Rectal disorders: hemorrhoids and fissures PP Week 4 Flashcards Preview

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Flashcards in Rectal disorders: hemorrhoids and fissures PP Week 4 Deck (46)
1

rectum

lower 10- 15cm of the large intestine

2

anatomical anal canal

outlet of the digestive system, tube that is 3.8 cm long running from perianal skin of the buttock to the mucosal lining of the rectum

3

internal sphincter

subconsciously controlled so you don't shit yourself

4

external sphincter

action is voluntary, it is highly innervated (vagal nerve)

5

both sphincters

are highly vascular

6

where the anal canal meets the rectum there is a ring of folds

called the the dentate line; it separates the anal canal and the rectum and dilineates where the nerve fibers end (below is innervated/ extremely sensitive to pain, above is not)

7

within the dentate lines are

anal crypts which are small tube like depressions opening into the anal canal

8

veins from rectum and anus drain into

the portal vein, which leads to the liver, and then to the general circulation

9

the lymph vessels of the rectum drain into

lymph nodes in the lower abdomen

10

the lymph of the anus drain into

the lymph nodes in the groin

11

rectal exam

inspect the skin around the anus for any abnormality, with a gloved finger- probe rectum clockwise for documentation

12

an anoscope or protoscope

3- 10 inch rigid viewing tubes- if you palpated something on the DRE that was abnormal, use this to visualize

13

sigmoidoscope

longer, more flexible, can observe as much as 2 or more feet of the large intestine- would use if pt was having dark red stools

14

stop if

area in or around anus proves to be painful- use some type of anesthetic before continuing. ex anal ca

15

sometimes give what before a sidmoidoscopy to rid lower bowel of stool

cleansing enema

16

what may be obtained during sigmoidoscopy?

stool samples for microscopic examination and cultures

17

hemorrhoids

dilated, twisted (aka varicose) veins located in the wall of the rectum and anus

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when do hemorrhoids occur

when veins in the rectum or anus enlarge; they may eventually bleed, may also develop a blood clot

19

internal hemorrhoids

above the boundary between the rectum and the anus (anorectal junction)

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eternal hemorrhoids

below the anorectal junction

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both internal and external hemorrhoids may

remain in the anus or protrude outside the anus

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hemorrhoidal bleeding

bleeding is actually arterial

23

hemorrhoidal tissue is thought to contribute

to anal incontinence and functions as a compressible lining that provides complete closure of the anus

24

external hemorrhoids located

distal to dentate line

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internal hemorrhoids located

proximal to dentate line

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mixed hemorrhoids are located

both proximal and distal to dentate line

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internal hemorrhoid classification**

graded according to the degree to which they prolapse from the anal canal
grade 1- viusualized on anoscopy and may buldge into the lumen but do not prolapse below dentate line
grade 2- prolapse out of the canal with defecation or with straining but reduce spontaneously
grade 3- prolapse out of the canal with defecation or straining, and will require manual reduction
grade 4- are irreducible and may strangulate

28

most common cause of hemorrhoids

constipation

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other causes of hemorrhoids

preggo, intreased intra- abdominal pressure (portal HTN, hep c, liver ca), hereditary, aging (d/t thinning of supportive tissue), prolonged straining

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internal hemorrhoid-

portal venous system (heptasplenomegaly, hep c), not thrombosed

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external hemorrhoid

systemic venous system; can become thrombosed with resultant bluish mass called external hemorrhoid

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generalized sx of hemorrhoids

bleeding on stool or in toilet, mucosal protrusion, discharge, soiled underwear (d/t internal), sensation of incomplete evacuation, PAINLESS UNLESS THROMBOSED, bleeding from external is darker, thrombosed blood

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sx of internal hemorrhoids

pain not a usual feature until thrombosus, infection or erosion of the overlying mucosal surface. Most pts c/o BRBPR with a feeling of vague anal discomfort which is increased when hemorrhoid enlarges or prolapses

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prolapse internal hemorrhoid sx

edema and sphincteric spasm

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prolapsed chronic internal hemorrhoid

constant soiling, very little pain

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sx of external hemorrhoids

usually very painful because they lie under the skin, tender blue swelling at the anal verge d/t thrombosis of a vein in the external plexus (need not be associated with enlargement of internal veins). Spasm often occurs since the thrombus usually lies at the level of the sphinteric muscles

37

dx of internal or external hemorrhoids

is clinical; inspection, DRE, direct vision through anoscope and proctoscope

38

what position for DRE

prone, jack- knife position or lateral Sim's position

39

location of hemorrhoids should be described according to their anatomic position

using a clockwise pattern

40

**since hemorrhoids are very common,

they must not be regarded as the cause of rectal bleeding or chronic hypochromic anemia until a through investigation has been made of the more proximal GI tract

41

chronic anemia in the presence of a large but not bleeding hemorrhoid should provoke

a search for a polyp, cancer, or ulcer

42

treatment for hemorrhoids

includes medical as well as surgical modalities- medical: stool bulking agents i.e. psyllium or methylcellulose, sitz bath (probably most effective topical treatment for relief of symptoms) most hemorrhoids respond to conservative therapies such as these

43

treatment for internal hemorrhoids

if remain permanently prolapsed, best tx is surgery. Milder degrees of prolapse or enlargement with pruritis ani or intermittent bleeding can be successfully handled by banding or injection of sclerosing solutions

44

treatment for external hemorrhoids

if acutely thrombosed, treated with incision, extraction of the clot and compression of the incised area following clot removal. No surgical procedure if there is acute inflammation of the anus, ulcerative proctitis, or UC

45

what should be done before a pt is subjected to a hemorrhoidectomy

proctoscopy and barium enema

46

surgical therapy

rubber band ligation, infared photocoagulation (laser), sclerotherapy or hemorrhoidectomy (only for symptomatic combined internal and external)