Anorectal Disorders

Question 1

anorectal anatomy

Answer 1

*internal sphincter
*external sphincter
*perianal spaces

Question 2

perianal spaces

Answer 2

*intersphincteric space
*perianal space
*ischioanal space
*supralevator space

Question 3

anal suppurative diseases - etiology

Answer 3

*obstruction, then infection of anal glands (cryptoglandular)
*process invades structures external to anal canal
*extent of invasion dictates site of abscess

Question 4

anal suppurative disease - perianal abscess

Answer 4

*invasion into intersphincteric plane, then down to skin
*presents at anal verge

Question 5

anal suppurative disease - ischioanal abscess

Answer 5

*invasion through sphincter into ischioanal fossa
*presents further from anal verge
*deeper
*aka perirectal abscess (inaccurate)

Question 6

anal suppurative disease - supralevator abscess

Answer 6

*invasion upward above sphincter
*no obvious outward presentation

Question 7

anal suppurative disease - intersphincteric abscess

Answer 7

*invasion just into intersphincteric groove
*pain in anal canal, no outward presentation

Question 8

ED management of perianal abscess

Answer 8

*easily drained in ambulatory setting
*wick for few days
*follow-up within few days
*education

Question 9

fistula en ano

Answer 9

*a connection from the outside to the inside that results after/was created by an abscess but persists due to epithelialization of the tract

Question 10

hemorrhoids

Answer 10

*submucosal arteriovenous connection
*normal “vascular cushion” in all humans (we all have them)

*when pathologic:
-bleed (arterial in nature)
-prolapse
-cause pain only if ACUTELY THROMBOSED

Question 11

treatment algorithm for hemorrhoids

Answer 11

*1st degree: stool bulking, occasionally banding
*2nd degree: stool bulking, banding (also sclerotherapy, laser, cryo, infrared photocoagulation)
*3rd and 4th degree: operative hemorrhoidectomy

Question 12

thrombosed external hemorrhoid

Answer 12

*ED emergency
*excision, not incision, is best therapy:
-most effective if done in first 48-72 hrs
-less persistent pain, bleeding
-more complete resolution of tag

Question 13

acute fissures

Answer 13

*simple linear ulcer
*granulation base
*like a split or tear in the anus

Question 14

chronic fissures

Answer 14

*thickened, rolled edges
*exposed internal sphincter
*sentinel tag and/or hypertrophied papilla

Question 15

etiology of anal fissures

Answer 15

*increased pressure in the anal canal leads to less delivery of blood to the posterior & anterior aspects of the anus
*overall increased tone may lead to ischemia

Question 16

pharmacologic therapy for anal fissures

Answer 16

*nitric oxide
*botox injections
*surgical = lateral internal sphincterotomy

Question 17

anal cancer - 2 classifications by location

Answer 17

1. anal margin: perianal skin cancer
   -treatment similar to other body locations (i.e. excision)
2. anal canal: above anal verge, up to anorectal ring
   -tx: combined chemo/radiation
   -surgery reserved for failures of above

Question 18

epidemiology of anal cancer

Answer 18

*relative risk for HIV infected persons is extremely higher risk
*older female & younger male prevalence
*risk factors: HPV, hx of anoreceptive intercourse, hx of STD, > 10 sexual partners, hx of cervical, vaginal, vulvar cancer, immunosuppression after transplantation

Question 19

condyloma acuminata

Answer 19

*HPV-related
*warty growths
*can be external, internal, or both
*more common in AIDS patients/immunosuppressed individuals