Surgery Marrow Pg 231-240 (GIT)
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Surgery Marrow Pg 231-240 (GIT)

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Questions and Answers

Which treatment involves cutting off the blood supply to hemorrhoids?

  • Open hemorrhoidectomy
  • Banding (correct)
  • Sclerotherapy
  • Stapled hemorrhoidopexy

    • Sclerotherapy is performed below the dentate line.

    False

    What is the primary purpose of a sitz bath in the management of hemorrhoids?

    To relax the sphincter

    Grade 4 hemorrhoids generally require __________.

    <p>surgery</p> Signup and view all the answers

    Match the following hemorrhoid management techniques with their descriptions:

    <p>Banding = Cuts off blood supply and sloughs off hemorrhoid Sclerotherapy = Application of sclerosing agents pulls hemorrhoids up Stapled hemorrhoidopexy = Surgery of choice for hemorrhoids Closed hemorrhoidectomy = Type of hemorrhoid surgery involving wound closure</p> Signup and view all the answers

    What is the length of the rectum?

    <p>12-14 cm</p> Signup and view all the answers

    The proximal part of the anal canal is covered by peritoneum.

    <p>False</p> Signup and view all the answers

    Which of the following is considered a risk factor for squamous cell carcinoma of the anal cancer?

    <p>Human papilloma virus</p> Signup and view all the answers

    What nerve supplies the external sphincter?

    <p>Pudendal nerve</p> Signup and view all the answers

    Adenocarcinoma of the anal region is the most common type of anal cancer.

    <p>False</p> Signup and view all the answers

    The area above the dentate line is associated with __________ carcinoma.

    <p>adenocarcinoma</p> Signup and view all the answers

    Match the components of the anal canal with their characteristics:

    <p>Proximal to dentate line = Adenocarcinoma Distal to dentate line = Squamous cell carcinoma Hemorrhoidal cushions = Site of hemorrhoids Anorectal ring = Levator ani</p> Signup and view all the answers

    What is the purpose of MRI in the management of anal cancer?

    <p>For local staging</p> Signup and view all the answers

    The treatment regimen for anal squamous cell carcinoma includes combined ____ and _____ prior to surgery.

    <p>chemoradiation, surgery</p> Signup and view all the answers

    Match the treatment response with its description:

    <p>Complete response = The tumor is no longer detectable Monitor 40-30% = Regular follow-up to check for recurrence Recurrence = Return of the tumor after treatment Residual tumor = Tumor still present within 5 cm after treatment</p> Signup and view all the answers

    Which finger is typically used for a digital rectal examination in adults?

    <p>Index finger</p> Signup and view all the answers

    A digital rectal examination is contraindicated if there are painful fissures present.

    <p>True</p> Signup and view all the answers

    What is the purpose of using an anoscope during a rectal examination?

    <p>To inspect the anal canal and lower rectum.</p> Signup and view all the answers

    The __________ is approximately 110-140 cm in length and visualizes from the anal canal to the cecum.

    <p>colonoscope</p> Signup and view all the answers

    Match the following instruments with their lengths:

    <p>Anoscope = ~10 cm Proctoscope = ~13 cm Sigmoidoscope = 60 cm Colonoscope = 110-140 cm</p> Signup and view all the answers

    What is the most common complication following a hemorrhoidectomy?

    <p>Urinary retention</p> Signup and view all the answers

    Anal fissures are typically found above the dentate line.

    <p>False</p> Signup and view all the answers

    What are two clinical features of anal fissures?

    <p>Pain and bleeding</p> Signup and view all the answers

    A high fiber diet is recommended for managing __________.

    <p>hemorrhoids</p> Signup and view all the answers

    Match the following treatments to their descriptions:

    <p>2% Xylocaine jelly = Topical anesthetic to relieve pain Diltiazem cream = Calcium channel blocker for relaxation of sphincter Nitrate gel = Vasodilator to reduce sphincter pressure Sitz bath = Warm water immersion to soothe anal discomfort</p> Signup and view all the answers

    Which drug is included in the FOL FIRI regimen?

    <p>Irinotecan</p> Signup and view all the answers

    Radiotherapy is indicated for colonic cancer.

    <p>False</p> Signup and view all the answers

    What is the minimum functional liver reserve required for resection in colorectal carcinoma management?

    <p>25%</p> Signup and view all the answers

    The primary function of Bevacizumab in colorectal cancer treatment is as an __________ inhibitor.

    <p>Anti VEGF</p> Signup and view all the answers

    What is the most common cause of rectal bleeding?

    <p>Hemorrhoids</p> Signup and view all the answers

    Match each drug with its corresponding function for colorectal cancer treatment:

    <p>Cetuximab = Anti EGFR Pembrolizumab = PD-L1 inhibitor Panitumumab = Anti EGFR Bevacizumab = Anti VEGF</p> Signup and view all the answers

    Bleeding from hemorrhoids is typically painful.

    <p>False</p> Signup and view all the answers

    What is the investigation of choice for diagnosing hemorrhoids?

    <p>Proctoscopy</p> Signup and view all the answers

    Grade 2 hemorrhoids are characterized by prolapse that is __________.

    <p>spontaneously reduced</p> Signup and view all the answers

    Match the grades of hemorrhoids with their features:

    <p>Grade 1 = Only bleed, don't prolapse Grade 2 = Prolapse, spontaneously reduced Grade 3 = Prolapse, manually reduced Grade 4 = Remain prolapsed</p> Signup and view all the answers

    Which of the following is NOT a clinical feature of an anorectal abscess?

    <p>Itching</p> Signup and view all the answers

    Fluctuation is an early sign of an anorectal abscess.

    <p>False</p> Signup and view all the answers

    What is the common management technique for an anorectal abscess?

    <p>Incision &amp; drainage</p> Signup and view all the answers

    The condition characterized by an external and internal opening is known as a __________.

    <p>fistula</p> Signup and view all the answers

    Match the causes of perianal sinus/fistula with their descriptions:

    <p>Crohn's disease = A chronic inflammatory bowel disease Trauma = Injury leading to anal sepsis Tuberculosis (TB) = An infectious disease caused by Mycobacterium tuberculosis Cancer = Malignant growth affecting tissue</p> Signup and view all the answers

    What is the primary purpose of Goodsall’s rule in fistula management?

    <p>To determine the location of the internal opening of a fistula</p> Signup and view all the answers

    High fistulas are appropriately managed by performing a fistulectomy.

    <p>False</p> Signup and view all the answers

    What are the two management options for low fistulas?

    <p>Fistulectomy and fistulotomy</p> Signup and view all the answers

    A transsphincteric fistula is the most __________ type of fistula.

    <p>common</p> Signup and view all the answers

    Match the types of fistula-in-ano with their descriptions:

    <p>Intersphincteric fistula = Located between the internal and external anal sphincter Transsphincteric fistula = Passes through the external anal sphincter Suprasphincteric fistula = Above both sphincters Extrasphincteric fistula = Extends outside of the anal sphincter complex</p> Signup and view all the answers

    What is the primary feature that differentiates pilonidal sinus disease between genders?

    <p>Hairy men are more frequently affected.</p> Signup and view all the answers

    Anal advancement flap is a surgical procedure used primarily for managing hemorrhoids.

    <p>False</p> Signup and view all the answers

    List two clinical features of pilonidal sinus disease.

    <p>Pain, Swelling, Discharge</p> Signup and view all the answers

    Pilonidal sinus disease can lead to _______ and _______ due to inward growth of hair.

    <p>Abscess, sinus</p> Signup and view all the answers

    Match the type of surgical technique with its description:

    <p>Rhomboid/Limberg flap = A flap design used for closing the defect after sinus excision Bascom's technique = A method involving the clearance and suturing of the sinus Karydakis technique = A technique aimed at minimizing tension on the wound edge Anal advancement flap = A procedure that repositions tissue to cover the defect</p> Signup and view all the answers

    Study Notes

    Grade 1 Hemorrhoids

    • Lifestyle changes: Increase high fiber diet, increase liquid intake, avoid fried/fatty/spicy food.
    • Laxative use.
    • Sitz bath: Warmwater relaxes the sphincter.

    Grade 2 Hemorrhoids

    • Management is similar to Grade 1 plus:
      • Banding
        • Cuts off blood supply.
        • Hemorrhoid sloughs off.
        • Performed above dentate line
      • Sclerotherapy
        • Performed above dentate line.
        • Sclerosing agents pull hemorrhoids up.
        • Sloughs them off.
        • Common sclerosing agents include:
          • Sodium tetradecyl sulfate
          • Sodium morrhuate
          • Polidocanol
          • Phenol in almond oil
        • Complications:
          • Deep sclerotherapy can cause Pain, Infection, Prostatitis (anteriorly).

    Grade 3 Hemorrhoids

    • Management includes Grade 2 treatment options plus surgery.

    Grade 4 Hemorrhoids

    • Requires surgery.

    Hemorrhoid Surgery

    • Types:
      • Open hemorrhoidectomy (Milligan-Morgan) (obsolete)
      • Closed hemorrhoidectomy (Ferguson)
      • Stapled hemorrhoidopexy (preferred method)
      • Doppler guided hemorrhoidal artery ligation (DGHAL)

    Anal Cancer

    • Most common type: Squamous Cell Carcinoma
      • Risk Factors:
        • Human papilloma virus
        • HIV
        • Homosexual individuals (more common in men than women)
      • Clinical Features:
        • Mass
        • Bleeding
    • Adenocarcinoma: Uncommon
    • Treatment: Similar to rectal cancer if less than 5 cm from anal verge.

    Staging and Treatment for Anal Cancer

    • Initial evaluation (IOC): Biopsy
    • MRI: Used for local staging
    • Nigro Regime:
      • Combination chemotherapy and radiation therapy
      • Administered 1-month prior to surgery
      • Radiation therapy + Chemotherapy: 5-FU & mitomycin C (used for downstaging)

    Anal Cancer Response to Treatment

    • Complete response.
    • Monitoring required (40-30%)
    • Recurrence: Abdomino-Perineal Resection
    • Residual tumor (within 5 cm): Further treatment needed.

    Rectum and Anal Canal Anatomy

    • Rectum length: 12-14 cm
    • Upper and lower rectum: Convex towards the right
    • Middle rectum: Convex towards the left
    • Lower rectum: Not covered by peritoneum.
    • Applied Anatomy: Resection of rectum below the peritoneum requires a low anterior resection.

    Anorectal Ring

    • Formed by levator ani muscle.
    • Located 2-2.5 cm above the dentate line (no pain sensation)
    • Located 2-2.5 cm below dentate line (pain sensation)

    Dentate Line

    • Anal verge
    • Sphincters:
      • Injury leads to incontinence.

    Anal Canal

    Region Epithelium Applied Aspect
    Proximal to dentate line Columnar Adenocarcinoma
    Distal to dentate line Modified squamous Squamous cell carcinoma
    • Mucosa above the dentate line.
    • Communication between crypts and anal glands: Site of abscess
    • Submucosa in distal anal canal: 3 hemorrhoidal cushions/vascular channels
      • Left anterior
      • Right anterior
      • Right posterior

    Nerve Supply of the Anal Canal

    • Internal sphincter innervation:
      • Sympathetic: L5
      • Parasympathetic: S2, S3, S4
    • External sphincter innervation:
      • Pudendal nerve (S2, S3, S4)
        • Bilateral injury: Incontinence
        • Unilateral injury: No incontinence
    • Sacral promontory nerve.
      • Injury: Ejaculatory & bladder dysfunction.

    Rectal Examination (DRE)

    • Position: Sims or Left lateral position.
    • Obtain informed consent.

    DRE Inspection

    • Look for:
      • External fistula opening
      • External hemorrhoids
      • Fissures (Painful - Contraindicated for DRE)
      • Growths

    DRE Technique

    • Digit used:
      • Adults: Index finger
      • Children: Little finger
    • Regions to examine:
      • Anterior (12 o'clock): Males - Prostate, Females - Cervix, Pouch of Douglas
      • Posterior (6 o'clock): Sacral hollow
      • Lateral wall (3 o'clock)

    Visualization Tools

    • Anoscope: ~10 cm
    • Proctoscope: ~13 cm
    • Sigmoidoscope: 60 cm in length, visualizes until sigmoid colon.
    • Colonoscope: 110-140 cm in length, visualizes from anal canal to cecum.

    Colorectal Polyps and Cancer (Part 2)

    Chemotherapeutic Regimens

    • FOLFOX:
      • 5-Fluorouracil (5-FU)
      • Folinic acid
      • Oxiplatinum
    • FOL FIRI:
      • 5-FU
      • Folinic acid
      • Irinotecan

    Radiation Therapy

    • Indications:
      • Rectal cancer (not for colonic cancer)
      • Advanced rectal cancer: Neoadjuvant chemoradiation followed by surgery
      • Advantages: Sphincter preservation

    Radiation Therapy in Rectal Cancer

    • Duration:
      • Short course: 5-6 days
      • Long course: Few weeks
    • Intracavity radiotherapy: Papillon

    Immunotherapy for Colorectal Cancer

    • Indications: Metastasis (most common site: Liver)
    Drug Function
    Bevacizumab Anti VEGF (Vascular growth factor inhibitor)
    Cetuximab Anti EGFR (Epidermal growth factor inhibitor)
    Panitumumab Anti EGFR
    Pembrolizumab PDLI inhibitor

    Liver Metastasis

    • Occurs in 60% of colorectal carcinoma.
    • Types: Synchronous (liver mets occur within 1 year of colorectal cancer diagnosis)

    Liver Metastasis Management

    • Resection:
      • Improves survival.
      • Indication: FLR (Functional liver reserve) > 25%
        • Minimum liver reserve needed for rejuvenation
      • Number of metastases is not a criteria for resection.

    Rectum & Anal Canal Complications

    Hemorrhoidectomy

    • Urinary retention (most common) due to reflex retention caused by pain.
    • Reactionary hemorrhage.
    • Pain.

    Hemorrhoids

    • Thrombosis
    • Fibrosis
    • Ulceration
    • Gangrene
    • Portal pyemia

    Anal Fissure

    • Breach in anal epithelium.
    • Below dentate line.
    • Midline position: 6 o'clock (posterior midline), 12 o'clock (in obstructed labour).

    Anal Fissure Clinical Features

    • Pain.
    • Bleeding per rectum.

    Anal Fissure Investigation

    • External Inspection (IOC)
    • Digital Rectal Examination (DRE): Contraindicated

    Skin Tag (Sentinel Pile)

    • Seen with chronic fissures.
    • Accumulation of lymphatics.

    Anal Fissure Management

    • Lifestyle Changes:
      • High fiber diet.
      • Increased fluid intake.
      • Avoid fried/fatty foods.
    • Sitz bath.
    • Laxative.

    Anal Fissure Medical Management

    • Topical Medications:
      • 2% Xylocaine jelly before/after defecation.
      • Diltiazem cream.
      • Nitrate gel (relaxes the sphincter).
      • Side Effects: Headache, Hypertension.

    Anorectal Abscess

    • Infection of the anal glands leading to perianal abscess.

    Anorectal Abscess Clinical Features

    • Pain
    • Fever
    • Swelling
    • Fluctuation (late sign)

    Anorectal Abscess Management

    • Incision and drainage.
    • Poorly drained abscess can lead to Perianal sinus/fistula.

    Perianal Sinus/Fistula

    • Secondary to anal sepsis.
    • Single or multiple fistulas.
    • Two openings (internal opening connected to external opening).
    • AKA Water-can perineum: due to multiple external openings.

    Causes of Perianal Sinus/Fistula

    • Crohn's disease
    • Trauma
    • Tuberculosis
    • Cancer
    • Immunocompromised

    Perianal Sinus/Fistula Clinical Features

    • Staining of underwear with pus.
    • Pain
    • Itching

    Perianal Sinus/Fistula Examination

    • External opening identified on inspection.
    • Internal opening confirmed by DRE.

    Diagram: Anorectal Abscess Types

    • Anterior (12 o'clock position): Straight, radial tracts.
    • Posterior: Curved tracts, open in the midline.
    • Mnemonic for causes of fistulas: Krohn, Krush, Cancer, Koch's
    • Goodsall's rule (illustrated in the diagram).

    Hemorrhoids

    • Dilated vascular channels
    • Arterial bleeding
    • Most common cause of rectal bleeding

    Hemorrhoid Clinical Features

    • Bleeding per rectum (usually painless).
    • Painful bleeding can occur with:
      • External hemorrhoids (below dentate line)
      • Thrombosed hemorrhoids
    • Constipation

    Hemorrhoid Investigation

    • Proctoscopy (preferred method).

    Thrombosed Piles

    • Meleney's 5 day self-healing lesion.
    • Painful.
    • Mass felt on DRE.

    Thrombosed Piles Management

    • Immediate surgery:
      • Excision
      • Evacuation of clot
    • Conservative management:
      • Healing within 5 days to a few weeks.
      • May require definitive surgery.

    Thrombosed Piles Investigation

    • Proctoscopy
    • DRE: Thrombosed piles are palpable (Hemorrhoids are not palpable).

    Hemorrhoid Grades

    Grade Features
    1 Only bleed, don't prolapse
    2 Prolapse, spontaneously reduced
    3 Prolapse, manually reduced
    4 Remain prolapsed

    Fistula Management

    Active Space

    • Goodsall's rule: Horse shoe fistula in a posterior fistula.

    Fistula Investigation

    • MR fistulogram: 10C, Park's classification: Based on MR fistulogram.

    General Fistula Management Principles

    • Eliminate all septic foci.
    • Delineate the fistula tract anatomy.
    • Preserve continence.
    • Prevent recurrence.

    Fistula Classification Based on Internal Opening

    • Landmark: Anorectal ring.
    • Above: High fistula
    • Below: Low fistula

    Low Fistula Management

    • Fistulectomy: Removal of the entire fistula tract, cost-effective.
    • Fistulotomy: Tract is opened and granulation tissue removed.

    High Fistula Management:

    • Fistulectomy: Can cause incontinence if performed in high fistulas (avoid if possible).
    • Ligation of fistulous tract (LIFT): Sphincter-preserving surgery.
    • Video-assisted fistula therapy (VAFT): Fistula is coagulated through endoscopy.

    Types of Fistula-in-ano

    • Intersphincteric fistula
    • Transsphincteric fistula (most common)
    • Suprasphincteric fistula
    • Extrasphincteric fistula

    Pilonidal Sinus (Jeep Driver's Disease)

    Pilonidal Sinus Surgical Management

    • 1. Lateral Anal Sphincterotomy:
      • Internal sphincter is cut → incontinence.
      • External sphincter cutting → Fissure heals.
      • Sphincter relaxes → Fissure heals.
    • 2. Anal Advancement Flap.

    Pilonidal Sinus Locations

    • Natal cleft (most common).
    • Interdigital area (seen in barbers).
    • Face.

    Pilonidal Sinus Characteristics

    • More common in males.
    • Hairy men.
    • Caused by friction leading to inward hair growth → Abscess & sinus.

    Pilonidal Sinus Clinical Features

    • Pain
    • Swelling
    • Discharge

    Pilonidal Sinus Management

    • Antibiotics
    • Analgesics
    • Drain abscess, remove hair (to prevent recurrence).

    Surgical Procedures for Pilonidal Sinus

    • Incision lateral to midline.
    • Surgery:
        1. Rhomboid/Limberg flap
        1. Bascom's technique
        1. Karydakis technique

    Pilonidal Sinus Procedures

    • Sinus cleared
    • Sutured
    • Bascom's technique

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    Description

    This quiz covers the various grades of hemorrhoids and their management options, including lifestyle changes, medications, and surgical interventions. Learn about treatment differences from Grade 1 to Grade 4 hemorrhoids, including techniques like banding and sclerotherapy.

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