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Flashcards in Anorectal Disease Deck (84):
1

Anal Fissures definition?

Painful linear tear or crack in the distal anal canal

2

Etiologies 3

Most common area of injury?

Usually from trauma to anal canal
1. Defecation
2. Straining
3. Constipation

Most commonly occur in the 12 or 6 O’clock area

3

Clinical presentation of anal fissures?
2

1. c/o severe tearing pain during defecation
2. Mild associated hematochezia
--Blood on stool or toilet paper

4

Anal Fissure
What confirms the Dx?

PE:
Confirmed by visual inspection of the anus

5

On PE what would we find for acute anal fissures?

Chronic?

1. Acute: look like cracks in the epithelium

2. Chronic: fibrosis and development of a skin tag

6

First line treatment for anal fissure? 3

Seond line treatment? 1

SE? 6

1. First-line
-Fiber supplements,
-stool softeners
-sitz baths

2. Second-line
-0.4% nitroglycerin ointment
-Bid for 6-8 weeks

3. SE
-Headaches and dizziness
-Botulinum toxin (Botox)
-Inject into internal anal sphincter
-Last about 3 months
-Internal anal sphincterotomy
-Risk is minor fecal incontinence

7

Perianal abscess
1. PP?
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

8

Perianal abscess
1. Causes? 3
2. Risk factors? 3

1. Causes
-Anal fissure/fistulas
-hemorrhoids
-Blocked anal glands

2. Risk factors
-Colitis
-Inflammatory bowel disease
-DM2

9

Perianal abcess Clinical presentation
4

Deeper abscesses present how?
3

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. Fever
2. Chills
3. malaise

10

Perianal abscess
1. Lab studies?
2. Treatment? 4

1. Laboratory studies
Wound cultures when I&D done

Treatment
1. I&D
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

11

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

3. Etiology
-Anorectal abscess
-Crohn’s
-Radiation proctitis

12

Anal Fistula Clinical presentation 3

PE
2

Clinical presentation
1. History of drained abscess
2, Anorectal pain
3. Purulent drainage and irritation from the skin

PE
1. Identification of the external opening that drains pus, blood or stool
2. DRE may express pus or stool from the opening

13

Treatment of anal fistula?
1

Complex fistulas?
2

Treatment
1. Fistulotomy

Complex fistulas
1. Fibrin glue
2. Fistula plug

14

Pruritus Ani
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

15

Causes of Pruritis Ani?
6

1. Idiopathic
2. Hygiene related
3. Fistulas/fissures
4. Fecal incontinence
5. Parasites
6. Lichens sclerosis

16

Prutitis PE?
4

1. Inspection of the area may reveal anal excoriations and erythema
2. Hygiene issues
3. Chronic issues show thickened or leathery skin
4. Anoscopy

17

Pruritis treatment and prevention
6

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


18

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
3.
-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

19

Rectal Prolapse symptoms?
3

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

20

Causes of rectal prolapse? 4

Causes
1. Chronic constipation or diarrhea
2. Straining during BM
3. Weakness of the anal sphincter
4. Damage to nerves

21

Diagnosis of rectal prolapse? 5

Diagnosis
1. Anal EMG
2. Anal manometry
3. Anal ultrasound
4. Colonoscopy
5. proctosigmoidoscopy

22

Rectal prolapse Treatment? 2

1. Treat first at home with stool softeners and pushing the fallen tissue back up into the anus by hand
2. Surgery

23

Rectal prolapse surgeries? 2

Recovery consists of? 2

1. Surgery
-Abdominal repair
-Rectal (perineal) repair

2. Recovery
-3-5 hospital stay
-Complete recovery in 3 months

24

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

25

Pilonidal cyst
1. Clinical presentation? 3
2. Risk factors? 3

Clinical presentation
1. Pain
2. Erythema and swelling of the skin
3. Drainage of foul smelling pus or blood from the opening of the skin

Risk factors
1. Obesity
2. Prolonged sitting
3. Local trauma/irritation

26

Pilonidal cyst
Treatment and prevention
3

1. I & D cyst first
--May need to leave open or pack to heal
2. If reoccurs will need surgical cyst removal
3. Antibiotics

27

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)

28

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

3.
-External hemorrhoids
-Internal hemorrhoids

29

Classification of Hemorrhoids?
Describe grades I-IV?

Classification
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

30

Hemorrhoids causes?
4

1. Pregnancy
2. Frequent heavy lifting
3. Repeated straining during defecation
4. Constipation

31

Clinical presentation
1. Most often they present how? 2

2. External hemorrhoids may become thrombosed
-Whats it look like?
-Complications? 2
-Usually resolves when?
-Swelling lasts how long?
-Can have what symptom around the anus?

1.
-Often asymptomatic or
-may simply protrude

2.
-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

32

1. Internal hemorrhoids manifest how?
2. 3 main symptoms?

1. with bleeding after defecation

2.
-On stool or TP
-Mucous and fecal incontinence
-Itchiness

33

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.

34

Diagnosis of hemorrhoids? 2

1. Anoscopy
2. Sometimes sigmoidoscopy or colonoscopy

35

Treatment of hemorrhoids
1. First line 3
2. Second line?
3. Third line?

1. Symptomatic treatment is usually all that is needed
-Stool softeners/Fiber
-Sitz baths after BM
-Anesthetic ointments

2. Second-line would be banding if conservative treatment is unsuccessful

3. Third-line would be surgical

36

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

37

Types of hernias?
6

1. Inguinal
2. Umbilical
3. Incisional /Ventral
4. Epigastric
5. Femoral
6. Spigelian

38

What are the following found:
1. Inguinal
2. Umbilical
3. Incisional /Ventral
4. Epigastric
5. Femoral

1. Inguinal
-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

39

What is the most common type of hernia in adults?

Inguinal hernia

40

Inguinal hernia
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

Risk factors
1. History of hernia or repair
2. Chronic cough or constipation
3. Abdominal wall injury
smoking

41

Whats the most common type of inguinal hernia?

indirect

42

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

43

Direct Inguinal
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

44

What are the boundaries of Hesselbach triangle:
1. Laterally?
2. Medially?
3. Inferiorly?

1. inferior epigastric artery
2. lateral border or restus abdominis
3. Base/Inguinal ligament

45

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
3. strangulation

46

Inguinal hernias clinical presentation?
3

1. Painless bulge in the groin or scrotum
2. Groin discomfort of pain
3. Swelling or tugging in the groin

47

When would you be concerned that the hernia has strangulated?
2

1. Sudden pain,
2. N/V

48

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

49

On PE what signs would tell us its a strangulated inguinal hernia?
4

1. Irreducible
2. Painful to palpation
3. N/V
4. Patient may appear ill with or without fever

50

Inguinal hernia
diagnosis?
3

1. Usually done with history and exam
2. Not apparent, then initial study is groin ultrasound
3. CT/MRI

51

Treatment inguinal
1. nonsurgical? 2
2. Surgical? 2

Non-surgical
1. Watchful waiting
2. TRUSS

Surgical
1. Open repair
2. Laparoscopic repair

52

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

53

Causes of umbilical hernia?

Muscle through which the umbilical cord passes doesn’t close completely after birth

54

Umbilical hernia:
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
3. Adults
-May cause abdominal discomfort
-Bulging with straining or coughing

55

Umbilical hernia causes?

4


Treatment?

1. Obesity
2. Multiple pregnancies
3. Fluid in abdominal cavity (ascites)
4. Previous abdominal surgery

Surgery
+/- mesh

56

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


Iatrogenic

57

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
-obesity and
-pregnancy

58

1. What is a spigelian hernia?
2. Presentation? 6
3. Diagnosed how?
4. Treated how?

Rare

1. Hernia through the spigelian fascia
2.
-Often no notable swelling
-Risk of strangulation is high due to small size
-Most occur on right side
-intermittent mass,
-localized pain, or
-N/V

3. Diagnosed made with ultrasound
4. Surgery is the treatment of choice

59

Acute abdominal pain:
Which populations pose the most diagnostic challenge?
3

1. The elderly,
2. immunocompromised and
3. women of childbearing age

pose special diagnostic challenges

60

Acute abdomen
DDx: Immediate life threatening conditions?
8

1. AAA
2. Mesenteric ischemia
3. Perforation of GI tract
4. Acute bowel obstruction
5. Volvulus
6. Ectopic pregnancy
7. MI
8. Splenic rupture

61

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
-distention and
-muscular contraction

4. Pain is typically vague, dull and nauseating

62

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,
-chemical and
-inflammatory process

4. Pain is sharp and well localized

63

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

64

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)
3.
-severe dehydration and
-electrolyte problems

65

Most common extrauterine cause for abdominal surgery in pregnant women?

Appendicitis

66

Appendicitis
1. First symptoms? 3
2. Leads to?
3. What kind presents with urinary symtpoms and diarrhea?

1.
-Anorexia and
-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

67

Biliary disease:
\Clinical presentation?
4

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

68

Biliary disease:
Progress seriously to what?

Progression of septic shock can occur

69

Pancreatitis:
Clinical presentation?
4

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

70

Diverticular disease:
1. Most common complaint?
2. Other symptoms? 2

1. LLQ pain most common complaint
2.
-N/V and
+/- change in bowel habits

71

Peptic ulcer disease
1. Symptoms? 3
2. Complications? 2

1.
-Epigastric pain,
-indigestion
-reflux symptoms

2. Complications
-Bleeding
-perforation

72

Incarcerated hernia
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

73

Complications of Inflammatory bowel disease?
6

1. pain,
2. bleeding,
3. perforation,
4. bowel obstruction,
5. fistula and abscess formation
6. toxic megacolon

74

Irritable bowel syndrome
1. Symptoms need to last how long for diagnosis?
2. presentation?

1. Symptoms need to persist for 3 months over a one year period
2. Abdominal pain associated with change in stool frequency or consistency

75

Features of high risk abdominal pain:
1. History? 7
2. Pain characteristic? 4
3. Exam findings? 3

1.
-Age over 65
-Immunocomprimised
-Alcoholism
-Cardiovascular dz
-Major comorbidities
-Prior sugery or recent GI instrumentation
-Early pregnancy

2.
-Sudden onset
-Maximal at onset
-Pain then subsequent vomiting
-Constant pain of less than two days duration

3.
-Tense or rigid abdomen
-Involuntary guarding
-Signs of shock

76

Important History for acute abdomen pain?
6

1. Age
2. Sex
3. PMHX & SHX
4. Meds
5. Characterize pain as precisely as possible
6. Women of childbearing age pregnancy status must be determined

77

See slide 99

See slide 99

78

PE for acute abdomen pain?
7

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

79

Red flags on physical exam?
4

Red flags
1. Severe pain
2. Signs of shock
3. Signs of peritonitis
4. Abdominal distention

80

Acute abdominal pain testing?
5

1. Urine pregnancy test for all women of childbearing age

Exception
2. Serum lipase and amylase strongly suggest diagnosis of acute pancreatitis

3. Plain x-rays
4. US
5. CT

CBC, chemistries, UA are of little value

81

What are plain xrays good for in abdominal pain assessment?
3

Helpful for
1. bowel obstruction,
2. bowel perforation,
3. radiopaque foreign body

82

What are US good for in abdominal pain assessment?
4

1. Biliary tract disease
2. Ectopic pregnancy
3. Appendicitis in children
4. AAA

83

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

84

What are the four important key points for acute abdominal pain?
4

1. Look for life-threatening causes first
2. Rule out pregnancy in women of childbearing age
3. Seek signs of peritonitis, shock, and obstruction
4. Blood test are of minimal value except specific labs