Disorders of the Anus and Rectum Flashcards
What are the two types of hemorrhoids?
Internal
External
Which type of hemorrhoids is described below?
Located above dentate line, subepithelial vascular cushions; contribute to normal anal pressures and water tight closure of anal canal
Arise from the normal vascular entities that communicate between rectal arteries and veins
Arise from superior hemorrhoidal cushion
Viscerally innervated columnar epithelium
Not sensitive to pain, touch, or temperature
Not palpable on PE
Painless bleeding after defecation
Internal hemorrhoids
Which type of hemorrhoids is described below?
Located below the dentate line
Arise from inferior hemorrhoidal plexus
Covered by modified squamous epithelium (anoderm)
Contains multiple somatic pain receptors (i.e. painful)
Rarely bleed
Visible, can poke out
External hemorrhoids
What grading of internal hemorrhoids is described below?
The hemorrhoids do not prolapse
Grade I
Are part of normal anatomy
Become symptomatic from distension and
engorgement secondary to increased venous pressure
Hemorrhoids
What grading of internal hemorrhoids is described below?
The hemorrhoids prolapse upon defecation but reduce spontaneously
Grade II
What grading of internal hemorrhoids is described below?
The hemorrhoids prolapse upon defecation and must be reduced manually
Grade III
What grading of internal hemorrhoids is described below?
The hemorrhoids are prolapsed and cannot be reduced manually
Grade IV
Which type of hemorrhoids are not graded?
External hemorrhoids
What are some predisposing factors for hemorrhoids?
Straining/Constipation
Prolonged Sitting
Pregnancy
Obesity
Low fiber diet
What is the clinical presentation of hemorrhoids?
Pruritis
Dull, aching pain (external more than internal)
BRBPR (bright red blood per rectum)
Fissure
prolapse
What are the treatment options for hemorrhoids?
Mild = conservative
Fiber supplements
Fluid increase
Sitz baths
Anusol with or without HC
Mod/Severe: more invasive
Banding
Photocoagulation
Cryosurgery
Surgery
Rupture of a vein at the anal margin 🡪 clot in the SC tissue
Patients typically complain of a painful lump (severe pain)
PE - Tense, tender, bluish mass covered with skin
Thrombosed External Hemorrhoid
What is the treatment for thrombosed external hemorrhoids?
Excision of hemorrhoid: removes clot and hemorrhoidal tissues
A split in anal mucosa
Occur midline, just distal to dentate line
Sometimes you can see it, sometimes you cannot (deeper)
Anal Fissure
List some causes of anal fissures
Vigorous stretching of anal canal during defecation of large, firm bowel movement
Digital insertion
Sexual trauma
Foreign body insertion
List some predisposing factors for the development of anal fissures
Previous anorectal surgery (leads to scarring of anoderm and loss of
elasticity)
Anodermal tearing exposures internal sphincter muscle which leads to muscle spasms
Spasm can prevent the sphincter from relaxing 🡪 further tearing, fissure deepening and further spasms
Persistent spasm also creates a degree of ischemia that further prevents healing
What are some signs/symptoms of an anal fissure?
Severe pain, especially during bowel movements (tearing, burning, throbbing)
Bleeding with defecation
Constipation (pain is so severe they are afraid to have a bowel movement)
Unable to do anal/rectal exam
Linear tear in anoderm
Anal spasm with limited DRE
What are some treatment options for anal fissures?
Stool softeners
High fiber diet
Bulking agents
Sitz baths
Medications: NTG, hydrocortisone suppository, hydrocortisone cream
Surgery
What percentage of anal abscesses will result in a fistula?
30-40%
Develops when anal crypt gland becomes infected
Gland is obstructed with debris permitting bacterial overgrowth and abscess formation
Anal abscess
Communication between an abscess with an identifiable opening within the anal canal
Frequently at dentate line
Anal fistula
If you have a patient with an anal fistula, what condition do you need to rule out?
Need to rule out IBD when you see a fistula
Anal abscesses/fistulas are associated with what other conditions?
Constipation
Diarrhea
Infection
Perianal trauma
Crohn’s disease
Immunocompromised patients
Malignancy
Prior radiation
What are some signs/symptoms of anal abscesses/fistulas?
Severe anal or rectal pain
Mass
Fever
Malaise
With fistula: Purulent drainage
What is the treatment for anal abscesses/fistulas?
Surgical I&D
Broad spectrum antibiotics
Sitz baths
Abscess in the sacrococcygeal cleft with resultant sinus tract
development
“jeep rider’s disease”
Highest incidence in white males; peak incident 16-20 year olds
Male:female is 3:1
Were once believed to be congenital, now believed to be acquired
Pilonidal Disease
What is the pathophysiology of pilonidal disease?
Natal cleft hair follicle becomes infected 🡪 rupture into surrounding
tissues 🡪 abscess 🡪 surrounding hair is pulled into the cavity
What are some signs/symptoms of pilonidal disease?
Painful, fluctuant area at sacrum/coccyx
Chronic draining sinuses with hair protruding from pits
What is the treatment for pilonidal disease?
Surgical I&D: Unroofing, cure rate of 60-80%
For chronic draining cysts or failure to heal after 3 months: Excision of midline pits and hair removal
Most common viral STD in the United States
HPV
Condylomata acuminate or genital warts
Highest prevalence: 16-25 year olds
Highly transmissible
anal warts
Condylomata acuminate or genital warts are caused by what?
HPV
What is the pathophysiology of anal warts?
HPV invades superficial layers of anogenital region during sexual contact
What is the incubation period for HPV and the development of anal warts?
Incubation period of approximately 4 months
What are some treatment options for anal warts?
Topical podofilox 0.5% cream
Topical Imiquimod 5% cream
Topical sinecatechins 15%
Cryotherapy
Podophyllin
Surgery (including laser surgery)
What is the most concerning aspect about anal warts?
Malignant transformation is possible
