Anal fissures/Abcess/Hemorrhoids Flashcards
Anal Fissure
general
Acute longitudinal tear in the anal mucosa (squamous epithelium) of the anal canal distal to the dentate line
Typical/Primary → local trauma
Atypical/Secondary → associated with a condition
Common in infants and middle-aged adults, but can occur at any age
fissures
Causes
Most common
Passing large or hard stools
Constipation and straining during bowel movements
Chronic diarrhea
Anal intercourse
Childbirth
Less Common
Inflammatory bowel disease (Crohn’s disease)
Anal cancer
HIV
Syphilis
Fissures
Signs & Symptoms
Usually occur in the posterior midline or anterior midline
Off the midline (atypical) → Crohn’s disease
Chronic fissure/ulcer
External skin tag (sentinel pile) at the lower end
Enlarged (hypertrophic) papilla at the upper end
Pain
Present at rest
Severe during bowel movements → persists for several hours
Bleeding
Bright red blood (hematochezia) on the stool or toilet paper after a bowel movement
midline is primary
fissures
Dx
Complete history and physical examination, to include gentle inspection of the anal area
Tears are most often visible
Acute – paper cut
Chronic – deeper with internal or external fleshy growths (sentinel pile and hypertrophic papilla)
If a specific cause cannot be identified, additional testing may be needed:
Anoscopy
Flexible sigmoidoscopy
Colonoscopy
Biopsy
Fissure
Tx
Increase fiber in the diet
Stool softeners
Protective ointments - zinc oxide
Bland suppositories (glycerin)
Lubricate the lower rectum and softens stool
Sitz baths
Warm, NOT HOT, for 10-15 minutes after each bowel movement and as needed for relief
Topical anesthetics – benzocaine, xylocaine, lidocaine
Topical vasodilators
nitroglycerin 0.2% ointment
Relax the anal sphincter and increases blood flow to the area to allow for healing
nifedipine 0.2% cream
Relax the anal sphincter and decrease anal resting pressure to allow for healing
Surgical repair if conservative measures fail
Anorectal Abscess
general and pathogens
Localized collection of pus in the perirectal spaces that results from perianal gland blockage
Superficial or deep
Mixed infection
Escherichia coli
Proteus vulgaris
Bacteroides
Enterococcus
Streptococci
Staphylococci
Levator ani muscle is composed ofthree striated muscles on each side: iliococcygeus, pubococcygeus, and the puborectalis muscles
Abcess
Perianal abscess (60%)
Below the levator ani muscle
Superficial
Only involves the skin
Ischiorectal abscess (30%)
below the levator ani muscle
Deeper
Extends across the sphincter into the ischiorectal space below the levator ani
May penetrate to the contralateral side (forms a horseshoe abscess)
Diabetic patients
Intersphincteric abscess
Below the levator ani muscle
Deeper
Forms between the internal and external sphincters
Supralevator abscess
Seen in which pts
Above the levator ani muscle
Extremely deep
May extend to the peritoneum of abdominal organs
Seen with Crohn’s disease, diverticulitis, or pelvic inflammatory disease
Perianal abcess
RF
Pregnancy
Diabetes
Crohn’s disease
Certain medicines (chemotherapy drugs or immunosuppressive drugs)
Foreign objects placed in the rectum
Anal fissures
Sexually transmitted disease (STD)
abcess
S/Sx
Below the dentate line
Very painful
Perianal swelling and erythema
Marked tenderness to palpation
Intermittent malodorous drainage
Fever is rare
abcess
S/Sx
above the dentate line
Less painful
Toxic symptoms – fever, chills, and malaise
No perianal findings
DRE – tender, fluctuant swelling of the rectal wall
abcess
Dx
Clinical diagnosis
Cutaneous abscess with no signs of systemic illness and normal DRE (perianal abscess)
Anoscopy or sigmoidoscopy
MRI of the pelvis without and with IV contrast
Deep abscess
Determine the location and extent of the abscess
Abcess
Tx
Incision & Drainage
Promptly performed
Superficial – in-office procedure
Deep – operating room procedure
Antibiotics
Febrile, immunocompromised, diabetic, or marked cellulitis is present
Cipro 500 mg IV every 12 hours plus metronidazole 500 mg IV every 8 hours
Ampicillin/sulbactam (Unasyn) 1.5 g IV every 8 hours
Fistula
general
Abnormal connection or passageway that connects two organs or vessels that do not usually connect
Hemorrhoids
general
Normal swollen vascular structures in the anorectal canal
Vascular cushions that assist with stool passage:
Composed of vascular tissue, smooth muscle, and connective tissue
Do not cause issues unless they are enlarged, inflamed, thrombosed, or prolapsed
Prevalence increases with age
Peak at 45–65 years old
Hemorrhoids affect up to 10 million patients in the United States annually
About 40% of patients are asymptomatic
1/3 people seek medical care
hemorrhoids
RF
Chronic diarrhea
Chronic constipation (straining)
Inflammatory bowel disease
Obesity
Pregnancy
Prolonged sitting
Heavy lifting
Hypertension
Portal hypertension
External Hemorrhoids
general
Below the dentate (pectinate) line
Arise from the inferior (external) hemorrhoidal plexus
Covered by modified squamous epithelium with somatic pain receptors
External Hemorrhoids
Acute thrombosis pathogenesis
Extreme pain caused by skin distention and edema
Caused by straining, diarrhea, or constipation
Can persist as excess skin tags after healing
Usually last 7–14 days
Internal Hemorrhoids
general
Above the dentate line
Unclear pathogenesis; possible theories include:
Deterioration of connective tissue anchoring hemorrhoids
Hypertrophy or increased internal anal sphincter tone
Abnormal arteriovenous distention within hemorrhoidal cushions
Abnormal dilation of internal hemorrhoidal venous plexus
Not supplied by somatic sensory nerves → usually painless
External Hemorrhoids
Clin man
Acute perianal pain (without bleeding) with associated bowel movement
Likely from acute thrombosis(purplish)
Prolapsed or strangulated hemorrhoids
Painful mass at the rectum or feeling of fullness
May also have nontender skin tags (redundant fibrotic skin) near the rectum
Itching – ↑ sebaceous gland secretions
Internal Hemorrhoids
clin man
Usually painless, with bright red blood from rectum associated with bowel movement
Can be associated with mucous discharge and itching of perianal skin
May have associated fecal incontinence and leakage
Wetness or fullness sensation at the perianal area for prolapsed internal hemorrhoid
Rectal bleeding in patient ≥ 40 years should be attributed to hemorrhoids only after more serious conditions are excluded by sigmoidoscopy or colonoscopy
Internal Hemorrhoids
Grading
Grade I: prominent hemorrhoidal vessels without prolapse
Grade II: prolapse with Valsalva maneuver with spontaneous reduction
Grade III: prolapse with Valsalva maneuver with manual reduction
Grade IV: chronically prolapsed with ineffective manual reduction (incarcerated = unreducible)
hemorrhoids
Dx
Made clinically on physical examination for external hemorrhoids
Best patient position: left lateral decubitus, knees to chest
May be made clinically on digital rectal examination for internal hemorrhoids
Anoscopy
Used when no hemorrhoid is detected on physical examination
Allows for evaluation of the anal canal and distal rectum
How to do Anoscopy
https://www.merckmanuals.com/professional/multimedia/video/v23370794
hemorrhoids
Tx
Emergency care:
Excise acutely thrombosed external hemorrhoids
Instill local anesthetic and create elliptical excision of thrombosed hemorrhoid
If 72 hours or more after onset of symptoms → conservative management
Hemorrhoidal Thrombectomy
https://www.merckmanuals.com/professional/multimedia/video/v23370801
Treat only symptomatic patients
Conservative management
Counsel patients on dietary modifications (avoiding fatty foods; increased fiber)
Improve toilet habits with no prolonged sitting
Sitz baths
-Warm, NOT HOT, for 10-15 minutes after each bowel movement and as needed for relief
Stool softeners (docusate sodium)
Topical analgesics (benzocaine, xylocaine, lidocaine)
Topical corticosteroidsfor up to 1 week
Topical nifedipine and nitroglycerin to relieve anal sphincter spasms
hemorrhoids
nonsurgical procedures
For grades I and II internal hemorrhoids that do not respond to conservative management
Rubber band ligation
Band ligature passed via anoscope; causes tissue necrosis
Hemorrhoid sloughs off in 1–2 weeks
Electrocautery
Cryotherapy
Sclerotherapy
hemorrhoids
Surgical Treatment
indications
Hemorrhoidectomy
Indications:
Symptomatic grade III and IV hemorrhoids or severe external hemorrhoids
Other treatments have failed
Open approach or minimally invasive laserapproach
hemorrhoids
Key Points
External hemorrhoids may thrombose and become very painful, but rarely bleed
Internal hemorrhoids often bleed, but are not often painful
Stool softeners, topical treatments, and analgesics are usually adequate treatment for external hemorrhoids
Bleeding internal hemorrhoids may require injection sclerotherapy, rubber band ligation, or infrared photocoagulation
Surgery is a last resort
Internal or External Hemorrhoid?
Treatment?
excision, external
