Anorectal Disease Flashcards by Courtney Birkett

What is the purpose of the dentate/pectinate line?

Above it the patient is not sensitive to pain (inside the anus) and below is where there is sensation

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Red flags for anorectal complaints

Unintentional weight loss
IDA
Personal or FH of IBD or CRC
Persistent anorectal bleeding or anorectal sxs despite adequate tx of a suspected benign condition

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How do hemorrhoids occur?

They are normal vascular structures that arise from a fibrovascular cushion (protect anal canal during defecation and help maintain continence)

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When do hemorrhoids develop sxs?

When the supporting structures of the hemorrhoidal tissue (anal cushions) begin to deteriorate

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Causes of hemorrhoids

Prolonged sitting or straining
Chronic constipation
Diarrhea
Pregnancy
Advancing age

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Types of hemorrhoids

External (distal to dentate line and painful!!)-blueish

Internal (proximal to dentate line and painless!!)-red

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How to classify internal hemorrhoids

*this determines the tx
I- bulge in anal canal without prolapse
II- prolapse that reduces spontaneously
III-prolapse that requires manual reduction
IV-chronic prolapse and irreducible

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Presentation of hemorrhoids

Bleeding with BM (usually bright red and painless)
Sensation of perianal fullness (prolapse)
Pruritus (pruritis ani)
Fecal incontinence, mucoid discharge, acute perianal pain and palpable lump if thrombosed

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What kind of PE needs to be done for hemorrhoids?

Inspect perianal skin
DRE
Anoscopy (optimal visualization of internal hemorrhoids)

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Diagnostics used for hemorrhoids

CBC when needed (bleeding)

Flex sig or colonoscopy if needed (probably should if they have bleeding tho or if concerned for IBD or malignancy)

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General types of tx for hemorrhoids

Diet and lifestyle (all)
Conservative medical therapies
Office-based procedures
Surgery

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What diet and lifestyle changes need to happen with hemorrhoids?

(ALL grades of hemorrhoids need this)
Fluid and fiber (dietary/bulk laxatives)
Toilet habits
Sitz baths for itching relief

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Conservative medical tx for hemorrhoids

Stool softeners
Maybe topical agents for sx relief (tucks pads or a SHORT course of corticosteroid creams or suppositories)
Antispasmodic agents (nitro ointment)

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Office based/non-surgical tx for hemorrhoids

(pts refractory to conservative medical txs)
Internal hemorrhoids- rubber band ligation, infrared coagulation or sclerotherapy
External hemorrhoids- excision of thrombosed one

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Most commonly used technique for tx of symptomatic bleeding internal hemorrhoids

Rubber band ligation

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When do you consider a hemorrhoidectomy?

Persistent sxs despite early tries on management
Symptomatic grade III hemorrhoids
Grade IV internal hemorrhoids
Pts with extensive pain from thrombosed external hemorrhoids

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Most common cause of pruritus ani

Mechanical (ex: prolapsing tissue, incontinence, inadequate hygiene)

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Presentation of pruritus ani

Intense itching and burning

Circumferential erythematous and irritated perianal skin

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Management for pruritus ani

Eliminate offending agent
Good hygiene (gentle cleaners, don’t do overzealous hygiene and sitz baths)
Keep it dry
Eliminate tight clothing
Topical astringent (witch hazel) or topical barrier (zinc oxide)
Short course of topical steroid cream appropriate for severe skin eruptions

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What are perianal skin tags?

Outgrowth of normal skin
Sequelae of thrombosed external hemorrhoids or Crohns
Loose, flesh colored, pedunculated tissues

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Tx for perianal skin tags

Not usually indicated (pts might want them excised if they interfere with hygiene or cause discomfort)

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What might be seen with perianal Crohn’s disease?

Fissures, abscesses or fistulas

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Most common cause of severe anorectal pain

Anal fissure

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What is an anal fissure?

Study These Flashcards

Linear tear or split in the lining of the anal canal distal to the dentate line that causes spasm of anal sphincters (decreased blood flow more and prevents healing)

Causes of anal fissure

Primarily local trauma to anal canal, passage of large hard stools or a foreign body Secondary can be Crohns, malignancy or HIV/AIDS

Presentation of an anal fissure

Severe pain during and often persisting after defecation (passing glass or sitting on a knife) Bright red blood on TP or streaking of stool Might see tear in anodermal tissue, minimal edema, erythema or bleeding

Most common place for an anal fissure

Posterior midline due to lowest blood supply (if more than 1 or not here than maybe think Crohns)

Diagnostics for anal fissure

DRE or anoscopy if can tolerate | Flex sig/colonoscopy if recurrence

Management of an anal fissure

Adequate fiber/fluid, hygiene, sitz baths, stool softeners Topical analgesic-lidocaine gel Topical vasodilators-nifedipine or nitro ointment (decrease spasms and increase BF) Surgery if chronic (sphincterectomy in pts with low risk of developing fecal incontinence)

How does a perianal abscess occur?

From obstructed/infected anal crypt gland (chronically can progress to a fistula)

Presentation of perianal abscess

Localized anal or rectal pain (maybe drainage or constitutional sxs) Erythematous, palpable, tender, fluctuant mass with surrounding edema (palpate for inguinal LAD)

Diagnostics for perianal abscess

Maybe CT/MRI pelvis to determine extent

Management for perianal abscess

I&D Maybe abx Post op tx with sitz baths and adequate fluid and fiber

How does an anorectal fistula occur?

Abnormal connection between anal canal and the perianal area | Chronic manifestation of perianal abscess

When can you see anorectal fistulas?

Crohns, radiation proctitis or diverticulitis

Presentation of anorectal fistula

Chronic drainage of blood or pus & occasionally stool from fistula Rectal pain, itching, swelling, fever Might see perianal skin excoriated or inflamed

What might be felt on exam of anorectal fistula?

Palpable cord beneath skin between anus and abscess opening | might see external opening

Diagnostics for anorectal fistula

MRI pelvis for recurrent or complex fistula | Colonoscopy if concern for IBD!

Mainstay of tx for anorectal fistula

Surgery (fisulotomy)-unroof the fistula tract to allow for healing

What causes anal condyloma?

HPV

Presentation of anal condyloma

Asymptomatic but maybe pruritis | Cauliflower like appearance, in clusters or singles

Diagnostics for anal condyloma

Anoscopy

Management for anal condyloma

Removal or destruction of visible lesions Topical podofilox or imiquimoid cream Trichloroacetic acid in office Surgery

What are most anal cancers?

Squamous cell

When is there an increased incidence of anal cancer?

Practicing receptive anal intercourse History of anorectal condyloma History of HPV or HIV

Presentation of anal cancer

Rectal bleeding, anorectal pain, sensation of anal mass Anal warts, perianal skin irritation, hard, friable or ulcerating internal or external lesions Inguinal LAD

Diagnostics for anal cancer

Biopsy and scope/imaging for extent Chemoradiotherapy Surgery

What is rectal prolapse?

Pelvic floor disorder when rectal tissue protrudes through the anus May see with chronic constipation, straining, multiparity or prior pelvic surgery

History described with anal prolapse

Constipation/fecal incontinence Incomplete bowel evacuation, seepage Mass protruding through anus

What is seen on the PE for rectal prolapse?

Strain to reproduce Protruding circumferential mass DRE shows mucosa of rectal wall feeling floppy or loos with redundant tissue

Diagnostic for rectal prolapse

Defecography/anorectal manometry to look for pelvic floor descent

Management of rectal prolapse

Prevent constipation so increase fiber and fluids | Surgical repair is mainstay tho!

How does a rectocele occur?

When fascia weakens and allows rectum to bulge into vagina

Potential causes of a rectocele

Vaginal childbirths, increasing age and increasing BMI

Presentation of rectocele

Need to apply pressure on vagina/rectum etc to defecate Pelvic pressure Constipation or fecal incontinence Sexual dysfunction

PE for rectocele

Do a rectovaginal exam and when pt bears down, there is a bulge of the rectum into the vagina

Tx for rectocele

Expectant management or non-surgical options first (pelvic floor muscle training or pessary)

What should you do if you're unsure of any diagnosis?

Refer to gastroenterologist or colorectal surgeon

Anorectal Disease Flashcards

(58 cards)