Disease of the anus and rectum

Question 1

anal fissure S&S, dx

Answer 1

-Linear rocket shaped ulcer <5mm in length
-Due to trauma during defecation
-tears
-painful
-Location:
-Most in posterior midline
-10% anteriorly (most posterior)
-Off the midline consider Crohn’s, HIV/AIDS, cancer, TB, syphilis
-S&S- severe pain and tearing during defecation, throbbing discomfort, bright red blood on stool or toilet paper, constipation
-dx- visual inspection of anal verge- crack in epithelium, pain on rectal exam, skin tag

Question 2

anal fissure tx

Answer 2

-Addressing the bowel pattern
-Cortisone cream vs supp
-Topical anesthetics
-Chronic fissures:
-Nitroglycerin or diltiazem ointment 2 x day
-Botox
-Lateral internal sphincterotomy

Question 3

perianal abscess and fistula

Answer 3

-Abscess: Anal glands may become INFECTED
-Symptoms: Throbbing perianal pain
-Signs: Erythema, fluctuance and swelling on exam
-Treatment: Incision and drainage

Question 4

anal fistula

Answer 4

-Most often in anal crypt
-Often evolves from a spontaneously draining anorectal abscess
-Consider: Crohn’s**, lymphogranuloma venereum, rectal TB, cancer
-Signs and symptoms: Purulent discharge*, +/- itching, tenderness and pain
-Treatment: Surgical tx unless Crohn’s fistula
-seton- needle and thread through it to ensure drainage

Question 5

perianal pruritis

Answer 5

-Perianal itching and discomfort
-Causes: Poor hygiene or Overzealous cleansing with soaps
-R/o: STD, bacterial infection, parasites, fungal infection, psoriasis
-exam- erythema, excoriations, lichenified skin
-tx:
-Education
-Wet nonscented wipes and pat dry
-Short course of topical steroid +/- anesthetic
-Consider antihistamine
-Consider antifungal

Question 6

fecal impaction

Answer 6

-Severe impaction of stool in the rectal vault
-Can lead to obstruction of fecal flow when severe- Partial or complete bowel obstruction
-predisposing factors: Psychiatric disorder (MS), prolonged bed rest, neurogenic disorders of colon, spinal cord ds, opiates
-clinical presentation is variable”
-decreased appetite, nausea, vomiting, abdominal pain, distention, paradoxical diarrheas as stool leaks around impaction
-Firm feces is found on rectal exam
-tx- enemas, PEG (Polyethylene glycol-laxative) +/- manual disruption of fecal material
-long term care is aimed at avoiding constipation

Question 7

Internal Hemorrhoids

Answer 7

-Subepithelial vascular cushions
-Sinusoidal pattern of arteriovenous communication in cushions between superior and inferior hemorrhoidal arteries and superior, middle, and inferior hemorrhoidal veins.
-Rich in muscular fibers
-Normal entity:
-Contribute to normal pressures
-Ensure water tight closure of anal canal
-3 primary locations of internal hemorrhoids -> right anterior, right posterior, left lateral
-S&S- bleeding with wiping (painless), prolapse, mucoid discharge, soiling, dull ache/fullness from engorgement of tissue, severe pain may indicate a thrombosed hemorrhoid
-possibility of other causes of bleeding must be considered

Question 8

external hemorrhoids

Answer 8

-Arise from inferior hemorrhoid veins located below the dentate line
-Covered with squamous epithelium of anal canal or perianal region
-prolapsed

Question 9

hemorrhoids S&S

Answer 9

-Become symptomatic due to increase in venous pressure -> distention and engorgement:
-Straining
-Constipation
-Prolonged sitting (on toilet)
-Pregnancy
-Obesity
-Low fiber diet -> constipation
-In time redundancy and enlargement of the venous cushion may develop- Bleeding and protrusion

Question 10

classification of hemorrhoids

Answer 10

-based on progression of disease from their normal internal location to the prolapsing external position -> affects treatment
-stage 1- confined to anal canal
-stage 2- prolapse with straining and reduces spontaneously
-stage 3- prolapse with straining requiring manual reduction
-stage 4- remain chronically protruding

Question 11

hemorrhoid treatment

Answer 11

-stage 1- enlargement with bleeding
-Fiber supplementation
Cortisone suppository
Sclerotherapy
Endolase
Banding

-stage 2- protrusion with spontaneous reduction
-Fiber supplementation
-Cortisone suppository
-Sclerotherapy
-Endolase*- for bleeding hemorrhoids
-Banding

-stage 3- protrusion requiring manual reduction
-Fiber supplementation
Cortisone suppository
Banding*
Operative hemorrhoidectomy (stapled or traditional)

-stage 4- irreducible protrusion
-Fiber supplementation
-Cortisone suppository
-Operative hemorrhoidectomy

-Thrombosed Hemorrhoid-> supportive or surgery - these usually decompress themselves (these are painful, others are just annoying)
-cold is better than hot