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Anorectal disease Flashcards

1
Q

What are anal fissures? etiology?

A
  • painful linear tear or crack in distal anal canal
  • etiology:
    usually from trauma to anal canal through defecation, straining, constipation
  • most commonly occur in 12 or 6 o’clock area
  • if 3 or 9 o’clock presentation - crohns
  • most are posterior
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2
Q

Clinical presentation of anal fissures? What will you see on PE?

A
  • c/o severe tearing pain during defecation
  • mild assoc hematochezia: blood on stool or tp
  • PE:
    confirmed by visual inspection of anus
    acute: look like cracks in epithelium
    chronic: fibrosis and development of skin tag
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3
Q

Tx of anal fissures?

A
  • first line: fiber supps, stool softeners and sitz baths
  • 2nd line: 0.4% nitroglycerin ointment (increases blood flow to area)
    BID for 6-8 wks
    SE: HAs and dizziness
  • Botox: inject into internal anal sphincter, lasts for 3 months
  • Last option: internal anal sphincterotomy - risk is minor fecal incontinence
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4
Q

What is a perianal abscess?

A
  • anal glands at base of rectum become infected
  • appears as boil like swelling near the anus
  • most common typeL perianal abscess
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5
Q

Causes and RFs of perianal abscess?

A
  • causes:
    anal fissure/fistulas
    hemorrhoids
    blocked anal glands
  • RFs:
    colitis
    IBD
    DM2
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6
Q

Clinical presentation of perianal abscess?

A
  • constant pain, throbbing and worse when sitting
  • swelling and redness around the anus
  • d/c of pus from around the anus
  • painful BMs
  • deeper abscesses: fever, chills and malaise
  • these can travel to scrotum and lead to gangrene
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7
Q

Lab studies and tx of perianal abscesses?

A
  • lab studies: wound cultures when I&D done
    tx:
    I&D
  • packing and return in 24 hrs
  • sitz baths tid and after BMs
  • f/u in 2-3 wks for wound eval and inspection for possible fistula formation
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8
Q

What is an anal fistula? Etiologies?

A
  • also known as fistula-in-ano
  • usually results from previous or current anal abscess
  • etiolgies:
    anorectal abscess, crohn’s, radiation proctitis
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9
Q

Clinical presentation of anal fistula? What will you see on PE?

A
  • clinical presentation:
    hx of drained abscess
    anorectal pain
    purulent drainage and irritation from skin

PE:

  • ID of external opening that drains pus, blood or stool
  • DRE may express pus or stool from opening
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10
Q

Tx of anal fistula?

A
  • fistulotomy (cut out fistula)
  • complex fistulas:
    fibrin glue
    fistula plug
    (not as commonly used - cause infections)
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11
Q

What is pruritus ani? causes?

A
  • perianal itching or discomfort
  • an itch-scratch-itch cycle: skin becomes excoriated and secondary infections
  • causes:
    idiopathic
    hygiene related
    fistulas/fissures
    fecal incontinence
    parasites
    lichens sclerosis
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12
Q

What will you see on PE of pt with pruritus ani?

A
  • inspection of area may reveal anal excoriations and erythema
  • hygiene issues
  • chronic issues show thickened or leathery skin
  • anoscopy
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13
Q

Tx and prevention of pruritus ani?

A
  • tx 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
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14
Q

What is rectal prolapse?

A
  • AKA rectal procidentia
  • painless protrusion of rectum through the anus
  • common in older adults with long hx of constipation and weak pelvic floor muscles
  • more common in women over 50
  • can also occur in infants - esp in CF
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15
Q

Sxs of rectal prolapse?

A
  • feeling a bulge or appearance of reddish-colored mass that extends outside the anus
  • pain in anus or rectum
  • leakage of blood or stool
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16
Q

Causes of rectal prolapse?

A
  • chronic constipation or diarrhea
  • straining during BM
  • weakness of anal sphincter
  • damage to nerves
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17
Q

Dx rectal prolapse?

A
  • PE
  • anal EMG
  • anal manometry: strength of muscles
  • anal US
  • colonoscopy
  • proctosigmoidoscopy
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18
Q

Tx of rectal prolapse?

A
  • tx first at home with stool softeners and pushing the fallen tissue back into anus by hand
  • surgery:
    abdominal repair
    rectal (perineal) repair
  • recovery:
    3-5 days hosp. stay
    complete recovery in 3 months
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19
Q

What is a pilonidal cyst?

A
  • cyst near the natal cleft of 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 (truckers)
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20
Q

Clinical presentation of a pilonidal cyst?

A
  • pain
  • erythema and swelling of the skin
  • drainage of foul smelling pus or blood from the opening of the skin
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21
Q

RFs for pilonidal cyst?

A
  • obesity
  • prolonged sitting
  • local trauma/irritation
  • deep natal cleft
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22
Q

Tx and prevention of pilonidal cysts?

A
  • I&D cyst first: may need to leave open or pack to heal
  • if reoccurs will need surgical cyst removal
  • abxs:
    usually in setting of cellulitis
    use first gen cephalosporin (cefazolin) plus metronidazole (flagyl)
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23
Q

What are hemorrhoids?

A
  • dilated veins of hemorrhoidal plexus in lower rectum
  • normal vascular structures in anal canal
  • arise from a channel of arteriovenous CT that drains into superior and inferior hemorrhoidal veins
  • external hemorrhoids
  • internal hemorrhoids (inside anus and/or rectum)
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24
Q

Classification of hemorrhoids?

A
  • grade 1: hemorrhoids that don’t prolapse
  • grade 2: hemorrhoids prolapse on defecation and reduce spontaneously
  • grade 3: hemorrhoids prolapse on defectation and must be reduced manually
  • grade 4: are prolapsed and can’t be reduced manually
    these are likely to strangulate, very painful
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25
Q

Causes of hemorrhoids?

A
  • pregnancy
  • frequent heavy lifting
  • repeated straining during defecation (low fiber diet)
  • constipation
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26
Q

Clinical presentation of hemorrhoids? External and internal

A
  • often asx or may simply protrude
    external hemorrhoids may become thrombosed:
    -painful and purplish swelling
    -rarely ulcerate and cause minor bleeding
  • usually resolves in 2-3 days
  • swelling lasts a few weeks
  • can have itchiness around anus

internal hemorrhoids: manifest with bleeding after defectation

  • on stool or TP
  • mucous and fecal incontinence
  • itchiness
  • strangulated hemorrhoids: blood flow constriction
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27
Q

How do you dx hemorrhoids? Tx?

A

dx:

  • rectal exam
  • anoscopy
  • sometimes sigmoidoscopy or colonoscopy

tx:
- sx tx is usually all that is needed:
stool softeners/fiber
sitz baths after BM
anesthetic ointments
- 2nd line would be banding if conservative tx is unsuccessful
- 3rd line: surgical - excise and clot evacuation, stapled hemorrhoidectomy

28
Q

Do external hemorrhoids usually bleed?

A
  • no, they may thrombose and become very painful but they rarely bleed
29
Q

Are internal hemorrhoids painful?

A
  • no, often not painful

- they often bleed though

30
Q

Tx for external hemorrhoids?

A
  • stool softeners
  • topical tx
  • analgesics
31
Q

Tx for bleeding internal hemorrhoids?

A
  • may reqr injection
  • rubber band ligation
  • surgery is last resort
32
Q

What is a hernia? What is a potential risk?

A
  • a protrusion, bulge or projection of an organ or part of an organ through the body wall that normally contains it
  • hernias by themselves usually are harmless but nearly all have potential risk of having their blood supply cut off (becoming strangulated)
  • if blood supply is cut off at hernia opening in abdomina wall - it becomes a medical and surgical emergency
33
Q

Types of hernias?

A
  • inguinal
  • umbilical
  • incisional/ventral
  • epigastric
  • femoral
  • spigelian
34
Q

Most common type of hernia in adults? More common in men or women? RFs?

A
  • inguinal hernia
  • more common in men
  • weak areas occurs in inguinal canal where spermatic cord or round ligament exits the abdomen

RFs:

  • hx of hernia or repair
  • chronic cough or constipation
  • abdominal wall injury
  • smoking: cough, bad tissue health
35
Q

2 types of inguinal hernias?

A

indirect: most common
- hernia protrudes through internal inguinal ring
- hernia sac is located lateral to inferior epigastric artery
- sometimes hernia will protrude into scrotum
- can occur at any age, but becomes more common as you age

direct:

  • protrude medial to inferior epigastric vessels w/in Hesselbach’s triangle
  • result of weakness in floor of inguinal canal
  • rarely protrude into scrotum: doesn’t pass through inguinal ring
  • almost always occur in older individuals as their abdominal walls weaken with age and stretching
36
Q

What are the boundries of the hesselbach triangle?

A
  • laterally: inferior epigastric artery
  • medially: lateral border or rectus abdominis
  • inferiorly: (base) - inguinal ligament
37
Q

What is a femoral hernia? More common in?

A
  • hernia located inferior to inguinal ligament and protrudes through femoral ring
  • more common in women
  • least common type of groin hernia, but has high chance of strangulation
38
Q

Clinical presentation of inguinal hernia?

A
  • painless bulge in groin or scrotum
  • groin discomfort of pain
  • swelling or tugging in the groin
  • sudden pain, N/V: concenr with strangulated hernia
  • need to tx quickly
39
Q

What will you see on PE of inguinal hernia?

A
  • msot common finding is bulge in groin
  • exam best done with pt standing and asking them to cough or valsalva
  • reducible vs irreducible: try to reduce
  • strangulated:
    irreducible
    painful to palpation
    N/V
    pt may appear ill with or w/o fever
40
Q

how do you dx inguinal hernias?

A
  • usually done with hx and exam
  • not apparent, then initial study is groin U/S
  • CT/MRI
41
Q

Tx of inguinal hernia?

A
  • non surgical: watchful waiting, TRUSS (metal support underwear)
  • surgical:
    open repair
    laparoscopic repair
42
Q

What is an umbilical hernia? More common in what pop? Causes?

A
  • outward bulging of lining of the abdomen or abdominal organs around the belly button
  • more common in infants
  • causes: muscle through which the umbilical cord passes doesn’t close completely after birth
43
Q

Clinical presentation of umbilical hernia?

A
  • a soft swelling or bulge near umbilicus
  • in infants: more noticeable when baby cries, coughs or strains
  • adults:
    may cause abdominal discomfort, bulging with straining or coughing

can become strangulated: reducible or irreducible

44
Q

Causes of umbilical hernias?

A
  • obesity
  • mult pregnancies
  • fluid in abdominal cavity (ascites)
  • previous abdominal surgery

PE:
usually found on exam

45
Q

Tx of umbilical hernia?

A
  • surgery: with or w/o mesh
46
Q

What is an incisional/ventral hernia? Caused by what?

A
  • abdominal surgery causes a flaw in the abdominal wall that must heal on its own
  • this flaw can create an area of weakness where a hernia may develop
  • after surgical repair they have a high reoccurence rate (20-45%): use of mesh has helped
  • iatrogenic
  • coughing post abdominal surgery is a big risk
47
Q

What is an epigastric hernia?

A
  • type of hernia that develops in epigastrium b/t breast bone and belly button
  • usually appears in adults
  • may trap fat and other tissues which cause discomfort
  • risks: obesity and pregnancy
  • see also with sugery
  • tx: surgery
48
Q

What is a spigelian hernia?

A
  • hernia through the spigelian fascia
  • often no notable swelling
  • risk of strangulation is high due to small size
  • most occur on R side
  • rare
  • present with intermittent mass, localized pain or N/V
  • dx made with U/S
  • surgery is TOC
49
Q

Acute abdominal pain - why is it hard figuring out dx?

A
  • acute abdominal pain has large differentia;, ranging from benign to life-threatening conditions
  • the elderly, immunocompromised and women of childbearing age pose special dx challenges
  • textbook descriptions of abdominal pain have limitations b/c people react to pain differently
50
Q

DDx of acute abdominal pain - immediate life-threatening conditions?

A
  • AAA
  • mesenteric ischemia
  • perforation of GI tract
  • acute bowel obstruction
  • volvulus
  • ectopic pregnancy
  • MI
  • splenic rupture
51
Q

PP behind acute abdominal pain? Diff b/t visceral, somatic pain. referred pain and peritonitis?

A

visceral pain:

  • from abdominal viscera
  • innervated by autonomic nerve fibers
  • respond to sensations of distension and muscular contraction
  • pain is typically vague, dull and nauseating

somatic pain:

  • from parietal peritoneum
  • innervated by somatic nerves
  • respond to irritation from infection, chemical and inflammatory process
  • pain is sharp and well localized

referred pain:

  • pain perceived distant from its source
  • results from convergence of nerve fibers at spinal cord

peritonitis:
- inflammation of peritoneal cavity
- most serious cause is perforation of GI tract
- blood
- causes fluid shift into peritoneal cavity and bowel, leads to severe dehydration and electrolyte problems

52
Q

Presentation of appendicitis?

A
  • anorexia and vague periumbilical discomfort that develops into RLQ pain
  • N/V generally not first
    sxs
  • pelvic appendix can present with urinary sxs and diarrhea
  • ***most common extrauterine cause for abdominal surgery in pregnant women
53
Q

Presentation of biliary disease?

A
  • acute cholecystitis complain of RUQ or epigastrium pain
  • pain may radiate to R shoulder or back
  • N/V and anorexia
  • murphy’s sign may be present
  • progression of septic shock can occur (tachy, febrile, may be jaundice)
54
Q

Presentation of pancreatitis?

A
  • pain is steady in upper abdomen
  • band like radiation to back is common
  • pain often reaches max intensity within 10-20 min of onset
  • N/V common
55
Q

Presentation of diverticular disease?

A
  • LLQ pain most common complaint

- N/V and +/- change in bowel habits

56
Q

Presentation of peptic ulcer disease?

A
  • epigastric pain, indigestion, and reflux sxs: none is sensitive or specific
  • complications:
    bleeding and perforation
57
Q

Presentation of incarcerated hernia?

A
  • inguinal most common with mild lower abdominal discomfort exacerbated by straining
  • incarcerated hernias cause severe pain and reqr immediate surgical consultation
58
Q

Presentation of IBD?

A
  • acute complications include pain, bleeding, perforation, bowel obstruction, fistula, and abscess formation and toxic megacolon
59
Q

Presentation of IBS?

A
  • sxs need to persist for 3 months over a 1 yr period

- abdominal pain assoc with change in stool frequency or consistency

60
Q

Eval of acute abdominal pain - depending on pain level?

A
  • mild and severe pain follow same process of dx
  • severe pain may reqr consultation with surgeon
  • H&P usually will exclude all but a few possible causes, with labs and imaging giving final dx
  • life threatening causes should be ruled out first
  • pts that are at high risk: over 65, immunocompromised, alcoholism, CVD, major comorbidities - GI or renal, prior surgery, early pregnancy, if pain is sudden and maximal at onset, subsequent vomiting, constant pain of less than 2 days, exam findings: tense or rigid abdomen, involuntary guarding, signs of shock
61
Q

Hx of acute abdominal pain?

A
  • age
  • sex
  • PMHX and SHX
  • meds
  • characterize pain as precisely as possible
  • women of childbearing age pregnancy status must be determined!
62
Q

PE of acute abdominal pain?

Red flags?

A
  • general appearance is impt
  • focus of exam on abdomen:
    begin with inspection and auscultation, followed by palpation and percussion
  • rectal and pelvic exam
  • palpation begins away from area of greatest pain: looking for guarding, rigidity, and rebound
  • surgical scars should be palpated
  • Red flags:
    severe pain
    signs of shock
    signs of peritonitis
    abdominal distension
63
Q

Tests to order for acute abdominal pain?

A
  • urine pregnancy test for all women of childbearing age
  • CBC, chemistries, UA little value
  • exception: serum lipase and amylase strongly suggest dx of acute pancreatitis
  • order LFTs with RUQ pain
  • UA: if blood in urine
  • CBC: suspect infection
  • plain xrays: helpful for bowel obstruction, bowel perf, radiopaque fb
  • U/S: biliary tract disease, ectopic pregnancy, appendicitis in kids, AAA
  • CT: study of choice in eval of undiff abdominal pain
    CT with oral and IV contrast is dx in about 95% of pts with sig abdominal pain
64
Q

What are the test of choices depending on quadrant?

A
  • RUQ pain: US
  • LUQ: endoscopy, US or CT
  • RLQ: CT IV contrast
  • LLQ: CT IV and oral contrast
  • suprapubic: US
65
Q

What are impt key pts in acute abdominal pain?

A
  • look for life-threatening causes first
  • rule out pregnancy in women of childbearing age
  • seek signs of peritonitis, shock, and obstruction
  • blood test are minimal value except specific labs

GI (21 decks)

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