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Q1: Perianal abscess (2 min)
"A patient has severe perianal pain and a tender swelling. What do you do?"
- Diagnosis: perianal abscess (cryptoglandular infection)
- Management: incision and drainage under GA — never antibiotics alone
- Antibiotics only if: cellulitis, sepsis, diabetes, immunosuppression
- Warn patient: 30-50% develop fistula
Q2: Goodsall's rule (2 min)
"State Goodsall's rule."
- Anterior external opening = straight radial tract to nearest crypt
- Posterior external opening = curved to 6 o'clock posterior midline
- Exception: anterior opening >3cm from verge may curve
- Significance: predicts internal opening for surgical planning
Q3: Park's classification (3 min)
"Classify anal fistulas."
- Intersphincteric (70%) — between sphincters, safest to treat
- Transsphincteric (25%) — crosses both sphincters
- Suprasphincteric (5%) — above puborectalis
- Extrasphincteric (1%) — from rectum, outside sphincters; usually secondary (Crohn's, malignancy)
- Surgical approach depends on classification and sphincter involvement
Q4: High fistula management (2 min)
"How do you manage a high transsphincteric fistula?"
- Loose seton — maintains drainage, does NOT divide sphincter (avoids incontinence)
- LIFT procedure — ligate intersphincteric tract, 70-80% success
- NEVER fistulotomy for high fistula (incontinence risk)
- Crohn's: anti-TNF + seton, never divide sphincter