ANATOMY

What is the lymphatic drainage below the dentate line?

Are most patients with anal cancer diagnosed early or late?

Chapter 49 / Anus 327

Below to inguinal lymph nodes (above to pelvic chains)

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

Canal cancer

How is an anal canal epidermal carcinoma treated?

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

Anal verge out 5 cm onto the perianal skin

Proximal to anal verge up to the border of the internal sphincter

NIGRO protocol:

1.Chemotherapy (5-FU and mitomycin C)

2.Radiation

3.Postradiation therapy scar biopsy (6–8 weeks post XRT)

90%

How can Goodsall’s rule be remembered?

Chapter 49 / Anus 329

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

What is the management of anorectal fistulas?

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

How do you find the internal rectal opening of an anorectal fistula in the O.R.?

What is a sitz bath?

PERIRECTAL ABSCESS

Inject H2O2 (or methylene blue) in external opening—then look for bubbles (or blue dye) coming out of internal opening!

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

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 conservative treatment?

What disease processes must be considered with a chronic anal fissure?

What are the indications for surgery?

What is one surgical option?

Hypertrophic papilla

Fissure

Sentinel pile

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

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

Chronic fissure refractory to conservative treatment

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

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‘07

1st degree hemorrhoid

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‘07

2nd degree hemorrhoid

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‘07

3rd degree hemorrhoid

334 Section II / General Surgery

Fourth-degree hemorrhoid

What is the treatment?

What is a “closed” vs. an “open” hemorrhoidectomy?

What are the dreaded complications of hemorrhoidectomy?

What condition is a contraindication for hemorrhoidectomy?

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

Prolapsed hemorrhoid that cannot be reduced

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

Closed (Ferguson) “closes” the mucosa with sutures after hemorrhoid tissue removal

Open (Milligan-Morgan) leaves mucosa “open”

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

Crohn’s disease

Colon cancer (colonoscopy)

C h a p t e r 50

What is the definition of lower GI bleeding?

What are the symptoms?

Lower GI Bleeding

Bleeding distal to the ligament of Treitz; vast majority occurs in the colon

Hematochezia (bright red blood per rectum [BRBPR]), with or without abdominal pain, melena, anorexia, fatigue, syncope, shortness of breath, shock

What are the signs?

What are the causes?

What medicines should be looked for causally with a lower GI bleed?

Chapter 50Chapter/ Lower43 GI/OstomBleedinges 335

BRBPR, positive hemoccult, abdominal tenderness, hypovolemic shock, orthostasis

Diverticulosis (usually right-sided in severe hemorrhage), vascular ectasia, colon cancer, hemorrhoids, trauma, hereditary hemorrhagic telangiectasia, intussusception, volvulus, ischemic colitis, IBD (especially ulcerative colitis), anticoagulation, rectal cancer, Meckel’s diverticulum (with ectopic gastric mucosa), stercoral ulcer (ulcer from hard stool), infectious colitis, aortoenteric fistula, chemotherapy, irradiation injury, infarcted bowel, strangulated hernia, anal fissure

Coumadin®, aspirin, Plavix®

What are the most common causes of massive lower GI bleeding?

What lab tests should be performed?

What is the initial treatment?

1.Diverticulosis

2.Vascular ectasia

CBC, Chem-7, PT/PTT, type and cross

IVFs: lactated Ringer’s; packed red blood cells as needed, IV 2, Foley catheter to follow urine output, d/c aspirin, NGT

What diagnostic tests should be performed for all lower GI bleeds?

What must be ruled out in patients with lower GI bleeding?

How can you have a UGI bleed with only clear succus back in the NGT?

History, physical exam, NGT aspiration (to rule out UGI bleeding; bile or blood must be seen; otherwise, perform EGD), anoscopy/proctoscopic exam

Upper GI bleeding! Remember, NGT aspiration is not 100% accurate (even if you get bile without blood)

Duodenal bleeding ulcer can bleed distal to the pylorus with the NGT sucking normal nonbloody gastric secretions! If there is any question, perform EGD

What test is performed to localize bleeding if there is too much active bleeding to see the source with a colonoscope?

What is more sensitive for a slow, intermittent amount of blood loss: A-gram or tagged RBC study?

What is the colonoscopic treatment option for bleeding vascular ectasia or polyp?

What is the treatment if bleeding site is KNOWN and massive or recurrent lower GI bleeding continues?

Chapter 50 / Lower GI Bleeding 337

A-gram (mesenteric angiography)

Radiolabeled RBC scan is more sensitive for blood loss at a rate of 0.5 mL/min or intermittent blood loss because it

has a longer half-life (for arteriography, bleeding rate must be 1.0 mL/min)

Laser or electrocoagulation; local epinephrine injection

Segmental resection of the bowel

What is the surgical treatment of massive lower GI bleeding WITHOUT localization?

What percentage of cases spontaneously stop bleeding?

What percentage of patients require emergent surgery for lower GI bleeding?

Exploratory laparotomy with intraoperative enteroscopy and total abdominal colectomy as last resort

80%–90% stop bleeding with resuscitative measures only (at least temporarily)

Only 10%

Does melena always signify active colonic bleeding?

What is the therapeutic advantage of doing a colonoscopy?

What is the therapeutic advantage of doing an A-gram?

NO—the colon is very good at storing material and often will store melena/ maroon stools and pass them days later (follow patient, UO, HCT, and vital signs)

Options of injecting substance (epinephrine) or coagulating vessels is an advantage with C-scope to control bleeding

Ability to inject vasopressin and/or embolization, with at least temporary control of bleeding in 85%

C h a p t e r 51

What is IBD?

What are the two inflammatory bowel diseases?

What is another name for Crohn’s disease?

What is ulcerative colitis often called?

What is the cause of IBD?

What is the differential diagnosis?

What are the extraintestinal manifestations seen in both types of IBD?

Inflammatory

Bowel Disease:

Crohn’s Disease

and Ulcerative

Colitis

Inflammatory Bowel Disease,

inflammatory disease of the GI tract

Crohn’s disease and ulcerative colitis

Regional enteritis

UC

No one knows, but probably an autoimmune process with environmental factors contributing

Crohn’s versus ulcerative colitis, infectious colitis (e.g., C. difficile, amebiasis, shigellosis), ischemic colitis, irritable bowel syndrome, diverticulitis, Zollinger-Ellison syndrome (ZES), colon cancer, carcinoid, ischemic bowel

Ankylosing spondylitis, aphthous (oral) ulcers, iritis, pyoderma gangrenosum, erythema nodosum, clubbing of fingers, sclerosing cholangitis, arthritis, kidney disease (nephrotic syndrome, amyloid deposits)

What are the common surgical options for ulcerative colitis?

1.Total proctocolectomy, distal rectal mucosectomy, and ileoanal pull through

2.Total proctocolectomy and Brooke ileostomy

Rectal bleeding/bloody diarrhea is a hallmark of which disease?

Ulcerative colitis (rare in Crohn’s disease)

What is the operation for short strictures of the small bowel in Crohn’s disease?

Should the appendix be removed during a

laparotomy for abdominal pain if Crohn’s disease is discovered?

Stricturoplasty; basically a HeinekeMikulicz pyloroplasty on the strictured segment (i.e., opened longitudinally and sewn closed in a transverse direction)

Yes, if the cecum is not involved with active Crohn’s disease

Do you need a frozen section for margins during a bowel resection for Crohn’s disease?

No, you need only grossly negative margins