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Clin Med II - GI > Anorectum Dettmann > Flashcards

Anorectum Dettmann Flashcards

1
Q

What is one of the MC causes of anal pain?

A

Anal fissure

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2
Q

Describe anal fissures (shape, length, location)

A
  • Linear or rocket shaped ulcers
  • Usually less than 5 mm in length
  • Located MC in posterior midline
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3
Q

What types of anal fissures are cause for suspicion?

A

Anal fissures off the midline

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4
Q

What should anal fissures off the midline raise suspicion for?

A
  • UC
  • Crohn’s
  • HIV/AIDS
  • TB
  • Syphilis
  • Anal carcinoma
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5
Q

Causes of anal fissures

A
  • Trauma
  • Defecation (straining, C/D, high sphincter tone)
  • Tear in anal lining
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6
Q

What is the MC cause of anal fissure?

A

Trauma

MC from defecation

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7
Q

Symptoms of anal fissures

A
  • Pain (can be mod or severe)
  • Tearing/throbbing (esp during defecation/after)
  • Hematochezia +/-
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8
Q

Signs of anal fissures

A
  • Visually confirmed
  • Acute: looks like “cracks” in epithelium
  • Chronic: fibrosis and development of skin tags at outer most edge (sentinel pile)
  • Digital and anoscopic exams may be painful to perform
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9
Q

What do acute anal fissures look like?

A

“Cracks” in epithelium

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10
Q

What do chronic anal fissures look like?

A

Fibrosis and development of skin tags at outer most edge (aka sentinel pile)

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11
Q

Treatment of anal fissures

A
  • Promote effortless painless BMs (fiber/bulk agents, stool softeners)
  • Sitz baths
  • Topical anesthetics
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12
Q

Treatment of chronic anal fissures

A
  • Topical nitro or dilt ointment
  • Botox (2-3 mos of sphincter relaxation)
  • Surgery (lateral internal sphincterotomy)
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13
Q

How are anal fissures successfully healed?

A

Conservative tx (80% heal this way)

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14
Q

Do anal fissures recur?

A

Yes in about 40% pts

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15
Q

What is a complication of surgical tx of anal fissures?

A

Minor incontinence

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16
Q

Define anal fistula

A
  • Hollow tract, primary opening inside anal canal
  • Leads to a secondary opening in perianal skin
  • Lined w/granulation tissue
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17
Q

MC cause of anal fistulas

A

Anorectal or perianal abscess

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18
Q

What does a DRE show with anal fistula?

A
  • Spontaneous or expressible discharge
  • Fibrous tract or cord beneath skin
  • Check sphincter tone before surgery
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19
Q

What does a lateral or posterior induration on DRE suggest?

A

Deep post-anal or ischiorectal extension of anal fistula

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20
Q

Medical treatments of anal fistulas

A
  • Sitz baths
  • Analgesics
  • Stool bulking agents
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21
Q

Surgical treatments of anal fistulas

A
  • Fistulotomy/fistulectomy
  • Seton placement
  • Silver nitrate in office
  • Fistula plug
  • Fibrin glue injection
  • Colostomy
  • Endorectal mucosal advancement flap/LIFT
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22
Q

Complications of anal fistulas

A
  • Bleeding
  • Fecal impaction
  • Thrombosed hemorrhoids
  • Recurrence
  • Incontinence
  • Anal stenosis
  • Delayed wound healing
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23
Q

How long does post-surgical healing take for anal fistulas?

A

At least 6-12 weeks

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24
Q

What are the rates of recurrence and incontinence following standard fistulotomy?

A
  • 0-20% recurrence

- Less than 10% incontinence

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25
Q

What are the rates of recurrence and incontinence following Seton use tx of anal fistulas?

A
  • 0-20% recurrence

- Less than 10% incontinence

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26
Q

What are the rates of recurrence and incontinence following mucosal advancement flap tx of anal fistulas?

A
  • 1-10% recurrence

- Less than 10% incontinence

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27
Q

What are the different types of hemorrhoids?

A
  • Internal
  • External
  • Thrombosed
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28
Q

What is the peak age of hemorrhoids?

A

45-65 yo

29
Q

What particular condition increases incidence of hemorrhoids?

A

Pregnancy

30
Q

Describe hemorrhoids

A
  • Normal anatomical structures
  • Ensure water tight seal
  • Help maintain normal anal pressure
31
Q

Describe internal hemorrhoids (what? where do they originate? do they cause pain?)

A
  • Subepithelial vascular cushions b/w superior rectal artery and vein
  • Originate ABOVE dentate line
  • Rarely cause pain
32
Q

Describe external hemorrhoids (what? where do they originate? do they cause pain?)

A
  • Arise from inferior hemorrhoidal veins
  • Originate BELOW dentate line
  • Cause swelling, pain, hygiene issues
33
Q

Where do external and internal hemorrhoids occur?

A
  • Right anterior
  • Right posterior
  • Left lateral
34
Q

When do hemorrhoids become symptomatic?

A
  • Activities that increase venous pressure

- Distension occurs leading to engorgement

35
Q

Causes of hemorrhoids

A
  • Low fiber diet
  • Pregnancy
  • Obesity
  • Abnormally high tension of internal sphincter muscle
  • Prolonged sitting on toilet
  • Aging
  • Diarrhea
36
Q

Symptoms of hemorrhoids

A
  • BRBPR
  • Prolapse
  • Mucoid discharge
37
Q

Stages of internal hemorrhoids

A

1: Confined to anal canal (bleeding, no prolapse)
2: Protrude from anal opening (bleeding, mild prolapse w/spontaneous reduction)
3: Prolapsed (requires manual reduction s/p BM)
4: Chronically prolapsed (strangulated)

38
Q

What may allow visibility of internal hemorrhoids on PE?

A

Gentle straining

39
Q

What do prolapsed internal hemorrhoids look like?

A

Protuberant purple nodules covered with mucosa

40
Q

What is the best way to visualize internal hemorrhoids?

A

Anoscopic evaluation

41
Q

Conservative treatment of Stage 1 and 2 hemorrhoids

A
  • High fiber diet
  • Increased fluid intake
  • Fiber supplement
  • Manual reduction w/suppository
42
Q

Medical treatment of Stages 1, 2, 3 hemorrhoids?

A
  • Injection sclerotherapy
  • Rubber band ligation
  • Electrocoagulation
43
Q

What are the complications of electrocoagulation?

A
  • Pelvic sepsis, abscess
  • Urinary retention
  • Bleeding
44
Q

What stages of hemorrhoids can be treated surgically?

A

3 and 4

45
Q

Surgical treatment of Stage 3 and 4 hemorrhoids?

A

Hemorrhoidectomy if chronic severe bleeding and/or acute thrombosed

46
Q

What is a perianal hematoma?

A

Thrombosis of external hemorrhoidal plexus

47
Q

What causes thrombosed external hemorrhoids?

A

Coughing, heavy lifting, straining

48
Q

How does a thrombosed external hemorrhoid present?

A
  • Acute onset severe pain
  • Tense bluish perianal nodule covered w/skin
  • Can be several cm in size
49
Q

Treatment of thrombosed external hemorrhoids?

A
  • Symptom relief (warm Sitz bath, analgesics, ointments)

- Elliptical incision and removal (if someone comes less than 24-48 hours…bc pain will resolve after that)

50
Q

How do anal abscesses begin?

A

Infection in anal glands

51
Q

How does an anal abscess present?

A

Continuous throbbing perianal pain

52
Q

How is an anal abscess treated?

A

Drained under local anesthesia

53
Q

How does an ischiorectal abscess occur? How is it diagnosed? How is it treated?

A
  • Infection may track through internal and external sphincter muscles to enter ischiorectal space
  • Visible on surface of buttocks
  • Treated by surgical drainage
54
Q

What should always be considered in pt w/acute rectal pain?

A

Abscess - can lead to necrotizing infections (esp. in immune-compromised)

55
Q

Perianal vs. perirectal abscess

A
  • Perianal = located at anal verge

- Perirectal = everything else

56
Q

Treatment of perianal or perirectal abscess

A

NO abx needed unless DM, systemic inflamm response, or immunosuppressed

57
Q

What causes pilonidal abscesses?

A

Hair

*Tx w/I&D

58
Q

Treatment of perianal pruritus

A
  • Avoid caffeine, spicy food, citrus, peppermint, tomatoes, ETOH, smoked/cured foods, perfumes
  • After BM: cleanse w/lanolin wipes
  • Clean w/warm water w/o soap
59
Q

Define fecal incontinence

A

Inability of sphincter complex to contract sufficiently to control the release of gas or stool

60
Q

What are common causes of fecal incontinence?

A
  • Childbirth
  • Rectal prolapse
  • Prior pelvic radiation
  • Episiotomy
61
Q

Treatment of fecal incontinence

A
  • Fiber
  • Avoid caffeine
  • Bowel training w/biofeedback or exercises
62
Q

Describe rectal prolapse

A
  • Prolapse or intussusception of rectum
  • Partial or complete
  • Under straining conditions
  • Best to examine w/pt on toilet
  • Full thickness prolapse should be surgically corrected
63
Q

What is the MC form of rectal cancer?

A

Adenocarcinoma

64
Q

How does rectal cancer usually start?

A

Precancerous polyp that develops over years

65
Q

Risk factors for rectal cancer

A
  • Age
  • Smoking
  • Fam hx
  • High fat diet from primarily animal sources
66
Q

Anal cancer in the US

A

Uncommon (up to 93% of cases a/w HPV)

67
Q

MC STD in US

A

HPV

68
Q

Predisposing factors of fecal impaction?

A
  • Meds
  • Severe psychosocial disease
  • Neurogenic/spinal cord diseases
69
Q

Treatment of fecal impaction

A
  • Relieve impaction by digital disruption/enema

- Maintain soft and regular BMs

Clin Med II - GI (17 decks)

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