2- Anorectal disease

Question 1

What should you always check for with DRE? (4)

Answer 1

Anal tone
Palpate for tenderness, mass or induration
Note any blood upon removal
Stool guaiac

Question 2

What is the next step if you notice any red flags in pt w/ anorectal complaint?

• Unintentional weight loss
• IDA
• PMH or FH IBD or CRC
• Persistent anorectal bleeding or sx despite tx

Answer 2

Refer to GI/colorectal specialist

Question 3

What very common pathology arises from the fibrovascular cushion?

Answer 3

Hemorrhoids

Question 4

What is the difference b/w internal and external hemorrhoids?

Answer 4

Internal: Proximal to dentate line. PAINLESS

External: Distal to dentate line. PAINFUL

Question 5

What is the classification scale used to dx hemorrhoids?

Answer 5

Grade I-IV

I - Bulge in anal canal w/o prolapse
II - Prolapse that reduces spontaneously
III - Prolapse that requires manual reduction
IV - Chronic prolapse, irreducible

Question 6

Pt presents w/ hx of bright red blood w/ BM, sensation of perianal fullness and anal pruritus. What are you concerned about?

Answer 6

Hemorrhoids

*Perianal fullness sx due to prolapse

Question 7

What portion of hemorrhoid PE will allows for true optimal visualization of internal hemorrhoids?

Answer 7

Anoscopy

Question 8

The ACG (guidelines) requires what test at the very least if you note hemorrhoid-patten bleeding on exam ?

Answer 8

Sigmoidoscopy to r/o other anorectal pathology

Question 9

What are the general txs for symptomatic hemorrhoids?

Answer 9

1. Diet/lifestyle mod
2. Conservative therapies/office-base procedures
3. Surgical management

Question 10

What dietary/life style mods are recommended for all grades of hemorrhoids? (3)

Answer 10

Increase FIBER and FLUID intake (dietary/bulk laxatives)
Avoid lingering and straining on the toilet
Sitz baths

Question 11

What conservative medical therapies are recommended for the tx hemorrhoids?

Answer 11

Stool softeners
SHORT course of corticosteroid cream or suppositories
Nitroglycerin ointment (antispasmodic)

Question 12

What office based procedures are recommended for the tx hemorrhoids (pts REFRACTORY to conservative medical therapies)?

Answer 12

Internal hemorrhoids:

• Rubber band ligation
• Infrared coagulation
• Sclerotherapy

External hemorrhoids:
- Excision

Question 13

When is hemorrhoidectomy performed?

Answer 13

• Grade IV internal hemorrhoid
• Symptomatic grade III hemorrhoid
• Persistent sx despite conservative or office based procedures
• Extensive pain from thrombosed external hemorrhoid

Question 14

Pt presents w/ painless rectal bleeding, perianal itching w/ evidence of grade II internal hemorrhoid. What recommendation is most appropriate initially?

Answer 14

High fiber and fluid diet

Question 15

What often develops from local irritation and resultant inflammation to the skin of the anus?

Answer 15

Pruritis Ani

Question 16

What is the most common cause of pruritis ani?

Answer 16

Mechanical

- Prolapsing tissue, fecal incontinence/soiling, poor hygiene

Question 17

On exam you note circumferential erythematous and irritated perianal skin. What sx does the pt complain of?

Answer 17

Intense itching and burning

Dx: pruritis ani

Question 18

What is the tx for pruritis ani? (5)

Answer 18

• Eliminate offending agent
• Proper hygiene (avoid aggressive wiping/overzealous hygiene)
• Keep area dry/avoid tight clothing
• Topical astringent (witch hazel) or barrier (zinc oxide)
• If severe: short course of topical steroid cream

Question 19

On exam of the anal region you note an outgrowth of normal skin/loose, flesh-color, pedunculated tissues. What are you concerned about?

Answer 19

Perianal skin tags

Question 20

Are perianal skin tags a clinical dx?

Answer 20

Yes

*If uncertain referral/biopsy

Question 21

What is the tx for perianal skin tags?

Answer 21

TX not usually indicated

+/- Referral for excision if tags interfere w/ hygiene or cause discomfort

Question 22

What is defined as a linear tear or split in the lining of the anal canal distal to the dentate line that causes spasm of the anal sphincters?

Answer 22

Anal fissure

Question 23

What is the most common cause of severe anorectal pain?

Answer 23

Anal fissure

Question 24

Anal fissures can be caused by local trauma to the anal canal (passage of large stools, FB). They are also associated w/ what disease states?

Answer 24

Crohn’s disease, malignancy, HIV/AIDs

Question 25

Pain from an anal fissure will cause spasm of the sphincters. What does this result in?

Answer 25

Further decreases blood flow and prevent healing

Question 26

Pt reports bright red blood on toilet paper and states that is feels like they "passing glass" or "sitting on a knife". What do you suspect?

Answer 26

Anal fissures

Question 27

What is the most common location for an anal fissure?

Answer 27

Posterior midline (lowest blood supply)

Question 28

How are anal fissures dx?

Answer 28

DRE/anoscopy (may be too uncomfortable to tolerate) Flex sig/colonoscopy if unsure/recurrent sx

Question 29

What is the tx for anal fissures? (6)

Answer 29

- Fiber/fluid - Anal hygiene/sitz baths - Stool softeners - Topical lidocaine gel - Topical vasodilator (Nifedipine or Nitro ointment) - If chronic/refractory → surgery (sphincterotomy)

Question 30

What risk is a/o Sphincterotomy?

Answer 30

Low risk for fecal incontinence

Question 31

What results from an obstructed/infected anal crypt gland?

Answer 31

Perianal abscess

Question 32

Chronic perianal abscesses can progress to what?

Answer 32

Fistula

Question 33

Perianal abscesses can be a/w what disease?

Answer 33

Crohn's disease

Question 34

On anal/rectal exam you note a palpable fluctuant mass w/ surrounding edema, localized erythema and tenderness. What is your suspected dx?

Answer 34

Perianal abscess

Question 35

In pts w/ suspected perianal abscess, what should be included a part of your exam?

Answer 35

Palpate for inguinal lymphadenopathy

Question 36

What is the tx for perianal abscess?

Answer 36

- CT/MRI to determine extent - I & D - ABX for DM or IMC pts - Post-op: sitz baths, fluid and fiber

Question 37

24 y/o F presents w/ recurrent perianal fistula and hx of perirectal abscess. She has a hx of IBS type sx which have not been tx. In addition to her fistula, what other disease should she be worked up for?

Answer 37

Crohn's disease

Question 38

What is a chronic manifestation of a perianal abscess that results in an abn communication b/w the anal canal and perianal area?

Answer 38

Anorectal fistula

Question 39

Anorectal fistulas can be seen w/ what disease? (3)

Answer 39

Crohn's, radiation proctitis (damage to colon due to radiation exposure), diverticulitis

Question 40

Pt presents with hx of chronic drainage of blood/pus and occasionally stool from anal area. On exam you note perianal skin is excoriated/inflamed and there is a palpable cord beneath the skin b/w the anus and abscess. What is your suspected dx?

Answer 40

Anorectal fistula

Question 41

What is the dx/tx for anorectal fistula?

Answer 41

- MRI pelvis for complex/recurrent fistula - COLONOSCOPY if concern for IBD - Fistulotomy: surgical unroofing of the fistula tract to allow for healing

Question 42

What is the etiology of anal condyloma?

Answer 42

HPV

Question 43

On exam w/ anoscopy you note cauliflower like growths in clusters or single entities. What is your suspected DX?

Answer 43

Anal condyloma

Question 44

What is the tx for anal condyloma?

Answer 44

Removal or destruction of visible lesions - Topical Podofilox, Imiquimoid cream - Office tx w/ trichloroacetic acid - Surgical removal + f/u intervals to assess to recurrence

Question 45

Majority of anal cancer are what type?

Answer 45

Squamous cell cancers

Question 46

Presentation for anal CA varies from rectal bleeding, pain, to warts and internal/external lesions. What should be included in your exam?

Answer 46

DRE, Palpate for inguinal lymphadenopathy

Question 47

What is the tx for anal CA?

Answer 47

- Biopsy + scope to determine extent - Chemoradiotherapy - Surgery

Question 48

What is a pelvic flood disorder in which rectal tissue protrudes through the anus?

Answer 48

Rectal prolapse

Question 49

Chronic constipation, straining, multiparity, or prior pelvic surgery may be a/w with what?

Answer 49

Rectal prolapse

Question 50

Pt presents with constipation and bowel seepage and hx of "mass" protruding through anus. On exam you are able to have them reproduce the sx w/ straining. On DRE what are your expectant findings? What is your suspected dx?

Answer 50

Mucosa of rectal wall may feel floppy or loose w/ redundant tissue Rectal prolapse

Question 51

What is the dx/tx for rectal prolapse?

Answer 51

Anorectal manometry Prevent constipation/increase fiber/fluid Surgical repair - consult colorectal surgery

Question 52

What is defined as weakened fascia that allows the rectum to bulge into the vagina and is often a/w vaginal childbirth, age, high BMI?

Answer 52

Rectocele

Question 53

F pt presents w/ hx of sexual dysfunction and pelvic pressure reports needing to apply pressure on vagina/perineum/rectum in order to defecate. What is your suspected dx? How could you confirm your dx?

Answer 53

Rectocele Defecography (fluoroscopy while defecating)

Question 54

What is the tx for rectocele?

Answer 54

Pelvic flood muscle training, pessary (device into vagina to prevent rectum from bulging)

Question 55

If you are unsure of dx for pt w/ anorectal sx. What is your course of action?

Answer 55

Refer to GI/colorectal surgeon