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Clin Med III Exam 2 > AnoRectal Disease > Flashcards

AnoRectal Disease Flashcards

1
Q

Red flags for anorectal complains

A

– Unintentional weight loss
– IDA
– Personal or FH of IBD or CRC
– Persistent anorectal bleeding or anorectal symptoms despite adequate treatment of a suspected benign condition

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2
Q

Peak age of hemorrhoids

A

45-65 YO

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3
Q

Hemorrhoid role

A

normal vascular structures
arise from fibrovascular cushion
- protect anal canal during defecation
- help maintain continence

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4
Q

Symptomatic hemorrhoid cause

A

when supporting structures of hemorrhoidal tissue (i.e anal cushions) deteriorate

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5
Q

Etiology of hemorrhoids

A
  • Prolonged sitting and straining
  • Chronic constipation
  • Diarrhea
  • Pregnancy
  • Advancing age
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6
Q

painful hemorroid

A

external (distal to dentate line)

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7
Q

Painless hemorrhoid

A

painless (proximal to dentate line)

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8
Q

Grading of hemorrhoids

A
  • Grade I: Bulge in anal canal without prolapse
  • Grade II : Prolapse that reduces spontaneously
  • Grade III: Prolapse that requires manual reduction
  • Grade IV: Chronic prolapse, irreducible
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9
Q

Presentation of hemorrhoids

A
  • Bleeding with BM, usually bright red
  • +/- sensation of perianal fullness (prolapse)
  • +/- fecal incontinence
  • +/- mucoid discharge
  • +/- pruritus (“pruritis ani”)
  • +/- acute perianal pain and palpable “lump” if thrombosed
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10
Q

PE for hemorrhoids

A

perianal skin – hemorrhoid degree, fissures, fistula, abscess, condyloma, neoplasms

DRE: fissures, ulcers, tenderness, fluctuance, masses

Anoscopy (+/-): visualize internal hemorrhoids

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11
Q

Dx of hemorrhoids

A

CBC if appropriate (can cause severe bleeding)
+/- flex sig/colonoscopy
- flex sig: hemorrhoid-pattern bleeding; r/o anorectal pathology
- colonoscopy: IBD or malignancy concern

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12
Q

Tx for symptomatic hemorrhoids

A
  • Dietary and Lifestyle modifications (all patients)
  • Conservative Medical Therapies
  • Office-Based Procedures
  • Surgical Management
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13
Q

Diet mod for hemorrhoids

A

Fluid + fiber (dietary/bulk laxative)
toilet habits
sitz baths

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14
Q

Med therapy for hemorrhoids

A

stool softener
+/- topical agent (tuck pads, SHORT COURSE of corticosteroid cream or suppository)
+/- Antispasmodic agent - nitroglycerin ointment

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15
Q

Office base procedure for hemorrhoids

A 
Refractory to conservative
Internal:
- Rubber-band ligation (banding)- MOST COMMON
- infrared coagulation
- Sclerotherapy

External hemorrhoids: exision of thrombosed external hemorrhoid

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16
Q

Reasons for surgery for hemorrhoids

A

– Persistent symptoms despite conservative measures or office- based procedures
– Symptomatic grade III hemorrhoids
– Grade IV internal hemorrhoids
– Patients with extensive pain from thrombosed external hemorrhoids

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17
Q

Sx of pruritis ani

A
  • Intense itching and burning

* Circumferential erythematous and irritated perianal skin

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18
Q

Most common cause of pruritus ani

A

prolapsing tissue

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19
Q

Tx of pruritis ani

A

• Eliminate offending agent
• Proper hygiene
– Gentle cleansers (water only, mild soap)
– Avoid aggressive wiping and overzealous hygiene – Sitz baths
• Keep region dry
• Eliminate tight clothing
• Topical astringent (witch hazel) or topical barrier (zinc oxide)
• Short course of topical steroid cream appropriate for severe skin eruptions

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20
Q

Etiology of perianal skin tags

A

thrombosed external hemorrhoids
Crohn Disease
Outgrowth of normal skin

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21
Q

Tx for perianal skin tag

A

not indicated

excision if interfere w/ hygiene or cause discomfort

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22
Q

Most common cause of severe anorectal pain

A

anal fissure

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23
Q

What is a fissure

A

Linear tear, or split, in the lining of the anal canal distal to the dentate line that causes spasm of the anal sphincters

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24
Q

Etiology of anal fissure

A 
trauma
passage of hard stools
FB
Crohn Disease***
malignancy
HIV/AIDSs
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25
Q

Pathophys of fissure

A

Pain causes spasm of sphincters, which further decreases blood flow and prevents healing

26
Q

Presentation of fissure

A

• Severe pain during and often persisting after defecation
– “like passing glass” or “sitting on a knife”
• Bright red blood on toilet paper or streaking on the stool
• Tear in the anodermal tissue, minimal edema, erythema, or bleeding may be seen
• Posterior midline most common (lowest blood supply)

27
Q

Dx of fissure

A

DRE/anoscopy

Flex sig/colonoscopy if unsure

28
Q

Tx of fissure

A 
fiber/fluid
proper hygiene
sitz
stool softener
topical analgesic: lidocaine
Topical vasodilator: Nifedipine or Nitroglycerin ointment (reduce spasm, increase BF)

if chronic/refractory: surgery- sphincterotomy in those w/ low risk of developing fecal incontinence

29
Q

Common location of anal fissure

A

posterior midline (lowest blood supply)

30
Q

Pathophys behind perianal abscess

A

originates from obstructed/infected anal crypt gland

Can be a/w perianal Crohn Disease

31
Q

Abscess can progress to

A

fistula

32
Q

Presentation of perianal abscess

A
  • Localized anal or rectal pain , +/- drainage, constitutional symptoms
  • Erythematous, palpable, tender, fluctuant mass with surrounding edema
  • +/- DRE
  • Palpate for inguinal lymphadenopathy
33
Q

Dx of perianal abscess

A

+/- CT/MRI to determine extent

34
Q

Tx of perianal abscess

A

I&D
+/- abx
Post op: sitz bath, fluid/fiber

35
Q

Pathophys behind anorectal fistula

A
  • Abnormal communication (tract/tunnel) between anal canal (internal opening) and the perianal area (external opening)
  • Chronic manifestation of a perianal abscess
36
Q

Fistula’s are associated w/

A

Crohn Disease
Radiation proctitis
Diverticulitis

37
Q

Presentation of anorectal fistula

A

• Chronic drainage of blood or pus & occasionally stool from fistula, rectal pain, itching, swelling, fever
• Perianal skin may be excoriated or inflamed
• Palpable cord beneath the skin between anus and abscess
opening
• External opening may be visualized
– Careful exam under anesthesia is useful

38
Q

Dx of anorectal fistula

A

MRI pelvis for complex or recurrent fistula

Colonoscopy if concerned for IBD

39
Q

Tx for anorectal fistula

A

Surgical (Fistulotomy) - unroofing fistula tract to allow healing

40
Q

Cause of anal condyloma

A

HPV

41
Q

Sx of anal condyloma

A

asymptomatic
may be pruritic
cauliflower like appearance, in clusters or single entities

42
Q

Dx of anal condyloma

A

Anoscopy

43
Q

Management of anal condyloma

A 
Removal of lesions
Topical Podofilox & Imiquidmoid cream
Office tx w/ Trichloroacetic acid
Surgical removal
f/u for recurrence
44
Q

Majority of anal cancers

A

SCC

45
Q

Increased risk of anal cancer

A

Practicing receptive anal intercourse
Hx of anorectal condyloma
History HPV, HIV

46
Q

Presentation of anal CA

A
  • +/- rectal bleeding, anorectal pain, sensation of rectal mass
  • +/- anal warts, perianal skin irritation, hard, friable or ulcerating internal or external lesions
  • Palpate for inguinal lymphadenopathy
47
Q

Dx of anal cancer

A

Bx + scope/imaging to determine extent

48
Q

Tx of anal CA

A

chemoradiotherapy

Surgery

49
Q

Rectal prolapse associated w/

A

chronic constipation
straining
multiparity
prior pelvic surgery

50
Q

Presentation of rectal prolapse

A

– Constipation/fecal
incontinence
– Incomplete bowel evacuation, seepage
– “Mass” protruding through anus

51
Q

PE for rectal prolapse

A

– Strain to reproduce
– Protruding circumferential mucosa tissue
– DRE: mucosa of rectal wall may feel floppy or loose with redundant tissue

52
Q

Dx of rectal prolapse

A

+/- Defecography/anorectal manometry

53
Q

Tx for rectal prolapse

A

prevent constipation
Increase fiber/fluid
Surgical repair is mainstay !! (consult colorectal surgery)

54
Q

What is rectocele

A

Occurs when fascia weakens and allows rectum to bulge into vagina

55
Q

Causes of rectocele

A

vaginal childbirth
increasing age
Increasing BMI

56
Q

Presentation of rectocele

A
  • +/- need to apply pressure on vagina, rectum or perineum to defecate
  • Pelvic pressure
  • Constipation
  • Fecal incontinence
  • Sexual dysfunction
57
Q

PE for rectocele

A

patient bears down and you may see bulge of rectum into vagina

58
Q

Dx of rectocele

A

defecography if unsure

59
Q

Tx of rectocele

A

pelvic floor muscle training

Pessary

60
Q

Most common location for anal fissure

A

posterior midline (lowest blood supply)

61
Q

Most common location for anal fissure

A

posterior midline (lowest blood supply)

Clin Med III Exam 2 (8 decks)

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