Disorders of the anus and rectum Flashcards

Question

Presentation for anal fissures

Answer 1

● Severe pain with bowel movements ○ Minutes to hours ● Usually occurs with every bowel movement ● Patient begins to avoid bowel movements out of fear/apprehension. Worse with Constipation and Harder stools ● 70-75% of patients note bright red blood, especially with wiping

Answer 2

● Not indicated for an ordinary fissure, if Anterior midline or posterior midline ● If irregular, not midline, or if underlying pathology suspected ○ ESR ○ Culture ○ STD testing (including HIV) ○ Biopsy

Answer 3

○ Acute fissures appear as fresh, superficial lacerations, almost like a paper cut. ○ Chronic fissures have raised edges exposing the white, horizontally oriented fibers of the internal anal sphincter muscle fibers

Answer 4

Just visual exam needed ususally ● Digital rectal exam - Avoid ○ WILL BE PAINFUL - May worsen inflammation ● Anoscopy/rigid proctosigmoidoscopy ○ WILL BE PAINFUL ○ Only perform once symptoms have improved ● Chronic fissures are less painful, exam techniques are better tolerated and can be included

Answer 5

○ Fiber supplementation ○ Stool softeners (like Docusate) ○ Laxatives as needed (like Senna) ○ Mineral oil ● Lidocaine-hydrocortisone rectal for pain ● Sitz baths - Provides good relief, helps heal Next step? ● Intra-anal nitroglycerin 0.4%

Answer 6

Botox (Botulinum toxin) ● Acute or chronic fissures ● Injected directly into the internal anal sphincter ● Effect lasts for 3 months Subcutaneous fissurectomy ● Cuts out the fissure without affecting the sphincters ● Less chance of incontinence than sphincterotomy

Answer 7

● Lateral internal anal sphincterotomy

Answer 8

SOC for Anal fissures ○ Avoid on those with high risk of incontinence (like multiparous women or older patients) ○ Surgical procedure of choice ○ General or local anesthesia ○ Only the internal sphincter is cut ○ Continence disturbance rate at 2 years, about 14 percent (flatus incontinence 9 %, soilage/seepage 6 %, accidental defecation 1 %, solid stool incontinence 0.83 %)

Answer 9

● Arise from infection of the epithelium lining of the anal canal ● Severity and depth of abscesses vary ● Abscess cavity often associated with the development of a fistula

Answer 10

○ Intersphincteric (70%) - Found between the internal and external sphincters ○ Transsphincteric (23%) - Extends through the external sphincter into the ischiorectal fossa ○ Extrasphincteric (5%) - Passes from the rectum to the skin through the levator ani ○ Suprasphincteric (2%) - Extends from the intersphincteric plane through the puborectalis, exiting the skin after traversing the levator ani

Answer 11

● Anaerobes ○ Bacteroides fragilis, Peptostreptococcus, Prevotella, Fusobacterium, Porphyromonas, Clostridium ● Aerobes ○ Staphylococcus aureus, Streptococcus, Escherichia coli, MRSA ● 10% of anorectal abscesses form for reasons other than bacterial infection ○ Crohn’s, HIV, tuberculosis, cancer, STD, IBD, diverticular disease, foreign body, appendicitis

Answer 12

● Perianal pain, varies with abscess location ● Swelling around the rectum ● Perirectal drainage that is bloody, purulent, or mucoid ● Constipation ● Diarrhea

Answer 13

○ Recurrent, malodorous perianal drainage ○ Pruritis ○ Perianal pain (if occluded) ○ Recurrent abscess ○ Pain occurs with sitting, moving, defecating, and coughing and is throbbing in nature ○ Patient may feel indent

Answer 14

A fluctuant, indurated mass

Answer 15

○ A fibrous tract or cord beneath the skin ○ Pus or blood may be expressible

Answer 16

● Immunocompromised patients are at an increased risk of sepsis as a results of anorectal abscess ○ CBC with diff ○ ESR ● Cultures - VERY IMPORTANT ○ All I&D patients

Answer 17

● Usually not necessary in the evaluation of simple perianal abscesses and fistulas ● Clinical suspicion of an intersphincteric or supralevator abscess may require confirmation ○ CT is readily available in most ERs and is commonly used ○ MRI is the best (if available) for imaging of anorectal abscesses (91% sensitivity)

Answer 18

● To evaluate anal fistulas ○ Injection of contrast into the internal opening, radiographs performed ○ Can be painful when injecting the contrast material into fistulous ○ Generally reserved for cases in which there is a concern about a fistulous connection between the rectum and adjacent organs such as the bladder

Answer 19

● Emerging as an excellent way of evaluating complex cases of perianal abscess and fistula ● Extent and configuration of the abscess and fistulas can be clearly visualized ● Becoming a test of choice where available

Answer 20

F - ○ Urgent incision and drainage with culture collection ○ No “watchful waiting” while administering antibiotics. It is inadequate ○ Delaying surgical intervention results in chronic tissue destruction, fibrosis, and stricture formation and may impair anal continence

Answer 21

○ Routine antibiotic treatment (in addition to drainage) ○ Bactrim DS or vancomycin ● Acute abscesses recur in roughly 10% of patients ○ Patients should be advised to return to the clinic or ER if symptoms of an abscess recur

Answer 22

○ Treat intra-abdominal disease ■ Crohn’s ○ Surgical intervention indicated for symptomatic patients ■ Fistulotomy vs. fistulectomy ■ Marsupialization ■ Anal flaps ○ Alternatively, a draining seton may be used to keep the fistula tract open, which often prevents recurrent abscess.