Ano-rectal Flashcards
Linear or rocket-shaped ulcers, generally <5 mm in length
Acute = <8 weeks, severe tearing pain during defecation followed by throbbing, hematochezia
Chronic = >8 weeks, severe, tearing pain during defecation followed by throbbing, hematochezia
anal fissures
anal fissures are common in
Infants and middle-aged adults
Large caliber stool/constipation, vaginal delivery, anal intercourse
MC in posterior midline
Can also be from cancer (anything that deviates from midline is suspicious), Crohn’s, HIV/AIDs, anorectal TB, lymphogranuloma venereum
anal fissures
PE: upon anal exam:
crack in epithelium, fibrosis, skin tag “sentinel pile”
anal fissure
how do you treat an anal fissure?
Increased fiber, sitz bath
Acute = topical anesthetic (lidocaine)
Chronic = topical NTG, diltiazem ointment, nifedipine, botox injection, sphincterotomy
Acute: Rectal pain, deep-seated, swelling
Tenderness or redness, fluctuant mass, fever
Chronic: Persistent or recurrent perianal pain, swelling or tenderness, lump and/or discharge from opening
abscess
Perianal itching, purulent discharge, inability to sit down
perianal fistula
RFs for — —-/—:
Men
30s-50s
Crohn’s
Previous infection
DM
HIV
Pregnancy
Anal intercourse
perianal abscess/fistula
acute or chronic, primary (abscess) or secondary (disease)
Glands become infected
Staph aureus
MC location = posterior rectal wall
perianal abscess/fistula
PE: tender, fluctuant mass on palpation
DRE + may need imaging needed to check for deeper abscess
Labs
Parks classification of fistulas
perianal abscess/fistula
How do you treat perianal abscesses and fistulas?
Abscess: Surgical drainage (local or OR)
Cellulitis, underlying immunosuppression, or systemic signs of infection :
→ metronidazole and ciprofloxacin
OR augmentin
Fistula: treat infection, surgery/fistulotomy
WASH: warm water cleansing, analgesics, sitz baths, high fiber
bright red and painless discharge in stool should make you think what?
internal hemorrhoid
perianal pain with no blood should make you think what?
a lot of things but external hemorrhoids are the answer!
Bright red blood on toilet paper or stool, mucus/stool leakage, “fullness” sense in perianal area, itching/burning, visible if external
Internal = painless bright red blood, pruritus, fullness, mucus discharge
External = perianal pain aggravated with defecation (thrombosed!)
hemorrhoids
RF for ——-:
Developed countries
Low fiber, high fat western diet → constipation, straining
Diarrhea
Prolonged period of sitting
Obesity
Low fiber
hemorrhoids
Internal = cluster of tissue containing arterioles, veins, and smooth muscle above the pectinate line (generally painless, and bleed)
External = cluster of tissue containing vessels and muscle below pectinate line (generally painFUL and don’t bleed)
hemorrhoids
PE: DRE to grade internal hemorrhoids, always examine for other abnormalities, performed in prone or left lateral position
Bright red blood or thrombosed or not detected = anoscopy
With hematochezia = proctosigmoidoscopy or colonoscopy
Discolored, very tender = thrombosed
hemorrhoids
How do you treat stage I/II hemorrhoids conservatively?
Decrease straining: high fiber diet, increase fluid intake with meals, avoid straining, limit time on toilet <5 min
How do you treat stage I/II/III hemorhoids medically?
rubber band ligation, injection sclerotherapy, application of electrocoagulation
how do you treat stage IV hemorrhoids?
prolapsed = topical creams, foams, suppositories with emollients, topical anesthetics, vasoconstrictors, astringents, steroids
How do you treat thrombosed hemorrhoids?
Surgery for chronic severe bleeding, acute thrombosed stage IV (few people)
Excision for thrombosed hemorrhoids within 24-48 hours of onset or refer to surgeon!
>48 = resolves spontaneously
Early lesions silent
Anal itching and bleeding, pain/pressure, localized tumor/tissue looks abnormal
anal carcinoma
Common patients at risk for anal carcinomas include
Receptive anal intercourse
Anorectal warts
MSM
HIV+
Solid organ transplant
Women who have HPV-ass lesions
MCC = SCC, associated with HPV (16 and 18)
Gardasil vaccine lowers risk
anal carcinoma
How do you treat an anal carcinoma?
2-3cm = wide excision
Larger or involving deeper tissue → combo therapy (excision, radiation, chemo)
Acutely spontaneously reduces, but after time results in
Mucous discharge, bleeding, incontinence, sphincter damage
rectal prolapse
Full thickness uncommon and caused by surgery, trauma, excessive straining with weak pelvic support
rectal prolapse
How do you treat a rectal prolapse?
surgery
