Anorectal Disorders

Question 1

vascular structures that aid in continence by preventing damage to the sphincter muscle during defecation

Answer 1

hemorrhoidal cushions

Question 2

what leads to prolapse of vascular tissue into the anal canal?

Answer 2

engorgement and straining

Question 3

when a blood clot forms in a portion of the hemorrhoid that is not dangerous, but is painful

Answer 3

thrombosed hemorrhoid

Question 4

hemorrhoid that originates proximal to the dentate line

Answer 4

internal hemorrhoid

Question 5

what type of hemorrhoids are the majority?

Answer 5

internal hemorrhoids

Question 6

why is it important to grade internal hemorrhoids?

Answer 6

to determine treatment

Question 7

grade the internal hemorrhoid: patient presents with painless bleeding. Physical exam shows vascular engorgement bulging into the anal canal without prolapse.

Answer 7

grade 1

Question 8

grade the internal hemorrhoid: patient presents with painless bleeding with perianal itching. Physical exam shows hemorrhoidal prolapse with straining that reduces spontaneously

Answer 8

grade 2

Question 9

grade the internal hemorrhoid: patient presents with painless bleeding, perianal itching, and swelling/straining/soilage with mucus and feces. Physical exam shows hemorrhoid prolapses beyond the dentate line with straining and is only reducible by manual pressure

Answer 9

grade 3

Question 10

grade the internal hemorrhoid: patient presents with pain, bleeding, swelling, soilage, with mucus and feces. Physical exam shows grossly evident prolapse of hemorrhoidal tissue that is non-reducible and chronic inflammatory changes (mucosal atrophy, friability, maceration, and ulceration)

Answer 10

grade 4

Question 11

hemorrhoid that originates distal to the dentate line

Answer 11

external hemorrhoid

Question 12

what is the difference in symptoms between internal and external hemorrhoids?

Answer 12

internal hemorrhoids are normally painless

external hemorrhoids are painful when thrombosed

Question 13

hemorrhoids can exist asymptomatically, but become symptomatic when they are _____ and _____

Answer 13

distended
engorged

Question 14

rectal bleeding can be caused by: (2)

Answer 14

external, thrombosed hemorrhoids
grade 4 internal hemorrhoids

Question 15

why can hemorrhoids be reported as “lumps” or “masses”?

Answer 15

with time, internal hemorrhoids protrude further and become irreducible

Question 16

a patient presents with a bluish perianal nodule, which is erythematous, firm, and tender to touch when thrombosed and inflamed. Dx?

Answer 16

external hemorrhoid

Question 17

what can help visualize an internal hemorrhoid? (2)

Answer 17

anoscopy
gentle straining

Question 18

when does an internal hemorrhoid become palpable on digital rectal exam? (2)

Answer 18

prolapsed
thrombosed

Question 19

what is the conservative treatment for grade 1 and 2 internal hemorrhoids? (2)

Answer 19

increased fiber + fluids
limit straining + lingering

Question 20

what is the conservative treatment for external hemorrhoids? (3)

Answer 20

warm sitz bath, analgesics, ointment

prep H
Tucks
Anusol

resolves over 2-3 days

Question 21

what is the preferred medical treatment for grade 1-3 internal hemorrhoids that have recurrent bleeding despite conservative treatment?

Answer 21

rubber band ligation

Question 22

what is the medical treatment for edematous, painful stage 4 internal hemorrhoids? (2)

Answer 22

acutely: prep H, tucks, anusol
ligated later

Question 23

what is the treatment for chronic severe bleeding in grade 3-4 internal hemorrhoid or acute thrombosed grade 4 internal hemorrhoid with necrosis?

Answer 23

surgical hemorrhoidectomy

Question 24

what is the treatment for an acutely thrombosed external hemorrhoid?

Answer 24

thrombectomy + elliptical incision + clot removal within first 24-48 hours

Question 25

linear or triangular tears/ulcers that are around 5mm in length

Answer 25

anal fissures

Question 26

what is the most common cause of anal fissures?

Answer 26

trauma to the anal canal during defecation

Question 27

where do anal fissures most commonly occur?

Answer 27

in midline

Question 28

what should we worry about when anal fissures do not occur midline?

Answer 28

crohn disease

Question 29

a patient presents with severe, sharp, tearing pain that is worse during BM +/- blood in stool or on toilet paper. There are cracks visible in epithelium of sphincter. Dx?

Answer 29

anal fissures

Question 30

what can chronic anal fissures lead to?

Answer 30

skin tags at outer edge

Question 31

what 2 diagnostics can cause severe pain and may be deferred if a patient has anal fissures?

Answer 31

anoscopy DRE

Question 32

what is the conservative treatment for anal fissures? (3)

Answer 32

increase fiber sitz baths = reduce pain with BM topical anesthetics = relief prior to BM

Question 33

what is the prognosis of anal fissures with conservative treatment?

Answer 33

healing within 2 months in 45% of patients

Question 34

what are treatment options for anal fissures that do not respond to conservative treatment? (3)

Answer 34

topical nitroglycerine OR diltiazem botox injection internal lateral sphincterotomy

Question 35

present around the rectum and helps protect muscles and nerves

Answer 35

anal crypt glands

Question 36

inflammation and infection with accumulation of purulent material near the anus

Answer 36

anorectal abscess

Question 37

what typically causes anorectal abscesses?

Answer 37

infection of anal crypt gland after obstruction

Question 38

abscesses have the chance of becoming ____ _____

Answer 38

chronic fistulas

Question 39

a patient presents with local swelling around the anus and has severe constant pain that is worse with sitting or having a BM. Dx?

Answer 39

anorectal abscess

Question 40

what diagnostic is required if a patient may have an anorectal abscess?

Answer 40

digital rectal exam

Question 41

what kind of abscess requires an experienced surgeon?

Answer 41

any abscess that involves tissue under the sphincter

Question 42

what imaging should be ordered for suspected anorectal abscess?

Answer 42

CT scan w/ contrast

Question 43

what will be seen in labs if a patient has an anorectal abscess?

Answer 43

elevated WBCs

Question 44

what are the 3 possible outcomes of an anorectal abscess?

Answer 44

spontaneously drain + heal spontaneously drain + form permanent fistula to skin remain undrained + lead to sepsis with high M+M

Question 45

what is the treatment for an anorectal abscess?

Answer 45

surgical drainage + culture antibiotics: *augmentin OR ciprofloxacin + metronidazole*

Question 46

what is the post-op care for anorectal abscess? (4)

Answer 46

regular diet fiber + stool softener sitz bath f/u in 2-4 weeks

Question 47

what are 4 risk factors for necrotizing anorectal infections?

Answer 47

delay in dx of abscess virulence of pathogen metastatic infection previous abscesses

Question 48

a persistent epithelialized track that connects an abscess with the perirectal skin on the outside skin of buttocks

Answer 48

anorectal fistula

Question 49

what is the most common cause of anorectal fistulas?

Answer 49

anal abscess

Question 50

a patient presents with erythematous, inflamed perianal skin, tenderness, drainage/bleeding. pn physical exam, an indurated cord is felt in soft tissue. Dx?

Answer 50

anorectal fistula

Question 51

what 2 diagnostics can be used by an experience provider to explore the fistula track?

Answer 51

anoscopy or sigmoidoscopy

Question 52

how is the diagnosis of anorectal fistula made?

Answer 52

H&P

Question 52

what 2 diagnostics should be performed if a patient has IBD or recurrent anorectal fistulas?

Answer 52

colonoscopy + barium enema

Question 53

what diagnostic can help with the treatment of anorectal fistulas and diagnose recurrent disease?

Answer 53

CT or MRI w/ contrast

Question 54

what is the mainstay of treatment for anorectal fistulas?

Answer 54

surgery