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1. Clin Med III > 2- Anorectal disease > Flashcards

2- Anorectal disease Flashcards

1
Q

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

A

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

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2
Q

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
A

Refer to GI/colorectal specialist

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3
Q

What very common pathology arises from the fibrovascular cushion?

A

Hemorrhoids

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4
Q

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

A

Internal: Proximal to dentate line. PAINLESS

External: Distal to dentate line. PAINFUL

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5
Q

What is the classification scale used to dx hemorrhoids?

A

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

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6
Q

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

A

Hemorrhoids

*Perianal fullness sx due to prolapse

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7
Q

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

A

Anoscopy

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8
Q

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

A

Sigmoidoscopy to r/o other anorectal pathology

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9
Q

What are the general txs for symptomatic hemorrhoids?

A
  1. Diet/lifestyle mod
  2. Conservative therapies/office-base procedures
  3. Surgical management
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10
Q

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

A

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

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11
Q

What conservative medical therapies are recommended for the tx hemorrhoids?

A

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

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12
Q

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

A

Internal hemorrhoids:

  • Rubber band ligation
  • Infrared coagulation
  • Sclerotherapy

External hemorrhoids:
- Excision

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13
Q

When is hemorrhoidectomy performed?

A
  • Grade IV internal hemorrhoid
  • Symptomatic grade III hemorrhoid
  • Persistent sx despite conservative or office based procedures
  • Extensive pain from thrombosed external hemorrhoid
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14
Q

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

A

High fiber and fluid diet

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15
Q

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

A

Pruritis Ani

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16
Q

What is the most common cause of pruritis ani?

A

Mechanical

- Prolapsing tissue, fecal incontinence/soiling, poor hygiene

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17
Q

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

A

Intense itching and burning

Dx: pruritis ani

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18
Q

What is the tx for pruritis ani? (5)

A
  • 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
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19
Q

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

A

Perianal skin tags

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20
Q

Are perianal skin tags a clinical dx?

A

Yes

*If uncertain referral/biopsy

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21
Q

What is the tx for perianal skin tags?

A

TX not usually indicated

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

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22
Q

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?

A

Anal fissure

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23
Q

What is the most common cause of severe anorectal pain?

A

Anal fissure

24
Q

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?

A

Crohn’s disease, malignancy, HIV/AIDs

25
Q

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

A

Further decreases blood flow and prevent healing

26
Q

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?

A

Anal fissures

27
Q

What is the most common location for an anal fissure?

A

Posterior midline (lowest blood supply)

28
Q

How are anal fissures dx?

A

DRE/anoscopy (may be too uncomfortable to tolerate)

Flex sig/colonoscopy if unsure/recurrent sx

29
Q

What is the tx for anal fissures? (6)

A
  • Fiber/fluid
  • Anal hygiene/sitz baths
  • Stool softeners
  • Topical lidocaine gel
  • Topical vasodilator (Nifedipine or Nitro ointment)
  • If chronic/refractory → surgery (sphincterotomy)
30
Q

What risk is a/o Sphincterotomy?

A

Low risk for fecal incontinence

31
Q

What results from an obstructed/infected anal crypt gland?

A

Perianal abscess

32
Q

Chronic perianal abscesses can progress to what?

A

Fistula

33
Q

Perianal abscesses can be a/w what disease?

A

Crohn’s disease

34
Q

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

A

Perianal abscess

35
Q

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

A

Palpate for inguinal lymphadenopathy

36
Q

What is the tx for perianal abscess?

A
  • CT/MRI to determine extent
  • I & D
  • ABX for DM or IMC pts
  • Post-op: sitz baths, fluid and fiber
37
Q

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?

A

Crohn’s disease

38
Q

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

A

Anorectal fistula

39
Q

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

A

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

40
Q

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?

A

Anorectal fistula

41
Q

What is the dx/tx for anorectal fistula?

A
  • MRI pelvis for complex/recurrent fistula
  • COLONOSCOPY if concern for IBD
  • Fistulotomy: surgical unroofing of the fistula tract to allow for healing
42
Q

What is the etiology of anal condyloma?

A

HPV

43
Q

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

A

Anal condyloma

44
Q

What is the tx for anal condyloma?

A

Removal or destruction of visible lesions

  • Topical Podofilox, Imiquimoid cream
  • Office tx w/ trichloroacetic acid
  • Surgical removal

+ f/u intervals to assess to recurrence

45
Q

Majority of anal cancer are what type?

A

Squamous cell cancers

46
Q

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

A

DRE, Palpate for inguinal lymphadenopathy

47
Q

What is the tx for anal CA?

A
  • Biopsy + scope to determine extent
  • Chemoradiotherapy
  • Surgery
48
Q

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

A

Rectal prolapse

49
Q

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

A

Rectal prolapse

50
Q

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?

A

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

Rectal prolapse

51
Q

What is the dx/tx for rectal prolapse?

A

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

52
Q

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?

A

Rectocele

53
Q

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?

A

Rectocele

Defecography (fluoroscopy while defecating)

54
Q

What is the tx for rectocele?

A

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

55
Q

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

A

Refer to GI/colorectal surgeon

1. Clin Med III (29 decks)

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