Anal Disorders

Question 1

Patho Rectal Abscess

Answer 1

collection of purulent material in a glandular crypt

Question 2

Where is a rectal abscess located?

Answer 2

in the perirectal area

Question 3

Clinical rectal abscess

Answer 3

• sudden onset of severe pain and swelling
• fluctuant mass that feels like fluid inside
• fever
• cellulitis possible

Question 4

Dx rectal abscess

Answer 4

H/ PE

Question 5

Tx rectal abscess

Answer 5

• I&D

- ABX only if cellulitis

Question 6

Patho Rectal Fistula

Answer 6

chronic manifestation of acute perirectal abscess that has ruptured or drained –> formation of an epithelialized track to anus or rectum from perirectal skin

Question 7

Causes Rectal Fistula

Answer 7

• Perirectal abscess ruptured/drained
• crohn’s
• radiation proctitis
• rectal foreign bodies due to laceration

Question 8

Clinical Rectal fistula

Answer 8

• pain
• purulent drainage
• perirectal skin lesion

Question 9

Dx rectal fistula

Answer 9

• fistula probe
• CT, MRI, fistulography (shows air/ contrast in area)
• Non-healing anorectal abscess after drainage

Question 10

Tx Rectal fistula

Answer 10

Surgery- eradicate fistula and preserve fecal continence with little rubber tubing tie that they use to tie and pinch off fistula

Question 11

What is one of the most common anorectal conditions?

Answer 11

anal fissure

Question 12

Patho of anal fissure

Answer 12

• due to high anal pressure

- sphincter spasms and anal mucosa tears

Question 13

Tx Goals Anal fissure

Answer 13

• relax internal sphincter
• maintain less trauma with stooling
• pain relief

Question 14

Medical tx anal fissure

Answer 14

• fiber
• cortisone
• topical nitro, diltiazem, bathanechol
• oral: nifedipine, diltiazem
• botulin toxin to paralyze the rectal spasm

Question 15

Surgical tx anal fissure

Answer 15

• failure of other tx
• lateral sphincterotomy
• dilatation

Question 16

Functional Constipation

Answer 16

1) 2 of the following with 25% of bowel movements:
- straining
- lumpy hard stools
- sensation of incomplete evacuation
- use of digital maneuvers
- sensation of anorectal obstruction/ blockage
2) less than 3 bowel movements a week
3) all of this lasting more than 3 months

Question 17

What is the most common digestive complaint in the general population?

Answer 17

constipation

Question 18

Causes of constipation

Answer 18

• Primary colorectal dysfunction
• inadequate fiber/ fluid intake
• pool bowel habits
• opioids
• iron supplementation

Question 19

Explain primary colorectal dysfunction

Answer 19

• slow transit constipation
• dyssynergic defecation: pelvic walls don’t fxn correctly and sphincter muscles contract instead of relax
• IBS

Question 20

Clinical constipation

Answer 20

• straining
• lumpy hard stools
• sensation of incomplete evacuation
• use of digital maneuvers
• sensation of anorectal obstruction/ blockage
• decreased frequency
• abdominal discomfort or pain
• abdominal distention
• nausea

Question 21

Alarm symptoms for constipation

Answer 21

• Hematochezia
• obstructive symptoms
• acute onset of constipation
• severe persistent constipation that is unresponsive to tx
• weight loss more than 10 pounds
• change in stool caliber- pencil thin stool
• family hx of colon cancer or IBD

Question 22

What lab tests can you do for constipation?

Answer 22

BMP
CBC
TSH

Question 23

Tx constipation

Answer 23

Initial Management
- patient education
- dietary changes: more fiber and water
- bulk- forming laxatives (metamucil, citrucel, fibercon, benefiber)
PRN
- non-bulk forming laxatives (milk of magnesia, miralax, lactulose, senna, biscodyl)
- Enemas- (colace and mineral oil)

Question 24

Post op give what for constipation

Answer 24

colace and senna

Question 25

When to refer for constipation

Answer 25

- refractory constipation - defacatory disorders - alarm sx or over 50

Question 26

Patho fecal impact

Answer 26

solid immobile bulk of stool in the rectum

Question 27

Clinical fecal impact

Answer 27

- abdominal cramping & bloating - leakage of liquid or sudden episodes of watery diarrhea when normally constipated - rectal bleeding - small, semi-formed stools - straining when trying to pass stools - bladder pressure/ loss of control - lower back pain - fluid leaks out but no evacuation of bowels - pressure on bladder and urethra--> can't void

Question 28

Dx fecal impact

Answer 28

- digital rectal exam to look for firm or large amount of stool in rectal volt - abdominal radiograph is DRE is normal but high suspicion

Question 29

Tx fecal impact

Answer 29

- Disimpact and colon evacuation: manual fragmentation, mineral oil enemal to soften and lubricate, PEG after evactuate a little - identify causes - maintain bowel regimen

Question 30

Patho Pilonidal Dz

Answer 30

- infection of skin and subcutaneous tissue at or near the upper part of the natal cleft of the buttocks - irritation of skin--> pockets form where there are hair follicles--> pit forms--> tract forms due to continuous trauma--> infection and abscess

Question 31

Are pilonidal cavities true cysts?

Answer 31

No because they lack fully epithelialized lining

Question 32

Causes Pilonidal Dz

Answer 32

prolonged sitting and riding in a jeep

Question 33

Pilonidal Dz occurs in what age

Answer 33

19yo women and 21yo men

Question 34

RF Pilonidal Dz

Answer 34

- overweight/ obese - local trauma - sedentary lifestyle - deep natal cleft - family history

Question 35

Clinical Pilonidal Dz

Answer 35

- painless cyst or sinus opening at the top of the natal cleft

Question 36

Clinical Pilonidal Dz with acute abcess

Answer 36

- sudden onset of severe pain and swelling - acutely inflamed and fluctuant mass overlying the sacrum or coccyx - fever if cellulitis

Question 37

Clinical Pilonidal Dz with chronic Pilonidal cyst

Answer 37

- painless cyst or sinus opening at the top of the natal cleft - persistent drainage from a sinus track connected to the cyst - mucoid/ purulent material

Question 38

Tx Pilonidal Dz

Answer 38

- sitz bath - I&D if abscess - surgical excision of sinus tract and cysts - ABX for cellulitis - be careful shaving hair in gluteal area - recurrent