Chapter 85: Anorectal Disorders

Question 1

The rectum begins at

Answer 1

The S3 vertebral body and descends for about 13 to 15 cm becoming the anus, which is comprised of the anal canal, anal verge, and anal margin

Question 2

True or False
The rectum narrows and traverses through the muscular pelvic floor, at the level of the levator ani and coccygeal muscles, and becomes the anal canal, 4 cm in length, surrounded by the anal sphincter muscle

Answer 2

True
The rectum narrows and traverses through the muscular pelvic floor, at the level of the levator ani and coccygeal muscles, and becomes the anal canal, 4 cm in length, surrounded by the anal sphincter muscle

Question 3

The junction of rectum and anal canal is called

Answer 3

Dentate line

Question 4

Rectal ampulla narrows to conform to the opening of the anal canal. A pleated appearance, forming 8 to 14 convoluted longitudinal folds

Answer 4

Columns of morgagni

Question 5

True or False

Just proximal to the dentate line, the mucosa transitions from rectal columnar to cuboidal to squamous epithelium

Answer 5

True

Just proximal to the dentate line, the mucosa transitions from rectal columnar to cuboidal to squamous epithelium

Question 6

Supplies the proximal 2/3 of the rectum

Answer 6

The superior hemorrhoidal artery, from the internal mesenteric artery

Question 7

Supplies the distal 1/3 of the rectum

Answer 7

The middle hemorrhoidal artery, from the internal iliac artery

Question 8

Supplies the anus

Answer 8

Inferior hemorrhoidal artery

Question 9

True or False
The superior rectal vein drains into the portal system, whereas the middle rectal vein drains into the inferior vena cava

Answer 9

True
The superior rectal vein drains into the portal system, whereas the middle rectal vein drains into the inferior vena cava

Question 10

The most common position for routine digital rectal examination and anoscopy

Answer 10

The lateral or Sims position

Question 11

In debilitated patients, one may have to perform the examination with the patient in ____

Answer 11

In debilitated patients, one may have to perform the examination with the patient in a supine, lithotomy position

Question 12

Skin tags covering anal crypts, fistulas, and fissures are called

Answer 12

Sentinel tags

Question 13

True or False
Surgical referral for excision and/or biopsy is warranted because inflammatory bowel disease may be associated with sentinel tags

Answer 13

True
Surgical referral for excision and/or biopsy is warranted because inflammatory bowel disease may be associated with sentinel tags

Question 14

Internal hemorrhoids originate from

Answer 14

Proximal to the dentate line

Question 15

Location of internal hemorrhoids?

Answer 15

• Right posterolateral
• Right anterolateral
• Left lateral positions
  (2, 5 (most common, and 9 o’clock)

Question 16

True or False
Although the most common cause with sentinel tags.
of bright red rectal bleeding is hemorrhoids, tumors must be ruled out HEMORRHOIDS
as a cause of rectal bleeding in patients >50 years of age

Answer 16

False
Although the most common cause with sentinel tags.
of bright red rectal bleeding is hemorrhoids, tumors must be ruled out HEMORRHOIDS
as a cause of rectal bleeding in patients >40 years of age

Question 17

A rare complication of hemorrhoidal banding is ____

Answer 17

A rare complication of hemorrhoidal banding is pelvic sepsis

Question 18

Grading for internal hemorrhoids

Answer 18

• Grade I (luminal protrusion above dentate line)
• Grade II (prolapse with spontaneous reduction)
• Grade III (prolapse needing manual reduction)
• Grade IV (nonreducible prolapse)

Question 19

The result of a superficial linear tear of the anal canal below the dentate line and extending distally to the anal verge

Answer 19

Anal fissures

Question 20

True or False

Anal fissures are usually single and occur in the midline posteriorly in 80% to 90% of cases

Answer 20

True

Anal fissures are usually single and occur in the midline posteriorly in 80% to 90% of cases

Question 21

Chronic anal fissures

Answer 21

> 6 weeks

Question 22

True or False

Fissures due to Crohn’s disease are multiple, off midline, and asymptomatic more commonly than in the general population

Answer 22

True

Fissures due to Crohn’s disease are multiple, off midline, and asymptomatic more commonly than in the general population

Question 23

Supportive treatment for anal fissure

Answer 23

Warm baths for at least 15 minutes three to four times a day and after each bowel movement along with stool softeners may suffice

Question 24

Occurs when the pliable tissue is replaced by scarred fibrotic tissue

Answer 24

Anal stenosis

Question 25

Most common cause of anal stenosis

Answer 25

Secondary cause

Question 26

The common denominator for the development of fissure- in-ano, fistula-in-ano, and perirectal abscesses

Answer 26

Cryptitis

Question 27

Cardinal signs of cryptitis

Answer 27

Anal pain, spasm, and itching with or without bleeding

Question 28

Fistula-in-ano originates from an ____

Answer 28

Fistula-in-ano originates from an infected crypt and tracks to the skin

Question 29

True or False | CT scan is more accurate than US in the evaluation of perirectal fistulas

Answer 29

False | US is more accurate than CT scan in the evaluation of perirectal fistulas

Question 30

True or False | Anorectal abscesses are typically monomicrobial

Answer 30

False | Anorectal abscesses are typically polymicrobial

Question 31

The most common anorectal abscess location ____

Answer 31

The most common anorectal abscess location is perianal

Question 32

The least common is ____

Answer 32

The least common is supralevator (pelvirectal)

Question 33

True or False | Isolated perianal abscesses are generally the only type of anorectal abscess that can be adequately treated in the ED

Answer 33

True | Isolated perianal abscesses are generally the only type of anorectal abscess that can be adequately treated in the ED

Question 34

True or False Perianal abscesses are easily palpable at the anal verge, whereas deeper perirectal abscesses may be palpated through the rectal wall or more lateral to the anal verge, on the buttocks

Answer 34

True Perianal abscesses are easily palpable at the anal verge, whereas deeper perirectal abscesses may be palpated through the rectal wall or more lateral to the anal verge, on the buttocks

Question 35

Often painful on rectal examination and are lateral to the anal verge

Answer 35

Ischiorectal abscesses

Question 36

Painful with defecation, may be associated with rectal discharge and fever, and a tender mass may be palpable on digital examination of the rectal canal, often in the posterior midline

Answer 36

Intersphinteric abscesses

Question 37

Often an extension of an intersphincteric abscess, frequently present with few outward signs and palpable on vaginal examination

Answer 37

Supralevator abscesses

Question 38

Often a clue to these deeper abscesses

Answer 38

Tender inguinal adenopathy

Question 39

Is inflammation of the rectal mucosa

Answer 39

Proctitis

Question 40

Three types of rec- tal prolapse

Answer 40

(1) prolapse involving the rectal mucosa only (2) prolapse involving all layers of the rectum (complete) (3) intussusception of the upper rectum into and through the lower rectum so that the mucosal apex of the intussusception nearly extends to the anus (incomplete or internal)

Question 41

True or False | Rectal prolapse in children is generally mucosal and occurs more commonly in females less than 3 years old

Answer 41

False | Rectal prolapse in children is generally mucosal and occurs more commonly in males less than 3 years old

Question 42

True or False | Mucosal prolapse is believed to occur due to a lack of the natural sacral curve reducing the anorectal angulation

Answer 42

True | Mucosal prolapse is believed to occur due to a lack of the natural sacral curve reducing the anorectal angulation

Question 43

It is not a significant feature with complete prolapse, but abdominal or pelvic discomfort may be present

Answer 43

Pain

Question 44

A distinguishing feature between mucosal and complete prolapse

Answer 44

With complete prolapse, a sulcus may be palpated between the extruded bowel and anus, compared to no sulcus with a mucosal prolapse

Question 45

An effective technique for allowing for easier prolapse reduction

Answer 45

Application of granulated sugar over the entire prolapsed segment

Question 46

Where is the transitional zone seen?

Answer 46

At the level of the dentate line and extending approximately 1 cm proximal

Question 47

Malignancies of the portion proximal to the dentate line and including the transitional zone, which are referred to as

Answer 47

Anal canal neoplasms

Question 48

Tumors arising in the anoderm distal to the dentate line, which are referred to as

Answer 48

Anal margin neoplasms

Question 49

Anal margin neoplasms have a low-grade malignant potential and are slow to metastasize, with the exception of ____

Answer 49

Anal margin neoplasms have a low-grade malignant potential and are slow to metastasize, with the exception of melanoma

Question 50

The third most common site of malignant melanoma (after the skin and the eye)

Answer 50

Anal canal

Question 51

Arise from the rectal columnar epithelium, frequently produce clear, watery diarrhea and a profuse rectal discharge

Answer 51

Villous adenomas

Question 52

Any ulcer that fails to heal within ____ or any discrete skin lesion that fails to improve with appropriate therapy must be biopsied to rule out the presence of malignancy

Answer 52

Any ulcer that fails to heal within 30 days or any discrete skin lesion that fails to improve with appropriate therapy must be biopsied to rule out the presence of malignancy

Question 53

Most foreign bodies are in the ___

Answer 53

Ampulla

Question 54

Useful when the foreign body is radiolucent and for the detection of free air

Answer 54

CT scan

Question 55

The second most common anorectal condition after hemorrhoids

Answer 55

Pruritus ani

Question 56

Etiologic cause of pruritus

Answer 56

Staphylococci and Streptococci

Question 57

Common cause of anal pruritus in children

Answer 57

Pinworms (Enterobius vermicularis)

Question 58

True or False | Lumbosacral radiculopathy has been associated with idiopathic pruritus ani

Answer 58

True | Lumbosacral radiculopathy has been associated with idiopathic pruritus ani

Question 59

Provide a protective covering for the perianal skin and may promote healing in pruritus ani

Answer 59

Zinc oxide

Question 60

May be used as an effective bedtime sedative in patient with pruritus ani

Answer 60

Hydroxyzine hydrochloride may be used as an effective bedtime sedative

Question 61

An acquired problem formed by the penetration of the skin by an ingrown hair, which causes a foreign body granuloma reaction

Answer 61

Pilonidal sinus

Question 62

True or False | An abscessed pilonidal sinus is almost always located in the posterior midline over the sacrum and coccyx

Answer 62

True | An abscessed pilonidal sinus is almost always located in the posterior midline over the sacrum and coccyx

Question 63

True or False | Perineal disease is more common in females, whereas axillary disease is more common in males

Answer 63

False | Perineal disease is more common in males, whereas axillary disease is more common in females

Question 64

Fistulas that extend above the dentate line may suggest coexisting ____

Answer 64

Fistulas that extend above the dentate line may suggest coexisting cryptoglandular or Crohn’s disease

Question 65

Treatment for perianal hidradenitis suppurativa

Answer 65

Topical clindamycin or oral clindamycin with rifampin can be helpful

Question 66

Flatulence and/or malodorous vaginal discharge or gross stool ema- nating from the vagina

Answer 66

Rectovaginal fistula