| What are the causes of hemorrhoids? | Constipation/straining, portal hypertension, pregnancy |
| What are the causes of hemorrhoids? | Constipation/straining, portal hypertension, pregnancy |
| What are the causes of hemorrhoids? | Constipation/straining, portal hypertension, pregnancy |
| What are the causes of hemorrhoids? | Constipation/straining, portal hypertension, pregnancy |
| What are the causes of hemorrhoids? | Constipation/straining, portal hypertension, pregnancy |
| What is the most common carcinoma of the anus? | Squamous cell carcinoma (80%)
(Think: ASS = Anal Squamous Superior) |
| What cell types are found in carcinomas of the anus? | . Squamous cell carcinoma (80%)
2. Cloacogenic (transitional cell)
3. Adenocarcinoma/melanoma/mucoepidermal |
| What is the incidence of anal carcinoma? | Rare (1% of colon cancers incidence) |
| What is anal Bowen’s disease? | Squamous cell carcinoma in situ
(Think: B.S. = Bowen Squamous) |
| How is Bowen’s disease treated? | With local wide excision |
| What is Paget’s disease of the anus? | Adenocarcinoma in situ of the anus
(Think: P.A. = Paget’s Adenocarcinoma) |
| How is Paget’s disease treated? | With local wide excision |
| What are the risk factors for anal cancer? | Human papilloma virus, condyloma, herpes, HIV, chronic inflammation
(fistulae/Crohn’s disease) immunosuppression, homosexuality in males,
cervical/vaginal cancer, STDs, smoking |
| What is the most common symptom of anal carcinoma? | Anal bleeding |
| What are the other signs/symptoms of anal carcinoma? | Pain, mass, mucus per rectum, pruritus |
| What percentage of patients with anal cancer is asymptomatic? | ≈25% |
| To what locations do anal canal cancers metastasize? | Lymph nodes, liver, bone, lung |
| What is the lymphatic drainage below the dentate line? | Below to inguinal lymph nodes (above to pelvic chains) |
| Are most patients with anal cancer diagnosed early or late? | Late (diagnosis is often missed) |
| What is the workup of a patient with suspected anal carcinoma? | History
Physical exam: digital rectal exam, proctoscopic exam, and colonoscopy
Biopsy of mass
Abdominal/pelvic CT scan, transanal U/S
CXR
LFTs |
| Define:
Margin cancer | Anal verge out 5 cm onto the perianal skin |
| Define Canal cancer? | Proximal to anal verge up to the border of the internal sphincter |
| How is an anal canal epidermal carcinoma treated? | NIGRO protocol:
1. Chemotherapy (5-FU and mitomycin C)
2. Radiation
3. Postradiation therapy scar biopsy (6 to 8 weeks post radiation therapy
[XRT]) |
| What percentage of patients have a “complete” response with the
NIGRO protocol? | 90% |
| What is the 5-year survival with the NIGRO protocol? | 85% |
| What is the treatment for local recurrence of anal cancer after the
NIGRO protocol? | May repeat chemotherapy/XRT or salvage Abdominoperineal resection (APR) |
| How is a small (<5 cm) anal margin cancer treated? | Surgical excision with 1-cm margin |
| How is a large (>5 cm) anal margin cancer treated? | Chemoradiation |
| What is the treatment of anal melanoma? | Wide excision or APR (especially if tumor is large) ± XRT, chemotherapy,
postoperatively |
| What is the 5-year survival rate with anal melanoma? | <10% |
| How many patients with anal melanoma have an amelanotic anal
tumor? | Approximately one third, thus making diagnosis difficult without pathology |
| What is the prognosis of anal melanoma? | <5% 5-year survival rate |
| What is ano fistula? | Anal fistula, from rectum to perianal skin |
| What are causes of anofistula? | Usually anal crypt/gland infection (usually perianal abscess) |
| What are S&S of anofistula? | Perianal drainage, perirectal abscess, recurrent perirectal abscess, “diaper rash,”
itching |
| What disease should be considered with fistula in ano? | Crohn's |
| How is dx of anofistula? | Exam proctoscope |
| 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 |
| How can Goodsall’s rule be remembered? | Think of a dog with a straight nose (anterior) andcurved tail (posterior) |
| What is the management of anorectal fistulas? | 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 |
| 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 |
| What percentage of patients with a perirectal abscess develop a
fistula in ano after drainage? | 50% |
| How do you find the internal rectal opening of an anorectal fistula in
the O.R.? | Inject H2O2
(or methylene blue) in external opening—then look for bubbles (or
blue dye) coming out of internal opening! |
| What is a sitz bath? | Sitting in a warm bath (usually done after bowel movement and TID) |
| What is perirectal abscess? | Abscess formation around the anus/rectum |
| What are the signs/symptoms of perirectal abscess? | Rectal pain, drainage of pus, fever, perianal mass |
| How is dx of perirectal abscess? | Physical/digital exam reveals perianal/rectal submucosal mass/fluctuance |
| What is cause of perirectal abscess? | Crypt abscess in dentate line with spread |
| What is tx of perirectal abscess? | As with all abscesses (except simple liver amebic abscess) drainage, sitz bath,
anal hygiene, stool softeners |
| What is the indication for postoperative IV antibiotics for drainage? | Cellulitis, immunosuppression, diabetes, heart valve abnormality |
| What is anal fissure? | Tear or fissure in the anal epithelium most common in Posterior midline (comparatively low blood flow) |
| What is the cause? of anal fissure? | Hard stool passage (constipation), hyperactive sphincter, disease process (e.g.,
Crohn’s disease) |
| What are the signs/symptoms of anal fissure? | 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 |
| What is a sentinel pile? | Thickened mucosa/skin at the distal end of an anal fissure that is often confused
with a small hemorrhoid |
| What is the anal fissure triad for a chronic fissure? | 1. Fissure
2. Sentinel pile
3. Hypertrophied anal papilla |
| What disease processes must be considered with a chronic anal
fissure? | Crohn’s disease, anal cancer, sexually transmitted disease, ulcerative colitis,
AIDS |
| What are the indications for surgery? | Chronic fissure refractory to conservative treatment |
| What is one surgical option? | Lateral internal sphincterotomy (LIS)—cut the internal sphincter to release it
from spasm |
| 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 |
| What are perianal warts? | Warts around the anus/perineum
cause: Condyloma acuminatum (human papillomavirus)
Risk: Squamous cell carcinoma
tx small (Topical podophyllin, imiquimod (Aldara®)
Big (Surgical resection or laser ablation) |
| What are hemorrhoids? | Engorgement of the venous plexuses of the rectum, anus, or both; with
protrusion of the mucosa, anal margin, or both
Healthy hemorhoid due toIt is thought to be involved with fluid/air continence |
| What are S&S of hemorrhoids? | Anal mass/prolapse, bleeding, itching, pain, painful one is External, below the dentate line |
| f a patient has excruciating anal pain and history of hemorrhoids,
what is the likely diagnosis? | Thrombosed external hemorrhoid (treat by excision) |
| What are the causes of hemorrhoids? | Constipation/straining, portal hypertension, pregnancy |
