Anorectal Disorders Flashcards
Red flags of colorectal cancers?
- Melana, hematochezia
- Altered bowel movements
- Unexplained weight loss
- Unexplained iron deficiency anemia
What are anal fissures?
Linear (longitudinal) or oval shaped ulcer or tear in the anal mucosa
What condition is among one of the main causes of anal pain?
Anal fissures
Usually, how long are anal fissures?
Usually <5mm in length
What are the two types of anal fissures?
- Acute (<8 weeks)
- Chronic (>8 weeks)
Most anal fissures occur where?
In the posterior midline of the anal canal (99% in men, 90% in women)
10% of anal fissures are located where?
In the anterior midline
*more common in females than males
Which anal fissures are atypical and should raise suspicion for secondary conditions?
Fissures that occur off midline (laterally)
Which secondary conditions should be considered if atypical lateral/off-midline fissures occur?
Crohn’s, HIV/AIDS, TB, Syphilis, malignancy (ex. anal carcinoma)
A majority of anal fissures are caused by what?
Local trauma: Straining, penetration/anal sex, constipation, diarrhea, vaginal delivery
Other causes of anal fissures are due to what?
Underlying disease: Crohn’s, STDs, HIV/AIDS, malignancy
Clinical manifestations of anal fissures?
-severe/sharp “passive knives/shards of glass” tearing pain w/ defecation followed by throbbing discomfort
-Can lead to constipation (fear of recurrent pain w/ defecation)
-Mild hematochezia (blood on outside of stool or on TP following BMs)
Physical exam findings of anal fissures?
-confirm by visual inspection of anal verge
-acute fissures look like cracks in epithelium
-anal tenderness
-digital/anoscopic exam may not be possible d/t pain (often deferred)
Chronic anal fissures can result in what?
Fibrotic changes, develop skin tag at fissure’s distal end (sentinel pile) & hypertrophied anal papilla at fissure’s proximal end
Anoscopy clock locations?
12 o’clock: Anterior
3 o’clock: Left
6 o’clock: Posterior
9 o’clock: Right
Dx of anal fissures based on what?
Hx and physical exam
When are no lab tests necessary for anal fissures?
If anal fissure is located in the posterior and anterior midline
If atypical lateral/off-midline fissures occur with suspicion of underlying conditions, which tests should be ordered?
ESR, Stool/viral cultures, HIV testing, Bx of lesion/fissure as warranted
Conservative treatment of anal fissures promotes what?
Effortless and painless bowel movements
Conservative tx for anal fissures?
High fiber diet/fiber supplements, stool softeners/laxatives, increased fluid intake, sitz baths for relief, topical anesthetics for sx relief, topical vasodilators
Topical anesthetics for conservative tx of anal fissures?
5% lidocaine, 2.5% lidocaine + 2.5% prilocaine
(sx relief)
Topical vasodilators for conservative tx of anal fissures?
0.4% nitroglycerin ointment, 2% diltiazem ointment, or 0.5% nifedipine ointment 2-3x/day x 4 weeks
*to the internal sphincter for healing
If symptoms of anal fissures continue after conservative treatment, what should be done?
Re-evaluate and continue w/ 4 more weeks of conservative tx
What should be performed if anal fissure sx continue after 8 weeks of conservative tx?
Endoscopy to exclude Crohn’s
If IBD is excluded: refer to colorectal surgeon
When is lateral internal sphincterectomy indicated when conservative tx is unsuccessful for anal fissures?
If patient has low risk of fecal incontinence
What is recommended for patients with high fecal incontinence risk when conservative tx for anal fissures fails?
Outpatient procedure w/ injection of botox (20 units) into internal anal sphincter to relieve spasm
or
Anal advancement flap
Anorectal abscess and fistulae represent what?
Different stages of the same anorectal infectious process
What is an anorectal abscess?
Acute manifestation of purulent infection most commonly developing from infected anal crypt gland –> 90% of cases (Anal crypts of Morgani)
How does an anal crypt gland become infected?
Gland becomes obstructed w thickened debris, permitting bacterial growth & abscess formation
What is a perianal fistula?
A tract (ductal connection) between the anorectal abscess and the anal canal or perianal skin
*chronic manifestation
Other causes of formation of anorectal abscesses/fistulae?
Crohn’s (IBD), infected anal fissures, secondary to trauma (obstetric, FB), Carcinoma, Radiation therapy, Actinomycoses bacterial infection (rare), Rectal TB, STIs (chlamydia, lymphogranuloma venerum)
Anorectal abscesses are a result of what?
Infection (aerobic and anaerobic bacteria)
Obstruction of anal glands by thick debris triggers what?
Stasis and bacterial overgrowth (E. coli, Proteus mirabilis, S. aureus) –> Abscess formation–>abscesses may extend into perirectal spaces –> possible fistula formation
When do anal fistulas form?
When abscesses ruptures/drains and forms and epithelial tract between anorectal abscess and perianal skin or rectum
Extension of anal abscess/fistula infection can involve what areas?
Intersphincteric, ischiorectal, or even supralevator space
The _______ and _______ of abscesses can vary
Severity and depth
Major types of anorectal abscesses are based according to what?
Anatomical location
Major types of anorectal abscesses?
- Perianal (MC)
- Ischiorectal (ischioanal)
- Intersphincteric (in between internal/external sphincters)
- Supralevator
What are the 4 types of fistula tracts (Parks’s Classification)?
I. Intersphinctereric fistula (MC)
II. Transsphincteric fistula
III. Suprasphincteric fistula
IV. Extrasphincteric fistula
Clinical manifestations of perianal abscesses?
Throbbing, continuous pain around the anus, erythematous palpable mass near anus, rectal pain worse w/ sitting/coughing/defecation, +/- fever
Clinical manifestations of perirectal (deeper) abscesses?
Buttock or coccyx pain, fever/chills more likely, rectal pain worse w/ sitting/coughing/defecation
Physical external exam in perianal regions for anorectal abscesses may have what characteristics?
Localized tenderness, erythema/warmth, swelling, fluctuant mass, purulent discharge if abscess is draining
Physical exam of deeper anorectal abscesses may cause what?
DRE showing rectal fullness/palpable mass, Boggy area of tenderness/fluctuance, EUA if clinical exam cannot be performed in office
Clinical manifestations of anal fistulae?
Perianal/anal canal discharge (bloody, purulent, malodorous/smelly), painful defecation, anal itching/pruritus
Physical exam of anal fistulae may show what?
Perianal skin may be excoriated/inflamed, external opening may be visualized or palpated as indurated just below skin, external opening may be inflamed/tender/draining fluid, palpable cord leading from external opening to anal canal
What is a EUA?
Exam performed under anesthesia
What does EUA avoid?
Probing in the office
Process of EUA?
Injection of H2O2 or povidone iodine allowing for visualization of bubbles at internal opening of anal fistulas
EUA must be done for anal fistulas before what?
Any surgical intervention
Digital rectal exam for anal fistulas hold what purpose?
Check sphincter tone before surgical intervention (for both abscess & fistulae), internal opening may be palpated in some cases
Anoscopy for anal fisulas allows for viewing of what?
Internal opening in the anus (but EUA often necessary)
Proctosigmoidoscopy inspection can be used to inspect for what with anal fistulas?
Underlying disease processes, can view opening in the rectum
If the anorectal abscess is deep, and cannot be palpated, then what imaging can be used to confirm dx?
CT of pelvis, Endorectal US, MRI of pelvis
Preferred imaging for fistula tract and extent of anal sphincter involvement?
MRI of pelvis w/ and w/o contrast and endosonography
Other indications for MRI of pelvis w/ and w/o contrast and endosonography?
If primary opening hard to find, recurrent fistulas, complex fistulas, esp. if associated w perianal Crohn’s
What test can be used to determine other pathology (malignancy, IBD) related to anorectal abscess symptoms?
Colonoscopy
DDX for anorectal pain and perirectal skin lesions?
Hemorrhoids (thrombosed), anal fistulas, anal fissures, IBD, rectal prolapse, Acute proctitis (STDs), Anal abscesses, Hidradenitis suppurativa, infected inclusion cysts, pilodonal cyst, Bartholin gland abscess in females
Treatment of acute perianal abscess requires what?
Incision and drainage (I&D)
I&D for simple perianal abscesses?
May be treated in ED under local anesthesia
I&D for complex perianal abscesses?
By a surgeon in the OR under general anesthesia
Which perirectal abscesses should be referred to surgical service for I&D?
Ischiorectal, intersphincteric, supralevator
American Society of Colorectal Surgery guidelines suggest what for the role of abx for anorectal abscesses?
A course of empiric abx after I&D ONLY in patients with: Systemic infection/sepsis, Extensive perianal/perineal cellulitis, Diabetes, Immunosuppression, Heart valve abnormalities/prostheses
UpToDate suggestion for abx follwing I&D of anorectal abscesses?
Course of empiric abx for ALL patients after I&D (evidence that such may reduce rate of fistula formation)
What is Goodsall’s rule for surgical planning of anorectal fistulas?
-All fistula tracks w/ external openings within 3cm of anal verge and posterior to a line drawn through the ischial spines travel in a curvilinear fashion to the posterior midline
-All tracks w/ external openings anterior to this line enter the anal canal in a radial fashion
-line of demarcation is depicted as transverse anal line
Do fistula tracks longer than 3 cm from the anal verge necessarily follow Goodsall’s rule?
No, often have an internal opening in the posterior midline regardless of the location of the external opening
If Crohn disease of the perineum is present w/ multiple or complex fistulas, what tx is required?
Surgical tx + additional management with Abx & immunosuppressants
Surgical incision or excision of anal fistulae is indicated for which cases?
Symptomatic cases
Standard surgical treatment for symptomatic anal fistulae?
Fistulotomy/Fistulectomy
Other surgical interventions for symptomatic anal fistulae?
Seton placement, Fibrin glue injection, Fistula plug, Colostomy, Endorectal mucosal advancement flap, LIFT procedure
What is the postoperative WASH regimen post I&D or surgical procedure for anorectal fistulae/abscesses?
Warm water/cleansing sitz baths
Analgesics
Stool softeners
High fiber diet/bulking agents (bran, psyllium, metamucil)
What is a pilonidal cyst?
Abscess in the sacrococcygeal cleft associated w/ subsequent sinus tract development
Pilonidal cysts are uncommon in what ages?
Individuals under 40
Cause of pilonidal cysts?
Ingrown hair (one of the MC causes)
Risk factors for pilonidal cysts?
Male sex (4x more likely than females), Hirsute individuals, Obese individuals, Family hx
Signs and symptoms of pilonidal abscesses?
Painful/swollen fluctuant area ar sacrococcygeal cleft about 4-5 cm posterior to anal orifice, +/- loose hair projecting from site, +/- spontaneous purulent mucoid or bloody drainage, Afebrile
Treatment for pilonidal abscesses?
Surgery: I&D preferred, complete excision if recurrent/chronic
*possible abx if cellulitis is present
What is perianal pruritus?
Perianal itching and discomfort
Causes of perianal pruritus?
Poor anal hygiene, overzealous cleansing w/ soaps, topical irritants from soap/laundry detergent (contact derm), skin conditions (psoriasis, paget’s, liche sclerosis, atopic derm), Bacterial infection, Parasites (pinworms, scabies), Candidal infections (DM), STDs
Signs and symptoms of perianal pruritus?
Perianal itching, erythema, excoriations, lichenified eczematous skin
Tx for perianal pruritus?
-Diet: avoid spicy, chocolate, coffee, tomatoes
-Avoid perfumes
-After BMs: wash w/ unscented pre-moistened wipes or warm water w/o soap, pat gently
-Tuck a piece of cotton ball to anal opening to absorb perspiration/fecal seepage
-High potency topical corticosteroid
-Tx underlying cause
Definition of Hemorrhoids (piles)?
Engorgement of venous plexus in anal canal (swollen BV in anus and lower rectum)
How many people in the US affected by hemorrhoids?
10 million+
What gender is more likely to seek treatment for hemorrhoids?
Male
Which hemorrhoids occur more commonly occur in young and middle aged adults?
External hemorrhoids
Prevalence of hemorrhoids increases with what?
Age
Are hemorrhoids common in pregnancy?
Yes
Causes of hemorrhoids?
-Higher intra-abdominal pressure (pregnancy, ascites, portal HTN, obesity, heavy lifting)
-Constipation, straining, diarrhea, coughing
-Low fiber diet
-Alcoholism
-Anal sex/trauma
-Standing/sitting for prolonged time periods
-Aging
How does aging cause hemorrhoids?
Weakening of the support structures leads to prolapse
Where are internal hemorrhoids located?
Above the dentate (pectinate) line
Where are external hemorrhoids located?
Below the dentate (pectinate) line
Where do internal hemorrhoids originate?
Superior hemorrhoid plexus
Where do external hemorrhoids originate?
Inferior hemorrhoidal plexus
How do internal hemorrhoids develop?
Develop from endoderm, covered with columnar epithelium of anal mucosa
How do external hemorrhoids develop?
Develop from ectoderm, covered by squamous epithelium
What are mixed hemorrhoids?
Combined internal and external hemorrhoids
Internal hemorrhoids have how many main venous cushions?
3
Common positions of internal hemorrhoids (when patient is in lithotomy position)?
L lateral (3 o’clock), R anterior (11 o’clock), R posterior (7 o’clock)
Stage 1 of internal hemorrhoid prolapse?
Occasional bleeding only, no prolapse below dentate line, confined to anal canal
Stage 2 of internal hemorrhoid prolapse?
Prolapse out of anal canal with defecation but spontaneously reduces, bleeding, seepage
Stage 3 of internal hemorrhoid prolapse?
Prolapses but needs to be replaced manually, bleeding, seepage
Stage 4 of internal hemorrhoid prolapse?
Permanent prolapse that cannot be reduced, may strangulate
Signs and symptoms of internal hemorrhoids?
Usually painless unless extensive inflammation, intermittent bright red rectal bleeding w/ defecation (on TP, dripping in bowl, coating stool), rectul fullness/discomfort, pruritus ani (itch), mucus discharge
May prolapse into anal canal/cause pain w/ increased size
Signs and symptoms of external hemorrhoids?
Perianal pain aggravated by defecation, usually do not bleed, +/- tender palpable mass around anus, may have skin tags, Thrombosis (perianal hematoma) may develop/cause significant pain
What is a perianal hematoma?
Thrombosis of the external hemorrhoidal plexus (contains blood clot)
What is a perianal hematoma precipitated by?
Coughing, heavy lifting, straining
Onset of perianal hematoma?
Acute onset w/ severe pain
*pain most severe w/in first few hours and subsides over 2-3 days
Perianal hematoma examination?
Palpable, tender, dark red to purple nodule at anal verge/just within anal canal
Perianal hematoma may leave what?
Skin tags
Visual inspection for dx of hemorrhoids?
Left lateral decubitus w/ patient’s knee flexed toward chest
-examine entire perianal area, gently spread buttocks for easy visualization
DRE for dx of hemorrhoids?
Checks for induration/ulcerated areas, masses, tenderness, discharge, rectal tone
Are internal hemorrhoids usually palpable on DRE?
Not usually palpable (unless dilitated/enlarged), soft vascular structures
Anoscopy is useful for examining which type of hemorrhoid?
Internal
Proctosigmoidoscopy or colonoscopy for hemmorrhoids is indicated for what?
Evaluate for any bright red bleeding, inconclusive initial eval, concern for malignancy
DDX for hemorrhoids?
Anorectal fistula, Anorectal fissures, Rectal abscess, Colorectal cancer/neoplasm, Anal warts, Rectal prolapse, Rectal polyps, IBD (UC & Crohns)
Lifestyle modifications recommended for all patients with hemorrhoids?
Dietary and education on defecation habits to reduce strain
-High fiber, avoid fatty foods, inc. fluid intake, regular physical activity, avoid excessive strain, limit time spent on toilet
Conservative treatment for hemorrhoids (initial management)?
Sitz baths, Stool softeners (ex. docusate) or laxatives (ex. Miralax) prn, topical creams/ointments/foams (topical anesthetics: lidocaine, steroids: hydrocortisone)
When are non-surgical procedures indicated for hemorrhoids?
Stage 1-3 internal hemorrhoids unresponsive to conservative tx
Non-surgical procedures for stage 1-3 internal hemorrhoids unresponsive to conservative tx?
Injection sclerotherapy, infrared coagulation, rubber band ligation*
When is surgery indicated for hemorrhoids?
Stage 4 hemorrhoids with chronic bleeding, thrombosis, strangulation, gangrene, and those unresponsive to medical and conservative tx
Surgicial options for stage 4 internal hemorrhoids?
Hemorrhoidectomy (open/closed), Stapled hemorrhoidectomy
Treatment for external hemorrhoids?
Conservative tx
If symptomatic and refractory to conservative tx: refer to surgery
Treatment for thrombosed external hemorrhoids?
-Excision within 48-72 hours of sx onset
-Delayed presentation (>72 hours): conservative management
Conservative management for thrombosed external hemorrhoids?
-Analgesia: warm sitz baths, antispasmodic agents (topical nitroglycerin, nifedipine), analgesic creams (lidocaine)
-Topical anti-inflammatories: Hydrocortisone cream
-Improve passage of stool w/ stool softeners (docusate), increased fluid/fiber intake
Definition of rectal prolapse?
Medical condition where walls of rectum have lost their attachments and protrude through anus/become visible outside the body
3 types of rectal prolapse?
Full thickness **MC, Mucosal prolapse/partial prolapse, Internal prolapse (internal intussusception)
What is a full thickness rectal prolapse?
Entire rectum (all layers) protrude through anus manifesting as concentric rings/folds of rectal mucosa **MC type
What is a mucosal prolapse/partial prolapse?
Only the rectal mucosa (not entire wall) prolapses, radial folds in the mucosa
What is an internal prolapse (internal intussusception)?
Rectal wall collapses but does not exit the anus, “telescoping” of the bowel on itself internally
Are rectal prolapses common?
No
80-90% of rectal prolapses happen in which gender?
Female
Peaks of rectal prolapse happens in which decades of life?
4th and 7th decades
Causes of rectal prolapse?
Weakness of pelvis floor muscles and ligaments that hold the rectum in place
Causes of weakness in pelvic floor leading to rectal prolapse?
Age >40, chronic straining/constipation/diarrhea, pregnancy (muliparous), vaginal delivery, previous pelvic surgery, cytsic fibrosis (kids), COPD/chronic cough, anal sex, neurolgic disorders (dementia, stroke), pelvid floor defects (rectocele, cytocele)
Signs and symptoms of rectal prolapse?
Painless mass protruding through anus, pain not a typical presenting feature (suggests another dx), +/- rectal bleeding, possible associated uterine/bladder prolapse or cystocele, possible constipation/diarrhea/fecal incontinence
Rectal prolapse progression characteristics?
Initially produces after BM (usually retracts w/ standing), as dz progresses: mass protrudes more often (w/ straining, valsalva, sneezing, coughing), Eventually will prolapse with daily activities (walking) and does not retract (must be manually replaced), May progress even further to continuous prolapse immediately after manual replacement
Examination of peritoneum for rectal prolapse exam?
Should be examined w/ pt squatting or straining
Physical signs of rectal prolapse include what?
Protruding rectal mucosa, thick concentric mucosal ring in complete prolapse (stacked coin appearance), radial mucosal folds in mucosal prolapse, Sulcus (groove) between walls of anal canal & rectum (emerging mass), possible solitary rectal ulcer on prolapse, dec. anal sphincter tone w/ DRE
DDX for rectal prolapse?
Hemorrhoids, intussusception, proctitis
Rectal prolapse is primarily what kind of dx?
Clinical
What can be used to differentiate between full thickness & mucosal rectal prolapse when dx is unclear from exam alone?
Video defecography
What should be performed with anal prolapse before any surgical therapy to rule out malignancy?
Colonoscopy or proctoscopy
What test should be done for rectal prolapse if fecal incontinence is present?
Anal-rectal manometry to assess sphincter function
What test should be done for rectal prolapse if rectal ulcer is present?
Biopsy
What test should be done for rectal prolapse if pelvic floor weakness is present?
Dynamic pelvic floor MRI
What test should be done for rectal prolapse present in children to rule out cystic fibrosis?
Sweat chloride test
A prolapsed rectum can be reduced with what?
Gentle digital pressure
Tx of rectal prolapse in adults?
Surgery
Maneuvers to help reduce prolapse include what?
Sedation, field block w/ local anesthetic, reduction of edema by applying sugar or salt, reduction and confirmation w/ DRE, covering perineum with tight pad to prevent recurrence
Tx of rectal prolapse in children?
Nonsurgical tx by managing underlying condition and performing manual reduction if spontaneous reduction does not occur
Tx for rectal prolapse in patients w/ comorbidites that preclude sugery or patients that refuse surgery?
Medical management: adequate fluid intake, high fiber food/supplements, enemas or suppositories for constipation if present, biofeedback or pelvic floor exercises (kegels) to alleviate sx
Fecal incontinence includes involuntary loss of what?
Solid or liquid stool, gas
What is true anal incontinence?
Loss of anal sphincter control leading to inability to control passage of stool or gas (flatus)
What is fecal urge incontinence?
Incontinence that occurs despite awareness and active effort to retain stool suggesting sphincteric damage
Causes of sphincteral damage in fecal urge incontinence?
Childbirth, rectal prolapse, prior pelvic radiation, episiotomy, prior anal surgery, physical trauma
What is passive fecal incontinence?
Incontinence that occurs without awareness from loss of central awareness or peripheral nerve injury
Loss of central awareness causes for passive fecal incontinence?
Dementia, CVA, MS
Peripheral nerve injury causes for passive fecal incontinence?
Spinal cord injury, Cauda equine syndrome, pudenal nerve injury, aging, diabetes
Important history inquiry for fecal incontinence?
Surgical and obstetric hx, hx of Dm or neurologic dz, hx of hemorrhoids or rectal prolapse
Clinical features of fecal incontinence?
Chronic or recurring fecal leakage with possible flatus, abdominal discomfort, bloating
Physical exam for fecal incontinence?
Abdominal exam for masses, perianal inspection for hemorrhoids/prolapse/fistulae/fissures, Check anocutaneous “Wink” reflex is intact, DRE for rectal masses and rectal tone, anoscopy for eval of possible hemorrhoids/fissures/fistulas
Lab studies for fecal incontinence?
Stool tests, endoscopy, anorectal manometry, balloon expulsion test, other studies if indicated
When are stool studies indicated for fecal incontinence?
pts with diarrhea to assess for underlying pathogen
What type of endoscopy is indicated for fecal incontinence in pts </=40 and w/ average risk for colon cancer?
flexible sigmoidoscopy to exclude mucosal inflammation/masses
What type of endoscopy is indicated for fecal incontinence in pts >40 w/ persistent or chronic diarrhea or risk for colon cancer or IBD?
Colonoscopy
1st diagnostic test for fecal incontinence to assess for functional sphincter weakness?
Anorectal manometry
What test is performed to diagnose refractory cases of fecal incontinence?
Balloon expulsion test
Possible Barium or MRI defecography
What test is performed if structural abnormalities of anal sphincters are present in fecal incontinence?
Endorectal US or MR imaging
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