Anorectal Disorders Flashcards
vascular structures that aid in continence by preventing damage to the sphincter muscle during defecation
hemorrhoidal cushions
what leads to prolapse of vascular tissue into the anal canal?
engorgement and straining
when a blood clot forms in a portion of the hemorrhoid that is not dangerous, but is painful
thrombosed hemorrhoid
hemorrhoid that originates proximal to the dentate line
internal hemorrhoid
what type of hemorrhoids are the majority?
internal hemorrhoids
why is it important to grade internal hemorrhoids?
to determine treatment
grade the internal hemorrhoid: patient presents with painless bleeding. Physical exam shows vascular engorgement bulging into the anal canal without prolapse.
grade 1
grade the internal hemorrhoid: patient presents with painless bleeding with perianal itching. Physical exam shows hemorrhoidal prolapse with straining that reduces spontaneously
grade 2
grade the internal hemorrhoid: patient presents with painless bleeding, perianal itching, and swelling/straining/soilage with mucus and feces. Physical exam shows hemorrhoid prolapses beyond the dentate line with straining and is only reducible by manual pressure
grade 3
grade the internal hemorrhoid: patient presents with pain, bleeding, swelling, soilage, with mucus and feces. Physical exam shows grossly evident prolapse of hemorrhoidal tissue that is non-reducible and chronic inflammatory changes (mucosal atrophy, friability, maceration, and ulceration)
grade 4
hemorrhoid that originates distal to the dentate line
external hemorrhoid
what is the difference in symptoms between internal and external hemorrhoids?
internal hemorrhoids are normally painless
external hemorrhoids are painful when thrombosed
hemorrhoids can exist asymptomatically, but become symptomatic when they are _____ and _____
distended
engorged
rectal bleeding can be caused by: (2)
external, thrombosed hemorrhoids
grade 4 internal hemorrhoids
why can hemorrhoids be reported as “lumps” or “masses”?
with time, internal hemorrhoids protrude further and become irreducible
a patient presents with a bluish perianal nodule, which is erythematous, firm, and tender to touch when thrombosed and inflamed. Dx?
external hemorrhoid
what can help visualize an internal hemorrhoid? (2)
anoscopy
gentle straining
when does an internal hemorrhoid become palpable on digital rectal exam? (2)
prolapsed
thrombosed
what is the conservative treatment for grade 1 and 2 internal hemorrhoids? (2)
increased fiber + fluids
limit straining + lingering
what is the conservative treatment for external hemorrhoids? (3)
warm sitz bath, analgesics, ointment
prep H
Tucks
Anusol
resolves over 2-3 days
what is the preferred medical treatment for grade 1-3 internal hemorrhoids that have recurrent bleeding despite conservative treatment?
rubber band ligation
what is the medical treatment for edematous, painful stage 4 internal hemorrhoids? (2)
acutely: prep H, tucks, anusol
ligated later
what is the treatment for chronic severe bleeding in grade 3-4 internal hemorrhoid or acute thrombosed grade 4 internal hemorrhoid with necrosis?
surgical hemorrhoidectomy
what is the treatment for an acutely thrombosed external hemorrhoid?
thrombectomy + elliptical incision + clot removal within first 24-48 hours
linear or triangular tears/ulcers that are around 5mm in length
anal fissures
what is the most common cause of anal fissures?
trauma to the anal canal during defecation
where do anal fissures most commonly occur?
in midline
what should we worry about when anal fissures do not occur midline?
crohn disease
a patient presents with severe, sharp, tearing pain that is worse during BM +/- blood in stool or on toilet paper. There are cracks visible in epithelium of sphincter. Dx?
anal fissures
what can chronic anal fissures lead to?
skin tags at outer edge
what 2 diagnostics can cause severe pain and may be deferred if a patient has anal fissures?
anoscopy
DRE
what is the conservative treatment for anal fissures? (3)
increase fiber
sitz baths = reduce pain with BM
topical anesthetics = relief prior to BM
what is the prognosis of anal fissures with conservative treatment?
healing within 2 months in 45% of patients
what are treatment options for anal fissures that do not respond to conservative treatment? (3)
topical nitroglycerine OR diltiazem
botox injection
internal lateral sphincterotomy
present around the rectum and helps protect muscles and nerves
anal crypt glands
inflammation and infection with accumulation of purulent material near the anus
anorectal abscess
what typically causes anorectal abscesses?
infection of anal crypt gland after obstruction
abscesses have the chance of becoming ____ _____
chronic fistulas
a patient presents with local swelling around the anus and has severe constant pain that is worse with sitting or having a BM. Dx?
anorectal abscess
what diagnostic is required if a patient may have an anorectal abscess?
digital rectal exam
what kind of abscess requires an experienced surgeon?
any abscess that involves tissue under the sphincter
what imaging should be ordered for suspected anorectal abscess?
CT scan w/ contrast
what will be seen in labs if a patient has an anorectal abscess?
elevated WBCs
what are the 3 possible outcomes of an anorectal abscess?
spontaneously drain + heal
spontaneously drain + form permanent fistula to skin
remain undrained + lead to sepsis with high M+M
what is the treatment for an anorectal abscess?
surgical drainage + culture
antibiotics: augmentin OR ciprofloxacin + metronidazole
what is the post-op care for anorectal abscess? (4)
regular diet
fiber + stool softener
sitz bath
f/u in 2-4 weeks
what are 4 risk factors for necrotizing anorectal infections?
delay in dx of abscess
virulence of pathogen
metastatic infection
previous abscesses
a persistent epithelialized track that connects an abscess with the perirectal skin on the outside skin of buttocks
anorectal fistula
what is the most common cause of anorectal fistulas?
anal abscess
a patient presents with erythematous, inflamed perianal skin, tenderness, drainage/bleeding. pn physical exam, an indurated cord is felt in soft tissue. Dx?
anorectal fistula
what 2 diagnostics can be used by an experience provider to explore the fistula track?
anoscopy or sigmoidoscopy
how is the diagnosis of anorectal fistula made?
H&P
what 2 diagnostics should be performed if a patient has IBD or recurrent anorectal fistulas?
colonoscopy + barium enema
what diagnostic can help with the treatment of anorectal fistulas and diagnose recurrent disease?
CT or MRI w/ contrast
what is the mainstay of treatment for anorectal fistulas?
surgery
