Anorectal Lecture Flashcards
Do you feel pain above or below the dentate line?
BELOW!
(no pain felt above the dentate line)
Divides the rectal mucosa above from the squamous epithelium below
Divides the:
Nervous system*
Vascular supply
Lymphatic drainage
Dentate line
insensate- anorectal mucoa
sensate- anoderm
..which one is above and which one is below the dentate line?
Insensate (anorectal)= ABOVE
Sensate (anoderm)= BELOW..*pain*
Which anal sphincter….
smooth muscle, involuntary
Internal
Which anal sphincter…
skeletal muscle (voluntary)
External
Squamous epithelium
Anoderm
Sensate
PAIN*
Below the dentate line
Tear in the anoderm
90% are posterior
Causes: hard stool or prolonged diarrhea
Sx: “tearing” pain with BM
hematochezia (blood on TP)
pain usually subsides between BMs
Anal fissure
MC cause of painful rectal bleeding
Anal fissure
Should you do a rectal exam if pt has anal fissure?
NO
Bulk agents
Stool softners
Sitz baths
Hydrocortisone containing ointments
Medical tx for anal fissures
(90% heal with medical tx)
If medical tx fails,
what is the gold standard surgery for anal fissures?
Lateral internal anal sphincterotomy
Location of most anorectal abscesses
Posterior rectal wall
Anal crypts with gland obstruction is the origin for…
Anorectal abscesses
S. Aureus
Bacteroides
Proteus
Strep
..all cause?
Infection of anal ducts and glands..leading to anorectal abscesses
MC anorectal abscess
Perianal abscess
These start from the anal crypts and can spread…..
- superficially to external sphincter, resulting in perianal abscess* (MC!)
- deep thru external sphincter into fat of ischiorectal fossa
- deep into supralevator space
- intersphincteric
Anal abscess
Severe pain!
worse with.. sitting, coughing, defecating
PE: palpable fuctuant mass
VERY painful DRE
Anal abscess
Tx= surgical drainage
postop Sitz bath
50% cured with just drainage
50% develop fistula
Anal abscess
Chronic cryptoglandular abscess
abnormal communication between 2 epithelium lined surfaces
*has an external oepning in perirectal skin and an internal opening in anal canal
*originates in infected crypt and tracks externally to site of previous drainage
Fistula
Used as a guide to determine location of internal opening
Goodsall’s Rule
Fistulas with an external opening anteriorly
…will track internally via a ______ line
straight
Fistulas with an external opening posteriorly
…will track internally via a _______ line
curved
Persistent drainage
Usually painless but can have itching
tx= fistulotomy, tract left open to heal by secondary intention
(MUST preserve sphincter muscle)
Fistulas
External venous tissue
50% of ppl over 50 have
MC anorectal problem in adults >50
Hemorrhoids
Anal canal is lined by these “cushions” that consist of vascular and connective tissue
3 columns: R anterolateral, L lateral, R posterolateral
*these cushions engorge during defecation to protect anal canal from abrasions
Hemorrhoid plexus
Caused by:
Hard stool
Excessive straining
Pregnancy
Increased intraabdominal pressure
(leading to increased venous engorgement)
Hemorrhoids
These hemorrhoids are painless! bc they are above the dentate line
Bleed
May prolpase, are palpable on DRE
*painless bright red blood with defecation
MC cause of rectal bleeding
Internal hemorrhoids
These hemorrhoids are painful! bc they are below the dentate line
Covered with anoderm
Usually dont bleed
May thrombose, VERY painful!
Pain and discomfort, esp at time of defecation
External hemorrhoids
Which type of polyp is the most rare of the adenomas but has the highest risk of cancer, with 40%
Villous adenomas
MC type of polyp but only has a 5% risk of cancer
Tubular adenoma
1st and 2nd degree hemorrhoids
1st degree= bleed
2nd degree= bleed and prolapse
spontaneously reduce*
Which degree internal hemorrhoid…
Bleed and prolapse, require manual reduction
3rd degree
Which degree internal hemorrhoid:
automatic referall
bleed/incarcerate
4th degree
Fiber, water, stool softner, avoid straining
Cortisone to shrink (Anusol HC)
Nupercainal ointment numbing agent
Tx for 1st and 2nd degree internal hemorrhoids
Tx= surgical!
Excisional hemorrhoidectomy
tx for 3rd and 4th degree hemorrhoids
What is the grading of external hemorrhoids?
There are none!
Acutely thrombosed hemorrhoids are excised outside mucocutanous junction usually within how many hours?
24-48
Midline post- sacral intergluteal fold superior to anus
clinically identified by opening of sinus tract that may contain a tuft of hair
MC men 20-30 (almost always under 40!!)
Pilonidal cyst
Usually asymptomatic but can develop abscess formation and drainage
Sx: like perianal abscess but different spot
PE: fluctuant mass with erythematous “halo”
purulent D/C
Pain at gluteal cleft
Pilonidal cyst
Tx for Pilonidal cyst?
Surgery with secondary closure
Sudden watery diarrhea after pt has had chronic constipation
Fecal impaction
