Anal fissures/Abcess/Hemorrhoids

Question 1

Anal Fissure

general

Answer 1

Acute longitudinal tear in the anal mucosa (squamous epithelium) of the anal canal distal to the dentate line
Typical/Primary → local trauma
Atypical/Secondary → associated with a condition
Common in infants and middle-aged adults, but can occur at any age

Question 2

fissures

Causes

Answer 2

Most common
Passing large or hard stools
Constipation and straining during bowel movements
Chronic diarrhea
Anal intercourse
Childbirth

Less Common
Inflammatory bowel disease (Crohn’s disease)
Anal cancer
HIV
Syphilis

Question 2

Fissures

Signs & Symptoms

Answer 2

Usually occur in the posterior midline or anterior midline
Off the midline (atypical) → Crohn’s disease

Chronic fissure/ulcer
External skin tag (sentinel pile) at the lower end
Enlarged (hypertrophic) papilla at the upper end

Pain
Present at rest
Severe during bowel movements → persists for several hours

Bleeding
Bright red blood (hematochezia) on the stool or toilet paper after a bowel movement

midline is primary

Question 3

fissures

Dx

Answer 3

Complete history and physical examination, to include gentle inspection of the anal area

Tears are most often visible
Acute – paper cut
Chronic – deeper with internal or external fleshy growths (sentinel pile and hypertrophic papilla)

If a specific cause cannot be identified, additional testing may be needed:
Anoscopy
Flexible sigmoidoscopy
Colonoscopy
Biopsy

Question 4

Fissure

Tx

Answer 4

Increase fiber in the diet
Stool softeners
Protective ointments - zinc oxide
Bland suppositories (glycerin)
Lubricate the lower rectum and softens stool

Sitz baths
Warm, NOT HOT, for 10-15 minutes after each bowel movement and as needed for relief

Topical anesthetics – benzocaine, xylocaine, lidocaine

Topical vasodilators
nitroglycerin 0.2% ointment
Relax the anal sphincter and increases blood flow to the area to allow for healing
nifedipine 0.2% cream
Relax the anal sphincter and decrease anal resting pressure to allow for healing

Surgical repair if conservative measures fail

Question 5

Answer 5

Question 6

Anorectal Abscess

general and pathogens

Answer 6

Localized collection of pus in the perirectal spaces that results from perianal gland blockage
Superficial or deep

Mixed infection
Escherichia coli
Proteus vulgaris
Bacteroides
Enterococcus
Streptococci
Staphylococci

Question 7

Answer 7

Levator ani muscle is composed ofthree striated muscles on each side: iliococcygeus, pubococcygeus, and the puborectalis muscles

Question 8

Abcess

Perianal abscess (60%)

Answer 8

Below the levator ani muscle

Superficial
Only involves the skin

Question 9

Ischiorectal abscess (30%)

Answer 9

below the levator ani muscle

Deeper
Extends across the sphincter into the ischiorectal space below the levator ani
May penetrate to the contralateral side (forms a horseshoe abscess)
Diabetic patients

Question 10

Intersphincteric abscess

Answer 10

Below the levator ani muscle

Deeper
Forms between the internal and external sphincters

Question 11

Supralevator abscess
Seen in which pts

Answer 11

Above the levator ani muscle

Extremely deep
May extend to the peritoneum of abdominal organs
Seen with Crohn’s disease, diverticulitis, or pelvic inflammatory disease

Question 12

Question 13

Perianal abcess

RF

Answer 13

Pregnancy
Diabetes
Crohn’s disease
Certain medicines (chemotherapy drugs or immunosuppressive drugs)
Foreign objects placed in the rectum
Anal fissures
Sexually transmitted disease (STD)

Question 14

abcess

S/Sx
Below the dentate line

Answer 14

Very painful
Perianal swelling and erythema
Marked tenderness to palpation
Intermittent malodorous drainage
Fever is rare

Question 15

abcess

S/Sx
above the dentate line

Answer 15

Less painful
Toxic symptoms – fever, chills, and malaise
No perianal findings
DRE – tender, fluctuant swelling of the rectal wall

Question 16

abcess

Dx

Answer 16

Clinical diagnosis
Cutaneous abscess with no signs of systemic illness and normal DRE (perianal abscess)

Anoscopy or sigmoidoscopy

MRI of the pelvis without and with IV contrast
Deep abscess
Determine the location and extent of the abscess

Question 17

Abcess

Tx

Answer 17

Incision & Drainage
Promptly performed
Superficial – in-office procedure
Deep – operating room procedure

Antibiotics
Febrile, immunocompromised, diabetic, or marked cellulitis is present
Cipro 500 mg IV every 12 hours plus metronidazole 500 mg IV every 8 hours
Ampicillin/sulbactam (Unasyn) 1.5 g IV every 8 hours

Question 18

Fistula

general

Answer 18

Abnormal connection or passageway that connects two organs or vessels that do not usually connect

Question 19

Hemorrhoids

general

Answer 19

Normal swollen vascular structures in the anorectal canal

Vascular cushions that assist with stool passage:
Composed of vascular tissue, smooth muscle, and connective tissue

Do not cause issues unless they are enlarged, inflamed, thrombosed, or prolapsed
Prevalence increases with age

Peak at 45–65 years old
Hemorrhoids affect up to 10 million patients in the United States annually
About 40% of patients are asymptomatic
1/3 people seek medical care

Question 20

hemorrhoids

RF

Answer 20

Chronic diarrhea
Chronic constipation (straining)
Inflammatory bowel disease
Obesity
Pregnancy
Prolonged sitting
Heavy lifting
Hypertension
Portal hypertension

Question 21

External Hemorrhoids

general

Answer 21

Below the dentate (pectinate) line
Arise from the inferior (external) hemorrhoidal plexus
Covered by modified squamous epithelium with somatic pain receptors

Question 22

External Hemorrhoids

Acute thrombosis pathogenesis

Answer 22

Extreme pain caused by skin distention and edema
Caused by straining, diarrhea, or constipation
Can persist as excess skin tags after healing
Usually last 7–14 days

Question 23

Internal Hemorrhoids

general

Answer 23

Above the dentate line
Unclear pathogenesis; possible theories include:
Deterioration of connective tissue anchoring hemorrhoids
Hypertrophy or increased internal anal sphincter tone
Abnormal arteriovenous distention within hemorrhoidal cushions
Abnormal dilation of internal hemorrhoidal venous plexus

Not supplied by somatic sensory nerves → usually painless

Question 24

# External Hemorrhoids Clin man

Answer 24

Acute perianal pain (without bleeding) with associated bowel movement Likely from acute thrombosis (purplish) Prolapsed or strangulated hemorrhoids  **Painful** mass at the rectum or feeling of fullness  May also have nontender skin tags (redundant fibrotic skin) near the rectum **Itching** – ↑ sebaceous gland secretions

Question 25

# Internal Hemorrhoids clin man

Answer 25

Usually **painless, with bright red blood** from rectum **associated with bowel movement** Can be associated with mucous discharge and itching of perianal skin  May have associated fecal incontinence and leakage  Wetness or fullness sensation at the perianal area for prolapsed internal hemorrhoid **Rectal bleeding in patient ≥ 40 years should be attributed to hemorrhoids only after more serious conditions are excluded by sigmoidoscopy or colonoscopy**

Question 26

Question 27

# Internal Hemorrhoids Grading

Answer 27

Grade I: prominent hemorrhoidal vessels **without prolapse** Grade II: **prolapse with Valsalva** maneuver with spontaneous reduction Grade III: prolapse with Valsalva maneuver with **manual reduction** Grade IV: chronically prolapsed with ineffective manual reduction (**incarcerated = unreducible**)

Question 28

# hemorrhoids Dx

Answer 28

Made **clinically** on physical examination for **external hemorrhoids** Best patient position: left lateral decubitus, knees to chest May be made clinically on **digital rectal examination for internal hemorrhoids** Anoscopy Used when no hemorrhoid is detected on physical examination Allows for evaluation of the anal canal and distal rectum How to do Anoscopy https://www.merckmanuals.com/professional/multimedia/video/v23370794

Question 29

# hemorrhoids Tx

Answer 29

Emergency care: **Excise acutely thrombosed external hemorrhoids** Instill local anesthetic and create elliptical excision of thrombosed hemorrhoid **If 72 hours or more after onset of symptoms → conservative management** Hemorrhoidal Thrombectomy https://www.merckmanuals.com/professional/multimedia/video/v23370801 **Treat only symptomatic patients** Conservative management Counsel patients on dietary modifications (avoiding fatty foods; increased fiber) Improve toilet habits with no prolonged sitting Sitz baths -Warm, NOT HOT, for 10-15 minutes after each bowel movement and as needed for relief Stool softeners (docusate sodium) Topical analgesics (benzocaine, xylocaine, lidocaine) Topical corticosteroids for up to 1 week Topical nifedipine and nitroglycerin to relieve anal sphincter spasms

Question 30

# hemorrhoids nonsurgical procedures

Answer 30

For grades I and II internal hemorrhoids that do not respond to conservative management Rubber band ligation Band ligature passed via anoscope; causes tissue necrosis Hemorrhoid sloughs off in 1–2 weeks Electrocautery Cryotherapy Sclerotherapy

Question 31

# hemorrhoids Surgical Treatment indications

Answer 31

Hemorrhoidectomy Indications: Symptomatic grade III and IV hemorrhoids or severe external hemorrhoids Other treatments have failed Open approach or minimally invasive laser approach

Question 32

# hemorrhoids Key Points

Answer 32

External hemorrhoids may thrombose and become very painful, but rarely bleed Internal hemorrhoids often bleed, but are not often painful Stool softeners, topical treatments, and analgesics are usually adequate treatment for **external hemorrhoids** Bleeding **internal hemorrhoids** may require injection sclerotherapy, rubber band ligation, or infrared photocoagulation Surgery is a last resort

Question 33

Internal or External Hemorrhoid? Treatment?

Answer 33

excision, external