EOR GI part 8- anal disease

Question 1

What are the causes of an anal fistula?

Answer 1

Usually anal crypt/gland infection (usually perianal abscess)

Question 2

What are the s/sx of an anal fistula?

Answer 2

Perianal drainage
Perirectal abscess
Recurrent perirectal abscess
Diaper rash
Itching

Question 3

What dz should be considered with an anal fistula?

Answer 3

Crohn’s dz

Question 4

How is the dx of an anal fistula made?

Answer 4

Exam

Proctoscope

Question 5

What is Goodsall’s rule?

Answer 5

Fistulas originating anterior to a transverse line through the anus will course straight ahead and exit anteriorly, whereas those exiting posteriorly have a curved tract

Question 6

What is the management of anorectal fistulas?

Answer 6

Define the anatomy
Marsupialization of fistula tract
Wound care: routine sitz baths and dressing changes
Seton placement if fistula is through the sphincter muscle

Question 7

What is a seton

Answer 7

Thick suture placed through fistula tract to allow slow transection of sphincter muscle
Scar tissue formed will hold the sphincter muscle in place and allow for continence after transection

Question 8

How do you find the internal rectal opening of an anorectal fistula in the OR?

Answer 8

Inject hydrogen peroxide (or methylene blue) in external opening- then look for bubbles (or blue dye) coming out of internal opening

Question 9

What is a sitz bath?

Answer 9

Sitting in a warm bath (usually done after bowel movement and TID)

Question 10

Perirectal abscess

Answer 10

Abscess formation around the anus/rectum

Question 11

S/sx of perirectal abscess

Answer 11

Rectal pain
Drainage of pus
Fever
Perianal mass

Question 12

How is the dx of perirectal abscess made?

Answer 12

Physical/digital exam reveals perianal/rectal submucosal mass/fluctuance

Question 13

What is the cause of perirectal abscess?

Answer 13

Crypt abscess in dentate line with spread

Question 14

What is the tx for perirectal abscess?

Answer 14

As with all abscesses (except simple liver amebic abscess) drainage, sitz bath, anal hygiene, stool softeners

Question 15

What is the indication for postop IV abx for drainage in perirectal abscess?

Answer 15

Cellulitis
Immunosuppression
DM
Heart valve abnormality

Question 16

Anal fissure

Answer 16

Tear or fissure in the anal epithelium

Question 17

What is the most common site of anal fissures?

Answer 17

Posterior midline (comparatively low blood flow)

Question 18

What is the cause of anal fissures?

Answer 18

Hard stool passage
Hyperactive sphincter
Dz process

Question 19

S/sx of anal fissures?

Answer 19

Pain in the anus
Painful (can be excrutiating) bowel movement
Rectal bleeding
Blood on toilet tissue after bowel movement
Sentinel tag
Tear in the anal skin
Extremely painful rectal exam
Sentinel pile
Hypertrophic papilla

Question 20

What is a sentinel pile?

Answer 20

Thickened mucosa/skin at the distal end of an anal fissure that is often confused with a small hemorrhoid

Question 21

Whatis the anal fissure triad for a chronic fissure?

Answer 21

Fissure
Sentinel pile
Hypertrophied anal papilla

Question 22

What is the conservative tx for anal fissures?

Answer 22

Sitz baths
Stool softeners
High fiber diet
Excellent anal hygiene
Topical nifedipine
Botox

Question 23

What dz process must be considered with a chronic anal fissure?

Answer 23

Crohn's dz
Anal CA
Sexually transmitted dz
Ulcerative colitis
AIDS

Question 24

What are the indications for surgery in anal fissures?

Answer 24

Chronic fissure refractory to conservative tx

Question 25

What is one surgical option for an anal fissure?

Answer 25

Lateral internal sphincterotomy- cut the internal sphincter to release it from spasm

Question 26

What is the rule of 90% for anal fissures?

Answer 26

90% occur posteriorly 90% heal with medical tx alone 90% of pts who undergo an LIS heal successfully

Question 27

Hemorrhoids

Answer 27

Engorgement of the venous plexuses of the rectum, anus, or both; with protrusion of the mucosa, anal margin, or both

Question 28

Why do we have healthy hemorrhoidal tissue?

Answer 28

It is thought to be involved with fluid/air continence

Question 29

S/sx of hemorrhoids?

Answer 29

Anal mass/prolapse Bleeding Itching Pain

Question 30

What type of hemorrhoids, internal or external, is painful?

Answer 30

External, below the dentate line

Question 31

If a pt has excruciating anal pain and hx of hemorrhoids, what is the likely dx?

Answer 31

Thrombosed external hemorrhoid (treat by excision)

Question 32

What are the causes of hemorrhoids?

Answer 32

Constipation/straining Portal hypertension Pregnancy

Question 33

What is an internal hemorrhoid?

Answer 33

Hemorrhoid above the proximal dentate line

Question 34

What is an external hemorrhoid?

Answer 34

Hemorrhoid below the dentate line

Question 35

What are the three hemorrhoid quadrants?

Answer 35

Left lateral Right posterior Right anterior

Question 36

First degree hemorrhoid

Answer 36

Hemorrhoid that does not prolapse

Question 37

Second degree hemorrhoid

Answer 37

Prolapses with defecation but returns on its own

Question 38

Third degree hemorrhoid

Answer 38

Prolapses with defecation or any type of Valsalva maneuver and requires active manual reduction

Question 39

Fourth degree hemorrhoid

Answer 39

Prolapsed hemorrhoid that cannot be reduced

Question 40

What is the tx for hemorrhoids?

Answer 40

``` High-fiber diet Anal hygiene Topical steroids Sitz baths Rubber band ligation Surgical resection for large refractor hemorrhoids Infared coagulation Harmonic scalpel ```

Question 41

What is a closed versus open hemorrhoidectomy?

Answer 41

Closed closes the mucosa with sutures after hemorrhoid tissue removal Open leaves mucosa open

Question 42

What are the complications of hemorrhoidectomy?

Answer 42

Exsanguination Pelvic infection Incontinence Anal stricture

Question 43

What condition is a contraindication for hemorrhoidectomy?

Answer 43

Crohn's dz

Question 44

Classically, what must be ruled out with lower GI bleeding believed to be caused by hemorrhoids?

Answer 44

Colon CA