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Anorectal Disease Flashcards

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1
Q

Anorectal Disorders

A 
Anal fissures
Anal fistulas
Hemorrhoids
Rectal prolapse
Pilonidal disease
Pruritus ani
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2
Q

Define Anal Fissures

A

Painful linear tear or crack in the distal anal canal

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3
Q

Etiology of Anal Fissures

A

Trauma to anal canal: defecation, straining, constipation

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4
Q

Clinical Presentation of Anal Fissures

A

Complaint of severe tearing pain during defecation

Mild associated hematochezia

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5
Q

PE for Anal Fissures

A

Visual inspection of the anus

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6
Q

Appearance of Acute Anal Fissures

A

Cracks in the epithelium

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7
Q

Appearance of Chronic Anal Fissures

A

Fibrosis & development of a skin tag

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8
Q

First-Line Treatment of Anal Fissures

A

Fiber supplements
Stool softeners
Sitz baths

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9
Q

Second-line Treatment of Anal Fissures

A 
0.4% nitroglycerin ointment
Botulinum toxin (Botox)
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10
Q

SE of 0.4% Nitroglycerin Ointment

A

Headache

Dizziness

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11
Q

Last Option for the Treatment of Anal Fissures

A

Internal anal sphincterotomy

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12
Q

Location of Perianal Abscess

A

Anal glands at the base of the rectum become infected

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13
Q

Causes of Perianal Abscess

A

Anal fissure/fistulas
Hemorrhoids
Blocked anal glands

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14
Q

Risk Factors of Perianal Abscess

A 
Colitis
IBD
DM2
Mean age: 40 y.o.
Women > Men
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15
Q

Clinical Presentation of Perianal Abscess

A

Constant pain
Swelling & redness around the anus
Discharge of pus around the anus
Painful bowel movements

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16
Q

Deeper Perianal Abscess Clinical Presentation

A

Same as “normal” perianal abscess
Fever
Chills
Malaise

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17
Q

Laboratory Studies for Perianal Abscess

A

Wound Cultures

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18
Q

Treatment of Perianal Abscess

A

I&D
Pacing & return in 24 hours
Sitz baths TID & post BM
Follow up for inspection for possible fistula formation

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19
Q

Etiology of Anal Fistula

A

Anorectal abscess
Crohn’s
Radiation proctitis

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20
Q

Clinical Presentation of Anal Fistula

A

Hx of drained abscess
Anorectal pain
Purulent drainage & irritation from the skin

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21
Q

PE for Anal Fistula

A

Identification of external opening that drains pus, blood, or stool
DRE may express pus or stool from opening

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22
Q

Treatment of Anal Fistula

A

Fistulotomy
Complex fistulas: fibrin glue
fistula plug

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23
Q

Define Pruritus Ani

A

Perianal itching or discomfort

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24
Q

Causes of Pruritius Ani

A 
Idiopathic
Hygiene related
Fistulas/fissures
Fecal incontinence
Parasites
Lichens sclerosis
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25
PE of Pruritus Ani
Inspection may reveal anal excoriations & erythema Hygiene issues Thickened or leathery skin Anoscopy
26
Treatment & Prevention for Pruritus Ani
Treat underlying cause Avoid spicy & acidic foods After BM, clean with wipes Place gauze or cotton ball next to anal opening Talcum powder Use zinc oxide or hydrocortisone ointment
27
Define Rectal Prolapse
Painless protrusion of the rectum through the anus
28
Most Common Individuals that have Rectal Prolapse
Women >50 Infants CF patients
29
Symptoms of Rectal Prolapse
Feeling a bulge or appearance of reddish-colored mass outside the anus Pain in the anus or rectum Leakage of blood or stool
30
Causes of Rectal Prolapse
``` Chronic constipation or diarrhea Straining during BM Weakness of anal sphincter Damage to nerves Pregnancy Back surgery Women >40 ```
31
Diagnosis of Rectal Prolapse
``` Anal EMG Anal manometry Anal ultrasound Colonoscopy Proctosigmoidoscopy ```
32
Treatment of Rectal Prolapse
Stool softeners Pushing rectum back up into the anus Abdominal repair Rectal repair
33
Recovery of Surgery in Rectal Prolapse
Hospitalization 3-5 days | Complete recovery in 3 months
34
Define Pilonidal Cyst
Cyst near the natal cleft of the buttocks that often contain hair or skin debris
35
Risk Factors of Pilonidal Cyst
``` Hair punctures skin & becomes embedded Hairy young men Prolonged sitting Obesity Local trauma/irritation ```
36
Clinical Presentation of Pilonidal Cyst
Pain Erythema & swelling of the skin Drainage of foul smelling pus or blood from the opening skin
37
Treatment & Prevention of Pilonidal Cyst
I&D Surgical cyst removal Antibiotics in the case of cellulitis
38
Antibiotic options in Pilonidal Cyst
1st generation cephalosporin (cefazolin) + metronidazole (Flagyl)
39
Define Hemorrhoids
Dilated veins of the hemorrhoidal plexus in the lower rectum
40
Define External Hemorrhoids
Below edentate line consisting of squamous cells
41
Define Internal Hemorrhoids
Internal edentate line consisting of anal mucosal
42
Classification of Hemorrhoids
Grade 1: hemorrhoids that do not prolapse Grade 2: Hemorrhoids prolapse on defecation & reduce spontaneously Grade 3: hemorrhoids prolapse on defecation & reduce manually Grade 4: hemorrhoids are prolapse & cannot be reduce manually
43
Causes of Hemorrhoids
``` Pregnancy Frequency heavy lifting Repeated straining during defecation Constipation Prolonged sitting Obesity ```
44
Clinical Presentation of External Hemorrhoids
``` Painful/purplish swelling Rarely ulcerate & cause minor bleeding Resolves in 2-3 days Swelling lasts a few weeks Itchiness around anus ```
45
Clinical Presentation of Internal Hemorrhoids
Bleeding after defecation Mucous & fecal incontinence Itchiness
46
Clinical Presentation of Strangulated Hemorrhoids
Very painful Ulceration Necrosis
47
Diagnosis of Hemorrhoids
Anoscopy | Sigmoidoscopy or colonoscopy
48
Treatment of Hemorrhoids
``` Stool softeners/fiber Sitz baths after BM Anesthetic ointments Banding Surgical ```
49
Key Points of Hemorrhoids
External may thrombus & become painful Internal often bleed and not painful Stool softeners, topical treatments, & analgesics usually adequate for external Bleeding internal may require injection or rubber band ligation Surgery last resort
50
Define Hernias
Protrusion, bulge, or projection of an organ or part of an organ through the body wall that normally contains it
51
When does a hernia become a medical & surgical emergency?
When the blood supply is cut off at the hernia opening in the abdominal wall
52
Types of Hernias
``` Inguinal Umbilical incisional/Ventral Epigastric Femoral Spigelian ```
53
Where is an epigastric hernia?
Upper abdomen at midline
54
Where is an incisional hernia?
At site of previous surgical incision
55
Where is an umbilical hernia?
At the naval
56
Where is a direct inguinal hernia?
Near the opening of the inguinal canal
57
Where is an indirect inguinal hernia?
At the opening of the inguinal canal
58
Where is a femoral hernia?
In the femoral canal
59
What is the most common type of hernia?
Inguinal hernia
60
Why are inguinal hernias so prominent?
Weak area occurs in the inguinal canal where the spermatic cord or round ligament exits the abdomen
61
Risk Factors for Inguinal Hernia
``` Hx of hernia or repair Chronic cough or constipation Abdominal wall injury Smoking Older age ```
62
What are the 2 types of inguinal hernias?
Indirect | Direct
63
Indirect Inguinal Hernia
Protrudes through internal inguinal ring Hearnia sac located lateral to inferior epigastric artery May protrude into the scrotum Mor common as people age
64
Direct Inguinal Hernia
Protrude medial to inferior epigastric vessels Result of weakness in the floor of the inguinal canal Rarely protrude into scrotum Almost always in older individuals
65
Boundaries of Hesselbach Triangle
Laterally: inferior epigastric artery Medially: lateral border or rectus abdominis Inferiorly: inguinal ligament
66
Femoral Hernia
Located inferior to the inguinal ligament & protrudes through femoral ring More common in women Least common type of groin hernia High chance of strangulation
67
Clinical Presentation of an Inguinal Hernia
``` Painless bulge in groin or scrotum Groin discomfort or pain Swelling or tugging in the groin Sudden pain (strangulated) N/V (strangulated) ```
68
PE for an Inguinal Hernia
Bulge in groin Patient standing and Valsava Reducible vs. irreducible Strangulation
69
Clinical Manifestation of a Strangulated Hernia
Irreducible Painful to palpation N/V Appear ill with or without fever
70
Diagnosis of Inguinal Hernia
H&P Ultrasound CT/MRI
71
Treatment of Inguinal Hernia
Watchful waiting TRUSS Surgical (open or lap repair)
72
Define Umbilical Hernia
Outward bulging of the lining of the abdomen or abdominal organs around the umbilicus
73
Causes of Umbilical Hernias
``` Muscle through which the umbilical cord passes doesn't close completely after birth Obesity Multiple pregnancies Ascites Previous abdominal surgery ```
74
Clinical Presentation of an Umbilical Hernia
Soft swelling or bulge near umbilicus Infant: noticeable when baby cries, coughs, or strains Adults: abdominal discomfort, bulging with straining or coughing Can become strangulated
75
PE for Umbilical Hernia
Found on exam
76
Treatment of an Umbilical Hernia
Surgery with or without mesh
77
Define Incision or Ventral Hernia
Abdominal surgery causes a flaw in the abdominal wall that must heal on its own
78
Define Epigastric Hernia
Hernia that develops int he epigastrium between the breast bone and belly button
79
Risk Factors for an Epigastric Hernia
Obesity | Pregnancy
80
Define Spigelian Hernia
Hernia through the spigelian fascia
81
Risk of Strangulation in a Spigelian Hernia
High due to small size
82
Clinical Presentation of Spigelian Hernia
Intermittent mass Localized pain N/V
83
Diagnostics of Spigelian Hernia
Ultrasound
84
Treatment of Spigelian Hernia
Surgery
85
Differential Diagnosis of Acute Abdominal Pain
``` AAA Mesenteric ischemia Perforation of GI tract Acute bowel obstruction Volvulus Ectopic pregnancy MI Splenic rupture ```
86
Pathophysiology of an Acute Abdomen
Visceral pain Somatic pain Referred pain Peritonitis
87
Visceral Pain in an Acute Abdomen
Respond to sensations of dissension & muscular contraction Pain typically vague, dull, & nauseating
88
Somatic Pain in an Acute Abdomen
Respond to irritation from infection, chemical, & inflammatory process Pain sharp & well localized
89
Referred Pain in an Acute Abdomen
Perceived distant from source | Results from convergence of nerve fibers at spinal cord
90
Define Peritonitis
Inflammation of the peritoneal cavity
91
Most Common Cause of Peritonitis
Perforated GI tract
92
Common Conditions of an Acute Abdomen
``` Appendicitis Biliary disease Pancreatitis Diverticular disease PUD Incarcerated hernia IBD IBS ```
93
Appendicitis
``` Anorexia Vague periumbilical discomfort that radiates to RLQ N/V Urinary symptoms Diarrhea ```
94
What is the most common extrauterine cause for abdominal pain in pregnant women?
Appendicitis
95
Biliary Disease
``` Acute cholecystitis RUQ or epigastric pain Radiate to right shoulder or back N/V Anorexia Murphy's sign Progress to septic shock Jaundice ```
96
Pancreatitis
Pain in LUQ Band-like radiation to back Maximum pain intensity within 10-20 minutes N/V common
97
Diverticular Disease
LLQ pain N/V +/- change in bowel habits
98
PUD
Epigastric pain Indigestion Reflux symptoms
99
Complications of PUD
Bleeding | Perforation
100
Incarcerated Hernia
Inguinal most common Severe pain Require immediate surgical consultation
101
Acute Complications of IBD
``` Pain Bleeding Perforation Bowel obstruction Fistula Abscess formation Toxic megacolon ```
102
IBS
Persistent symptoms for >3 months in 1 year Pain associated with change in stool frequency of consistency Pain received by BM
103
Evaluation of an Acute Abdomen
H&P will exclude all but a few causes Labs & imaging give final diagnosis Rule out life-threatening causes
104
Features of High Risk Abdominal Pain
``` >65 years old Immunocompromised Alcoholism CV disease Major comorbidities Prior surgery or recent GI instrumentation Early pregnancy Sudden onset pain Pain maximal at onset Pain + vomiting Constant pain ```
105
Important History
``` Age Sex PMHx SHx Meds Location of pain HPI Pregnancy test ```
106
Causes of RUQ Abdominal Pain
``` Hepatitis Cholecystitis Cholangitis Biliary colic Pancreatitis Budd-Chiari syndrome Pneumonia/empyema pleurisy Sub-diaphragmatic abscess ```
107
Causes of RLQ Abdominal Pain
``` Appendicitis Salpingitis Ectopic pregnancy Inguinal hernia Nephrolithiasis IBD Mesenteric adenitis ```
108
Causes of Epigastric Abdominal Pain
``` PUD GERD Gastritis Pancreatitis MI Pericarditis Ruptured aortic aneurysm ```
109
Causes of Peri-umbilical Abdominal Pain
Early appendicitis Gastroenteritis Bowel obstruction Rupture aortic aneurysm
110
Causes of LUQ Abdominal Pain
``` Splenic abscess Splenic infarct Gastritis Gastric ulcer Pancreatitis ```
111
Causes of LLQ Abdominal Pain
``` Diverticulitis Salpingitis Ectopic pregnancy Inguinal hernia Nephrolithiasis IBS IBD ```
112
Causes of Diffuse Abdominal Pain
``` Gastroenteritis Mesenteric ischemia Metabolic Malaria Familial Mediterranean fever Bowel obstruction Peritonitis IBS ```
113
PE of an Acute Abdomen
General appearance important Inspection, auscultation, palpation, & percussion of abdomen Rectal/pelvic exam Surgical scars should be palpated
114
Red Flags of an Acute Abdomen
Severe pain Signs of shock Signs of peritonitis Abdominal distention
115
Acute Abdomen Diagnostics
``` Urine pregnancy test Serum lipase Serum amylase Plain x-rays Ultrasound CT ```
116
Diagnostic Test of Choice in RUQ Pain
Ultrasound
117
Diagnostic Test of Choice in RLQ Pain
Ultrasound with IV contrast
118
Diagnostic Test of Choice in LLQ Pain
CT with oral & IV contrast
119
Diagnostic Test of Choice in LUQ Pain
Endoscopy Ultrasound CT
120
Diagnostic Test of Choice in Suprapubic Pain
Ultrasound
121
Key Points of an Acute Abdomen
Look for life-threatening causes first Rule out pregnancy Seek signs of peritonitis, shock, obstruction Lipase/amylase on good blood tests

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