Ano-Rectal Conditions Flashcards by Dylan Null

Itching and discomfort of the perianal region caused by:

Poor Anal Hygiene
Fistulas
Fissures
Prolapsed Hemorrhoids
Skin Tags
Minor Incontinence
Overzealous Cleaning with Soaps
STIs

Perianal Pruritus

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What dermatological condition can cause Perianal Pruritus?

Atopic Dermatitis

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Which bacterial infections can cause Perianal Pruritus?

Staph or Strep

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Which parasites can cause Perianal Pruritus?

Pinworms
Scabies

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What pathology can cause Perianal Pruritus in patients with Diabetes?

Candidal Infection

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How do you treat Perianal Pruritus?

Education is vital

Avoid:
- Spicy Foods
- Coffee
- Chocolate
- Tomatoes

Non-scented wipes with Lanolin
- followed by gentle drying

Piece of cotton ball to absorb perspiration and fecal seepage

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What may exacerbate Perianal Pruritus and should be avoided?

Anal Ointments and Lotions

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Linear or rocket-shaped ulcers that are usually < 5mm in length.

Patients may present to the ER due to the degree of pain.

Anal Fissure

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What are the most common causes of Anal Fissures?

Large Caliber Stool or Constipation

Vaginal Delivery

Anal Intercourse

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Where are most Anal Fissures located?

Posterior Midline

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What are some secondary causes of Anal Fissures?

Malignancy
Crohn’s
HIV/AIDs
Anorectal TB

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Signs and Symptoms of ACUTE Anal Fissures

Symptoms < 8 weeks

Severe tearing pain during defecation
- followed by throbbing
Hematochezia

Crack in the Epithelium

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Signs and Symptoms of CHRONIC Anal Fissures

Symptoms > 8 Weeks

Fibrosis

Sentinel Pile
- Skin tag at the outermost edge

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How do you treat Anal Fissures?

Increased Fiber
Sitz Bath

Acute (Prescription)
- Lidocaine

Chronic (Prescription)
- Topical Nitroglycerin
- Topical Diltiazem
- Topical Nifedipine
- Botox Injection

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What ano-rectal condition can be thought of as two sequential phases of the same infectious process?

Perianal Abscess (Acute)
+
Perianal Fistula (Chronic)

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Occurs when the anal glands located at the base of the anal crypts at the dentate line become infected.

Perianal Abscess

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Many patients with Perianal Abscess and Fistulas have what chronic disease?

Crohn’s Disease

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How do Acute Anorectal Abscesses typically present?

Rectal Pain
- deep seated with swelling

Tenderness or Redness

Fluctuant Mass

Fever

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Persistent or recurrent perianal pain, swelling, or tenderness with a lump. May have discharge from perianal opening.

Perianal Fistula

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What are the hallmarks of a Perianal Abscess?

Perianal Pain + Fever

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What diagnostics are used for a Perianal Abscess or Fistula?

Digital Rectal Examination
- for deeper abscesses

CBC or Blood Culture

Most patients DO NOT require imaging

Perianal Abscess Treatment

Surgical Drainage

ABX not indicated for Uncomplicated Abscess

How is a Perianal Abscess treated if the patient has:

Cellulitis
Immunosuppression
Systemic Signs of Infection

Metronidazole + Ciprofloxacin

Augmentin

Chronic manifestation of the acute perirectal process that forms an anal abscess.

When the abscess ruptures or is drained, an epithelia zed tack can form that connects the abscess in the anus or rectum with perirectal skin.

Rectal Fistula
(Fistula-in-ano)

When should you suspect a Rectal Fistula?

Drainage that persists beyond 6-12 weeks after initial incision and drainage of an anorectal abscess.

Clinical Findings of a Rectal Fistula

Perianal Itching Purulent Discharge Pain → Inability to Sit Many times the patient will go to the ER due to the Pain

Rectal Fistula Treatment

Treat Infection Surgery + Fistulotomy - preserve anal sphincter

Clusters of tissue that contains arterioles, veins, and smooth muscle. → Located ABOVE Pectinate Line

Internal Hemorrhoids

Clusters of tissue that contains arterioles, veins, and smooth muscle. → Located BELOW Pectinate Line

External Hemorrhoids

What are some things that can cause Hemorrhoids?

Constipation + Straining Diarrhea Prolonged Periods of Sitting Pregnancy Obesity Low Fiber Diet

Signs and Symptoms of Hemorrhoids

Bright Red Blood - On Toilet Paper or in Stool Mucous or Stool Leakage "Fullness" Sense in Perianal Area Itching or Burning

How do you perform a physical exam on a patient with suspected hemorrhoids?

Digital Rectal Exam - prone or left lateral position - at rest and while straining

What procedures should be performed if there is bright red blood per rectum or in patients who are suspected of having a thrombosed hemorrhoid

Anoscopy Proctosigmoiydoscopy or Colonoscopy

How can most patients with Stage 1 or Stage 2 Hemorrhoids be treated?

Conservatively - High Fiber Diet - ↑ Fluids - Avoid Straining - Limit time on toilet to < 5 minutes

How do you treat Stage 1, 2 or 3 Hemorrhoids with recurrent bleeding despite conservative measures?

RUBBER BAND LIGATION - preferred Injection Sclerotherapy Electrocoagulation

How do you treat Stage 4 Hemorrhoids?

Topical Creams Foams Suppositories Containing: - emollients - anesthetics - vasoconstrictors - astringents (witch hazel) - Corticosteroids

If a patient has hemorrhoids with: - Chronic severe bleeding due to Stage 3 or 4 or - Acute thrombosed stage 4 with necrosis

Surgical: - Hemorrhoidectomy - Stapled Hemorrhoidopexy

Patient presents to the emergency department complaining of PAIN that started yesterday, extreme tenderness, and a discolored perianal mass. Patient states that the pain was most severe for the first few hours that it started but has gradually improved since yesterday. What is the most likely diagnosis?

Thrombosed Hemorrhoid

How do you treat a Thrombosed Hemorrhoid?

If within 24 - 48 hours of onset: - excision may speed up symptom relief Excise and Evacuate - Anesthetize - Elliptical Incision - Evacuate Clot If > 48 hours - symptoms usually resolve spontaneously

What is the most common type of Anal Carcinoma?

Squamous Cell Carcinoma

What are 90% of Anal Carcinomas associated with?

HPV 16 + 18

Increased Risk Factors of Anal Carcinoma

Receptive Anal Intercourse Anorectal Warts MSM HIV Organ Transplant HPV

What is a Decreased Risk Factor for Anal Carcinoma?

Gardasil Vaccine

Signs and Symptoms of Anal Carcinoma

Early Lesions are Silent Anal Itching and Bleeding Pain + Pressure Localized Tumor or Abnormal Tissue

Anal Carcinoma Treatment: Small (2 - 3cm)

Wide Excision

Anal Carcinoma Treatment: Large OR Involves Deeper Tissue

Combo Therapy Excision + Radiation + Chemo

Protrusion of some or all layers of the Rectum through the Anus

Rectal Prolapse

Causes of Full Thickness Rectal Prolapse

Surgery or Trauma or Excessive Straining with wearing Pelvic Muscles

Rectal Prolapses initially reduce spontaneously after defecation → with time the rectal mucosa becomes chronically prolapsed and results in what signs and symptoms?

Mucous Discharge Bleeding Incontinence Sphincteric Damage

How do you treat and Complete Rectal Prolapse?

Surgery