Anorectal Disease

Question 1

Bright red blood per rectum.

Protrusion, discomfort.

Characteristic findings on external anal inspection and anoscopic examination.

Answer 1

Hemorrhoids

Question 2

Normal vascular structures in anal canal arising from a channel of arteriesvenous connective tissues that drains into sup/inf hemorrhoidal veins

Answer 2

Hemorrhods

Contribute to normal anal pressures and ensure a water tight closure of the anal canal

Question 3

External hemorrhoids are where?

Arise from…?

Answer 3

Below the dentate/pectinate line

Covered in squamous epithelium

Arise from… superior hemorrhoidal veins

Question 4

External hemorrhoids are more painful because?

Answer 4

Below the dentate line, there are somatic pain receptors

Inferior hemorroidhal veins

Question 5

Most common complaint of hemorrhoids

Answer 5

Bright red rectal bleeding… streaks on TP or dripping into toilet

Other ssx include perianal itching, mucoid discharge

(external hemorrhoids = pain)

Question 6

COvered w/ columnar epithelium leading to mucous deposition on the perianal skin (causes pruritits)

Prolapse may permit leakage of rectal contents

Answer 6

Internal hemorroihds

Question 7

Skin tags associated may be difficult to clean resulting in n prolonged contact w/ fecal material

Answer 7

ExternalHemorrhodis

Question 8

On PE, hemorrhoids are often really visible. Also check for?

And what else is necessary?

Answer 8

Check for skin tags, fissures, fistulas, condylomata, dermatitis

DRE (though uncomplicated hemorrhoids will not be palpable or painful)!

Question 9

GRade 1?

Grade 2?

Grade 3?

Grade 4?

Grade 5?

Answer 9

1 - bleeding only, no prolapse

2 - prolapse w/ defecation, but spontaneous reduction

3 - prolapse w/ defecation that requires manual reduction

4 - prolapsed, incarcerated; CANNOT be reduced

Question 10

Acute unrelenting pain presentation… means?

Answer 10

Thrombosed external hemorrhoid that requires surgical evacuation of the clot

(Internal can also thombose, not as common)

Question 11

Method for hemorroidectomy?

Answer 11

1. Lidocaine infiltration
2. Elliptical incision
3. Evacuation of clot
4. Packing
5. Sitz baths, stool softeners, hemorrhoid donut

Question 12

General tx measures for hemorrhoids?

Answer 12

Increase fiber

INcreae fluid

Wet wipes for hygiene/pain

Question 13

Medical tx for hemorrhoids?

Answer 13

Topical astringents

Topical hydrocortisone

Topical anesthetics

Hydrocortisone suppositories

Question 14

If topical agents don’t work, what are some option for tx of hemorrhoids?

Answer 14

Rubber band ligation

Sclerotherpay

Electrocoagulation

Question 15

Surgical hemorrhoidectomy is an option… butttt…..

Answer 15

High risk of fecal inconinence

Question 16

Anal fissure is a tear in the?

Answer 16

Anoderm distal to the dentate line (so, external)

Question 17

Most anal fissures arise from?

Answer 17

Trauma to the anal canal during defection (straining, constipation, high internal sphincter tone)

Question 18

Anal fissures most commonly cur midline. If they occur elsewhere consider?

Answer 18

Crohn, HIV, TB, syphilis, anal carcinoma

Question 19

Anal fissures may be acute or chronic…

Answer 19

Chronic develops due to spasm of internal sphincter and may impair healing

Question 20

How do anal fissures clinically present?

Answer 20

Acute onset of severe tearing pain during defecation

Hematochezia (typically mild — some blood on TP)

(Pain may lead to self induced constipation)

Question 21

Examination reveals small tear in epithelium

Spreading buttocks may be painful

DRE not tolerable

May observe sentinel pile, which is?

Answer 21

Anal fissure

Sentinel pile = skin tag at outermost edge

Question 22

Anal fissure tx?

Answer 22

Sitz baths

Increase fiber/fluid

Stool softener

topical anesthetic (lidocaine jelly)

Question 23

Chronic fissures can be treated w/ topical vasodilator such as?

Answer 23

Nifedipine

Nitro

Diltiazem

(Or, Botulinum)

Question 24

Chronic fissures maybe treated surgically if refractory…

Answer 24

Fissurectomy

Lateral internal sphincerotomy

Question 25

Collection of purulent material that arises from glandular crypts in the anus or rectum NOT directly associated with defecation

Answer 25

Perianal abscess

Question 26

Severe pain that is NOT directly associated w/ defecation

Answer 26

perianal abscess (Unlike fissures/hemorrhoids) | Fever and malaise are common

Question 27

Perianal abscess on PE?

Answer 27

Ertytherma , edema, fluctuant W/ surrounding induration

Question 28

WHat is DEFINITELY indicated for perianal abscess... because they might not be readily apparent?

Answer 28

DRE!

Question 29

Tx for perianal abscess?

Answer 29

Simple = outpatient mgmt (Incision and drainage) Complex = Inpatient mgmt (surgical drainage)

Question 30

Complications of perianal abscess? And what’s it require?

Answer 30

Fistula formation (epitheliazed track connecting abscess to perirectal skin) Leads to chronic purulent discharge, pruritis, pain SURGERY

Question 31

Anorectal discomfort Tenesmus Constipation Mucus/blood discharge

Answer 31

Infectious prostitis

Question 32

Etiology of infectious prositits?

Answer 32

STI, usually Gonorrhea Syphilis Chlamydia Herpes

Question 33

Infectious prostitis presentation... 1. Syphilis -> 2. Herpes -> 3. Gonorrhea -> 4. Chlamydia ->

Answer 33

1. Chancre 2. Grouped vesicles 3. Mucopurulent discharge 4. Slight discharge (maybe asymptmatic) (Lab test for suspected pathogen)

Question 34

Itching/bleeding/pain May coalesce and obscure anal opening HAVE TO DISTINGUISH FROM CANCER!

Answer 34

Anal warts | Condylomata acuminata

Question 35

Carcinoma of the anus is rare... MOst common type? Higher risk in whom?

Answer 35

Squamous cell High risk = anoreceptive intercourse, anal warts

Question 36

Anal Carcinoma often confused for (so must be distinguished from)? TEst how?

Answer 36

Confused for hemorrhoids (because it presents w/ bleeding, pain, local mass) CT or MRI to diagnose