Anorectum Dettmann Flashcards
What is one of the MC causes of anal pain?
Anal fissure
Describe anal fissures (shape, length, location)
- Linear or rocket shaped ulcers
- Usually less than 5 mm in length
- Located MC in posterior midline
What types of anal fissures are cause for suspicion?
Anal fissures off the midline
What should anal fissures off the midline raise suspicion for?
- UC
- Crohn’s
- HIV/AIDS
- TB
- Syphilis
- Anal carcinoma
Causes of anal fissures
- Trauma
- Defecation (straining, C/D, high sphincter tone)
- Tear in anal lining
What is the MC cause of anal fissure?
Trauma
MC from defecation
Symptoms of anal fissures
- Pain (can be mod or severe)
- Tearing/throbbing (esp during defecation/after)
- Hematochezia +/-
Signs of anal fissures
- 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
What do acute anal fissures look like?
“Cracks” in epithelium
What do chronic anal fissures look like?
Fibrosis and development of skin tags at outer most edge (aka sentinel pile)
Treatment of anal fissures
- Promote effortless painless BMs (fiber/bulk agents, stool softeners)
- Sitz baths
- Topical anesthetics
Treatment of chronic anal fissures
- Topical nitro or dilt ointment
- Botox (2-3 mos of sphincter relaxation)
- Surgery (lateral internal sphincterotomy)
How are anal fissures successfully healed?
Conservative tx (80% heal this way)
Do anal fissures recur?
Yes in about 40% pts
What is a complication of surgical tx of anal fissures?
Minor incontinence
Define anal fistula
- Hollow tract, primary opening inside anal canal
- Leads to a secondary opening in perianal skin
- Lined w/granulation tissue
MC cause of anal fistulas
Anorectal or perianal abscess
What does a DRE show with anal fistula?
- Spontaneous or expressible discharge
- Fibrous tract or cord beneath skin
- Check sphincter tone before surgery
What does a lateral or posterior induration on DRE suggest?
Deep post-anal or ischiorectal extension of anal fistula
Medical treatments of anal fistulas
- Sitz baths
- Analgesics
- Stool bulking agents
Surgical treatments of anal fistulas
- Fistulotomy/fistulectomy
- Seton placement
- Silver nitrate in office
- Fistula plug
- Fibrin glue injection
- Colostomy
- Endorectal mucosal advancement flap/LIFT
Complications of anal fistulas
- Bleeding
- Fecal impaction
- Thrombosed hemorrhoids
- Recurrence
- Incontinence
- Anal stenosis
- Delayed wound healing
How long does post-surgical healing take for anal fistulas?
At least 6-12 weeks
What are the rates of recurrence and incontinence following standard fistulotomy?
- 0-20% recurrence
- Less than 10% incontinence
What are the rates of recurrence and incontinence following Seton use tx of anal fistulas?
- 0-20% recurrence
- Less than 10% incontinence
What are the rates of recurrence and incontinence following mucosal advancement flap tx of anal fistulas?
- 1-10% recurrence
- Less than 10% incontinence
What are the different types of hemorrhoids?
- Internal
- External
- Thrombosed
What is the peak age of hemorrhoids?
45-65 yo
What particular condition increases incidence of hemorrhoids?
Pregnancy
Describe hemorrhoids
- Normal anatomical structures
- Ensure water tight seal
- Help maintain normal anal pressure
Describe internal hemorrhoids (what? where do they originate? do they cause pain?)
- Subepithelial vascular cushions b/w superior rectal artery and vein
- Originate ABOVE dentate line
- Rarely cause pain
Describe external hemorrhoids (what? where do they originate? do they cause pain?)
- Arise from inferior hemorrhoidal veins
- Originate BELOW dentate line
- Cause swelling, pain, hygiene issues
Where do external and internal hemorrhoids occur?
- Right anterior
- Right posterior
- Left lateral
When do hemorrhoids become symptomatic?
- Activities that increase venous pressure
- Distension occurs leading to engorgement
Causes of hemorrhoids
- Low fiber diet
- Pregnancy
- Obesity
- Abnormally high tension of internal sphincter muscle
- Prolonged sitting on toilet
- Aging
- Diarrhea
Symptoms of hemorrhoids
- BRBPR
- Prolapse
- Mucoid discharge
Stages of internal hemorrhoids
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)
What may allow visibility of internal hemorrhoids on PE?
Gentle straining
What do prolapsed internal hemorrhoids look like?
Protuberant purple nodules covered with mucosa
What is the best way to visualize internal hemorrhoids?
Anoscopic evaluation
Conservative treatment of Stage 1 and 2 hemorrhoids
- High fiber diet
- Increased fluid intake
- Fiber supplement
- Manual reduction w/suppository
Medical treatment of Stages 1, 2, 3 hemorrhoids?
- Injection sclerotherapy
- Rubber band ligation
- Electrocoagulation
What are the complications of electrocoagulation?
- Pelvic sepsis, abscess
- Urinary retention
- Bleeding
What stages of hemorrhoids can be treated surgically?
3 and 4
Surgical treatment of Stage 3 and 4 hemorrhoids?
Hemorrhoidectomy if chronic severe bleeding and/or acute thrombosed
What is a perianal hematoma?
Thrombosis of external hemorrhoidal plexus
What causes thrombosed external hemorrhoids?
Coughing, heavy lifting, straining
How does a thrombosed external hemorrhoid present?
- Acute onset severe pain
- Tense bluish perianal nodule covered w/skin
- Can be several cm in size
Treatment of thrombosed external hemorrhoids?
- 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)
How do anal abscesses begin?
Infection in anal glands
How does an anal abscess present?
Continuous throbbing perianal pain
How is an anal abscess treated?
Drained under local anesthesia
How does an ischiorectal abscess occur? How is it diagnosed? How is it treated?
- Infection may track through internal and external sphincter muscles to enter ischiorectal space
- Visible on surface of buttocks
- Treated by surgical drainage
What should always be considered in pt w/acute rectal pain?
Abscess - can lead to necrotizing infections (esp. in immune-compromised)
Perianal vs. perirectal abscess
- Perianal = located at anal verge
- Perirectal = everything else
Treatment of perianal or perirectal abscess
NO abx needed unless DM, systemic inflamm response, or immunosuppressed
What causes pilonidal abscesses?
Hair
*Tx w/I&D
Treatment of perianal pruritus
- 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
Define fecal incontinence
Inability of sphincter complex to contract sufficiently to control the release of gas or stool
What are common causes of fecal incontinence?
- Childbirth
- Rectal prolapse
- Prior pelvic radiation
- Episiotomy
Treatment of fecal incontinence
- Fiber
- Avoid caffeine
- Bowel training w/biofeedback or exercises
Describe rectal prolapse
- 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
What is the MC form of rectal cancer?
Adenocarcinoma
How does rectal cancer usually start?
Precancerous polyp that develops over years
Risk factors for rectal cancer
- Age
- Smoking
- Fam hx
- High fat diet from primarily animal sources
Anal cancer in the US
Uncommon (up to 93% of cases a/w HPV)
MC STD in US
HPV
Predisposing factors of fecal impaction?
- Meds
- Severe psychosocial disease
- Neurogenic/spinal cord diseases
Treatment of fecal impaction
- Relieve impaction by digital disruption/enema
- Maintain soft and regular BMs
