Clin med: diseases of rectum and anus Flashcards
1
Q
Rectal Pain
- importance of PE
A
- a MUST
- women: lay on side and lift one side of buttocks
- man: bend over end of exam table, examiner on a stool
- both techniques acceptable
2
Q
Two muscle spasm syndromes
A
- Levator Ani syndrome
2. Protalgia fugax
3
Q
Muscle spasm syndromes
- sx
A
- recurrent pain
- difficult to localize
- feels like pain is in anus
4
Q
Levator Ani Syndrome
- defining sx
A
- tenderness in a muscle group on rectal exam
5
Q
Protalgia fugax
- sx
- common cause
- tx
A
- pain lasting >20 min
- commonly occurs after intercourse (either sex)
- usually requires no treatment
6
Q
Rectal examination
- inspection
A
- look for hemorrhoids, excoriations, fissures, abscesses
- look for tumors
7
Q
T/F tumors present with pain
A
False
- seldom present with pain
8
Q
- Two types of hemorrhoids
- what is defining anatomical feature
A
External
Internal
- Dentate line
9
Q
Internal hemorrhoids
A
- superior hemorrhoidal veins
- proximal to the dentate line
- portal circulation
- usually cause no pain
10
Q
External hemorrhoids
A
- inferior hemorrhoidal veins
- distal to dentate line
- systemic circulation
- commonly cause pain
11
Q
Risk factors for hemorrhoids
A
- increased intra-abdominal pressure
- Increased venous portal pressure
- Increased venous systemic pressure
12
Q
Examples of intra-abdominal pressure
A
- chronic constipation
- pregnancy
- ascites
- obesity
- heavy lifting
- space occupying lesion within the pelvis
13
Q
What causes internal hemorrhoids
A
increased portal pressure
- cirrhosis
- liver disease
14
Q
What causes external hemorrhoids
A
increased systemic pressure
- CHF
- chronic pulmonary disease
- inferior venacaval obstruction
15
Q
Hemorrhoids
- geriatric
- pediatric
A
- Geriatric: more common
- Pediatric: uncommon in infants and children
16
Q
Hemorrhoids in children
A
- if discover, look for underlying cause in portal/systemic venous system
- can be caused by chronic constipation
17
Q
Hemorrhoids in pregnancy
A
- common
- usually resolve after delivery
- no tx required unless painful
18
Q
Hemorrhoid treatment
A
- treat underlying cause
- goal: decrease cause of increased pressure in abdomen, portal venous system, systemic venous system
19
Q
How to treat acute hemorrhoid pain
A
- sitz bath
- up fiber in diet
- steroid cream or suppositories to decrease inflammation
20
Q
Hemorrhoid tx
- if steroids fail
- final option
A
- band ligation: cuts off blood supply and hemorrhoid tissue dies and falls off
- hemorroidectomy
21
Q
Hemorroidectomy indicatins
A
- repeat blood clots
- ligation fails
- Protruding hemorrhoids that cannot be reduced
- persistent bleeding
22
Q
Thrombosed hemorrhoid
- definition
A
tissue that is a collection of veins develops a clot
23
Q
Thrombosed hemorrhoid
- presentation
- visibility of hemorrhoid
A
- acute pain, painful to touch, hard
- if external can’t be pushed back into anus
- visible externally or with anoscope
24
Q
Anal fissure
- description
A
- longitudinal tear in lining of anal canal distal to dentate line
- most commonly at posterior midline
- characterized by a knifelike tearing sensation on defecation
- often associated with bright red blood per rectum
- seen on exam when separate buttocks and see the anus
- benign
25
what is anal fissure often confused with
hemorrhoids
26
Anal fissures
| acute vs. chronic
Acute: <6 weeks
Chronic: >6 weeks
27
Anal fissure
| - epidemiology
- all ages
- common in infants 2-24 months (usually self limiting and usually related to constipation)
- less common in elderly: usually only seek medical advice unless pain is severe
28
What causes anal fissure
- high pressure in anal canal (usually result of straining) leads to ischemia of anoderm
- splits anal mucosa dring defecation and spasm of exposed internal sphincter
- can also be a sign of trauma
- very hard to reduce inflammation due to proximity to bacteria
29
Risk factors for anal fissures
- passage of hard/large stool
- high-resting pressure (prolonged sitting at a stool or obesity)
- trauma (anal intercourse)
- IBD (Crohn's disease)
- Infection: chlamydia, syphilis, herpes, TB
30
Conditions associated with anal fissure
```
constipation
IBS
Crohn's
TB
Leukemia (immunocompromised)
HIV (immunocompromised)
```
31
Presentation of Anal Fissure
- pain of defecation
- bright red blood
- tearing sensation on passing stool
- anal spasm
32
Treatment of anal fissure
- avoid repeated tearing
- wash gently with warm water and soap
- high fiber diet
- stool softener
- medical therapy: nitrates, CCB, botulin toxin
33
Anal fistula description
- open communication between anal abscess and perirectal skin
- anorectal fistulas typically form from an abscess of the anal crypt glands
34
Anal fistula
| - classification
- based on anatomy
- submucosal or superficial
- four types in the sphincteric
35
Anal fistula
| - pathophysiology
- debris in obstructed anal crypt gland results in suppuration and abscess formation
- abscess rupture/drainage leads to epithelialized track or fistula formation
36
Risk factors for anal fistula
- IBD
- Pelvic radiation
- perianal trauma
- pelvic carcinoma or lymphoma
- abscess formation due to acute appendicitis, salpingitis, diverticulitis
- immunocompromised states
37
Anal fistula
| - PE
- look for redness and expression of pus
- Rectovaginal
* pus from vagina
* Stool from vagina
* Flatulus from vagina
- Rectovesicle fistula
* frequent UTI
38
Anal fistula
| - dx
- US
- Fistulogram
- CT of pelvis
- MRI of pelvis
39
Anal fistula
| - treatment
- bowel rest (??)
- skin care
- surgical intervention
40
Anorectal abscess
| - symptoms
- presents with pain
- high fever, high WBC (infection)
** pt looks very sick
41
Anorectal abscess
| - location
- perianal (outside the canal in the soft tissue, hasn't yet created a fistula tract)
- small percentage are complicated
42
Anorectal abscess
| history
- perirectal pain, esp during defecation
- constipation, fever, chills
- spontaneous foul smelling drainage
43
Anorectal abscess
| PE: what to do
- do inspection and palpation
- C&S
- possible endoscopy and fistulography
44
Anorectal abscess treatment
drain
| puss under pressure must be drained
45
Fecal impaction
| - description
- incomplete evacuation of feces leading to the formation of a large, firm, immovable mass of stool in the rectum or distal sigmoid colon
- resultant partial or complete obstruction
46
Fecal impaction
| - causes
- hypercalcemia
- hypermagnesemia
- narcotics
- immobility
47
Fecal impaction
| - history
- constipation
- rectal discomfort, pain
- n/v anorexia
- fecal incontinence - paradoxical diarrhea (overflow around impaction)
48
Fecal impaction
| - dx
- rectal exam
- plain x-ray
- possibly CT scan
49
Fecal impaction
| - treatment
- disimpaction (scoop it out)
- further workup
- help pt with increasing frequency of bowel movements
- possible surgery depending on what finds
50
Anal neoplasm
- rare
| - anal canal or anal margin
51
Anal neoplasm risk factors
- anogenital warts (HPV)
- hx of pelvic cancer
- Paget's dz
- Bowen's dz
52
Paget's and Bowen's
lesions in epithelium that are mostly benign. Dx via biopsy, generally dermatologist will care for these patients
53
Anal neoplasms
| - dx and tx
- biopsy is essential
| - tx usually sx followed by radiation or chemo
