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Flashcards in Anorectal disease Deck (65):
1

What are anal fissures? etiology?

- painful linear tear or crack in distal anal canal
- etiology:
usually from trauma to anal canal through defecation, straining, constipation
- most commonly occur in 12 or 6 o'clock area
- if 3 or 9 o'clock presentation - crohns
- most are posterior

2

Clinical presentation of anal fissures? What will you see on PE?

- c/o severe tearing pain during defecation
- mild assoc hematochezia: blood on stool or tp
- PE:
confirmed by visual inspection of anus
acute: look like cracks in epithelium
chronic: fibrosis and development of skin tag

3

Tx of anal fissures?

- first line: fiber supps, stool softeners and sitz baths
- 2nd line: 0.4% nitroglycerin ointment (increases blood flow to area)
BID for 6-8 wks
SE: HAs and dizziness
- Botox: inject into internal anal sphincter, lasts for 3 months
- Last option: internal anal sphincterotomy - risk is minor fecal incontinence

4

What is a perianal abscess?

- anal glands at base of rectum become infected
- appears as boil like swelling near the anus
- most common typeL perianal abscess

5

Causes and RFs of perianal abscess?

- causes:
anal fissure/fistulas
hemorrhoids
blocked anal glands

- RFs:
colitis
IBD
DM2

6

Clinical presentation of perianal abscess?

- constant pain, throbbing and worse when sitting
- swelling and redness around the anus
- d/c of pus from around the anus
- painful BMs
- deeper abscesses: fever, chills and malaise
- these can travel to scrotum and lead to gangrene

7

Lab studies and tx of perianal abscesses?

- lab studies: wound cultures when I&D done
tx:
I&D
- packing and return in 24 hrs
- sitz baths tid and after BMs
- f/u in 2-3 wks for wound eval and inspection for possible fistula formation

8

What is an anal fistula? Etiologies?

- also known as fistula-in-ano
- usually results from previous or current anal abscess
- etiolgies:
anorectal abscess, crohn's, radiation proctitis

9

Clinical presentation of anal fistula? What will you see on PE?

- clinical presentation:
hx of drained abscess
anorectal pain
purulent drainage and irritation from skin

PE:
- ID of external opening that drains pus, blood or stool
- DRE may express pus or stool from opening

10

Tx of anal fistula?

- fistulotomy (cut out fistula)
- complex fistulas:
fibrin glue
fistula plug
(not as commonly used - cause infections)

11

What is pruritus ani? causes?

- perianal itching or discomfort
- an itch-scratch-itch cycle: skin becomes excoriated and secondary infections
- causes:
idiopathic
hygiene related
fistulas/fissures
fecal incontinence
parasites
lichens sclerosis

12

What will you see on PE of pt with pruritus ani?

-inspection of area may reveal anal excoriations and erythema
- hygiene issues
- chronic issues show thickened or leathery skin
- anoscopy

13

Tx and prevention of pruritus ani?

- tx underlying cause
- avoid spicy and acidic foods
- after BM clean with unscented wipes
- place gauze or cotton ball next to anal opening
- talcum powder
- use zinc oxide or hydrocortisone ointment

14

What is rectal prolapse?

- AKA rectal procidentia
- painless protrusion of rectum through the anus
- common in older adults with long hx of constipation and weak pelvic floor muscles
- more common in women over 50
- can also occur in infants - esp in CF

15

Sxs of rectal prolapse?

- feeling a bulge or appearance of reddish-colored mass that extends outside the anus
- pain in anus or rectum
- leakage of blood or stool

16

Causes of rectal prolapse?

- chronic constipation or diarrhea
- straining during BM
- weakness of anal sphincter
- damage to nerves

17

Dx rectal prolapse?

- PE
- anal EMG
- anal manometry: strength of muscles
- anal US
- colonoscopy
- proctosigmoidoscopy

18

Tx of rectal prolapse?

- tx first at home with stool softeners and pushing the fallen tissue back into anus by hand
- surgery:
abdominal repair
rectal (perineal) repair
- recovery:
3-5 days hosp. stay
complete recovery in 3 months

19

What is a pilonidal cyst?

- cyst near the natal cleft of buttocks that often contains hair or skin debris
- usually happens when hair punctures the skin and becomes embedded
- occurs in hairy young men
- sitting for long periods of time (truckers)

20

Clinical presentation of a pilonidal cyst?

- pain
- erythema and swelling of the skin
- drainage of foul smelling pus or blood from the opening of the skin

21

RFs for pilonidal cyst?

- obesity
- prolonged sitting
- local trauma/irritation
- deep natal cleft

22

Tx and prevention of pilonidal cysts?

- I&D cyst first: may need to leave open or pack to heal
- if reoccurs will need surgical cyst removal
- abxs:
usually in setting of cellulitis
use first gen cephalosporin (cefazolin) plus metronidazole (flagyl)

23

What are hemorrhoids?

- dilated veins of hemorrhoidal plexus in lower rectum
- normal vascular structures in anal canal
- arise from a channel of arteriovenous CT that drains into superior and inferior hemorrhoidal veins
- external hemorrhoids
- internal hemorrhoids (inside anus and/or rectum)

24

Classification of hemorrhoids?

- grade 1: hemorrhoids that don't prolapse
- grade 2: hemorrhoids prolapse on defecation and reduce spontaneously
- grade 3: hemorrhoids prolapse on defectation and must be reduced manually
- grade 4: are prolapsed and can't be reduced manually
these are likely to strangulate, very painful

25

Causes of hemorrhoids?

- pregnancy
- frequent heavy lifting
- repeated straining during defecation (low fiber diet)
- constipation

26

Clinical presentation of hemorrhoids? External and internal

- often asx or may simply protrude
external hemorrhoids may become thrombosed:
-painful and purplish swelling
-rarely ulcerate and cause minor bleeding
- usually resolves in 2-3 days
- swelling lasts a few weeks
- can have itchiness around anus

internal hemorrhoids: manifest with bleeding after defectation
- on stool or TP
- mucous and fecal incontinence
- itchiness

- strangulated hemorrhoids: blood flow constriction

27

How do you dx hemorrhoids? Tx?

dx:
- rectal exam
- anoscopy
- sometimes sigmoidoscopy or colonoscopy

tx:
- sx tx is usually all that is needed:
stool softeners/fiber
sitz baths after BM
anesthetic ointments
- 2nd line would be banding if conservative tx is unsuccessful
- 3rd line: surgical - excise and clot evacuation, stapled hemorrhoidectomy

28

Do external hemorrhoids usually bleed?

- no, they may thrombose and become very painful but they rarely bleed

29

Are internal hemorrhoids painful?

- no, often not painful
- they often bleed though

30

Tx for external hemorrhoids?

- stool softeners
- topical tx
- analgesics

31

Tx for bleeding internal hemorrhoids?

- may reqr injection
- rubber band ligation
- surgery is last resort

32

What is a hernia? What is a potential risk?

- a protrusion, bulge or projection of an organ or part of an organ through the body wall that normally contains it
- hernias by themselves usually are harmless but nearly all have potential risk of having their blood supply cut off (becoming strangulated)
- if blood supply is cut off at hernia opening in abdomina wall - it becomes a medical and surgical emergency

33

Types of hernias?

- inguinal
- umbilical
- incisional/ventral
- epigastric
- femoral
- spigelian

34

Most common type of hernia in adults? More common in men or women? RFs?

- inguinal hernia
- more common in men
- weak areas occurs in inguinal canal where spermatic cord or round ligament exits the abdomen

RFs:
-hx of hernia or repair
-chronic cough or constipation
-abdominal wall injury
-smoking: cough, bad tissue health

35

2 types of inguinal hernias?

indirect: most common
- hernia protrudes through internal inguinal ring
- hernia sac is located lateral to inferior epigastric artery
- sometimes hernia will protrude into scrotum
- can occur at any age, but becomes more common as you age

direct:
- protrude medial to inferior epigastric vessels w/in Hesselbach's triangle
- result of weakness in floor of inguinal canal
- rarely protrude into scrotum: doesn't pass through inguinal ring
- almost always occur in older individuals as their abdominal walls weaken with age and stretching

36

What are the boundries of the hesselbach triangle?

- laterally: inferior epigastric artery
- medially: lateral border or rectus abdominis
- inferiorly: (base) - inguinal ligament

37

What is a femoral hernia? More common in?

- hernia located inferior to inguinal ligament and protrudes through femoral ring
- more common in women
- least common type of groin hernia, but has high chance of strangulation

38

Clinical presentation of inguinal hernia?

- painless bulge in groin or scrotum
- groin discomfort of pain
- swelling or tugging in the groin
- sudden pain, N/V: concenr with strangulated hernia
*need to tx quickly

39

What will you see on PE of inguinal hernia?

- msot common finding is bulge in groin
- exam best done with pt standing and asking them to cough or valsalva
- reducible vs irreducible: try to reduce
- strangulated:
irreducible
painful to palpation
N/V
pt may appear ill with or w/o fever

40

how do you dx inguinal hernias?

- usually done with hx and exam
- not apparent, then initial study is groin U/S
- CT/MRI

41

Tx of inguinal hernia?

- non surgical: watchful waiting, TRUSS (metal support underwear)
- surgical:
open repair
laparoscopic repair

42

What is an umbilical hernia? More common in what pop? Causes?

- outward bulging of lining of the abdomen or abdominal organs around the belly button
- more common in infants
- causes: muscle through which the umbilical cord passes doesn't close completely after birth

43

Clinical presentation of umbilical hernia?

- a soft swelling or bulge near umbilicus
- in infants: more noticeable when baby cries, coughs or strains

- adults:
may cause abdominal discomfort, bulging with straining or coughing

can become strangulated: reducible or irreducible

44

Causes of umbilical hernias?

- obesity
- mult pregnancies
- fluid in abdominal cavity (ascites)
- previous abdominal surgery

PE:
usually found on exam

45

Tx of umbilical hernia?

- surgery: with or w/o mesh

46

What is an incisional/ventral hernia? Caused by what?

- 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
- after surgical repair they have a high reoccurence rate (20-45%): use of mesh has helped
- iatrogenic
- coughing post abdominal surgery is a big risk

47

What is an epigastric hernia?

- type of hernia that develops in epigastrium b/t breast bone and belly button
- usually appears in adults
- may trap fat and other tissues which cause discomfort
- risks: obesity and pregnancy
- see also with sugery
- tx: surgery

48

What is a spigelian hernia?

- hernia through the spigelian fascia
- often no notable swelling
- risk of strangulation is high due to small size
- most occur on R side
- rare
- present with intermittent mass, localized pain or N/V
- dx made with U/S
- surgery is TOC

49

Acute abdominal pain - why is it hard figuring out dx?

- acute abdominal pain has large differentia;, ranging from benign to life-threatening conditions
- the elderly, immunocompromised and women of childbearing age pose special dx challenges
- textbook descriptions of abdominal pain have limitations b/c people react to pain differently

50

DDx of acute abdominal pain - immediate life-threatening conditions?

- AAA
- mesenteric ischemia
- perforation of GI tract
- acute bowel obstruction
- volvulus
- ectopic pregnancy
- MI
- splenic rupture

51

PP behind acute abdominal pain? Diff b/t visceral, somatic pain. referred pain and peritonitis?

visceral pain:
- from abdominal viscera
- innervated by autonomic nerve fibers
- respond to sensations of distension and muscular contraction
- pain is typically vague, dull and nauseating

somatic pain:
-from parietal peritoneum
- innervated by somatic nerves
- respond to irritation from infection, chemical and inflammatory process
- pain is sharp and well localized

referred pain:
- pain perceived distant from its source
- results from convergence of nerve fibers at spinal cord

peritonitis:
- inflammation of peritoneal cavity
- most serious cause is perforation of GI tract
- blood
- causes fluid shift into peritoneal cavity and bowel, leads to severe dehydration and electrolyte problems

52

Presentation of appendicitis?

- anorexia and vague periumbilical discomfort that develops into RLQ pain
- N/V generally not first
sxs
- pelvic appendix can present with urinary sxs and diarrhea
- ***most common extrauterine cause for abdominal surgery in pregnant women

53

Presentation of biliary disease?

- acute cholecystitis complain of RUQ or epigastrium pain
- pain may radiate to R shoulder or back
- N/V and anorexia
- murphy's sign may be present
- progression of septic shock can occur (tachy, febrile, may be jaundice)

54

Presentation of pancreatitis?

- pain is steady in upper abdomen
- band like radiation to back is common
- pain often reaches max intensity within 10-20 min of onset
- N/V common

55

Presentation of diverticular disease?

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

56

Presentation of peptic ulcer disease?

- epigastric pain, indigestion, and reflux sxs: none is sensitive or specific
- complications:
bleeding and perforation

57

Presentation of incarcerated hernia?

- inguinal most common with mild lower abdominal discomfort exacerbated by straining
- incarcerated hernias cause severe pain and reqr immediate surgical consultation

58

Presentation of IBD?

- acute complications include pain, bleeding, perforation, bowel obstruction, fistula, and abscess formation and toxic megacolon

59

Presentation of IBS?

- sxs need to persist for 3 months over a 1 yr period
- abdominal pain assoc with change in stool frequency or consistency

60

Eval of acute abdominal pain - depending on pain level?

- mild and severe pain follow same process of dx
- severe pain may reqr consultation with surgeon
- H&P usually will exclude all but a few possible causes, with labs and imaging giving final dx
- life threatening causes should be ruled out first
- pts that are at high risk: over 65, immunocompromised, alcoholism, CVD, major comorbidities - GI or renal, prior surgery, early pregnancy, if pain is sudden and maximal at onset, subsequent vomiting, constant pain of less than 2 days, exam findings: tense or rigid abdomen, involuntary guarding, signs of shock

61

Hx of acute abdominal pain?

- age
- sex
- PMHX and SHX
- meds
- characterize pain as precisely as possible
- women of childbearing age pregnancy status must be determined!

62

PE of acute abdominal pain?
Red flags?

- general appearance is impt
- focus of exam on abdomen:
begin with inspection and auscultation, followed by palpation and percussion
- rectal and pelvic exam
- palpation begins away from area of greatest pain: looking for guarding, rigidity, and rebound
- surgical scars should be palpated
- Red flags:
severe pain
signs of shock
signs of peritonitis
abdominal distension

63

Tests to order for acute abdominal pain?

- urine pregnancy test for all women of childbearing age
- CBC, chemistries, UA little value
- exception: serum lipase and amylase strongly suggest dx of acute pancreatitis
- order LFTs with RUQ pain
- UA: if blood in urine
- CBC: suspect infection
- plain xrays: helpful for bowel obstruction, bowel perf, radiopaque fb
- U/S: biliary tract disease, ectopic pregnancy, appendicitis in kids, AAA
- CT: study of choice in eval of undiff abdominal pain
CT with oral and IV contrast is dx in about 95% of pts with sig abdominal pain

64

What are the test of choices depending on quadrant?

- RUQ pain: US
- LUQ: endoscopy, US or CT
- RLQ: CT IV contrast
- LLQ: CT IV and oral contrast
- suprapubic: US

65

What are impt key pts in acute abdominal pain?

- look for life-threatening causes first
- rule out pregnancy in women of childbearing age
- seek signs of peritonitis, shock, and obstruction
- blood test are minimal value except specific labs