2- Anorectal disease Flashcards
What should you always check for with DRE? (4)
Anal tone
Palpate for tenderness, mass or induration
Note any blood upon removal
Stool guaiac
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
Refer to GI/colorectal specialist
What very common pathology arises from the fibrovascular cushion?
Hemorrhoids
What is the difference b/w internal and external hemorrhoids?
Internal: Proximal to dentate line. PAINLESS
External: Distal to dentate line. PAINFUL
What is the classification scale used to dx hemorrhoids?
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
Pt presents w/ hx of bright red blood w/ BM, sensation of perianal fullness and anal pruritus. What are you concerned about?
Hemorrhoids
*Perianal fullness sx due to prolapse
What portion of hemorrhoid PE will allows for true optimal visualization of internal hemorrhoids?
Anoscopy
The ACG (guidelines) requires what test at the very least if you note hemorrhoid-patten bleeding on exam ?
Sigmoidoscopy to r/o other anorectal pathology
What are the general txs for symptomatic hemorrhoids?
- Diet/lifestyle mod
- Conservative therapies/office-base procedures
- Surgical management
What dietary/life style mods are recommended for all grades of hemorrhoids? (3)
Increase FIBER and FLUID intake (dietary/bulk laxatives)
Avoid lingering and straining on the toilet
Sitz baths
What conservative medical therapies are recommended for the tx hemorrhoids?
Stool softeners
SHORT course of corticosteroid cream or suppositories
Nitroglycerin ointment (antispasmodic)
What office based procedures are recommended for the tx hemorrhoids (pts REFRACTORY to conservative medical therapies)?
Internal hemorrhoids:
- Rubber band ligation
- Infrared coagulation
- Sclerotherapy
External hemorrhoids:
- Excision
When is hemorrhoidectomy performed?
- Grade IV internal hemorrhoid
- Symptomatic grade III hemorrhoid
- Persistent sx despite conservative or office based procedures
- Extensive pain from thrombosed external hemorrhoid
Pt presents w/ painless rectal bleeding, perianal itching w/ evidence of grade II internal hemorrhoid. What recommendation is most appropriate initially?
High fiber and fluid diet
What often develops from local irritation and resultant inflammation to the skin of the anus?
Pruritis Ani
What is the most common cause of pruritis ani?
Mechanical
- Prolapsing tissue, fecal incontinence/soiling, poor hygiene
On exam you note circumferential erythematous and irritated perianal skin. What sx does the pt complain of?
Intense itching and burning
Dx: pruritis ani
What is the tx for pruritis ani? (5)
- 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
On exam of the anal region you note an outgrowth of normal skin/loose, flesh-color, pedunculated tissues. What are you concerned about?
Perianal skin tags
Are perianal skin tags a clinical dx?
Yes
*If uncertain referral/biopsy
What is the tx for perianal skin tags?
TX not usually indicated
+/- Referral for excision if tags interfere w/ hygiene or cause discomfort
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?
Anal fissure
What is the most common cause of severe anorectal pain?
Anal fissure
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?
Crohn’s disease, malignancy, HIV/AIDs
Pain from an anal fissure will cause spasm of the sphincters. What does this result in?
Further decreases blood flow and prevent healing
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?
Anal fissures
What is the most common location for an anal fissure?
Posterior midline (lowest blood supply)
How are anal fissures dx?
DRE/anoscopy (may be too uncomfortable to tolerate)
Flex sig/colonoscopy if unsure/recurrent sx
What is the tx for anal fissures? (6)
- Fiber/fluid
- Anal hygiene/sitz baths
- Stool softeners
- Topical lidocaine gel
- Topical vasodilator (Nifedipine or Nitro ointment)
- If chronic/refractory → surgery (sphincterotomy)
What risk is a/o Sphincterotomy?
Low risk for fecal incontinence
What results from an obstructed/infected anal crypt gland?
Perianal abscess
Chronic perianal abscesses can progress to what?
Fistula
Perianal abscesses can be a/w what disease?
Crohn’s disease
On anal/rectal exam you note a palpable fluctuant mass w/ surrounding edema, localized erythema and tenderness. What is your suspected dx?
Perianal abscess
In pts w/ suspected perianal abscess, what should be included a part of your exam?
Palpate for inguinal lymphadenopathy
What is the tx for perianal abscess?
- CT/MRI to determine extent
- I & D
- ABX for DM or IMC pts
- Post-op: sitz baths, fluid and fiber
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?
Crohn’s disease
What is a chronic manifestation of a perianal abscess that results in an abn communication b/w the anal canal and perianal area?
Anorectal fistula
Anorectal fistulas can be seen w/ what disease? (3)
Crohn’s, radiation proctitis (damage to colon due to radiation exposure), diverticulitis
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?
Anorectal fistula
What is the dx/tx for anorectal fistula?
- MRI pelvis for complex/recurrent fistula
- COLONOSCOPY if concern for IBD
- Fistulotomy: surgical unroofing of the fistula tract to allow for healing
What is the etiology of anal condyloma?
HPV
On exam w/ anoscopy you note cauliflower like growths in clusters or single entities. What is your suspected DX?
Anal condyloma
What is the tx for anal condyloma?
Removal or destruction of visible lesions
- Topical Podofilox, Imiquimoid cream
- Office tx w/ trichloroacetic acid
- Surgical removal
+ f/u intervals to assess to recurrence
Majority of anal cancer are what type?
Squamous cell cancers
Presentation for anal CA varies from rectal bleeding, pain, to warts and internal/external lesions. What should be included in your exam?
DRE, Palpate for inguinal lymphadenopathy
What is the tx for anal CA?
- Biopsy + scope to determine extent
- Chemoradiotherapy
- Surgery
What is a pelvic flood disorder in which rectal tissue protrudes through the anus?
Rectal prolapse
Chronic constipation, straining, multiparity, or prior pelvic surgery may be a/w with what?
Rectal prolapse
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?
Mucosa of rectal wall may feel floppy or loose w/ redundant tissue
Rectal prolapse
What is the dx/tx for rectal prolapse?
Anorectal manometry
Prevent constipation/increase fiber/fluid
Surgical repair - consult colorectal surgery
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?
Rectocele
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?
Rectocele
Defecography (fluoroscopy while defecating)
What is the tx for rectocele?
Pelvic flood muscle training, pessary (device into vagina to prevent rectum from bulging)
If you are unsure of dx for pt w/ anorectal sx. What is your course of action?
Refer to GI/colorectal surgeon
