Anorectal Disease Flashcards
What is the purpose of the dentate/pectinate line?
Above it the patient is not sensitive to pain (inside the anus) and below is where there is sensation
Red flags for anorectal complaints
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
How do hemorrhoids occur?
They are normal vascular structures that arise from a fibrovascular cushion (protect anal canal during defecation and help maintain continence)
When do hemorrhoids develop sxs?
When the supporting structures of the hemorrhoidal tissue (anal cushions) begin to deteriorate
Causes of hemorrhoids
Prolonged sitting or straining Chronic constipation Diarrhea Pregnancy Advancing age
Types of hemorrhoids
External (distal to dentate line and painful!!)-blueish
Internal (proximal to dentate line and painless!!)-red
How to classify internal hemorrhoids
*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
Presentation of hemorrhoids
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
What kind of PE needs to be done for hemorrhoids?
Inspect perianal skin
DRE
Anoscopy (optimal visualization of internal hemorrhoids)
Diagnostics used for hemorrhoids
CBC when needed (bleeding)
Flex sig or colonoscopy if needed (probably should if they have bleeding tho or if concerned for IBD or malignancy)
General types of tx for hemorrhoids
Diet and lifestyle (all)
Conservative medical therapies
Office-based procedures
Surgery
What diet and lifestyle changes need to happen with hemorrhoids?
(ALL grades of hemorrhoids need this)
Fluid and fiber (dietary/bulk laxatives)
Toilet habits
Sitz baths for itching relief
Conservative medical tx for hemorrhoids
Stool softeners
Maybe topical agents for sx relief (tucks pads or a SHORT course of corticosteroid creams or suppositories)
Antispasmodic agents (nitro ointment)
Office based/non-surgical tx for hemorrhoids
(pts refractory to conservative medical txs)
Internal hemorrhoids- rubber band ligation, infrared coagulation or sclerotherapy
External hemorrhoids- excision of thrombosed one
Most commonly used technique for tx of symptomatic bleeding internal hemorrhoids
Rubber band ligation
When do you consider a hemorrhoidectomy?
Persistent sxs despite early tries on management
Symptomatic grade III hemorrhoids
Grade IV internal hemorrhoids
Pts with extensive pain from thrombosed external hemorrhoids
Most common cause of pruritus ani
Mechanical (ex: prolapsing tissue, incontinence, inadequate hygiene)
Presentation of pruritus ani
Intense itching and burning
Circumferential erythematous and irritated perianal skin
Management for pruritus ani
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
What are perianal skin tags?
Outgrowth of normal skin
Sequelae of thrombosed external hemorrhoids or Crohns
Loose, flesh colored, pedunculated tissues
Tx for perianal skin tags
Not usually indicated (pts might want them excised if they interfere with hygiene or cause discomfort)
What might be seen with perianal Crohn’s disease?
Fissures, abscesses or fistulas
Most common cause of severe anorectal pain
Anal fissure
What is an anal fissure?
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)
Causes of anal fissure
Primarily local trauma to anal canal, passage of large hard stools or a foreign body
Secondary can be Crohns, malignancy or HIV/AIDS
Presentation of an anal fissure
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
Most common place for an anal fissure
Posterior midline due to lowest blood supply (if more than 1 or not here than maybe think Crohns)
Diagnostics for anal fissure
DRE or anoscopy if can tolerate
Flex sig/colonoscopy if recurrence
Management of an anal fissure
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)
How does a perianal abscess occur?
From obstructed/infected anal crypt gland (chronically can progress to a fistula)
Presentation of perianal abscess
Localized anal or rectal pain (maybe drainage or constitutional sxs)
Erythematous, palpable, tender, fluctuant mass with surrounding edema
(palpate for inguinal LAD)
Diagnostics for perianal abscess
Maybe CT/MRI pelvis to determine extent
Management for perianal abscess
I&D
Maybe abx
Post op tx with sitz baths and adequate fluid and fiber
How does an anorectal fistula occur?
Abnormal connection between anal canal and the perianal area
Chronic manifestation of perianal abscess
When can you see anorectal fistulas?
Crohns, radiation proctitis or diverticulitis
Presentation of anorectal fistula
Chronic drainage of blood or pus & occasionally stool from fistula
Rectal pain, itching, swelling, fever
Might see perianal skin excoriated or inflamed
What might be felt on exam of anorectal fistula?
Palpable cord beneath skin between anus and abscess opening
might see external opening
Diagnostics for anorectal fistula
MRI pelvis for recurrent or complex fistula
Colonoscopy if concern for IBD!
Mainstay of tx for anorectal fistula
Surgery (fisulotomy)-unroof the fistula tract to allow for healing
What causes anal condyloma?
HPV
Presentation of anal condyloma
Asymptomatic but maybe pruritis
Cauliflower like appearance, in clusters or singles
Diagnostics for anal condyloma
Anoscopy
Management for anal condyloma
Removal or destruction of visible lesions
Topical podofilox or imiquimoid cream
Trichloroacetic acid in office
Surgery
What are most anal cancers?
Squamous cell
When is there an increased incidence of anal cancer?
Practicing receptive anal intercourse
History of anorectal condyloma
History of HPV or HIV
Presentation of anal cancer
Rectal bleeding, anorectal pain, sensation of anal mass
Anal warts, perianal skin irritation, hard, friable or ulcerating internal or external lesions
Inguinal LAD
Diagnostics for anal cancer
Biopsy and scope/imaging for extent
Chemoradiotherapy
Surgery
What is rectal prolapse?
Pelvic floor disorder when rectal tissue protrudes through the anus
May see with chronic constipation, straining, multiparity or prior pelvic surgery
History described with anal prolapse
Constipation/fecal incontinence
Incomplete bowel evacuation, seepage
Mass protruding through anus
What is seen on the PE for rectal prolapse?
Strain to reproduce
Protruding circumferential mass
DRE shows mucosa of rectal wall feeling floppy or loos with redundant tissue
Diagnostic for rectal prolapse
Defecography/anorectal manometry to look for pelvic floor descent
Management of rectal prolapse
Prevent constipation so increase fiber and fluids
Surgical repair is mainstay tho!
How does a rectocele occur?
When fascia weakens and allows rectum to bulge into vagina
Potential causes of a rectocele
Vaginal childbirths, increasing age and increasing BMI
Presentation of rectocele
Need to apply pressure on vagina/rectum etc to defecate
Pelvic pressure
Constipation or fecal incontinence
Sexual dysfunction
PE for rectocele
Do a rectovaginal exam and when pt bears down, there is a bulge of the rectum into the vagina
Tx for rectocele
Expectant management or non-surgical options first (pelvic floor muscle training or pessary)
What should you do if you’re unsure of any diagnosis?
Refer to gastroenterologist or colorectal surgeon
