Flashcards in Anorectal Disease Deck (84):
Anal Fissures definition?
Painful linear tear or crack in the distal anal canal
Most common area of injury?
Usually from trauma to anal canal
Most commonly occur in the 12 or 6 O’clock area
Clinical presentation of anal fissures?
1. c/o severe tearing pain during defecation
2. Mild associated hematochezia
--Blood on stool or toilet paper
What confirms the Dx?
Confirmed by visual inspection of the anus
On PE what would we find for acute anal fissures?
1. Acute: look like cracks in the epithelium
2. Chronic: fibrosis and development of a skin tag
First line treatment for anal fissure? 3
Seond line treatment? 1
-0.4% nitroglycerin ointment
-Bid for 6-8 weeks
-Headaches and dizziness
-Botulinum toxin (Botox)
-Inject into internal anal sphincter
-Last about 3 months
-Internal anal sphincterotomy
-Risk is minor fecal incontinence
2. Appears as what?
3. Most common type?
1. Anal glands at the base of the rectum become infected
2. Appears as a boil-like swelling near the anus
3. Most common type is perianal abscess
1. Causes? 3
2. Risk factors? 3
-Blocked anal glands
2. Risk factors
-Inflammatory bowel disease
Perianal abcess Clinical presentation
Deeper abscesses present how?
1. Constant pain, throbbing and worse when sitting
2. Swelling and redness around the anus
3. Discharge of pus from around the anus
4. Painful bowel movements
1. Lab studies?
2. Treatment? 4
1. Laboratory studies
Wound cultures when I&D done
2. Packing and return in 24 hours
3. Sitz baths tid and after bowel movements
4. f/u in 2-3 weeks for wound evaluation and inspection for possible fistula formation
1. Anal fistula aka?
2. Usually results from what?
3. Etiology? 3
1. Also known as fistula-in-ano
2. Usually results from previous or current anal abscess
Anal Fistula Clinical presentation 3
1. History of drained abscess
2, Anorectal pain
3. Purulent drainage and irritation from the skin
1. Identification of the external opening that drains pus, blood or stool
2. DRE may express pus or stool from the opening
Treatment of anal fistula?
1. Fibrin glue
2. Fistula plug
1. What is this?
2. Characterized by what?
1. Perianal itching or discomfort
2. An itch-scratch-itch cycle
--Skin becomes excoriated and secondary infections
Causes of Pruritis Ani?
2. Hygiene related
4. Fecal incontinence
6. Lichens sclerosis
1. Inspection of the area may reveal anal excoriations and erythema
2. Hygiene issues
3. Chronic issues show thickened or leathery skin
Pruritis treatment and prevention
1. Treat underlying cause
2. Avoid spicy and acidic foods
3. After BM clean with unscented wipes
4. Place gauze or cotton ball next to anal opening
5. Talcum powder
6. Use zinc oxide or hydrocortisone ointment
1. Rectal Prolapse aka?
2. What is it?
3. Common in who? 3
1. Also called Rectal Procidentia
2. Painless protrusion of the rectum through the anus
-Common in older adults with long history of constipation and weak pelvic floor muscles
-More common in women over age 50
-Can also occur in infants
Rectal Prolapse symptoms?
1. Feeling a bulge or appearance of reddish-colored mass that extends outside the anus
2. Pain in the anus or rectum
3. Leakage of blood or stool
Causes of rectal prolapse? 4
1. Chronic constipation or diarrhea
2. Straining during BM
3. Weakness of the anal sphincter
4. Damage to nerves
Diagnosis of rectal prolapse? 5
1. Anal EMG
2. Anal manometry
3. Anal ultrasound
Rectal prolapse Treatment? 2
1. Treat first at home with stool softeners and pushing the fallen tissue back up into the anus by hand
Rectal prolapse surgeries? 2
Recovery consists of? 2
-Rectal (perineal) repair
-3-5 hospital stay
-Complete recovery in 3 months
1. What is a Pilonidal Cyst?
2. Usually happens how?
3. Occurs in who?
4. Risk factors?
1. Cyst near the natal cleft of the buttocks that often contains hair or skin debris
2. Usually happens when hair punctures the skin and becomes embedded
3. Occurs in hairy young men
4. Sitting for long periods of time can be a risk
1. Clinical presentation? 3
2. Risk factors? 3
2. Erythema and swelling of the skin
3. Drainage of foul smelling pus or blood from the opening of the skin
2. Prolonged sitting
3. Local trauma/irritation
Treatment and prevention
1. I & D cyst first
--May need to leave open or pack to heal
2. If reoccurs will need surgical cyst removal
1. Usually in the setting of what?
2. What kind of antibiotics for Pilonidal cyst? 2
1. Usually in setting of cellulitis
2. First generation cephalosporin (cefazolin) plus metronidazole (Flagyl)
1. What are hemorrhoids?
2. Arise from where?
3. What are the two different kinds?
1. Are dilated veins of the hemorrhiodal plexus in the lower rectum
- Normal vascular structures in the anal canal
2. Arise from a channel of arteriovenous connective tissue that drains into the superior and inferior hemorrhoidal veins
Classification of Hemorrhoids?
Describe grades I-IV?
1. Grade I
Hemorrhoids that do not prolapse
2. Grade II
Hemorrhoids prolapse on defecation and reduce spontaneously
3. Grade III
Hemorrhoids prolapse on defecation and must be reduced manually
4. Grade IV
Hemorrhoids are prolapsed and cannot be reduced manually
2. Frequent heavy lifting
3. Repeated straining during defecation
1. Most often they present how? 2
2. External hemorrhoids may become thrombosed
-Whats it look like?
-Usually resolves when?
-Swelling lasts how long?
-Can have what symptom around the anus?
-Often asymptomatic or
-may simply protrude
-Painful and purplish swelling
-Rarely ulcerate and cause minor bleeding
-Usually resolves in 2-3 days
-Swelling last a few weeks
-Can have itchiness around the anus
1. Internal hemorrhoids manifest how?
2. 3 main symptoms?
1. with bleeding after defecation
-On stool or TP
-Mucous and fecal incontinence
What are Strangulated hemorrhoids?
strangulated hemorrhoid an internal hemorrhoid that has prolapsed sufficiently and for a long enough time for its blood supply to become occluded by the constricting action of the anal sphincter.
Diagnosis of hemorrhoids? 2
2. Sometimes sigmoidoscopy or colonoscopy
Treatment of hemorrhoids
1. First line 3
2. Second line?
3. Third line?
1. Symptomatic treatment is usually all that is needed
-Sitz baths after BM
2. Second-line would be banding if conservative treatment is unsuccessful
3. Third-line would be surgical
1. Hernia definition?
2. They are usually harmless but what can cause serious complications?
3. When does it become a medical and surgical emergency?
1. A protrusion, bulge, or projection of an organ or part of an organ through the body wall that normally contains it
2. Hernias by themselves usually are harmless, but nearly all have potential risk of having their blood supply cut off (becoming strangulated)
3. If the blood supply is cut off at the hernia opening in the abdominal wall
Types of hernias?
3. Incisional /Ventral
What are the following found:
3. Incisional /Ventral
-Direct- near the opening of the inguinal canal
-Indirect- At the opening of the inguinal canal
2. Umbilical- at the navel
3. Incisional /Ventral- at the site of a previous surgery
4. Epigastric- upper abdomen at the midline
5. Femoral- Occur in the femoral canal
What is the most common type of hernia in adults?
1. What is it?
2. Risk factors? 3
Weak area occurs in the inguinal canal where the spermatic cord or round ligament exits the abdomen
1. History of hernia or repair
2. Chronic cough or constipation
3. Abdominal wall injury
Whats the most common type of inguinal hernia?
Indirect inguinal hernias
1. Hernia protrudes where?
2. Hernia sac is located where?
3. Sometimes it can protrude into where?
4. More common in who?
1. Hernia protrudes through the internal inguinal ring
2. Hernia sac is located lateral to the inferior epigastric artery
3. Sometimes the hernia will protrude into the scrotum
4. Can occur at any age, but becomes more common as people age
1. Protrudes where?
2. It is a result of what?
3. Rarely protrudes where?
4. Almost exclusively occurs in what people?
1. Protrude medial to the inferior epigastric vessels within the Hesselbach’s triangle
2. Result of a weakness in the floor of the inguinal canal
3. Rarely protrude into the scrotum
4. Almost always occur in older individuals as their abdominal walls weaken with age and stretching
What are the boundaries of Hesselbach triangle:
1. inferior epigastric artery
2. lateral border or restus abdominis
3. Base/Inguinal ligament
1. Where is a femoral hernia located?
2. More common in what gender?
3. Least common type of groin hernia but has a high chance of what?
1. Hernia located inferior to the inguinal ligament and protrudes through the femoral ring
2. More common in women
Inguinal hernias clinical presentation?
1. Painless bulge in the groin or scrotum
2. Groin discomfort of pain
3. Swelling or tugging in the groin
When would you be concerned that the hernia has strangulated?
1. Sudden pain,
PE inguinal hernia:
1. Most common finding is what?
2. Exam best done when?
1. Bulge in groin
2. Exam best done with patient standing and asking them to cough or Valsalva
On PE what signs would tell us its a strangulated inguinal hernia?
2. Painful to palpation
4. Patient may appear ill with or without fever
1. Usually done with history and exam
2. Not apparent, then initial study is groin ultrasound
1. nonsurgical? 2
2. Surgical? 2
1. Watchful waiting
1. Open repair
2. Laparoscopic repair
1. Umbilical hernia is what?
2. More common in what population?
1. An outward bulging of the lining of the abdomen or abdominal organs around the belly button
2. More common in infants
Causes of umbilical hernia?
Muscle through which the umbilical cord passes doesn’t close completely after birth
1. Clinical presentation?
2. Only infants?
3. Adults? 2
1. A soft swelling or bulge near the umbilicus
2. In infants
More noticeable when baby cries, coughs or strains
-May cause abdominal discomfort
-Bulging with straining or coughing
Umbilical hernia causes?
2. Multiple pregnancies
3. Fluid in abdominal cavity (ascites)
4. Previous abdominal surgery
1. What is a incisional/ventral hernia?
2. Describe reoccurrence after repair?
3. What has shown to help with this?
1. Abdominal surgery causes a flaw in the abdominal wall that must heal on its own
--This flaw can create an area of weakness where a hernia may develop
2. After surgical repair they have a high reoccurrence rate (20-45%)
3. Use of mesh has helped
1. What is an epigastric hernia?
2. What age group?
3. What may cause discomfort with this?
4. Risks for this are what? 2
1. A type of hernia that develops in the epigastrium between the breast bone and belly button
2. Usually appear in adults
3. May trap fat and other tissues which cause discomfort
4. Risk are
1. What is a spigelian hernia?
2. Presentation? 6
3. Diagnosed how?
4. Treated how?
1. Hernia through the spigelian fascia
-Often no notable swelling
-Risk of strangulation is high due to small size
-Most occur on right side
-localized pain, or
3. Diagnosed made with ultrasound
4. Surgery is the treatment of choice
Acute abdominal pain:
Which populations pose the most diagnostic challenge?
1. The elderly,
2. immunocompromised and
3. women of childbearing age
pose special diagnostic challenges
DDx: Immediate life threatening conditions?
2. Mesenteric ischemia
3. Perforation of GI tract
4. Acute bowel obstruction
6. Ectopic pregnancy
8. Splenic rupture
Pathophysiology of visceral pain:
1. Where is it coming from?
2. Innervated by what?
3. Responds to sensations of what? 2
4. Describe the pain.
1. From abdominal viscera
2. Innervated by autonomic nerve fibers
3. Respond to sensations of
4. Pain is typically vague, dull and nauseating
Pathophysiology of Somatic pain:
1. Where is it coming from?
2. Innervated by what?
3. Responds to sensations of what? 3
4. Describe the pain.
1. From parietal peritoneum
2. Innervated by somatic nerves
3. Respond to
-irritation from infection,
4. Pain is sharp and well localized
Pathophysiology of referred pain:
1. Pain is percieved where?
2. Results from what?
1. Pain perceived distant from its source
2. Results from convergence of nerve fibers at the spinal cord
Pathophysiology of peritonitis:
1. Caused by what?
2. What are the most serious cases that cause this?
3. Causes fluid shift into the peritoneal cavity and bowel, leads to what? 2
1. Inflammation of the peritoneal cavity
2. Most serious cause is perforation of GI tract (Blood)
-severe dehydration and
Most common extrauterine cause for abdominal surgery in pregnant women?
1. First symptoms? 3
2. Leads to?
3. What kind presents with urinary symtpoms and diarrhea?
-vague periumbilical discomfort that
-develops into RLQ pain
2. N/V generally not first symptoms
3. Pelvic appendix can present with urinary symptoms and diarrhea
1. Acute cholecystitis complain of RUQ or epigastrium pain
2. Pain may radiate to right shoulder or back
3. N/V and anorexia
4. Murphy’s sign may be present
Progress seriously to what?
Progression of septic shock can occur
1. Pain is steady in upper abdomen
2. Band-like radiation to the back is common
3. Pain often reaches maximum intensity within 10-20 minutes of onset
4. N/V common
1. Most common complaint?
2. Other symptoms? 2
1. LLQ pain most common complaint
+/- change in bowel habits
Peptic ulcer disease
1. Symptoms? 3
2. Complications? 2
1. What is the most common?
2. Cause what kind of symptoms and should be managed how?
1. Inguinal are most common with mild lower abdominal discomfort exacerbated by straining
2. Incarcerated hernias cause severe pain and require immediate surgical consultation
Complications of Inflammatory bowel disease?
4. bowel obstruction,
5. fistula and abscess formation
6. toxic megacolon
Irritable bowel syndrome
1. Symptoms need to last how long for diagnosis?
1. Symptoms need to persist for 3 months over a one year period
2. Abdominal pain associated with change in stool frequency or consistency
Features of high risk abdominal pain:
1. History? 7
2. Pain characteristic? 4
3. Exam findings? 3
-Age over 65
-Prior sugery or recent GI instrumentation
-Maximal at onset
-Pain then subsequent vomiting
-Constant pain of less than two days duration
-Tense or rigid abdomen
-Signs of shock
Important History for acute abdomen pain?
3. PMHX & SHX
5. Characterize pain as precisely as possible
6. Women of childbearing age pregnancy status must be determined
See slide 99
See slide 99
PE for acute abdomen pain?
1. General appearance is important
2. Begin with inspection and auscultation
3. Followed by palpation and percussion
4. Rectal and pelvic exam
5. Palpation begins away from area of greatest pain
6. Look for guarding, rigidity and rebound
7. Surgical scars should be palpated
Red flags on physical exam?
1. Severe pain
2. Signs of shock
3. Signs of peritonitis
4. Abdominal distention
Acute abdominal pain testing?
1. Urine pregnancy test for all women of childbearing age
2. Serum lipase and amylase strongly suggest diagnosis of acute pancreatitis
3. Plain x-rays
CBC, chemistries, UA are of little value
What are plain xrays good for in abdominal pain assessment?
1. bowel obstruction,
2. bowel perforation,
3. radiopaque foreign body
What are US good for in abdominal pain assessment?
1. Biliary tract disease
2. Ectopic pregnancy
3. Appendicitis in children
What are CT good for in abdominal pain assessment?
Study of choice in evaluation of
undifferentiated abdominal pain
CT with oral and IV contrast is diagnostic in about 95% of patients with significant abdominal pain