surg : anal canal disease and carcinoma *

Anal fissure is a ........ tear in the anoderm,

extending from the level of the dentate line to the anal margin.

longitudinal

most common site for anal fissure is ........ next most common is ....... and they can both ....

anterior fissures are more common in ... gender due to strech in ...

midline posterior

midline anterior

co exist

female , vaginal delivery

is is maily caused by ..... & ...... causing severe.... then reflex .... and .... blood supply and poor .....

constipation and straining

pain , spasm , reduced , healing

specific anal fissure is assoicated with .... disease and .... in git , tb and aids

crohns and ulcerative colitis

specific anal fissure features of is they are ...... , multiiple and found in ... sites

painless

unusual

acute fissure is painfull because anal canal is ... in nerve supply and there is vicious ....

rich and cycle

acute anal fissue

Longitudinal ...cut in the mucosa ...... the dentate line. ...... sphincter spasm.

superficial

below

Severe

Chronic Anal Fissure:

..... ulcer with white fibers of visible. Thick, .... edges ...... (skin tag) at the lower end ......papilla at the upper end (looks like white fibrotic polyp).

Deep , internal sphincter

fibrotic

Sentinel pile

Hypertrophied

the main symptom of anal fissure is ..... starts shortly after .... with some streaks of ...... on surface

pain

defication

blood

diagnosis of anal fissure is by ...... digital rectal exam is ...... and should be under .... in atypical use ..... to rule out

inspection

contraindicated , general anasthesia

histopatholgy

acute anal fissure ttt

conservative

chronic anal fissure ttt by relieving .... to improve blood supply by ..../..... or divide lower fibers of internal sphincter at .... a clock with ...% of minor fecal incontinence

spasm

gtn /ccb

lateral sphinterotomy . 3 aclock

15%

Hemorrhoids are ......, tortuous ...... in the submucosa of the anal canal.

dilated

arteriovenous cushion

Clockwise analogy:

• Blood vessels enter the anal canal mainly at ..., .... , and ....o'clock positions.

• They form a ..... of three venous channels in the submucosal plane ➡️ Hemorrhoidal plexus.

3,7,11

plexus

• Internal hemorrhoidal plexus ➡️ ....... the dentate line.

• External hemorrhoidal plexus ➡️......... the dentate line.

above

below

Internal hemorrhoidal plexus:

• Forms mucosal cushions at ....... o'clock.

• Important for preserving ............

•Cushions are anchored to underlying internal sphincter by ..........

3,7,11

continence

suspensory ligaments

Hemorrhoids result from:

• ...........and tortuosity of hemorrhoidal plexuses.

Internal hemorrhoids also due to:

• Laxity of ........... ➡️ Prolapse and congestion.

dilatation

suspensory ligament

mother piles develop at ...,...&.... daughter piles develop .......

3,7,11

elsewhere

causes of hemorrhoids primary hemorrhoids are majority ........ also congenital ....... of vessells and suspensory ligament also by ......

idopathic

weakness

straining

secondary hemorrhoids are less frequent caused by compressing .... vein ,preg , pelvic ......, venous relaxation from preg by .......

superior rectal

tumors

progesterone

Portal hypertension:

• Increases pressure in ........ vein.cause heamaroid dt presence of ......... Between ....... heamoroidal (portal) and.... heamoroidal (systemic )

superior rectal

porto-systemic anastomosis

superior , inf

degrees of hemorrhoids

first degree: do not prolapse anal verge

second degree : prolapse during defication and reduce spont

third degree : require manual reduction

forth : permanent prolapse

symptoms of anal hemorroids mainly is ..... also enlarged vascular cushoins ..... also anal discharge due to secreation of .... normaly no ....

bleeding

prolapse

mucus

pain

signs by analinspection you can find .... degree piles in digital exam they are ..... exam done to exclude .... proctoscopy will show ..... at 3,7&11

4th

impalpable

cancer

bluish bulges

Complications of hemorrhoids

Strangulation, Thrombosis, Ulceration and bleeding, Gangrene, Sepsis, Portal pyaemia, Fibrosis

Strangulation in hemorrhoids

Prolapsed hemorrhoid gripped by external sphincter → venous return obstructed → tense, very painful, swollen

Thrombosis in hemorrhoids

Blood clot formation if strangulation persists

Ulceration and bleeding in hemorrhoids

Occurs following thrombosis

Gangrene in hemorrhoids

Tight strangulation cuts arterial supply → black, gangrenous hemorrhoid

Sepsis in hemorrhoids

Infection of thrombosed hemorrhoids

Portal pyaemia in hemorrhoids

Rare complication from infected hemorrhoids

Fibrosis in hemorrhoids

Healed thrombosed hemorrhoids → hard, white fibrous polyp

asymptomatic hemorrhoids are treated ....... first and second degree treated ...... and surgery if fails third and fourth .... from start by .... operation

conservative

medically

surgery

milligan morgan

complications for classic open hemmorhoidectomy is reactonary and 2ry ...... also reflex ........ and anal . also fecal .....

hge

urinary retention

stenosis

incontinenece

less painfull procedures are like injection for ttt of .... degree injection of ...... that induce fibrosis also rubber band for .... degree for ..... hemorrhoids

infrared photocoagulation induce ..... but .... used

1st , 5% phenol in almond

fibrosis

2nd ,large

coagulating ,rarely

DGHAL detects ...... and ligate .... dentate live suitable for .... degrees

stapled hemorrhoidectomy reposition hemorrhoids ..... suitable expecialy for ... degree

laser hemmorhoidectomy has .... opertion time and minimal .... loss

arteries ,above , all

upward , fourth

shorter ,bleeding

secondry hemorrhoids treat the ...

treatmetn of prolapsed and strangulated if diagnosed early do ... management and surgery is .... initialy if gangrene develop ... indicated

underlying cause

conservative , avoided

hemorrhoidectomy

acute perianal hematoma is ....swelling caused by rupture of perianal .... at anal verge caused by excessive ... and signs include severe .... and a tense .... swelling it usually ..... resolve if severe agony ... to evacuate clot

painfull

venules

straining

pain

bluish

spontaneous

small incision

perianal abcess is also called 1ry .... abcess and cuased by infection of the ..... starts in .... space and might spread

sryptoglandular

anal glands

intersphinteric

frequency of intersphinteric ....

perianal .... and downward extention to ...........tissure

ischiorectal .... and out ward infection through external sphincter to ...... fossa

submucus... inward extention to reach .... space

supralevator ... upward extention to ..... space

5%

60% perianal

30% ischiorectal fossa

3% submucus

2% supralevator

grainage of perianal abcess may drain spontanues or establish communicating tract

• Internal opening (natural opening of duct) at the .......

• External opening (site of drainage of abscess) through .......

dentate line

perianal skin

causes of secondary abcess

IBS , TB , anorectal carcinoma , hemorrhoids

clinical picture of abcess include and ttt

throbbing pain ,superficial abcess

drainage and dont wait for fluctuation

anal fistula is a lined tract by ....... tissue that extend from the ..... to the cavity of the anal canal or rectum primary ..... are majority arise from .... glands that open in anal crypts

granulation tissue

perianal skin

cryptogenic

infected

Goodsall's law: External opening anterior to transverse anal line → fistula tract runs in a ..........course to the........... crypt

Straight course; nearest anal crypt

Goodsall's law: External opening posterior to transverse anal line → fistula tract usually runs in a ...........course to the ...........line

Curved course; posterior midline

Exception to Goodsall's law Anterior external opening more than ........... cm from anal verge → usually follows a ...........course to posterior midline

3 cm ,curved

goodsalls rule is true in .... % of cases

60

according to milligan morgan high fistula internal opening is ..... puborectalis while low fistula is...... puborectalis

above

below

parks anatomical calssification of anal fistulas

intersphinteric is ....... sphincters while transsphinteric is ..... sphincters suprasphinteric is over ...... then .......

extrasphinteric from .... to ..... through ......

horseshoe tract encircles and connects both ..... fossa

between , through

levator ani ,down

rectum to skin , levator

ischiorectal

clinical picture of anal fistulas is recurrent ...... abcesses and pressitant .... from smal external opening

perianal

discharge

the only treatment of anal fistula is ......

if low fistula then preform ........ and this cures .... and .... have minor incontinence

high fistula ...... tract and ......... of internal opening -+ ..... placement and removed after .... weeks

surgery

fistulotomy 85% , 15%

coring out and closure

seton , 2

pilonidal sinus A sinus or cavity in the ........(over sacrum) containing loose ....... causing foregin body reaction and infection causing ..........

natal cleft , hairs , sinus formation

pilonidal sinus is Subcutaneous cavity lined by ....... tissue more in ..... gender develop after age of ...

granulation

male , 30

treatment of pilonidal sinus is ........ generaly then if chronic do ......

conservative

excision

types of carcinoma of anal canal below and above dentate line

1. Below dentate line: more common Squamous carcinoma (arises from endoderm)

2. Above dentate line: less common Adenocarcinoma

clinical picture of cancer anal is .... DRE show ..... mass lymph node mets if ..... dentate line treatment is ................. and if adeno carcinoma do ......... resection

lump , easily bleeding

below

chemoradiation

abdominopernial resection

signs by analinspection you can find .... degree piles in digital exam they are ..... exam done to exclude .... proctoscopy will show ..... at 3,7&11