chapter 37: anal and rectal Flashcards Preview

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Flashcards in chapter 37: anal and rectal Deck (66):
1

arterial supply to the anus

inferior rectal artery

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venous drainage of the anus

above the dentate is internal hemorrhoid plexus and below the dentate is external hemorrhoid plexus

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hemorrhoidal plexuses

- left lateral
- right anterior
- right posterior

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- can pain when the thrombosis
- distal to the dentate line, covered by sensate squamous epithelium; can cause pain, swelling and itching

external hemorrhoids

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cause bleeding or prolapse

internal hemorrhoids

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internal hemorrhoids: slides below dentate with strain

primary

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internal hemorrhoids: prolapse that reduces spontaneously

secondary

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internal hemorrhoids: prolapse that has to be manually reduced

tertiary

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internal hemorrhoids: not able to reduce

quaternary

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tx: hemorrhoids

fiber and stool softeners (prevent straining); sitz baths

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tx: thromboses external hemorrhoid

lance open (if > 72 hours) or elliptical excision (if

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surgical indications for hemorrhoids:

recurrence, thrombosis multiple times, large external component

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hemorrhoids: can be resected with elliptical excision

external hemorrhoids

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type of internal hemorrhoids that can be banded

can band primary and secondary internal hemorrhoids
- do not band external hemorrhoids (painful)

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surgery required for what type of internal hemorrhoids

surgery for tertiary and quaternary internal hemorrhoids - 3 quadrant resection
- need to resect down to the internal anal sphincter (do not go through it)

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post op management of tertiary and quaternary internal hemorrhoids

sitz baths, stool softener, high-fiber diet

17

where does rectal prolapse start?

starts 6-7 cm form anal verge

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what causes rectal prolapse?

secondary to pudendal neuropathy and laxity of the anal sphincters

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risk factors for rectal prolapse

increased with female gender, straining, chronic diarrhea, previous pregnancy, and redundant sigmoid colons

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what layers of the rectum are involved in rectal prolapse?

prolapse involves all layers of the rectum

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medical treatment: rectal prolapse

high-fiber diet

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surgical tx: rectal prolapse

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

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caused by a split in the anodrem
- 90% in posterior midline
- causes pain and bleeding after defection; chronic ones will see a sentinel pile

anal fissure

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medical tx: anal fissure

sitz baths, lidocaine jelly, and stool softeners (90% heal)

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surgical tx: anal fissure

lateral subcutaneous internal sphincterotomy

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most serious complication of surgery for anal fissure

fecal incontinence

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what do you worry about with lateral or recurrent anal fissures?

worry about inflammatory bowel disease

28

can cause severe pain
- risk factors: antibiotics, cellulitis, DM, immunosuppressed or prosthetic hardware

anorectal abscess

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anorectal abscess: can be drained through the skill (all are below the elevator muscles)

perianal, intersphincteric, and ischiorectal abscesses

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anorectal abscess: can form horseshoe abscess

intersphincteric and ischiorectal abscesses

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anorectal abscess: need to be drained transrectally

supralevator abscesses

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- sinus or abscess formation over the sacrococcygeal junction; increased incidence in men
- tx?

pilonidal cysts

tx: drainage and packing; follow-up surgical resection of cyst

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do not need to excise the tract
- often occurs after anorectal abscess formation

fistula-in-ano

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what is goodsall's rule for fistula-in-ano?

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

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tx: fistula-in-ano (lower 1/3 of the external anal sphincter)

fistulotomy (open tract up, curettage out, let it heal by secondary intention)

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tx: fistula-in-ano (upper 2/3 of the external anal sphincter)

rectal advancement flap

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most worrisome complication of treatment for fistula in ano

risk of incontinence - you want to avoid damage to the external anal sphincter so fistulotomy is not used for fistulas above the 1/3 of the external anal sphincter

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tx -> rectovaginal fistulas:
- simple (low to mid-vagina)

tx: trans-anal rectal mucosa advancement flap
- many obstetrical fistulas heal spontaneously

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tx -> rectovaginal fistulas:
- complex (high in vagina)

abdominal or combined abdominal and perineal approach usual; resection and reanastomosis of rectum, close hole in vagina, interpose omentum, temporary ileostomy

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tx: neurogenic anal incontinence (gaping hole)

no good treatment

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chronic damage to levator ani muscle and pudendal nerves (obesity, multiparous women) and anus falls below levators

abdominoperineal descent

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tx: abdominoperineal descent

high-fiber diet, limit to 1 bowel movement a day; hard to treat

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tx: obstetrical trauma leading to anal incontinence

anterior anal sphincteroplasty

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what is anal cancer associated with?

xrt and hpv

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above dentate line

anal canal

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below dentate line

anal margin

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what are the different types of squamous cell carcinoma in the anal canal?

epidermoid CA
mucoepidermoid CA
cloacogenic CA
basaloid CA

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anal cancer:
- symptoms: pruritus, bleeding, and palpable mass

squamous cell CA

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tx: squamous cell CA - anal cancer

nigro protocol (chemo-XRT with 5FU and mitomycin), not surgery
- cures 80%
- APR for treatment failures or recurrent cancer

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tx: adenocarcinoma - anal cancer

APR usual; WLE if

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3rd most common site for melanoma

anal cancer (skin and eyes #1 and #2)

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how does melanoma spread?

1/3 has spread to mesenteric lymph nodes
- hematogenous spread to the liver and the lung is early and accounts for most deaths

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what is symptomatic melanoma of the anal cancer associated with?

significant metastatic disease

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anal melanoma: most common symptom

rectal bleeding

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anal melanoma: appearance

lightly pigmented or not pigmented at all

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tx: anal melanoma

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

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anal cancer below dentate line - have better prognosis than anal canal lesions

anal margin lesions (below dentate line)

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- ulcerating, slow growing; men with better prognosis
- metastases: go to inguinal nodes

squamous cell cancer - anal margin lesions

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sx: anal margin lesions (squamous cell CA)

WLE for lesions

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anal margin lesions: squamous cell CA - primary tx for lesions > 5cm, if involving sphincter or if positive nodes

chemo-XRT (5-FU and cisplatin) - try to preserve the sphincter here and avoid APR

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anal cancer: central ulcer, raised edges, rare metastases

basal cell CA

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tx: anal cancer - basal cell CA

WLE usually sufficient, only need 3-mm margins; rare need for APR unless sphincter involved

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nodal metastases: superior and middle rectum

IMA nodes

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nodal metastases: lower rectum

primarily IMA nodes, also to internal iliac nodes

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nodal metastases: upper 2/3 of anal canal

internal iliac nodes

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nodal metastases: lower 1/3 of anal canal

inguinal nodes