Anorectal Conditions Flashcards
Rectal Anatomy Review
- levator ani
- Dentate Line
- Anal Crypts of Morgagni
- Columns of MOrgani
- internal sphoncter
- external sphicncter
Levator Ani: the major muscle of the pelvic floor; resonsible for structure and support of the rectum (not working = bowel and bladder issues)
weak peliv floor can lead to rectal and vaginal prolapse
Dentate Line: “Transition Zone” where above the line is mucosa and below the line is squamoud epithelium
Crypts & Columns of Morgani: where abcesses can form
Internal Sphincter: under autonomic control: abcess and fissures can form here
External Sphincter: under voluntary control; abcesses and fissures can form here too
the Anorectal Exam
- what do you do
when is a colposcope used
Anorectal Exam
- inspect
- palpate
- DRE always!!
- can do an anoscopy: to visualize internal
Colposcope: can be used to magnify and visulize the inside of the anus better
Anorectal Bleeding
- conditions to think
- how to do the exam
Conditions
- hemorrhoids
- fissures
- polyps
- diverticular disease
- IBD
- colorectal cancer!!!
Exam
- inspection
- DRE
- anoscopy
- no need for FOBT: work them up with the gross blood
colonoscopy!!
when to get a colonoscopy
- unexplained bleeding
- bleeding which continues despite treatment
- systemic signs (weight loss, IDA)
- age older than 40 (unless they had colonoscopy in last year)
- family history of colorectal cancer
Pruritus Ani (anal itching)
- conditions
- the do not miss conditions
most commonl due to hygeine or due to atopic derm with the itch-scratch cycle
Conditions (some)
- fissures
- incontinence
- caffeine
- abcess
- canidida
- STI
- chemo
- DM
- IBD
- topic irritants
DO NOT MISS
- perirectal abcess
- fistulua
- STIs
- Malignancy
- Systemic Disease ( aplastic anemia, DM, IBD, leukemia, lymphoma)
Anorectal Mass
- conditions
- evaluation
Conditions (mostly they are benign)
- condyloma (warts)
- abcess
- polyp
- rectal prolapse
- hemorrhoids
- anal cancer
Evaluation
- inspection
- DRE (if internal mass)
- anscopy
- can use colposcope if needed magnification
Anorectal Pains
- conditions
- evaluation
Conditions
- fissure
- abscess
- thorbosed external hemorrhoid
- proctitis
- perneal sepsis (foriners gangrene)
- proctalgia fugax (pain comes and goes)
Evaluation
- inspection (preinal and perineum)
- DRE
- Anoscopy
DRE and anoscopy may need to wait becuase of how bad pain is
- colonoscopy if the fissures visable are not midline (that triggers chrons)
- refer to surgery: deep absecces or fistula
Fecal Incontinence
Conditions
Evaluation
Conditions
- Overflow: usually due to an obstruction (only liquid can pass)
- Reserovir: dimished colonic or rectal capacity due to strictures, carring, or congenital issues
- structural or neurologic issues
- medication (laxiitives!)
- disk herniation in the sacral region
- vaginal devliery complications
- dementia
Evaluation
- inspection
- DRE (impaction or rectal toen dimminshed)
- anal manometry (rectal tone)
- colonoscopy (for mass or obstrcuction)
- US or MRI for sphincter defects
- MMI for dementia
Hemorrhoids
- Etiology
- causes
- symptoms (for the 2 kinds)
Etiology
most commoon benign anorectal bleeding cause
- venous drainage of the anus is altered, this increases the pressure on the veins & the tissue = dilation occurs ; leads to outgrowth of the mucosa from the wall as a result
Causes
- obesity (increased pressure on venous return)
- pregnancy
- chornic diarrhea
- anal intercourse
- cirrhosis wih ascites
- pelvic floor dysfunction
- low-fiber diet -> constipation - strain
Two Kinds of Hemorrhoids : Symptoms
External
- exisit below the dentate line
- painful!
- bleeding
- pruritus
Internal
- exisit above the dentate line
- painless (visceral innnervation) bleeding (streaks)
- prolapse/grape-like tissue
- soiling
Hemorrhoids
Grading
Treatment
Thrombosed Hemorrhoid
Grading
- Grade I: asymptomatic outgrowth of mucosa due to the venous plexus outgrowth
- Grade II: hemorrhoids prolapse but spontaneously reduces
- Grade III: heorrhoid prolapses and must be manualy reduced ; ithcy and soiling
- Grafe IV: heorrhoid prolapses and cannot be reduced
Treatment
Conservative Treatment
- high-fiber diet (to reduce need to strain)
- increased water intake
- warm water sitz bath
- stool softeners
Medical Treatment
- OTCs: astringets (witch hazel), corticosteroids and topical anestetics
- Rx: topical nitroglycerine or topical nifedipine
Surgical Managment
- Grade I-III: outpt. procedure
1. banding: (wrap it, falls off)
2. infared photocoagulation
- if the above fails, or Grade IV
1. surgical removal or the columns of the hemorrhoid
2. reduce the tissue allowing for prolapse to occur
3. minimize pain and complications
Thrombosed Hemmrrhoid
- extremely painful!
- need a hemorrhoidectomy in 72 hours for best outcomes
- incision and evacualtion of the clot if ^^cannot hapeen
Anal Fissures
Etiology
Symptoms
Diagnosis
Treatment
Etiology
- a thin tear in the anal tissue; due to straining, anal intercourse, low fiber diet, anal trauma or secondary to other diseases
Symptoms
Acute presenation (< 8 weeks) :
- painful; shards of glass
- bleeding after defication
Chronic Presentation ( > 8 weeks)
- sentinel skin tag seen along with tears (normally at the tip of the laceration)
- enlarged anal papilla
- multiple tears, or tears not in midline = think Chron’s Disease
Diagnosis
on exam…
- a tear in the mucosa from the dentate line to the anal verge (way distal) = seen on acute presentation
- internal examination (shouldnt be needed) but if so, sedate pt.
Treatment (most should resolve spontaneously)
- fiber & fluid intake to soften stool
- sitz bath
- topical nitroglycerin or nifedipine
surgical intervention: if emdical management not effective after 8-12 weeks
Perirectal Abscess
- Etiology
- locations of abscess
- Symptoms
- Diagnosis
- Treatment
Etiology
- painful swelling within the rectal area (usually infected)
Symptoms
- pain is worse with defication, sitting or pressure on the abscess
Location of Abscess
- Perianal: the abscess around the anal verge (most distla opening of the anus)
- Ischiorectal/ischioanal: on the bottck
- intersphincteric: no changes to the skin, mass is protruding into the rectum interally
- Supralevator absess: SEVERE PAIN, fever, urinary retention, suppartion above the anal ring & minial PE findings; see on CT or US
Diagnosis
on exam….
- erythema
- pain
- induration
- mass
Treatment
- if perianal: I & D
- if anywhere else: surgery
- everyone gets emperic anx: amox.-clav. or cipro + metronidazole
risk of fistual (50%) or sepsis
Fistula in Ano
- Etiology
- Symptoms
Etiology
- most commonly a result of an abscess complications : the abscess ruptures when drained & the epithelialized tract forms connections to abscess to other areas of perianal skin
other cuases (if not an abscess)
- Chron’s
- Obstetric trauma
- radiation proctitis (due to infection)
- rectal foregin body
- infection: lymphogranuloma venerum (due to chalymida)
- malingnancy
Symptoms
- pain
- mild bleeding
- discharge (watery, blood-tinged)
- on exam: see the draining sinus tracking
Diagnosis
- see the sinuses on exam
- still need imaging: MRI with and without contrast
- endoscopic US can also be done
- (do not do CT – wont see it)
Fistula in Ano
Treatment
what makes it a complicated fistula
Complicated Fistula
- vaginal anterior tracking
- multipel tracts
- recurrent fistual forming
- extrasphincteric
- proximal to the dentate line (traveling up)
- related to IBD
- related to HIV or TB
- local radiation
Treatment (only exploration under sedation can determine if it is simple or complex)
Conservative (for simple)
- sitz baths
- high fiber diet
- analgesics
Surgery (fistulotomy)
- complex
- non healting
- multiple risk factors for a complex to form
- surgery goal is to preserve fecal continence
Pilonidal Disease
Etiology
Symptoms
Diagnosis
treatment
Etiology
- an infection of skin and subcutaneous tissue at or near the upper part of the natal cleft
- not a “true cyst” since there is not epithelial lining : but the cavity contains debris and liklely to be infected
Risk Factors for Infection
- obeseity
- prolonged sedintary lifestlye/sititng
- trauma/irritation
- deep cleft
- family hx.
Symptoms
- can be asymptomatic
- chronically draining
- abscessed: fever, redness, pain, mass
Treatment
- if asymptomatic without signs of infection: observe
- if abscessed: I&D
- if recurrent: surgical excision
Procidentia (Rectal Prolapse)
Etiology
Symptoms
Etiology
- a circumferentail full thickness protrusion of the rectum through the anal sphincters
Risk Factors for Rectal Prolaspe
- age > 60
- female with pelvic floor dysfunction
- cystic fiberosis
- connective tissue disorder
- congenital hypothyroidism
- hirshsprung disease ( constipation related strain = prolapse)
- dementia
procidentia: full thickness of the colon to prolapse = see conccentric circles
mucosal prolapse: just the mucosal layer prolasping: see more of folds radiating
Symptoms
- mass: often with or after defecation
- constipation & straining = leads to the prolapse
- incontinence
- rectal bleeding
- por hygeine
