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Flashcards in Anorectal Disease Deck (58)
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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


Red flags for anorectal complaints

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


How do hemorrhoids occur?

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


When do hemorrhoids develop sxs?

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


Causes of hemorrhoids

Prolonged sitting or straining
Chronic constipation
Advancing age


Types of hemorrhoids

External (distal to dentate line and painful!!)-blueish
Internal (proximal to dentate line and painless!!)-red


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


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


What kind of PE needs to be done for hemorrhoids?

Inspect perianal skin
Anoscopy (optimal visualization of internal hemorrhoids)


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)


General types of tx for hemorrhoids

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


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


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)


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


Most commonly used technique for tx of symptomatic bleeding internal hemorrhoids

Rubber band ligation


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


Most common cause of pruritus ani

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


Presentation of pruritus ani

Intense itching and burning
Circumferential erythematous and irritated perianal skin


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


What are perianal skin tags?

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


Tx for perianal skin tags

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


What might be seen with perianal Crohn's disease?

Fissures, abscesses or fistulas


Most common cause of severe anorectal pain

Anal fissure


What is an anal fissure?

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)