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
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
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
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
5
Q
Causes and RFs of perianal abscess?
A
- causes:
anal fissure/fistulas
hemorrhoids
blocked anal glands - RFs:
colitis
IBD
DM2
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
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
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
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
10
Q
Tx of anal fistula?
A
- fistulotomy (cut out fistula)
- complex fistulas:
fibrin glue
fistula plug
(not as commonly used - cause infections)
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
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
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
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
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
16
Q
Causes of rectal prolapse?
A
- chronic constipation or diarrhea
- straining during BM
- weakness of anal sphincter
- damage to nerves
17
Q
Dx rectal prolapse?
A
- PE
- anal EMG
- anal manometry: strength of muscles
- anal US
- colonoscopy
- proctosigmoidoscopy
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
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)
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
21
Q
RFs for pilonidal cyst?
A
- obesity
- prolonged sitting
- local trauma/irritation
- deep natal cleft
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)
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)
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
25
Causes of hemorrhoids?
- pregnancy
- frequent heavy lifting
- repeated straining during defecation (low fiber diet)
- constipation
26
Clinical presentation of hemorrhoids? External and internal
- 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
27
How do you dx hemorrhoids? Tx?
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
Do external hemorrhoids usually bleed?
- no, they may thrombose and become very painful but they rarely bleed
29
Are internal hemorrhoids painful?
- no, often not painful
| - they often bleed though
30
Tx for external hemorrhoids?
- stool softeners
- topical tx
- analgesics
31
Tx for bleeding internal hemorrhoids?
- may reqr injection
- rubber band ligation
- surgery is last resort
32
What is a hernia? What is a potential risk?
- 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
Types of hernias?
- inguinal
- umbilical
- incisional/ventral
- epigastric
- femoral
- spigelian
34
Most common type of hernia in adults? More common in men or women? RFs?
- 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
2 types of inguinal hernias?
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
What are the boundries of the hesselbach triangle?
- laterally: inferior epigastric artery
- medially: lateral border or rectus abdominis
- inferiorly: (base) - inguinal ligament
37
What is a femoral hernia? More common in?
- 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
Clinical presentation of inguinal hernia?
- 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
What will you see on PE of inguinal hernia?
- 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
how do you dx inguinal hernias?
- usually done with hx and exam
- not apparent, then initial study is groin U/S
- CT/MRI
41
Tx of inguinal hernia?
- non surgical: watchful waiting, TRUSS (metal support underwear)
- surgical:
open repair
laparoscopic repair
42
What is an umbilical hernia? More common in what pop? Causes?
- 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
Clinical presentation of umbilical hernia?
- 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
Causes of umbilical hernias?
- obesity
- mult pregnancies
- fluid in abdominal cavity (ascites)
- previous abdominal surgery
PE:
usually found on exam
45
Tx of umbilical hernia?
- surgery: with or w/o mesh
46
What is an incisional/ventral hernia? Caused by what?
- 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
What is an epigastric hernia?
- 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
What is a spigelian hernia?
- 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
Acute abdominal pain - why is it hard figuring out dx?
- 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
DDx of acute abdominal pain - immediate life-threatening conditions?
- AAA
- mesenteric ischemia
- perforation of GI tract
- acute bowel obstruction
- volvulus
- ectopic pregnancy
- MI
- splenic rupture
51
PP behind acute abdominal pain? Diff b/t visceral, somatic pain. referred pain and peritonitis?
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
Presentation of appendicitis?
- 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
Presentation of biliary disease?
- 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
Presentation of pancreatitis?
- 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
Presentation of diverticular disease?
- LLQ pain most common complaint
| - N/V and +/- change in bowel habits
56
Presentation of peptic ulcer disease?
- epigastric pain, indigestion, and reflux sxs: none is sensitive or specific
- complications:
bleeding and perforation
57
Presentation of incarcerated hernia?
- inguinal most common with mild lower abdominal discomfort exacerbated by straining
- incarcerated hernias cause severe pain and reqr immediate surgical consultation
58
Presentation of IBD?
- acute complications include pain, bleeding, perforation, bowel obstruction, fistula, and abscess formation and toxic megacolon
59
Presentation of IBS?
- sxs need to persist for 3 months over a 1 yr period
| - abdominal pain assoc with change in stool frequency or consistency
60
Eval of acute abdominal pain - depending on pain level?
- 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
Hx of acute abdominal pain?
- age
- sex
- PMHX and SHX
- meds
- characterize pain as precisely as possible
- women of childbearing age pregnancy status must be determined!
62
PE of acute abdominal pain?
| Red flags?
- 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
Tests to order for acute abdominal pain?
- 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
What are the test of choices depending on quadrant?
- RUQ pain: US
- LUQ: endoscopy, US or CT
- RLQ: CT IV contrast
- LLQ: CT IV and oral contrast
- suprapubic: US
65
What are impt key pts in acute abdominal pain?
- 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
