Clin med: diseases of rectum and anus Flashcards
Rectal Pain
- importance of PE
- 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
Two muscle spasm syndromes
- Levator Ani syndrome
2. Protalgia fugax
Muscle spasm syndromes
- sx
- recurrent pain
- difficult to localize
- feels like pain is in anus
Levator Ani Syndrome
- defining sx
- tenderness in a muscle group on rectal exam
Protalgia fugax
- sx
- common cause
- tx
- pain lasting >20 min
- commonly occurs after intercourse (either sex)
- usually requires no treatment
Rectal examination
- inspection
- look for hemorrhoids, excoriations, fissures, abscesses
- look for tumors
T/F tumors present with pain
False
- seldom present with pain
- Two types of hemorrhoids
- what is defining anatomical feature
External
Internal
- Dentate line
Internal hemorrhoids
- superior hemorrhoidal veins
- proximal to the dentate line
- portal circulation
- usually cause no pain
External hemorrhoids
- inferior hemorrhoidal veins
- distal to dentate line
- systemic circulation
- commonly cause pain
Risk factors for hemorrhoids
- increased intra-abdominal pressure
- Increased venous portal pressure
- Increased venous systemic pressure
Examples of intra-abdominal pressure
- chronic constipation
- pregnancy
- ascites
- obesity
- heavy lifting
- space occupying lesion within the pelvis
What causes internal hemorrhoids
increased portal pressure
- cirrhosis
- liver disease
What causes external hemorrhoids
increased systemic pressure
- CHF
- chronic pulmonary disease
- inferior venacaval obstruction
Hemorrhoids
- geriatric
- pediatric
- Geriatric: more common
- Pediatric: uncommon in infants and children
Hemorrhoids in children
- if discover, look for underlying cause in portal/systemic venous system
- can be caused by chronic constipation
Hemorrhoids in pregnancy
- common
- usually resolve after delivery
- no tx required unless painful
Hemorrhoid treatment
- treat underlying cause
- goal: decrease cause of increased pressure in abdomen, portal venous system, systemic venous system
How to treat acute hemorrhoid pain
- sitz bath
- up fiber in diet
- steroid cream or suppositories to decrease inflammation
Hemorrhoid tx
- if steroids fail
- final option
- band ligation: cuts off blood supply and hemorrhoid tissue dies and falls off
- hemorroidectomy
Hemorroidectomy indicatins
- repeat blood clots
- ligation fails
- Protruding hemorrhoids that cannot be reduced
- persistent bleeding
Thrombosed hemorrhoid
- definition
tissue that is a collection of veins develops a clot
Thrombosed hemorrhoid
- presentation
- visibility of hemorrhoid
- acute pain, painful to touch, hard
- if external can’t be pushed back into anus
- visible externally or with anoscope
Anal fissure
- description
- 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
what is anal fissure often confused with
hemorrhoids
Anal fissures
acute vs. chronic
Acute: <6 weeks
Chronic: >6 weeks
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
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
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
Conditions associated with anal fissure
constipation IBS Crohn's TB Leukemia (immunocompromised) HIV (immunocompromised)
Presentation of Anal Fissure
- pain of defecation
- bright red blood
- tearing sensation on passing stool
- anal spasm
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
Anal fistula description
- open communication between anal abscess and perirectal skin
- anorectal fistulas typically form from an abscess of the anal crypt glands
Anal fistula
- classification
- based on anatomy
- submucosal or superficial
- four types in the sphincteric
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
Risk factors for anal fistula
- IBD
- Pelvic radiation
- perianal trauma
- pelvic carcinoma or lymphoma
- abscess formation due to acute appendicitis, salpingitis, diverticulitis
- immunocompromised states
Anal fistula
- PE
- look for redness and expression of pus
- Rectovaginal
- pus from vagina
- Stool from vagina
- Flatulus from vagina
- Rectovesicle fistula
- frequent UTI
Anal fistula
- dx
- US
- Fistulogram
- CT of pelvis
- MRI of pelvis
Anal fistula
- treatment
- bowel rest (??)
- skin care
- surgical intervention
Anorectal abscess
- symptoms
- presents with pain
- high fever, high WBC (infection)
** pt looks very sick
Anorectal abscess
- location
- perianal (outside the canal in the soft tissue, hasn’t yet created a fistula tract)
- small percentage are complicated
Anorectal abscess
history
- perirectal pain, esp during defecation
- constipation, fever, chills
- spontaneous foul smelling drainage
Anorectal abscess
PE: what to do
- do inspection and palpation
- C&S
- possible endoscopy and fistulography
Anorectal abscess treatment
drain
puss under pressure must be drained
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
Fecal impaction
- causes
- hypercalcemia
- hypermagnesemia
- narcotics
- immobility
Fecal impaction
- history
- constipation
- rectal discomfort, pain
- n/v anorexia
- fecal incontinence - paradoxical diarrhea (overflow around impaction)
Fecal impaction
- dx
- rectal exam
- plain x-ray
- possibly CT scan
Fecal impaction
- treatment
- disimpaction (scoop it out)
- further workup
- help pt with increasing frequency of bowel movements
- possible surgery depending on what finds
Anal neoplasm
- rare
- anal canal or anal margin
Anal neoplasm risk factors
- anogenital warts (HPV)
- hx of pelvic cancer
- Paget’s dz
- Bowen’s dz
Paget’s and Bowen’s
lesions in epithelium that are mostly benign. Dx via biopsy, generally dermatologist will care for these patients
Anal neoplasms
- dx and tx
- biopsy is essential
- tx usually sx followed by radiation or chemo
