a small (<5 cm) anal
margin cancer treated?
P327

Surgical excision with 1-cm margins

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ANAL CANCER
How is a large (>5 cm) anal
margin cancer treated?
P327

Chemoradiation

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ANAL CANCER What is the treatment of anal melanoma? P328

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

ANAL CANCER What is the 5-year survival rate with anal melanoma? P328

<10%

``` ANAL CANCER How many patients with anal melanoma have an amelanotic anal tumor? P328 ```

Approximately one third, thus making | diagnosis difficult without pathology

ANAL CANCER What is the prognosis of anal melanoma? P328

<5% 5-year survival rate

FISTULA IN ANO What is it? P328

Anal fistula, from rectum to perianal skin

FISTULA IN ANO What are the causes? P328

Usually anal crypt/gland infection (usually | perianal abscess)

FISTULA IN ANO What are the signs/symptoms? P328

Perianal drainage, perirectal abscess, recurrent perirectal abscess, “diaper rash,” itching

``` FISTULA IN ANO What disease should be considered with fistula in ano? P328 ```

Crohn’s disease

FISTULA IN ANO How is the diagnosis made? P328

Exam, proctoscope

FISTULA IN ANO What is Goodsall’s rule? P328 (picture)

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

FISTULA IN ANO How can Goodsall’s rule be remembered? P329 (picture)

Think of a dog with a straight nose | anterior) and curved tail (posterior

FISTULA IN ANO What is the management of anorectal fistulas? P329

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

FISTULA IN ANO What is a seton? P329 (picture)

``` 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 ```

``` FISTULA IN ANO What percentage of patients with a perirectal abscess develop a fistula in ano after drainage? P330 ```

≈50%

``` FISTULA IN ANO How do you find the internal rectal opening of an anorectal fistula in the O.R.? P330 ```

``` Inject H(2)O(2) (or methylene blue) in external opening—then look for bubbles (or blue dye) coming out of internal opening! ```

FISTULA IN ANO What is a sitz bath? P330

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

PERIRECTAL ABSCESS What is it? P330

Abscess formation around the anus/rectum

PERIRECTAL ABSCESS What are the signs/symptoms? P330

Rectal pain, drainage of pus, fever, | perianal mass

PERIRECTAL ABSCESS How is the diagnosis made? P330

Physical/digital exam reveals perianal/ | rectal submucosal mass/fluctuance

PERIRECTAL ABSCESS What is the cause? P330

Crypt abscess in dentate line with spread

PERIRECTAL ABSCESS What is the treatment? P330

As with all abscesses (except simple liver amebic abscess) drainage, sitz bath, anal hygiene, stool softeners

``` PERIRECTAL ABSCESS What is the indication for postoperative IV antibiotics for drainage? P330 ```

Cellulitis, immunosuppression, diabetes, | heart valve abnormality

``` PERIRECTAL ABSCESS What percentage of patients develops a fistula in ano during the 6 months after surgery? P330 ```

≈50%

ANAL FISSURE What is it? P330

Tear or fissure in the anal epithelium

ANAL FISSURE What is the most common site? P330

``` Posterior midline (comparatively low blood flow) ```

ANAL FISSURE What is the cause? P330

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

ANAL FISSURE What are the signs/symptoms? P331

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

ANAL FISSURE What is a sentinel pile? P331

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

ANAL FISSURE What is the anal fissure triad for a chronic fissure? P331 (picture)

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

ANAL FISSURE What is the conservative treatment? P331

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

``` ANAL FISSURE What disease processes must be considered with a chronic anal fissure? P331 ```

Crohn’s disease, anal cancer, sexually transmitted disease, ulcerative colitis, AIDS

ANAL FISSURE What are the indications for surgery? P331

Chronic fissure refractory to conservative | treatment

ANAL FISSURE What is one surgical option? P331

Lateral internal sphincterotomy (LIS)— cut the internal sphincter to release it from spasm

ANAL FISSURE What is the “rule of 90%” for anal fissures? P331

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

PERIANAL WARTS What are they? P332

Warts around the anus/perineum

PERIANAL WARTS What is the cause? P332

``` Condyloma acuminatum (human papilloma virus) ```

PERIANAL WARTS What is the major risk? P332

Squamous cell carcinoma

PERIANAL WARTS What is the treatment if warts are small? P332

Topical podophyllin, imiquimod (Aldara®)

PERIANAL WARTS What is the treatment if warts are large? P332

Surgical resection or laser ablation

HEMORRHOIDS What are they? P332

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

HEMORRHOIDS Why do we have “healthy” hemorrhoidal tissue? P332

It is thought to be involved with fluid/air | continence

HEMORRHOIDS What are the signs/ symptoms? P332

Anal mass/prolapse, bleeding, itching, pain

HEMORRHOIDS Which type, internal or external, is painful? P332

External, below the dentate line

``` HEMORRHOIDS If a patient has excruciating anal pain and history of hemorrhoids, what is the likely diagnosis? P332 ```

Thrombosed external hemorrhoid | treat by excision

HEMORRHOIDS What are the causes of hemorrhoids? P332

Constipation/straining, portal | hypertension, pregnancy

HEMORRHOIDS What is an internal hemorrhoid? P332

Hemorrhoid above the (proximal) | dentate line

HEMORRHOIDS What is an external hemorrhoid? P332

Hemorrhoid below the dentate line

HEMORRHOIDS What are the three “hemorrhoid quadrants”? P332

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

Classification by Degrees Define the following terms for internal hemorrhoids: First-degree hemorrhoid P333 (picture)

Hemorrhoid that does not prolapse

Classification by Degrees Define the following terms for internal hemorrhoids: Second-degree hemorrhoid P333 (picture)

Prolapses with defecation, but returns on | its own

Classification by Degrees Define the following terms for internal hemorrhoids: Third-degree hemorrhoid P333 (picture)

``` Prolapses with defecation or any type of Valsalva maneuver and requires active manual reduction (eat fiber!) ```

Classification by Degrees Define the following terms for internal hemorrhoids: Fourth-degree hemorrhoid P334

Prolapsed hemorrhoid that cannot be | reduced

Classification by Degrees What is the treatment? P334

``` High-fiber diet, anal hygiene, topical steroids, sitz baths Rubber band ligation (in most cases anesthetic is not necessary for internal hemorrhoids) Surgical resection for large refractory hemorrhoids, infrared coagulation, harmonic scalpel ```

Classification by Degrees What is a “closed” vs. an “open” hemorrhoidectomy? P334

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

``` Classification by Degrees What are the dreaded complications of hemorrhoidectomy? P334 ```

``` Exsanguination (bleeding may pool proximally in lumen of colon without any signs of external bleeding) Pelvic infection (may be extensive and potentially fatal) Incontinence (injury to sphincter complex) Anal stricture ```

``` Classification by Degrees What condition is a contraindication for hemorrhoidectomy? P334 ```

Crohn’s disease

``` Classification by Degrees Classically, what must be ruled out with lower GI bleeding believed to be caused by hemorrhoids? P334 ```

Colon cancer (colonoscopy)

Anus, C49 P325-334 Flashcards

(81 cards)