Anorectal Conditions - Sasek

Question 1

External Hemorrhoids

Answer 1

• below dentate or pectinate line
• covered by squamous epithelium
• sensory innervation
• acute pain when thrombosed
  
  • if thrombosed typically bluish in color
  • excise clot if necessary
  • NSAIDs, analgeics, stool softeners, preparation H, Tucks

Question 1

Anorectal Abscess

Answer 1

secondary to infection originating in the anal glands

presentation: anorectal, drainage of blood/pus

*early sepsis can result

physical exam: hot, red, tender area; adjacent to anus

treatment: I&D, broad spectrum antibiotics

Question 2

Internal Hemorrhoids

Answer 2

• ABOVE dentate (pectinate) line
• covered by mucosa - no sensory innervation
• asymptomatic bleeding
• bright red spotting on toilet paper; dripping into toilet

Question 2

Classification of Internal Hemorrhoids

Answer 2

First Degree: small size, bleeding only

Second Degree: medium size, prolapse under pressure, reduce spontaneously

Third Degree: large size, permanent prolapse, reduce manually

Fourth Degree: large size, proplaspe can’t be reduced - refer to colorectal surgeon

Question 3

Management of Hemorrhoids

Answer 3

Conservative:

• decrease straining
• avoid prolonged sitting
• symptomatic treatment for pruitis/irritation
  
  • steroid creams
  • suppositories
  • analgesic cream
  • sitz bath

Office Based:

• rubber band ligation (1, 2, 3 degree)
• infrared coagulation (1, 2, 3 degree)

Surgery:

• when hemorrhoid is unreducable (4 degree)

Question 3

Rectal Carcinoma

Answer 3

painless mass or palpable mass on rectal exam

Question 5

Identify key history elements for anorectal disorders

Answer 5

HPI: OLD CHARTS + ICE

PMH:

• similar problems in past
• hx of IBD, IBS
• hx of radiation, cancer
• recent pregnancy
• chronic constipation
• bowel habits
• liver disease
• medications

FH:

• hemorrhoids

SH:

• sexual history
• anal intercourse (preferences, practices, protection)
• abuse
• drug use (cocaine)

Question 6

Proctitis

Answer 6

inflammation of the lining of the rectum

causes:

• IBD
• infectious: C. dif salmonella, N. gonorohoeae, chlamydia trachomatis, HSV, HPV
• icschemia
• radiation

symtpoms:

• rectal pain
• mucopurulent discharge
• fecal urgency or tenesmus
• constipation

physical exam:

• DRE may be difficult
• HSV may have vesicles

diagnosis:

• CBC
• stool culture
• gonoccal swabs
• endoscopy

treatment:

• treatment based on underlying cause

Question 8

Identify key physical exam findings and diagnostic tests for anorectal disorders

Answer 8

PHYSICAL EXAM

Age - peaks 45-65 years

GU Exam

• inspect rectal area
• DRE
• anoscopy

Abdominal Exam - if colonic etiology

DIAGNOSTICS

Laboratory - CBC for anemia, infection

Diagnostic Tests - anoscopy, colonoscopy

Question 11

Pruritis Ani

Answer 11

causes:

• fecal soilage
• perspiration
• hemorrhoids
• infection, malignancy

treatment:

• bulk forming agent
• sitz baths
• witch hazel pads
• steroid creams
• good hygiene

Question 12

Rectal Prolapse

Answer 12

• protrusion of mucosa or entire thickness of rectum

Question 12

Anal Fissure

Answer 12

laceration or tear in anal canal distal to dentate line (posterior midline)

painful with defecation; usually due to passing hard stool

viewed on inspection

treatment: topical analgesia, soften stool, may need surgery

Question 13

Pathophysiology &

Causes of Symptomatic Hemorrhoids

Answer 13

Pathophysiology: usually secondary to increased intra-abdominal pressure

Causes

• aging
• chronic diarrhea or constipation
• pregnancy/child birth
• prolonged sitting
• straining
• heavy lifting
• anal intercourse
• pelvic tumors

Question 14

Condyloma Accuminata

Answer 14

• anogenital warts from HPV

Question 15

Anal Skin Tag

Answer 15

• pervious thrombosed hemorrhoid