Anorectal Disorders Flashcards
1
Q
- soiling
- evidence of abscess, fistula- tenderness mass, erythema, swelling
- valsalva maneuver for rectal prolapse or prolapsing hemorrhoids
lower motor neuron reflex arc- pinprick sensation, anal wink reflex
A
Inspection
2
Q
- tone- rest and squeeze
- around circumference-mass, induration, tenderness- not lockaton
- presence of blood or stool
- avoid if neutropenia or obvious cause such as fissure
A
Digital Exam
3
Q
- in anal canal- vascular tissue covered by mucosa- everybody has, helps iwht continence
- when the tissue bleeds or enlarges and goes into anal canal
- pathophys- not completely known, likely loss of connective tissue support which makes more likely to be affected by straining or hard stools
- risk factors- constipation, hard stool consistency, lengthy periods on toilet, pregnancy
A
Hemorrhoids
4
Q
grading of internal hemorrhoids
A
- grade 1: no prolapse
- grade 2: prolapse with straining but retract after bowel movement
- grade 3: do not reduce retract unless manually reduced
- grade 4: no manually reducible
5
Q
- symptoms of painless bright red bleeding with bowel movements
- intermittent protrusion or prolapse (looks pink rather than skin colored), mucus or fecal leaking
- can be clotted blood
- prolapsed: can cause aching pain if not reducicble, more likely to have some scant fecal or mucus leakage
- not necessarily palpable- can feel soft and squishy
- exclude other causes
A
Internal hemorrhoids
6
Q
- past dentate line- so can be painful but typically more irritating
- covered in squamous epithelium, can be purple to blue
- painful and very tender with thrombosis
- present as painful swelling if thrmobosed
- history- constipation, diarrhea, heavy lifting
- can bleed but typically very scant compared to internal hemorrhoids
- thrombosed- sudden onset of pain, edema, can be strangulated
A
external hemorrhoids
7
Q
Hemorrhoid treatment
A
- conservative- helpful for both internal and external hemorrhoids
- increased fluid
- increased fiber
- decrease time on toilet and straining
- gentle hygiene
- topical- corticosteroids (limit duration of use)
- OTC-symptom relief only
8
Q
advanced hemorrhoid treatment
A
- if no response to conservative treatment- referral
- ruber band ligation- internal hemorrhoids grade I and II usually
- consider anticoagulation status
9
Q
treatment of thrombosed external hemorrhoids?
A
- treatment within 4 days of onset with clot excision, removal of skin over area
- alternatively- conservative treatment with pain control
10
Q
- tear to midline anal canal
- distal to dentate line = painful, like shard of glass with defecation and after
- tearing sensation, hard or loose liquid stool consistency, bright red with wiping or in toilet bowl- can be more than scant
- 90% posterior midline, others anterior midline
- if not midline, concern for other cause: Chron’s, TB, syphilis, HIV, skin conditions (psoriasis) and carcinoma
chronic- lasts more than 8-12 weeks
A
Anal fissures
50% recurrance rate
11
Q
Anal fissure treatment
A
- Sitz bath
- fiber 20-30 grams, increased fluids
- chronic anal fissure treatment- goal relax, smooth muscle, more blodo flow
- calcium channel blockers- diltiazem 2%, nifedipine 0.2-0.5%
- nitrates
- consider referral if non-healing: botox injection; surgery
12
Q
- residual redundant skin from previous episodes of inflammation and thrombosis
- loose flesh colored, pedunculated
- painless
- can result from old thrombosed external hemorrhoids, pregnancy, chron’s (suspect if inflamed, off midline, other signs and symptoms
A
Skin tags
13
Q
- common complaint
- many causes
- irritants: chemical, feces/seepage, dermatologic, clothing, dietary
- be wary of aggressive hygiene including wipes and chemicals
- infectious: pinworm, fungal, condyloma
- cancer: anal intraepithelial neooplasia, bowen disease
- if issues at night, can consider benadryl or hydroxyzine
- if seepage an issue- consider cotton ball, zinc ointment (desitin)
A
Perianal itching
14
Q
- caused by HPV type 6, 11 typical anal warts- low risk of cancer
- HPV 16,18- more commonly associated with dysplasia and malignant transformation
- transmission- anal intercourse, also other direct skin contact
- symptoms: asymptomatic, bleeding with defecation, rectal leakage between bowel movements, anal pruritus
- strong association between perianal and anorectal lesions
A
Condyloma Accuminata
15
Q
Risk factors for anal fissures
A
- hard stool consistency, straining, receptive anal intercourse or foreign object insertion
- acute- clean edge like paper cut
- chronic- last more than 8-12 weeks- heapead up, indurated
- trauma + internal anal sphincter muscle spasm with relative ischemia
- accompanied by sentinel skin tag at distal end or hypertrophied anal papilla in anal canal proximal to fissure
