Anorectal Lecture

Question 1

Do you feel pain above or below the dentate line?

Answer 1

BELOW!

(no pain felt above the dentate line)

Question 2

Divides the rectal mucosa above from the squamous epithelium below

Divides the:
Nervous system*
Vascular supply
Lymphatic drainage

Answer 2

Dentate line

Question 3

insensate- anorectal mucoa

sensate- anoderm

..which one is above and which one is below the dentate line?

Answer 3

Insensate (anorectal)= ABOVE

Sensate (anoderm)= BELOW..*pain*

Question 4

Which anal sphincter….

smooth muscle, involuntary

Answer 4

Internal

Question 5

Which anal sphincter…

skeletal muscle (voluntary)

Answer 5

External

Question 6

Squamous epithelium

Anoderm

Sensate

PAIN*

Answer 6

Below the dentate line

Question 7

Tear in the anoderm
90% are posterior

Causes: hard stool or prolonged diarrhea

Sx: “tearing” pain with BM
hematochezia (blood on TP)
pain usually subsides between BMs

Answer 7

Anal fissure

Question 8

MC cause of painful rectal bleeding

Answer 8

Anal fissure

Question 9

Should you do a rectal exam if pt has anal fissure?

Answer 9

NO

Question 10

Bulk agents

Stool softners

Sitz baths

Hydrocortisone containing ointments

Answer 10

Medical tx for anal fissures

(90% heal with medical tx)

Question 11

If medical tx fails,

what is the gold standard surgery for anal fissures?

Answer 11

Lateral internal anal sphincterotomy

Question 12

Location of most anorectal abscesses

Answer 12

Posterior rectal wall

Question 13

Anal crypts with gland obstruction is the origin for…

Answer 13

Anorectal abscesses

Question 14

S. Aureus
Bacteroides
Proteus
Strep

..all cause?

Answer 14

Infection of anal ducts and glands..leading to anorectal abscesses

Question 15

MC anorectal abscess

Answer 15

Perianal abscess

Question 16

These start from the anal crypts and can spread…..

1. superficially to external sphincter, resulting in perianal abscess* (MC!)
2. deep thru external sphincter into fat of ischiorectal fossa
3. deep into supralevator space
4. intersphincteric

Answer 16

Anal abscess

Question 17

Severe pain!
worse with.. sitting, coughing, defecating

PE: palpable fuctuant mass
VERY painful DRE

Answer 17

Anal abscess

Question 18

Tx= surgical drainage
postop Sitz bath

50% cured with just drainage
50% develop fistula

Answer 18

Anal abscess

Question 19

Chronic cryptoglandular abscess

abnormal communication between 2 epithelium lined surfaces

*has an external oepning in perirectal skin and an internal opening in anal canal

*originates in infected crypt and tracks externally to site of previous drainage

Answer 19

Fistula

Question 20

Used as a guide to determine location of internal opening

Answer 20

Goodsall’s Rule

Question 21

Fistulas with an external opening anteriorly

…will track internally via a ______ line

Answer 21

straight

Question 22

Fistulas with an external opening posteriorly

…will track internally via a _______ line

Answer 22

curved

Question 23

Persistent drainage
Usually painless but can have itching

tx= fistulotomy, tract left open to heal by secondary intention
(MUST preserve sphincter muscle)

Answer 23

Fistulas

Question 24

External venous tissue
50% of ppl over 50 have

MC anorectal problem in adults >50

Answer 24

Hemorrhoids

Question 26

Anal canal is lined by these “cushions” that consist of vascular and connective tissue

3 columns: R anterolateral, L lateral, R posterolateral
*these cushions engorge during defecation to protect anal canal from abrasions

Answer 26

Hemorrhoid plexus

Question 27

Caused by:
Hard stool
Excessive straining
Pregnancy
Increased intraabdominal pressure

(leading to increased venous engorgement)

Answer 27

Hemorrhoids

Question 28

These hemorrhoids are painless! bc they are above the dentate line

Bleed
May prolpase, are palpable on DRE
*painless bright red blood with defecation

MC cause of rectal bleeding

Answer 28

Internal hemorrhoids

Question 29

These hemorrhoids are painful! bc they are below the dentate line

Covered with anoderm
Usually dont bleed
May thrombose, VERY painful!

Pain and discomfort, esp at time of defecation

Answer 29

External hemorrhoids

Question 30

Which type of polyp is the most rare of the adenomas but has the highest risk of cancer, with 40%

Answer 30

Villous adenomas

Question 31

MC type of polyp but only has a 5% risk of cancer

Answer 31

Tubular adenoma

Question 32

1st and 2nd degree hemorrhoids

Answer 32

1st degree= bleed

2nd degree= bleed and prolapse

spontaneously reduce*

Question 33

Which degree internal hemorrhoid…

Bleed and prolapse, require manual reduction

Answer 33

3rd degree

Question 34

Which degree internal hemorrhoid:

automatic referall
bleed/incarcerate

Answer 34

4th degree

Question 35

Fiber, water, stool softner, avoid straining

Cortisone to shrink (Anusol HC)

Nupercainal ointment numbing agent

Answer 35

Tx for 1st and 2nd degree internal hemorrhoids

Question 36

Tx= surgical!

Excisional hemorrhoidectomy

Answer 36

tx for 3rd and 4th degree hemorrhoids

Question 37

What is the grading of external hemorrhoids?

Answer 37

There are none!

Question 38

Acutely thrombosed hemorrhoids are excised outside mucocutanous junction usually within how many hours?

Answer 38

24-48

Question 39

Midline post- sacral intergluteal fold superior to anus

clinically identified by opening of sinus tract that may contain a tuft of hair

MC men 20-30 (almost always under 40!!)

Answer 39

Pilonidal cyst

Question 40

Usually asymptomatic but can develop abscess formation and drainage

Sx: like perianal abscess but different spot

PE: fluctuant mass with erythematous “halo”
purulent D/C
Pain at gluteal cleft

Answer 40

Pilonidal cyst

Question 41

Tx for Pilonidal cyst?

Answer 41

Surgery with secondary closure

Question 42

Sudden watery diarrhea after pt has had chronic constipation

Answer 42

Fecal impaction