Anorectum Dettmann Flashcards
(69 cards)
1
Q
What is one of the MC causes of anal pain?
A
Anal fissure
2
Q
Describe anal fissures (shape, length, location)
A
- Linear or rocket shaped ulcers
- Usually less than 5 mm in length
- Located MC in posterior midline
3
Q
What types of anal fissures are cause for suspicion?
A
Anal fissures off the midline
4
Q
What should anal fissures off the midline raise suspicion for?
A
- UC
- Crohn’s
- HIV/AIDS
- TB
- Syphilis
- Anal carcinoma
5
Q
Causes of anal fissures
A
- Trauma
- Defecation (straining, C/D, high sphincter tone)
- Tear in anal lining
6
Q
What is the MC cause of anal fissure?
A
Trauma
MC from defecation
7
Q
Symptoms of anal fissures
A
- Pain (can be mod or severe)
- Tearing/throbbing (esp during defecation/after)
- Hematochezia +/-
8
Q
Signs of anal fissures
A
- Visually confirmed
- Acute: looks like “cracks” in epithelium
- Chronic: fibrosis and development of skin tags at outer most edge (sentinel pile)
- Digital and anoscopic exams may be painful to perform
9
Q
What do acute anal fissures look like?
A
“Cracks” in epithelium
10
Q
What do chronic anal fissures look like?
A
Fibrosis and development of skin tags at outer most edge (aka sentinel pile)
11
Q
Treatment of anal fissures
A
- Promote effortless painless BMs (fiber/bulk agents, stool softeners)
- Sitz baths
- Topical anesthetics
12
Q
Treatment of chronic anal fissures
A
- Topical nitro or dilt ointment
- Botox (2-3 mos of sphincter relaxation)
- Surgery (lateral internal sphincterotomy)
13
Q
How are anal fissures successfully healed?
A
Conservative tx (80% heal this way)
14
Q
Do anal fissures recur?
A
Yes in about 40% pts
15
Q
What is a complication of surgical tx of anal fissures?
A
Minor incontinence
16
Q
Define anal fistula
A
- Hollow tract, primary opening inside anal canal
- Leads to a secondary opening in perianal skin
- Lined w/granulation tissue
17
Q
MC cause of anal fistulas
A
Anorectal or perianal abscess
18
Q
What does a DRE show with anal fistula?
A
- Spontaneous or expressible discharge
- Fibrous tract or cord beneath skin
- Check sphincter tone before surgery
19
Q
What does a lateral or posterior induration on DRE suggest?
A
Deep post-anal or ischiorectal extension of anal fistula
20
Q
Medical treatments of anal fistulas
A
- Sitz baths
- Analgesics
- Stool bulking agents
21
Q
Surgical treatments of anal fistulas
A
- Fistulotomy/fistulectomy
- Seton placement
- Silver nitrate in office
- Fistula plug
- Fibrin glue injection
- Colostomy
- Endorectal mucosal advancement flap/LIFT
22
Q
Complications of anal fistulas
A
- Bleeding
- Fecal impaction
- Thrombosed hemorrhoids
- Recurrence
- Incontinence
- Anal stenosis
- Delayed wound healing
23
Q
How long does post-surgical healing take for anal fistulas?
A
At least 6-12 weeks
24
Q
What are the rates of recurrence and incontinence following standard fistulotomy?
A
- 0-20% recurrence
- Less than 10% incontinence
25
What are the rates of recurrence and incontinence following Seton use tx of anal fistulas?
- 0-20% recurrence
| - Less than 10% incontinence
26
What are the rates of recurrence and incontinence following mucosal advancement flap tx of anal fistulas?
- 1-10% recurrence
| - Less than 10% incontinence
27
What are the different types of hemorrhoids?
- Internal
- External
- Thrombosed
28
What is the peak age of hemorrhoids?
45-65 yo
29
What particular condition increases incidence of hemorrhoids?
Pregnancy
30
Describe hemorrhoids
- Normal anatomical structures
- Ensure water tight seal
- Help maintain normal anal pressure
31
Describe internal hemorrhoids (what? where do they originate? do they cause pain?)
- Subepithelial vascular cushions b/w superior rectal artery and vein
- Originate ABOVE dentate line
- Rarely cause pain
32
Describe external hemorrhoids (what? where do they originate? do they cause pain?)
- Arise from inferior hemorrhoidal veins
- Originate BELOW dentate line
- Cause swelling, pain, hygiene issues
33
Where do external and internal hemorrhoids occur?
- Right anterior
- Right posterior
- Left lateral
34
When do hemorrhoids become symptomatic?
- Activities that increase venous pressure
| - Distension occurs leading to engorgement
35
Causes of hemorrhoids
- Low fiber diet
- Pregnancy
- Obesity
- Abnormally high tension of internal sphincter muscle
- Prolonged sitting on toilet
- Aging
- Diarrhea
36
Symptoms of hemorrhoids
- BRBPR
- Prolapse
- Mucoid discharge
37
Stages of internal hemorrhoids
1: Confined to anal canal (bleeding, no prolapse)
2: Protrude from anal opening (bleeding, mild prolapse w/spontaneous reduction)
3: Prolapsed (requires manual reduction s/p BM)
4: Chronically prolapsed (strangulated)
38
What may allow visibility of internal hemorrhoids on PE?
Gentle straining
39
What do prolapsed internal hemorrhoids look like?
Protuberant purple nodules covered with mucosa
40
What is the best way to visualize internal hemorrhoids?
Anoscopic evaluation
41
Conservative treatment of Stage 1 and 2 hemorrhoids
- High fiber diet
- Increased fluid intake
- Fiber supplement
- Manual reduction w/suppository
42
Medical treatment of Stages 1, 2, 3 hemorrhoids?
- Injection sclerotherapy
- Rubber band ligation
- Electrocoagulation
43
What are the complications of electrocoagulation?
- Pelvic sepsis, abscess
- Urinary retention
- Bleeding
44
What stages of hemorrhoids can be treated surgically?
3 and 4
45
Surgical treatment of Stage 3 and 4 hemorrhoids?
Hemorrhoidectomy if chronic severe bleeding and/or acute thrombosed
46
What is a perianal hematoma?
Thrombosis of external hemorrhoidal plexus
47
What causes thrombosed external hemorrhoids?
Coughing, heavy lifting, straining
48
How does a thrombosed external hemorrhoid present?
- Acute onset severe pain
- Tense bluish perianal nodule covered w/skin
- Can be several cm in size
49
Treatment of thrombosed external hemorrhoids?
- Symptom relief (warm Sitz bath, analgesics, ointments)
| - Elliptical incision and removal (if someone comes less than 24-48 hours...bc pain will resolve after that)
50
How do anal abscesses begin?
Infection in anal glands
51
How does an anal abscess present?
Continuous throbbing perianal pain
52
How is an anal abscess treated?
Drained under local anesthesia
53
How does an ischiorectal abscess occur? How is it diagnosed? How is it treated?
- Infection may track through internal and external sphincter muscles to enter ischiorectal space
- Visible on surface of buttocks
- Treated by surgical drainage
54
What should always be considered in pt w/acute rectal pain?
Abscess - can lead to necrotizing infections (esp. in immune-compromised)
55
Perianal vs. perirectal abscess
- Perianal = located at anal verge
| - Perirectal = everything else
56
Treatment of perianal or perirectal abscess
NO abx needed unless DM, systemic inflamm response, or immunosuppressed
57
What causes pilonidal abscesses?
Hair
| *Tx w/I&D
58
Treatment of perianal pruritus
- Avoid caffeine, spicy food, citrus, peppermint, tomatoes, ETOH, smoked/cured foods, perfumes
- After BM: cleanse w/lanolin wipes
- Clean w/warm water w/o soap
59
Define fecal incontinence
Inability of sphincter complex to contract sufficiently to control the release of gas or stool
60
What are common causes of fecal incontinence?
- Childbirth
- Rectal prolapse
- Prior pelvic radiation
- Episiotomy
61
Treatment of fecal incontinence
- Fiber
- Avoid caffeine
- Bowel training w/biofeedback or exercises
62
Describe rectal prolapse
- Prolapse or intussusception of rectum
- Partial or complete
- Under straining conditions
- Best to examine w/pt on toilet
- Full thickness prolapse should be surgically corrected
63
What is the MC form of rectal cancer?
Adenocarcinoma
64
How does rectal cancer usually start?
Precancerous polyp that develops over years
65
Risk factors for rectal cancer
- Age
- Smoking
- Fam hx
- High fat diet from primarily animal sources
66
Anal cancer in the US
Uncommon (up to 93% of cases a/w HPV)
67
MC STD in US
HPV
68
Predisposing factors of fecal impaction?
- Meds
- Severe psychosocial disease
- Neurogenic/spinal cord diseases
69
Treatment of fecal impaction
- Relieve impaction by digital disruption/enema
| - Maintain soft and regular BMs
