Chapter 85: Anorectal Disorders Flashcards
The rectum begins at
The S3 vertebral body and descends for about 13 to 15 cm becoming the anus, which is comprised of the anal canal, anal verge, and anal margin
True or False
The rectum narrows and traverses through the muscular pelvic floor, at the level of the levator ani and coccygeal muscles, and becomes the anal canal, 4 cm in length, surrounded by the anal sphincter muscle
True
The rectum narrows and traverses through the muscular pelvic floor, at the level of the levator ani and coccygeal muscles, and becomes the anal canal, 4 cm in length, surrounded by the anal sphincter muscle
The junction of rectum and anal canal is called
Dentate line
Rectal ampulla narrows to conform to the opening of the anal canal. A pleated appearance, forming 8 to 14 convoluted longitudinal folds
Columns of morgagni
True or False
Just proximal to the dentate line, the mucosa transitions from rectal columnar to cuboidal to squamous epithelium
True
Just proximal to the dentate line, the mucosa transitions from rectal columnar to cuboidal to squamous epithelium
Supplies the proximal 2/3 of the rectum
The superior hemorrhoidal artery, from the internal mesenteric artery
Supplies the distal 1/3 of the rectum
The middle hemorrhoidal artery, from the internal iliac artery
Supplies the anus
Inferior hemorrhoidal artery
True or False
The superior rectal vein drains into the portal system, whereas the middle rectal vein drains into the inferior vena cava
True
The superior rectal vein drains into the portal system, whereas the middle rectal vein drains into the inferior vena cava
The most common position for routine digital rectal examination and anoscopy
The lateral or Sims position
In debilitated patients, one may have to perform the examination with the patient in ____
In debilitated patients, one may have to perform the examination with the patient in a supine, lithotomy position
Skin tags covering anal crypts, fistulas, and fissures are called
Sentinel tags
True or False
Surgical referral for excision and/or biopsy is warranted because inflammatory bowel disease may be associated with sentinel tags
True
Surgical referral for excision and/or biopsy is warranted because inflammatory bowel disease may be associated with sentinel tags
Internal hemorrhoids originate from
Proximal to the dentate line
Location of internal hemorrhoids?
- Right posterolateral
- Right anterolateral
- Left lateral positions
(2, 5 (most common, and 9 o’clock)
True or False
Although the most common cause with sentinel tags.
of bright red rectal bleeding is hemorrhoids, tumors must be ruled out HEMORRHOIDS
as a cause of rectal bleeding in patients >50 years of age
False
Although the most common cause with sentinel tags.
of bright red rectal bleeding is hemorrhoids, tumors must be ruled out HEMORRHOIDS
as a cause of rectal bleeding in patients >40 years of age
A rare complication of hemorrhoidal banding is ____
A rare complication of hemorrhoidal banding is pelvic sepsis
Grading for internal hemorrhoids
- Grade I (luminal protrusion above dentate line)
- Grade II (prolapse with spontaneous reduction)
- Grade III (prolapse needing manual reduction)
- Grade IV (nonreducible prolapse)
The result of a superficial linear tear of the anal canal below the dentate line and extending distally to the anal verge
Anal fissures
True or False
Anal fissures are usually single and occur in the midline posteriorly in 80% to 90% of cases
True
Anal fissures are usually single and occur in the midline posteriorly in 80% to 90% of cases
Chronic anal fissures
> 6 weeks
True or False
Fissures due to Crohn’s disease are multiple, off midline, and asymptomatic more commonly than in the general population
True
Fissures due to Crohn’s disease are multiple, off midline, and asymptomatic more commonly than in the general population
Supportive treatment for anal fissure
Warm baths for at least 15 minutes three to four times a day and after each bowel movement along with stool softeners may suffice
Occurs when the pliable tissue is replaced by scarred fibrotic tissue
Anal stenosis
Most common cause of anal stenosis
Secondary cause
The common denominator for the development of fissure- in-ano, fistula-in-ano, and perirectal abscesses
Cryptitis
Cardinal signs of cryptitis
Anal pain, spasm, and itching with or without bleeding
Fistula-in-ano originates from an ____
Fistula-in-ano originates from an infected crypt and tracks to the skin
True or False
CT scan is more accurate than US in the evaluation of perirectal fistulas
False
US is more accurate than CT scan in the evaluation of perirectal fistulas
True or False
Anorectal abscesses are typically monomicrobial
False
Anorectal abscesses are typically polymicrobial
The most common anorectal abscess location ____
The most common anorectal abscess location is perianal
The least common is ____
The least common is supralevator (pelvirectal)
True or False
Isolated perianal abscesses are generally the only type of anorectal abscess that can be adequately treated in the ED
True
Isolated perianal abscesses are generally the only type of anorectal abscess that can be adequately treated in the ED
True or False
Perianal abscesses are easily palpable at the anal verge, whereas deeper perirectal abscesses may be palpated through the rectal wall or more lateral to the anal verge, on the buttocks
True
Perianal abscesses are easily palpable at the anal verge, whereas deeper perirectal abscesses may be palpated through the rectal wall or more lateral to the anal verge, on the buttocks
Often painful on rectal examination and are lateral to the anal verge
Ischiorectal abscesses
Painful with defecation, may be associated with rectal discharge and fever, and a tender mass may be palpable on digital examination of the rectal canal, often in the posterior midline
Intersphinteric abscesses
Often an extension of an intersphincteric abscess, frequently present with few outward signs and palpable on vaginal examination
Supralevator abscesses
Often a clue to these deeper abscesses
Tender inguinal adenopathy
Is inflammation of the rectal mucosa
Proctitis
Three types of rec- tal prolapse
(1) prolapse involving the rectal mucosa only
(2) prolapse involving all layers of the rectum (complete)
(3) intussusception of the upper rectum into and through the lower rectum so that the mucosal apex of the intussusception nearly extends to the anus (incomplete or internal)
True or False
Rectal prolapse in children is generally mucosal and occurs more commonly in females less than 3 years old
False
Rectal prolapse in children is generally mucosal and occurs more commonly in males less than 3 years old
True or False
Mucosal prolapse is believed to occur due to a lack of the natural sacral curve reducing the anorectal angulation
True
Mucosal prolapse is believed to occur due to a lack of the natural sacral curve reducing the anorectal angulation
It is not a significant feature with complete prolapse, but abdominal or pelvic discomfort may be present
Pain
A distinguishing feature between mucosal and complete prolapse
With complete prolapse, a sulcus may be palpated between the extruded bowel and anus, compared to no sulcus with a mucosal prolapse
An effective technique for allowing for easier prolapse reduction
Application of granulated sugar over the entire prolapsed segment
Where is the transitional zone seen?
At the level of the dentate line and extending approximately 1 cm proximal
Malignancies of the portion proximal to the dentate line and including the transitional zone, which are referred to as
Anal canal neoplasms
Tumors arising in the anoderm distal to the dentate line, which are referred to as
Anal margin neoplasms
Anal margin neoplasms have a low-grade malignant potential and are slow to metastasize, with the exception of ____
Anal margin neoplasms have a low-grade malignant potential and are slow to metastasize, with the exception of melanoma
The third most common site of malignant melanoma (after the skin and the eye)
Anal canal
Arise from the rectal columnar epithelium, frequently produce clear, watery diarrhea and a profuse rectal discharge
Villous adenomas
Any ulcer that fails to heal within ____ or any discrete skin lesion that fails to improve with appropriate therapy must be biopsied to rule out the presence of malignancy
Any ulcer that fails to heal within 30 days or any discrete skin lesion that fails to improve with appropriate therapy must be biopsied to rule out the presence of malignancy
Most foreign bodies are in the ___
Ampulla
Useful when the foreign body is radiolucent and for the detection of free air
CT scan
The second most common anorectal condition after hemorrhoids
Pruritus ani
Etiologic cause of pruritus
Staphylococci and Streptococci
Common cause of anal pruritus in children
Pinworms (Enterobius vermicularis)
True or False
Lumbosacral radiculopathy has been associated with idiopathic pruritus ani
True
Lumbosacral radiculopathy has been associated with idiopathic pruritus ani
Provide a protective covering for the perianal skin and may promote healing in pruritus ani
Zinc oxide
May be used as an effective bedtime sedative in patient with pruritus ani
Hydroxyzine hydrochloride may be used as an effective bedtime sedative
An acquired problem formed by the penetration of the skin by an ingrown hair, which causes a foreign body granuloma reaction
Pilonidal sinus
True or False
An abscessed pilonidal sinus is almost always located in the posterior midline over the sacrum and coccyx
True
An abscessed pilonidal sinus is almost always located in the posterior midline over the sacrum and coccyx
True or False
Perineal disease is more common in females, whereas axillary disease is more common in males
False
Perineal disease is more common in males, whereas axillary disease is more common in females
Fistulas that extend above the dentate line may suggest coexisting ____
Fistulas that extend above the dentate line may suggest coexisting cryptoglandular or Crohn’s disease
Treatment for perianal hidradenitis suppurativa
Topical clindamycin or oral clindamycin with rifampin can be helpful
Flatulence and/or malodorous vaginal discharge or gross stool ema- nating from the vagina
Rectovaginal fistula
