Flashcards in CM- Colorectal Disease Deck (28)
What are the 4 chief complaints/symptoms patients present with regarding colorectal area?
What is the prognostic difference between pain with stool and a bowel movement vs. pain not associated with stool or a bowel movement?
Pain with a bowel movement - a problem that can easily be found on exam
Pain w/o = a more complicated pattern of occurrences that might not be visible on inspection.
How can you tell when bleeding occurs at the anus vs. more proximally?
The closer to the anus, the brighter red the blood will be.
Outlet anal pathology = bright red coating stool, on toilet paper or dripping into the toilet
Rectum or colon = dark blood and/or blood mixed in stool
What 3 things describe constipation?
1. infrequent bowel movement
2. hard stool
3. excessive straining
What is tenesmus?
the feeling of rectal fullness and an impending urge to defecate.
common feeling in persons that have had diarrhea
What is the very first step of the rectal examination?
1. inspect the abdomen for presence/absence of distension
What position should the patient be in for the rectal exam?
Left lateral with knees brought up to chest as much as possible.
Describe the steps of the rectal examination.
1. Inspection- look for abdominal distension AND part the butt cheeks to inspect:
- anus/perinanal skin
2. Make note of external draining sites and spread them to reveal anal fissure
3. Palpate perinanal skin including superficial sphincter at the verge which can disclose tunnel of induration leading to external draining site
Describe the steps of the DRE.
1. Lubricate your finger
2. Pressure on the posterior anus allows the finger to go into the canal
3. Once the finger is above levator ani, start posteriorly and feel the coccyx
4. Feel the sacral hollow and the soft mucosa over the sacrum
5. Turn finger anteriorly and feel for prostate or cervical tip
6. Palpate sphincteric mechanism in anal canal between finger and thumb for lumps, indurations, defects
7. Use stool on exam finger for guaiac test for the presence of blood in stool
Where are the pain fibers located in the rectum?
Distal to the dentate line so the DRE should be relatively gentle
What is anoscopy? What are the pros and cons?
The use of a short scope to look at the very distal rectum and anal canal.
Pro: essential for defining hemorrhoids
Con: none of the colon is visualized
What is proctoscopy?
What parts of the GI tract are visualized?
What are the pros and cons?
It is a 25cm tube with a light and eye piece to see the rectum up to the rectosigmoid junction.
Pro: excellent visualization, can biopsy, economic in terms of time/equipment
Con: usually only goes up to peritoneal reflection
What parts of the GI tract are visualized by fiberoptic sigmoidoscopy and colonoscopy?
What are pros and cons to each approach?
Flexible fiberoptic sigmoidoscopy - assesses descending colon down to the rectum
Pro: economic and cost saving with barium enema
Con: if a polyp is found, you have to do a colonoscopy anyway
Colonoscopy- assesses the entire colon
Pro: preferred method bc it views the whole colon
Con: expensive, risks of complications, needs extensive patient prep
What are the pros and cons of the barium enema?
Pros: cost effective, fine outline of bowel and mucosa
Con: miss 8-12% of polyps, can't biopsy or do therapeutic intervention
What is virtual colonoscopy?
What are pros/cons?
reconstruction of details of the colon by using CT images.
Cons: can't biopsy or do therapeutic intervention
What is diverticulosis?
What is it related to?
How many people over 50 in the US have it?
What percent remain asymptomatic?
It is multiple, acquired pseudodiverticula in the colon (usually sigmoid).
It is related to low fiber diet and 50% of people over 50 have it.
75% will remain asymptomatic.
What are the 4 major complications of diverticulosis?
How is each treated?
1. If the neck becomes obstructed there will be micro/macroperforations with inflammation and edema. LLQ pain, fever, constipation/diarrhea. Treat with antibiotics.
2. Abscess formation - palpable and visualized on CT. Treatment requires drainage.
3. Perforation causing peritonitis - emergency surgery is required
4. Fistula formation to bladder, vagina, small bowel. [bladder is the most common -colovesical]. Treat with surgery
A patient presents with constant pain at the anal outlet, which usually signifies ___________. When you do DRE, you note swelling and tenderness.
What is the likely cause?
Infection like perianal or perirectal abscesses
How do perianal and perirectal abscesses start/spread?
What is treatment?
Abscesses begin with obstruction of an anal gland and then spread to perianal area, ischiorectal fossa or supralevator space.
Treatment is drainage.
What can develop as a complication to a perianal, perirectal abscess?
What does the patient present with?
What is treatment?
Fistula-in-ano which is a connection between the anus at the level of the dentate line and perirectal skin.
The patient has chronic pus drainage.
Treatment is surgery.
What is an anal fissure?
Where are the 2 most frequent spots for them to occur?
What are the symptoms?
It is a tearing pain associated with bowel movement.
90% are in the posterior midline and 10% are in the anterior midline
Symptoms: minor bleeding.
[fissures can heal or become chronic]
What are hemorrhoids?
Normally there are 3 vascular cushions in the anal canal that:
1. protect during bowel movement
2. close anal canal btw bowel movements
Hemorrhoids is when these vessels become engorged/enlarged due to chronic constipation and straining.
What are the 3 types of hemorrhoids?
1. Internal - above the dentate line, color of the mucosa. May prolapse and bleed but PAINLESS [unless the hemorrhoids prolapse and cant be reduced]
2. External - below the dentate line, flesh colored
3. Thrombosed external - red/blue swelling w/o disruption of the overlying skin at the anal verge
What is rectal prolapse?
What are symptoms?
What is treatment?
When the full thickness of the rectal wall protrudes through the anal opening.
-pain, mild bleeding, mucous discharge, incontinence.
Treatment is surgical
How does rectal carcinoma present?
Bright red blood per rectum with or w/o pain.
Palpable tumor on DRE
What is the differential for anorectal bleeding?
1. anal fissure
2. internal hemorroids (++)
3 rectal prolapse
4. carcinoma of the rectum
What is the DDx for rectal pain?
1. anal fissure
2. perirectal abscess
3. thrombosed external hemorrhoid
+/- rectal prolapse
+/- carcinoma of the rectum