Anorectal Disease Flashcards
Anal Fissures definition?
Painful linear tear or crack in the distal anal canal
Etiologies 3
Most common area of injury?
Usually from trauma to anal canal
- Defecation
- Straining
- Constipation
Most commonly occur in the 12 or 6 O’clock area
Clinical presentation of anal fissures?
2
- c/o severe tearing pain during defecation
- Mild associated hematochezia
- -Blood on stool or toilet paper
Anal Fissure
What confirms the Dx?
PE:
Confirmed by visual inspection of the anus
On PE what would we find for acute anal fissures?
Chronic?
- Acute: look like cracks in the epithelium
2. Chronic: fibrosis and development of a skin tag
First line treatment for anal fissure? 3
Seond line treatment? 1
SE? 6
- First-line
- Fiber supplements,
- stool softeners
- sitz baths - Second-line
- 0.4% nitroglycerin ointment
- Bid for 6-8 weeks - SE
- Headaches and dizziness
- Botulinum toxin (Botox)
- Inject into internal anal sphincter
- Last about 3 months
- Internal anal sphincterotomy
- Risk is minor fecal incontinence
Perianal abscess
- PP?
- Appears as what?
- Most common type?
- Anal glands at the base of the rectum become infected
- Appears as a boil-like swelling near the anus
- Most common type is perianal abscess
Perianal abscess
- Causes? 3
- Risk factors? 3
- Causes
- Anal fissure/fistulas
- hemorrhoids
- Blocked anal glands - Risk factors
- Colitis
- Inflammatory bowel disease
- DM2
Perianal abcess Clinical presentation
4
Deeper abscesses present how?
3
- Constant pain, throbbing and worse when sitting
- Swelling and redness around the anus
- Discharge of pus from around the anus
- Painful bowel movements
- Fever
- Chills
- malaise
Perianal abscess
- Lab studies?
- Treatment? 4
- Laboratory studies
Wound cultures when I&D done
Treatment
- I&D
- Packing and return in 24 hours
- Sitz baths tid and after bowel movements
- f/u in 2-3 weeks for wound evaluation and inspection for possible fistula formation
- Anal fistula aka?
- Usually results from what?
- Etiology? 3
- Also known as fistula-in-ano
- Usually results from previous or current anal abscess
- Etiology
- Anorectal abscess
- Crohn’s
- Radiation proctitis
Anal Fistula Clinical presentation 3
PE
2
Clinical presentation
1. History of drained abscess
2, Anorectal pain
3. Purulent drainage and irritation from the skin
PE
- Identification of the external opening that drains pus, blood or stool
- DRE may express pus or stool from the opening
Treatment of anal fistula?
1
Complex fistulas?
2
Treatment
1. Fistulotomy
Complex fistulas
- Fibrin glue
- Fistula plug
Pruritus Ani
- What is this?
- Characterized by what?
- Perianal itching or discomfort
- An itch-scratch-itch cycle
- -Skin becomes excoriated and secondary infections
Causes of Pruritis Ani?
6
- Idiopathic
- Hygiene related
- Fistulas/fissures
- Fecal incontinence
- Parasites
- Lichens sclerosis
Prutitis PE?
4
- Inspection of the area may reveal anal excoriations and erythema
- Hygiene issues
- Chronic issues show thickened or leathery skin
- Anoscopy
Pruritis treatment and prevention
6
- Treat underlying cause
- Avoid spicy and acidic foods
- After BM clean with unscented wipes
- Place gauze or cotton ball next to anal opening
- Talcum powder
- Use zinc oxide or hydrocortisone ointment
- Rectal Prolapse aka?
- What is it?
- Common in who? 3
- Also called Rectal Procidentia
- Painless protrusion of the rectum through the anus
- Common in older adults with long history of constipation and weak pelvic floor muscles
- More common in women over age 50
- Can also occur in infants
Rectal Prolapse symptoms?
3
Symptoms
- Feeling a bulge or appearance of reddish-colored mass that extends outside the anus
- Pain in the anus or rectum
- Leakage of blood or stool
Causes of rectal prolapse? 4
Causes
- Chronic constipation or diarrhea
- Straining during BM
- Weakness of the anal sphincter
- Damage to nerves
Diagnosis of rectal prolapse? 5
Diagnosis
- Anal EMG
- Anal manometry
- Anal ultrasound
- Colonoscopy
- proctosigmoidoscopy
Rectal prolapse Treatment? 2
- Treat first at home with stool softeners and pushing the fallen tissue back up into the anus by hand
- Surgery
Rectal prolapse surgeries? 2
Recovery consists of? 2
- Surgery
- Abdominal repair
- Rectal (perineal) repair - Recovery
- 3-5 hospital stay
- Complete recovery in 3 months
- What is a Pilonidal Cyst?
- Usually happens how?
- Occurs in who?
- Risk factors?
- Cyst near the natal cleft of the buttocks that often contains hair or skin debris
- Usually happens when hair punctures the skin and becomes embedded
- Occurs in hairy young men
- Sitting for long periods of time can be a risk
Pilonidal cyst
- Clinical presentation? 3
- Risk factors? 3
Clinical presentation
- Pain
- Erythema and swelling of the skin
- Drainage of foul smelling pus or blood from the opening of the skin
Risk factors
- Obesity
- Prolonged sitting
- Local trauma/irritation
Pilonidal cyst
Treatment and prevention
3
- I & D cyst first
- -May need to leave open or pack to heal - If reoccurs will need surgical cyst removal
- Antibiotics
- Usually in the setting of what?
2. What kind of antibiotics for Pilonidal cyst? 2
- Usually in setting of cellulitis
2. First generation cephalosporin (cefazolin) plus metronidazole (Flagyl)
- What are hemorrhoids?
- Arise from where?
- What are the two different kinds?
- Are dilated veins of the hemorrhiodal plexus in the lower rectum
- Normal vascular structures in the anal canal - Arise from a channel of arteriovenous connective tissue that drains into the superior and inferior hemorrhoidal veins
- External hemorrhoids
- Internal hemorrhoids
Classification of Hemorrhoids?
Describe grades I-IV?
Classification
1. Grade I
Hemorrhoids that do not prolapse
- Grade II
Hemorrhoids prolapse on defecation and reduce spontaneously - Grade III
Hemorrhoids prolapse on defecation and must be reduced manually - Grade IV
Hemorrhoids are prolapsed and cannot be reduced manually
Hemorrhoids causes?
4
- Pregnancy
- Frequent heavy lifting
- Repeated straining during defecation
- Constipation
Clinical presentation
1. Most often they present how? 2
- External hemorrhoids may become thrombosed
- Whats it look like?
- Complications? 2
- Usually resolves when?
- Swelling lasts how long?
- Can have what symptom around the anus?
- Often asymptomatic or
- may simply protrude
- Painful and purplish swelling
- Rarely ulcerate and cause minor bleeding
- Usually resolves in 2-3 days
- Swelling last a few weeks
- Can have itchiness around the anus
- Internal hemorrhoids manifest how?
2. 3 main symptoms?
- with bleeding after defecation
- On stool or TP
- Mucous and fecal incontinence
- Itchiness
What are Strangulated hemorrhoids?
strangulated hemorrhoid an internal hemorrhoid that has prolapsed sufficiently and for a long enough time for its blood supply to become occluded by the constricting action of the anal sphincter.