Difference between revisions of "Anus"

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Anus (view source)

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The '''anus''' occasionally shows-up on the pathologists desk.  It sometimes comes with the rectum and [[colon]], as an abdominoperoneal resection (APR).
The '''anus''' occasionally shows-up on the pathologists desk.  It sometimes comes with the rectum and [[colon]], as an abdominoperoneal resection (APR).
=Normal=
*The dentate line (also known as the ''pectinate line'') divides the anal canal into upper two thirds and lower one third.
*Typically, the squamocolumnar junction is just above the dentate line.
Note:
*Squamous epithelium 1 cm proximal to the dentate line is considered abnormal.<ref name=pmid11174313>{{Cite journal  | last1 = Bujanda | first1 = L. | last2 = Iriondo | first2 = C. | last3 = Muñoz | first3 = C. | last4 = Etxezarraga | first4 = C. | last5 = Ramírez | first5 = MM. | last6 = Ramos | first6 = F. | last7 = Sánchez | first7 = A. | title = Squamous metaplasia of the rectum and sigmoid colon. | journal = Gastrointest Endosc | volume = 53 | issue = 2 | pages = 255-6 | month = Feb | year = 2001 | doi =  | PMID = 11174313 }}</ref>
==Squamous metaplasia of the anus==
{{Main|Squamous metaplasia of the anus}}


=Benign disease=
=Benign disease=
==Anal wart==
==Anal wart==
*See ''[[condyloma acuminatum]]''.
*See ''[[condyloma acuminatum]]''.
==Pilonidal cyst==
:Also ''pilonidal sinus'' and ''pilonidal disease''.
{{Main|Pilonidal cyst}}


==Perianal abscess==
==Perianal abscess==
===General===
===General===
*Common - often young men.<ref name=pmid22362468>{{Cite journal  | last1 = Ommer | first1 = A. | last2 = Herold | first2 = A. | last3 = Berg | first3 = E. | last4 = Fürst | first4 = A. | last5 = Sailer | first5 = M. | last6 = Schiedeck | first6 = T. | title = German S3 guideline: anal abscess. | journal = Int J Colorectal Dis | volume = 27 | issue = 6 | pages = 831-7 | month = Jun | year = 2012 | doi = 10.1007/s00384-012-1430-x | PMID = 22362468 }}</ref>
*Common [[ditzel]] - often young men.<ref name=pmid22362468>{{Cite journal  | last1 = Ommer | first1 = A. | last2 = Herold | first2 = A. | last3 = Berg | first3 = E. | last4 = Fürst | first4 = A. | last5 = Sailer | first5 = M. | last6 = Schiedeck | first6 = T. | title = German S3 guideline: anal abscess. | journal = Int J Colorectal Dis | volume = 27 | issue = 6 | pages = 831-7 | month = Jun | year = 2012 | doi = 10.1007/s00384-012-1430-x | PMID = 22362468 }}</ref>
*May be due to [[Crohn's disease]].<ref name=pmid21088749>{{Cite journal  | last1 = Lewis | first1 = RT. | last2 = Maron | first2 = DJ. | title = Efficacy and complications of surgery for Crohn's disease. | journal = Gastroenterol Hepatol (N Y) | volume = 6 | issue = 9 | pages = 587-96 | month = Sep | year = 2010 | doi =  | PMID = 21088749 }}</ref>
*May be due to [[Crohn's disease]].<ref name=pmid21088749>{{Cite journal  | last1 = Lewis | first1 = RT. | last2 = Maron | first2 = DJ. | title = Efficacy and complications of surgery for Crohn's disease. | journal = Gastroenterol Hepatol (N Y) | volume = 6 | issue = 9 | pages = 587-96 | month = Sep | year = 2010 | doi =  | PMID = 21088749 }}</ref>


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===Sign out===
===Sign out===
<pre>
<pre>
PERIANAL TISSUE ("OPENING OF FISUTLA"), EXCISION:
PERIANAL TISSUE ("OPENING OF FISTULA"), EXCISION:
- SCANT BENIGN SQUAMOUS MUCOSA AND MUSCLE.
- PERIANAL TISSUE CONSISTING OF SCANT SQUAMOUS EPITHELIUM AND MUSCLE  
- SMALL MICROABSCESS.
  WITH MILD INFLAMMATION.
- MILD FIBROSIS WITH PROMINENT BLOOD VESSELS.
- SMALL COLLECTION OF NEUTROPHILS.
- NEGATIVE FOR MALIGNANCY.
- MILD FIBROSIS WITH FOCALLY PROMINENT DILATED BLOOD VESSELS.
- NEGATIVE FOR DYSPLASIA AND NEGATIVE FOR MALIGNANCY.
</pre>
</pre>


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==Hemorrhoids==
==Hemorrhoids==
===General===
{{Main|Hemorrhoid}}
*Benign.
 
Clinical features:<ref>{{Cite journal  | last1 = Cazemier | first1 = M. | last2 = Felt-Bersma | first2 = RJ. | last3 = Cuesta | first3 = MA. | last4 = Mulder | first4 = CJ. | title = Elastic band ligation of hemorrhoids: flexible gastroscope or rigid proctoscope? | journal = World J Gastroenterol | volume = 13 | issue = 4 | pages = 585-7 | month = Jan | year = 2007 | doi =  | PMID = 17278225 }}</ref>
*Bright red blood per rectum (BRBPR).
*Pain.
*Itching.
*Prolapse.
 
===Gross===
Features:<ref name=Ref_GLP401>{{Ref GLP|401}}</ref>
*Grey mucosa.
*Pale or purple stroma.
 
===Microscopic===
Features:<ref name=Ref_GLP401>{{Ref GLP|401}}</ref>
*Polypoid lesion - epithelium on three sides:
**Large dilated veins and thick-walled vessels +/- fibrin thrombi - '''key feature'''.
**Edema.
**Squamous epithelium +/- keratinization ''or'' columnar epithelium.
 
DDx:
*[[Fibroepithelial polyp]].
*Vascular lesions.
**[[Kaposi sarcoma]].
**[[Angiosarcoma]].
**[[Arteriovenous malformation]] - has large arteries.
 
Image:
*[http://www.profimedia.si/picture/longitudinal-section-of-human-rectum-hemorrhoid-tissue/0039860546/ Hemorrhoids (profimedia.si)].
 
===Sign out===
<pre>
ANAL LESION, REMOVAL:
- HEMORRHOID.
</pre>
 
<pre>
HEMORRHOIDS, EXCISION:
- HEMORRHOIDS.
</pre>
 
====Micro====
The sections show rectal and anal mucosa, and a submucosa with prominent blood vessels in a fibrotic stroma.  The rectal mucosa has focal reactive nuclear changes and evidence of prior erosions. The anal mucosa is unremarkable.
 
=====Anal mucosa only=====
The sections show anal mucosa, and submucosa with prominent blood vessels in a
fibrotic stroma. The anal mucosa is unremarkable.


=Anal neoplasia=
=Anal neoplasia=
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==Anal intraepithelial neoplasia==
==Anal intraepithelial neoplasia==
*Abbreviated ''AIN''.
*Abbreviated ''AIN''.
===General===
{{Main|Anal intraepithelial lesions}}
*Precursor lesion of anal [[squamous cell carcinoma]].
*Usually [[HPV]] associated.
**May be prevented by HPV vaccine.
 
===Grading===
AIN is graded much like [[cervix|cervical intraepithelial neoplasia]]:
*High-grade anal intraepithelial neoplasia (HGAIN).
*Low-grade anal intraepithelial neoplasia (LGAIN).


===Sign out===
Note:
<pre>
*The terminology changing to match the one now widely used for the [[uterine cervix]].
ANAL CANAL, RIGHT UPPER QUADRANT, BIOPSY:
- LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESION (CONDYLOMA ACUMINATUM-LIKE).
</pre>
 
<pre>
ANAL CANAL, LEFT UPPER QUADRANT, BIOPSY:
- LOW-GRADE SQUAMOUS INTRAEPITHELIAL LESION.
- RECTAL MUCOSA WITHIN NORMAL LIMITS.
</pre>
 
<pre>
SKIN LESION, PERIANAL, BIOPSY:  
- ANAL INTRAEPITHELIAL NEOPLASIA 3 (SEVERE DYSPLASIA), WARTY-TYPE.
- MARGIN POSITIVE FOR ANAL INTRAEPITHELIAL NEOPLASIA 3.
</pre>
 
====Micro====
There is dysplastic squamous epithelium with coarse chromatin, nuclear hyperchromasia,
nuclear enlargement, irregular nuclear membranes, and an increase nuclear-to-cytoplasmic
ratio.  Mitotic activity is abundant. Several atypical mitoses are identified.
 
The dysplastic squamous epithelium shows minimal maturation toward the surface (AIN 3). A
sizable portion of the lesion show some maturation to the surface (AIN 2).
 
Inflammation at the dermal-epidermal interface is minimal and the dermal-epidermal
interface is well-demarcated.  Focal ulceration is present.
 
The margin of the biopsy has severely dysplastic epithelium (AIN 3).


=Anal cancer=
=Anal cancer=
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*[[AKA]] ''anal squamous carcinoma''.
*[[AKA]] ''anal squamous carcinoma''.
*[[AKA]] ''squamous cell carcinoma of the anus''.
*[[AKA]] ''squamous cell carcinoma of the anus''.
===General===
{{Main|Anal squamous cell carcinoma}}
*Most common form of anal cancer.
 
Risk factors:<ref name=pmid23806153>{{Cite journal  | last1 = Kutlubay | first1 = Z. | last2 = Engin | first2 = B. | last3 = Zara | first3 = T. | last4 = Tüzün | first4 = Y. | title = Anogenital malignancies and premalignancies: Facts and controversies. | journal = Clin Dermatol | volume = 31 | issue = 4 | pages = 362-73 | month =  | year =  | doi = 10.1016/j.clindermatol.2013.01.003 | PMID = 23806153 }}</ref>
*Men who have sex with men.
*Immunosuppressed.
*[[HIV]] infection.
===Microscopic===
Features:
*See ''[[squamous cell carcinoma]]''.
 
DDx:
*[[Anal gland adenocarcinoma]].
*Poorly differentiated [[rectal adenocarcinoma]].
 
===IHC===
*p16 +ve.<ref name=pmid23105122/>
*CDX2 -ve/+ve.
**May be useful to differentiate from vulva and penis.<ref name=pmid23105122>{{Cite journal  | last1 = Gunia | first1 = S. | last2 = Koch | first2 = S. | last3 = May | first3 = M. | title = Is CDX2 immunostaining useful for delineating anorectal from penile/vulvar squamous cancer in the setting of squamous cell carcinoma with clinically unknown primary site presenting with histologically confirmed inguinal lymph node metastasis? | journal = J Clin Pathol | volume = 66 | issue = 2 | pages = 109-12 | month = Feb | year = 2013 | doi = 10.1136/jclinpath-2012-201138 | PMID = 23105122 }}</ref>
 
===Sign out===
<pre>
RECTUM, DISTAL, BIOPSY:
- INVASIVE SQUAMOUS CELL CARCINOMA.
</pre>


==Anal gland adenocarcinoma==
==Anal gland adenocarcinoma==
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DDx:
DDx:
*[[Rectal adenocarcinoma]] - usu. CK7 -ve, CK20 +ve.
*[[Rectal adenocarcinoma]] - usu. CK7 -ve, CK20 +ve.
*Mucinous adenocarcinoma - usu. CK7 +ve, CK20 +ve.
*[[Mucinous adenocarcinoma]] - usu. CK7 +ve, CK20 +ve.


Image:
Image:
Michael
48,453

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