Anorectal Disorders - GI Flashcards
Anal fissures
- Tears or ulcers in the skin of the distal anal canal
- Tears – hard stool, loose stool: Constipation – opioid use
- New Theory: Ulcers – ischemia from internal anal sphincter spasm, skin break down
Anal fissures - Dx
History
-Pain with defecation
-Hematochezia – not mixed in - on toilet paper
Physical
-GENTLE rectal exam - very painful
-90% on posterior midline, rest on anterior
-If on lateral edges, consider alternate reason: Crohn’s, CA, HIV
-Paper cut looking
-Slightly indurated edges signify chronic fissures
Anal fissures - test/tx
-Tests: More thorough digital rectal exams/imaging only warranted if initial treatment fails, or if there are other red flags
Treatment
-Treat constipation: High fiber, increased fluids, stool softeners
-Treat pain: Sitz baths, Topical analgesic (Nitroglycerin intra-anal (0.2-0.4%) apply bid x 6 weeks prn, Side effect: HA 2/2 vasodilation, consider topical CCB)
Treat chronic fissures
-OnabotulinumtoxinA – use by specialist
-Surgical sphincterectomy – side effects
Anorectal abscesses
- Infection of the soft tissue around anus
- 2/2 infected anal glands
- Anal glands normally drain into the anal crypts
- Crypts blocked by food matter, edema, inflammation
- Strong association with anal fistulas (37%)
Anorectal abscesses - Diagnosis
- History of fistulas, Crohn’s
- Anal/perianal pain - worsening - very bad pain
- Swelling/redness/growth/mass
- Fever: if gone on for a long time, mild tachycardia - severe
- If abscess occurs above the anal ring – may mimic pelvic/intra-abdominal pain
- Extreme tenderness with digital rectal exam, may need anesthesia
- Induration (hardened area) within 3 cm of anus
Tests
- WBC – leukocytosis
- If recurrent, or patient is immune compromised, consider cx (culture)
- CT or MRI if unsure of diagnosis
Anorectal abscesses - Tx
- Incision and drainage: In OR or procedure room is best, Dependant on position, can drain to outside, or into anal canal
- If recurrent, refer to GI: Crohn’s, fistula
Antibiotics
- Diabetic, Elderly, Immunocompromised, Concomitant cellulitis
- Ampicillin/Sulbactam (Unasyn) 1 g PO/IV qid and -Metronidazole (Flagyl) 500 mg PO/IV qid
Follow-up/Complications
- Incomplete drainage
- Necrotizing infection
- Sepsis
- Recurrent abscess – look for other causes
Anal fistulas
- Results of chronic anal abscess
- Epithelialized track forms to connect abscess to perirectal skin
- Less common causes: Crohn’s disease, Lymphogranuloma venereum (chlamydia), radiation proctitis, rectal foreign bodies, actinomycosis
Anal fistulas - Dx
- History of non-healing abscess
- Drainage from rectum – purulent, malodorous
- Pain with defecation, sitting
- Pustule like lesion
- Perianal skin – excoriated, inflamed
- Possibly see external opening – inflamed, tender, fluid
- Fistula probe – experienced clinician
Tests
- Imaging: Ultrasound, CT, MRI
- Anoscope, sigmoidoscope
Anal fistulas - tx
Surgical
- If I&D of abscess ineffective 6-12 wks later, surgery indicated
- Dependent on type of fistula - classification
- Goals: Retain continence, Remove fistula, Close track or keep it open, Prevent recurrence
- Fistulotomy, fibrin sealant, setons
hemorrhoids
- Hemorrhoidal cushions are vascular beds within the anal canal
- When the cushions dilate and engorge, they can cause symptoms and are classified as hemorrhoidal disease
- Classified by the location in relation to the dentate line
- External – below the dentate line
- Internal – above the dentate line
hemorrhoids - dx
- BRBPR - bright red blood per rectum
- Blood following bowel movement, on tissue or in toilet bowl
- Feeling of incomplete evacuation
- History of constipation, straining, or increased intra-abdominal pressure (wt. lifters, obesity, pregnancy): often lead to hemrrhoids
- Internal hemorrhoid – painless, no mass felt
- External hemorrhoid - painful bowel movements, mass protruding from anus
Tests
- Hemoccult – if no blood seen
- CBC – if suspicious of anemia
- Endoscope – r/o more serious condition if other red flags
hemorrhoids - tx
- Treat symptoms
- Mild bleeding: Increase fluids and fiber, Topical steroids to treat pruritis and pain (Hydrocortisone rectal 2.5%, apply bid x 5-7d MAX)
Internal Hemorrhoids
-Rubber band ligation, infared photocoagulation, sclerotherapy, arterial ligation, stapled hemorrhoidopexy
External Hemorrhoids
- Surgical excision
- “De-roofing” thrombosed hemorrhoids can be done in office
Rectal prolapse (procidentia)
Complete prolapse
-Protrusion of all the layers of the rectum through the anus
Partial prolapse
-Protrusion of mucosal layer only
Risk Factors
-Female, > 40 y.o., multiparous, vaginal delivery, prior pelvic surgery, chronic straining, diarrhea or constipation; CF, dementia, stroke, pelvic floor defects (-cele), pelvic floor dysfunction
Rectal prolapse - dx
-Incomplete evacuation
-Rectal mass
-Abdominal discomfort – rectal pain is Uncommon
-History of risk factors
-Prolapse may by intermittent – squatting helps
-Decreased sphincter tone
-Check for concomitant pelvic floor disorder
Tests
-Unnecessary - clinical
Rectal prolapse - tx
Medical Management
- Fluids – 1-2 L per day
- Fiber – incr dietary intake, supplement to 25-30 g/day
- Enemas and suppositories to treat constipation
- Last resort – taping a pad against buttock
Surgical
- Only attempt for cure
- Intra-abdominal approach
- Rectopexy – “unstraighten” the rectum, move rectum posteriorly and attach it to sacral promontory
- Can be with or w/o sigmoid resection if redundant sigmoid tissue
Perineal Approach
- If intra-abdominal not tolerated
- Or young men – spares hypogastric nerves, no ED
- Rectosigmoidectomy
- Delorme procedure
- Both involve removal of the redundant sigmoid and anastomosing remaining sigmoid to rectum
Recurrence
- Up to 27% with intra-abdominal and 38% with -perineal approaches
- Incontinence
- Constipation
Anal cancer
- Classifications based on type of mucosa lining the anus
- Glandular – Adenocarcinomas, rare, treated as rectal adenocarcinomas
- Transitional and Squamous – Squamous cell carcinomas
- Above pectinate line: nonkeratinizing SCC
- Below: keratinizing SCC
- Perianal skin cancers – treated as skin cancers
- Rare: 6,230 cases anually
- Risk factors: HPV, Receptive anal intercourse, HIV, Smoking
Anal cancer - Dx
History
- Hx of risk factors
- Anal condyloma
- Mostly asymptomatic: 20%
- Anal pain, bleeding, discharge, rectal mass
Physical
- Skin discolorations
- Mass: wart like on external skin, firm on DRE
- Enlarged lymph nodes in groin (may be presenting sx)
- If there is blood (frank or occult), and you don’t see a hemorrhoid, don’t assume it is one
Tests
- Biopsy of mass
- CT chest, abdomen, pelvis
- Consider PET scan for other active sites
- Pap smear and thorough pelvic for women
Anal cancer - Tx
- Anal cancer: Radiation and chemotherapy (5-FU and mitomycin)
- Adenocarcinomas – APR, adjuncts of RT and chemo
- Perianal skin cancers – local excision, +/- LN bx
Follow-up/Complications
- For persistent or recurrent CA, consider surgery
- APR – abdominoperineal resection: Removes rectum and anus, Requires use of colostomy bag
- Follow-up: Re-examine every 3-6 months
