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X Clin Med III Exam 2 > Anorectal Disease > Flashcards

Anorectal Disease Flashcards

1
Q

What is the purpose of the dentate/pectinate line?

A

Above it the patient is not sensitive to pain (inside the anus) and below is where there is sensation

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2
Q

Red flags for anorectal complaints

A

Unintentional weight loss
IDA
Personal or FH of IBD or CRC
Persistent anorectal bleeding or anorectal sxs despite adequate tx of a suspected benign condition

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3
Q

How do hemorrhoids occur?

A

They are normal vascular structures that arise from a fibrovascular cushion (protect anal canal during defecation and help maintain continence)

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4
Q

When do hemorrhoids develop sxs?

A

When the supporting structures of the hemorrhoidal tissue (anal cushions) begin to deteriorate

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5
Q

Causes of hemorrhoids

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

Types of hemorrhoids

A

External (distal to dentate line and painful!!)-blueish

Internal (proximal to dentate line and painless!!)-red

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7
Q

How to classify internal hemorrhoids

A 
*this determines the tx
I- bulge in anal canal without prolapse
II- prolapse that reduces spontaneously
III-prolapse that requires manual reduction
IV-chronic prolapse and irreducible
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8
Q

Presentation of hemorrhoids

A

Bleeding with BM (usually bright red and painless)
Sensation of perianal fullness (prolapse)
Pruritus (pruritis ani)
Fecal incontinence, mucoid discharge, acute perianal pain and palpable lump if thrombosed

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9
Q

What kind of PE needs to be done for hemorrhoids?

A

Inspect perianal skin
DRE
Anoscopy (optimal visualization of internal hemorrhoids)

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10
Q

Diagnostics used for hemorrhoids

A

CBC when needed (bleeding)

Flex sig or colonoscopy if needed (probably should if they have bleeding tho or if concerned for IBD or malignancy)

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11
Q

General types of tx for hemorrhoids

A

Diet and lifestyle (all)
Conservative medical therapies
Office-based procedures
Surgery

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12
Q

What diet and lifestyle changes need to happen with hemorrhoids?

A

(ALL grades of hemorrhoids need this)
Fluid and fiber (dietary/bulk laxatives)
Toilet habits
Sitz baths for itching relief

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13
Q

Conservative medical tx for hemorrhoids

A

Stool softeners
Maybe topical agents for sx relief (tucks pads or a SHORT course of corticosteroid creams or suppositories)
Antispasmodic agents (nitro ointment)

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14
Q

Office based/non-surgical tx for hemorrhoids

A

(pts refractory to conservative medical txs)
Internal hemorrhoids- rubber band ligation, infrared coagulation or sclerotherapy
External hemorrhoids- excision of thrombosed one

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15
Q

Most commonly used technique for tx of symptomatic bleeding internal hemorrhoids

A

Rubber band ligation

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16
Q

When do you consider a hemorrhoidectomy?

A

Persistent sxs despite early tries on management
Symptomatic grade III hemorrhoids
Grade IV internal hemorrhoids
Pts with extensive pain from thrombosed external hemorrhoids

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17
Q

Most common cause of pruritus ani

A

Mechanical (ex: prolapsing tissue, incontinence, inadequate hygiene)

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18
Q

Presentation of pruritus ani

A

Intense itching and burning

Circumferential erythematous and irritated perianal skin

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19
Q

Management for pruritus ani

A

Eliminate offending agent
Good hygiene (gentle cleaners, don’t do overzealous hygiene and sitz baths)
Keep it 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

What are perianal skin tags?

A

Outgrowth of normal skin
Sequelae of thrombosed external hemorrhoids or Crohns
Loose, flesh colored, pedunculated tissues

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21
Q

Tx for perianal skin tags

A

Not usually indicated (pts might want them excised if they interfere with hygiene or cause discomfort)

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22
Q

What might be seen with perianal Crohn’s disease?

A

Fissures, abscesses or fistulas

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23
Q

Most common cause of severe anorectal pain

A

Anal fissure

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24
Q

What is an anal fissure?

A

Linear tear or split in the lining of the anal canal distal to the dentate line that causes spasm of anal sphincters (decreased blood flow more and prevents healing)

25
Q

Causes of anal fissure

A

Primarily local trauma to anal canal, passage of large hard stools or a foreign body
Secondary can be Crohns, malignancy or HIV/AIDS

26
Q

Presentation of an anal fissure

A

Severe pain during and often persisting after defecation (passing glass or sitting on a knife)
Bright red blood on TP or streaking of stool
Might see tear in anodermal tissue, minimal edema, erythema or bleeding

27
Q

Most common place for an anal fissure

A

Posterior midline due to lowest blood supply (if more than 1 or not here than maybe think Crohns)

28
Q

Diagnostics for anal fissure

A

DRE or anoscopy if can tolerate

Flex sig/colonoscopy if recurrence

29
Q

Management of an anal fissure

A

Adequate fiber/fluid, hygiene, sitz baths, stool softeners
Topical analgesic-lidocaine gel
Topical vasodilators-nifedipine or nitro ointment (decrease spasms and increase BF)
Surgery if chronic (sphincterectomy in pts with low risk of developing fecal incontinence)

30
Q

How does a perianal abscess occur?

A

From obstructed/infected anal crypt gland (chronically can progress to a fistula)

31
Q

Presentation of perianal abscess

A

Localized anal or rectal pain (maybe drainage or constitutional sxs)
Erythematous, palpable, tender, fluctuant mass with surrounding edema
(palpate for inguinal LAD)

32
Q

Diagnostics for perianal abscess

A

Maybe CT/MRI pelvis to determine extent

33
Q

Management for perianal abscess

A

I&D
Maybe abx
Post op tx with sitz baths and adequate fluid and fiber

34
Q

How does an anorectal fistula occur?

A

Abnormal connection between anal canal and the perianal area

Chronic manifestation of perianal abscess

35
Q

When can you see anorectal fistulas?

A

Crohns, radiation proctitis or diverticulitis

36
Q

Presentation of anorectal fistula

A

Chronic drainage of blood or pus & occasionally stool from fistula
Rectal pain, itching, swelling, fever
Might see perianal skin excoriated or inflamed

37
Q

What might be felt on exam of anorectal fistula?

A

Palpable cord beneath skin between anus and abscess opening

might see external opening

38
Q

Diagnostics for anorectal fistula

A

MRI pelvis for recurrent or complex fistula

Colonoscopy if concern for IBD!

39
Q

Mainstay of tx for anorectal fistula

A

Surgery (fisulotomy)-unroof the fistula tract to allow for healing

40
Q

What causes anal condyloma?

A

HPV

41
Q

Presentation of anal condyloma

A

Asymptomatic but maybe pruritis

Cauliflower like appearance, in clusters or singles

42
Q

Diagnostics for anal condyloma

A

Anoscopy

43
Q

Management for anal condyloma

A

Removal or destruction of visible lesions
Topical podofilox or imiquimoid cream
Trichloroacetic acid in office
Surgery

44
Q

What are most anal cancers?

A

Squamous cell

45
Q

When is there an increased incidence of anal cancer?

A

Practicing receptive anal intercourse
History of anorectal condyloma
History of HPV or HIV

46
Q

Presentation of anal cancer

A

Rectal bleeding, anorectal pain, sensation of anal mass
Anal warts, perianal skin irritation, hard, friable or ulcerating internal or external lesions
Inguinal LAD

47
Q

Diagnostics for anal cancer

A

Biopsy and scope/imaging for extent
Chemoradiotherapy
Surgery

48
Q

What is rectal prolapse?

A

Pelvic floor disorder when rectal tissue protrudes through the anus
May see with chronic constipation, straining, multiparity or prior pelvic surgery

49
Q

History described with anal prolapse

A

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

50
Q

What is seen on the PE for rectal prolapse?

A

Strain to reproduce
Protruding circumferential mass
DRE shows mucosa of rectal wall feeling floppy or loos with redundant tissue

51
Q

Diagnostic for rectal prolapse

A

Defecography/anorectal manometry to look for pelvic floor descent

52
Q

Management of rectal prolapse

A

Prevent constipation so increase fiber and fluids

Surgical repair is mainstay tho!

53
Q

How does a rectocele occur?

A

When fascia weakens and allows rectum to bulge into vagina

54
Q

Potential causes of a rectocele

A

Vaginal childbirths, increasing age and increasing BMI

55
Q

Presentation of rectocele

A

Need to apply pressure on vagina/rectum etc to defecate
Pelvic pressure
Constipation or fecal incontinence
Sexual dysfunction

56
Q

PE for rectocele

A

Do a rectovaginal exam and when pt bears down, there is a bulge of the rectum into the vagina

57
Q

Tx for rectocele

A

Expectant management or non-surgical options first (pelvic floor muscle training or pessary)

58
Q

What should you do if you’re unsure of any diagnosis?

A

Refer to gastroenterologist or colorectal surgeon

X Clin Med III Exam 2 (9 decks)

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