Fiser Chapter 37 ANAL AND RECTAL Flashcards Preview

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Flashcards in Fiser Chapter 37 ANAL AND RECTAL Deck (35):
1

Thrombosed external hemorrhoid tx

< 72 hours: elliptical excision to relieve pain (can also use elliptical excision to resect external hemorrhoids)

> 72 hours: lance open

2

Surgical tx of anal fissure

Lateral subcutaneous internal sphincterotomy

Complication: fecal incontinence

Do NOT perform if d/t Crohn's or UC

3

Rectal prolapse

Starts 6-7 cm from anal verge, involves all layers of rectum

Etiology: pudendal neuropathy and laxity of anal sphincters

Risk factors: Female, straining, chronic diarrhea, previous pregnancy, and redundant sigmoid

Tx: High-fiber diet, surgery (Altemeier or LAR)

4

Tx of anal canal adenocarcinoma

Usually APR, Postop chemoXRT (same as rectal cancer)

WLE if <3cm, <1/3 circumference, limited to submucosa (T1 tumors, 2-3 mm margin needed), well-differentiated, no lymphovascular invasion; needs about 1 cm margin

5

Etiologies of anal incontinence

Neurogenic (gaping hole): no good tx

Abdominoperineal descent: chronic damage to levator ani muscle and pudendal nerves (obesity, multiparity) and anus falls below levators; Tx high fiber diet, limit to 1 BM a day, hard to tx!

Obstetrical trauma: Tx anterior anal sphincteroplasty

6

Ulcerating, slow growing anal margin lesion

Anal margin squamous cell cancer

Men have better prognosis

Metastasizes to inguinal nodes

Tx: WLE for <5cm (need 0.5 cm margin)
>5 cm or involving sphincter or positive nodes, Chemo-XRT (5-FU and cisplatin), trying to preserve sphincter and avoid APR; inguinal node dissection if clinically positive

7

Anal canal lesion with pruritis, bleeding, and palpable mass

Squamous cell CA (e.g. epidermoid CA, mucoepidermoid CA, cloacogenic CA, basaloid CA)

-Tx: Nigro protocol (chemo-XRT with 5-FU and mitomycin), NOT surgery; cures 80%; APRT for tx failure or recurrence

8

Anal canal versus anal margin squamous cell cancer

Margin (below dentate line) better prognosis

9

Surgical tx of rectal prolapse

Perineal rectosigmoid resection (Altemeier) transanally if patient old and frail

LAR and pexy of residual colon if good condition patient

10

Anus blood supply

Inferior rectal artery

Internal hemorrhoid plexus (above dentate line) and external hemorrhoid plexus (below dentate line)

11

Anal margin central ulcer with raised edges

Basal cell CA

Rare mets

Tx: WLE usually sufficient (3 mm margins, rarely need APR unless sphincter involved)

12

AIDS patient presents with RLQ pain, fever, with shallow anorectal ulcers

CMV: similar presentation as appendicitis, tx Ganciclovir

13

#1 rectal ulcer etiology

HSV, can see in AIDS patients

14

Nigro protocol

Anal canal SqCC: Chemo-XRT, 5-FU, mitomycin

Anal margin SqCC: Chemo-XRT, 5-FU, cisplatin

15

Tx of anal canal melanoma characteristics and tx

Is 3rd most common site (1. skin, 2. eyes, 3, anal canal)

1/3 has mesenteric LN spread; if symptomatic, often significantly metastatic

Hematogenous spread to liver and lungy is early and accounts for most deaths

Most common symptom rectal bleeding

Most tumors lightly pigmented or not at all

Tx: Usually APR, margin dictated by depth of lesion (standard for melanoma)

16

Hemorrhoids tx

Fiber

Stool softeners

Sitz baths

17

AIDS patient with anal nodule and ulceration

Kaposi's sarcoma, most common cancer in AIDS patients

18

Internal hemorrhoid surgical tx

Primary and secondary can be banded

Tertiary and quaternary: 3-quadrant resection
-Resect down to internal anal sphincter (but NOT through)

Do NOT band external hemorrhoids (painful)

19

Difference between internal and external hemorrhoids

1. Internal hemorrhoids: cause bleeding or prolapse
-Primary: slides below dentate with strain
-Secondary: prolapses but reduces spontaneously
-Tertiary: must be manually reduced
-Quaternany: unable to reduce

2. External hemorrhoids: distal to dentate line, covered by sensate squamous epithelium, can cause pain/swelling/itching, especially when thrombosed

20

Surgical indications for hemorrhoids

Recurrence

Thrombosis multiple times

Large external component

21

Anal margin (below dentate line) lesions

Squamous cell CA

Basal cell CA

22

Pilonidal cyst

Sinus or abscess formation over sacrococcygeal junction, increased in men

Tx: Drain and pack, follow-up surgical resection of cyst

23

Anal cancer associated with what

HPV

XRT

24

Fistula-en-ano tx

-Often occurs after anorectal abscess

-Do NOT need to excise tract

Tx:
Upper 2/3 of external anal sphincter -> rectal advancement flap (incontinence most worrisome complication)

Lower 1/3 of external anal sphincter -> fustulotomy (open tract up, curettage out, let heal by secondary intention)

25

Anal fissure

Split in anoderm (90% in posterior midline) -> pain and bleeding after defecation -> if chronic will see a sentinel pile

Medical tx: sitz baths, bulk, lidocaine jelly, stool softeners (90% heal)

Surgery: lateral subcutaneous internal sphincterotomy (do NOT perform if d/t Crohn's or UC; higher suspicion if lateral or recurrent fissures)

26

Anorectal abscess

Antibiotics for cellulitis, DM, immunosuppressed, or prosthetic hardware

1. Perianal, intersphincteric, or ischiorectal: drain through skin, since are below levator muscles
-intersphincteric and ischiorectal abscesses can form horseshoe abscess

2. Supralevator abscess: must drain transrectally

27

Anal canal and margin

Canal above dentate line

Margin below dentate line

28

Why is fistulotomy NOT used for fistulas in upper 2/3 of external anal sphincter?

Risk of incontinence

29

Simple and complex rectovaginal fistulas

Simple (low to mid-vagina)
Tx: Trans-anal rectal mucosa advancement flap
Many obstetrical fistulas heal spontaneously

Complex (high in vagina):
-Tx: abdominal or combines abdominal and perineal approach usual; resection and re-anastomosis of rectum, close hole in vagina, interpose omentum, temporary ileostomy

30

AIDS patients with anorectal ulcer

Kaposi's sarcoma

CMV (similar presentation as appendicitis)

HSV (#1 rectal ulcer)

B cell lymphoma (can look like abscess or ulcer)

-Need to biopsy these ulcers to r/o cancer and differentiate problems

31

Hemorrhoidal plexuses

Left later, right anterior, right posterior

32

Anorectal nodal mets

Superior and middle rectum -> IMA nodes

Lower rectum -> Primarily IMA nodes, but also internal iliac nodes

Upper 2/3 anal canal -> internal iliac nodes

Lower 1/3 anal canal -> inguinal nodes

33

Goodsall's rule

Anterior fistulas connect with anus/rectum in a STRAIGHT line

Posterior fistulas go toward a midline internal opening in the anus/rectum

34

Anal canal (above dentate line) lesions

Squamous cell CA (e.g. epidermoid CA, mucoepidermoid CA, cloacogenic CA, basaloid CA)

Adenocarcinoma

Melanoma

35

Condylomata acuminata

Cauliflower mass

HPV papillomavirus

Tx: laser surgery