Disorders of the Rectum Flashcards
Where is the most common location for Anal fissures?
Posterior midline!!!
What might be indicated by anal fissures found off of the midline?
UC Crohn's HIV/AIDS TB Syphillis Anal Ca.
MC cause of Anal fissure?
Trauma (MC) Defecation Straining constipation high sphincter tone
What might a pt who presents to you say about their Anal Fissure pain?
“It feels like I’m shitting glass!”
What may occur d/t spasms created by anal fissure pain?
reduced blood flow which can lead to mucosal ischemia
sx of anal fissure
moderate to severe tearing/throbbing pain
Hematochezia may or may not be present on TP (not severe bleeding though)
What does an acute anal fissure look like?
crack in the epithelium (a crack in your back (posterior) crack)
What may a chronic anal fissure look like?
fibrosis and development of skin take “sentinel pile”
acute Tx for anal fissure?
promote effortless BM
Fiber
Stool softener
Topical anesthetics
Chronix tx for anal fissure?
topical NTG
Botox
What percent of anal fissures heal with conservative tx
80%
What surgery can be performed to prevent reucurrence of anal fissure?
sphincterotomy (may result in incontenence)
Define anal fistula
a hollow tract which has primary opening inside anal canal leading to secondary opening in perianal skin
What might cause an anal fistula?
Anorectal or perianal abscess crohsn fissures trauma ca radiation actinomyoces rectal tuberculosis chlamydial infections lympgranuloma venerum
Sx of Anal fistula?
Hx of IBD Perianal dc (chronic) itching Pain -mc in abscess stage swelling bleeding diarrhea skin excoriation external opening (chronic)
What is seen on visual exam of a pt with an anal fistula?
external opening
elevation of granulation tissue (fibrous tract)
On DRE what might be observed for a pt with an anal fistula?
spontaneous expressible discharge
feel fibrous tract (cord) below skin
sphincter tone
What is the “poor man’s test” anoscopy?
Anoscope and hydrogen peroxide. Look through scope into rectum and use syringe to flush hydrogen peroxide int the external opening of supposed fistula. If bubbling is seen through anoscope then it must track up that far.
DDX for anal fistula?
Hydradenitis suppurativa
pilonidal cyst
Bartholin gland abscess
Infected sebacceous cyst
Labs for anal fistula
none
Imaging for anal fistula?
fistulography endoanal/endorectal US MRI with rectal coil CT scan scope if suspect IBD
tx for anal fistula?
sitz baths, analgesics, stool bulking agents Surgical: fistolotomy/fistulectomy seton placement NaAg tx in office Fistula plug fibrin glue colostomy endorectal advancement flap (LIFT)
complications of anal fistula?
bleeding fecal impaction thromboses hemorrhoids recurrence incontinence anal steonsis delayed would healing esp with crohns
Post surgical healing is dependent upon?
surgical technique and pt’s compliance
What is the difference between internal hemorrhoids and external hemorrhoids?
internal-subepithelial vasculatures above the dentate line (rarely painful)
External-arise from inferior hemorrhoidal veins, below dentate line cause swelling, pain, hygiene issues
Where do hemorrhoids occur?
R anterior
R posterior
L lateral
What are M/c rf for hemorrhoids?
Diet (low fiber) Pregancy Obesity abnormally high tension of sphincter muscle Prolonged sitting on toilet aging diarrhea (irritation)
Symptoms of hemorrhoids
Bleeding-bright red blood streaks on TP/ stool dripping s/p BM
anemia unlikely
prolapse
mucoid dc
Stage one of internal hemorrhoids?
confined to anal canal
bleeding no prolapse
Stage 2 of internal hemorrhoids
Protrude from anal opening
bleeding, mild prolapse, w/ spontaneous reduction
Stage 3 of internal hemorrhoids
Prolapsed
requires manual reduction s/p BM
Stage 4 of internal hemorrhoids
chronically prolapsed won’t go back in
strangulated
sense of fullness, discomfort, mucoid d/c, irritation, staining, pain
Conservative tx is reserved for which stages of hemorrhoids?
1 and 2
What is the conservative tx for hemorrhoids?
high fiber diet
increased fluid intake
fiber supplement
manual reduction supplemented with suppository (sugar-weird)
What stages can be tx medically for hemorrhoids?
1, 2 (that have failed conservative tx), and 3
What is tx for stage 1, 2, and 3 medically for hemorrhoids?
Injection sclero
rubber band ligation
electrocoagulation
Surgical tx is reserved for which stages of hemorrhoid?
3 and 4
What is the surgical tx for hemorrhoids?
excision
reserved for chronic severe bleeding, acutely thromboses
What is the other name for thrombosed external hemorrhoid?
perianal hematoma
sx of thrombosed external hemorrhoid
otherwise healthy pt with hemorrhoid s/p coughing or heavy lifting
-acute onset severe pain
tense bluish perianal nodule covered with skin
pain most severe first few hours and gradually subsides 2-3 days
Tx for thromboses hemorrhoid?
Warm sitz bath, analgesics ointments
if eval within 24-48hr’s removal of clot hastens symptoms resolution
Where do rectal abscesses begin?
in the anal glands and teach through various planes in the anorectal region. May track through internal and external sphincter muscles to enter ischiorectal space.
sx of rectal abscess?
continuous throbbing perianal pain
Why is it important to always consider rectal abscess with acute rectal pain?
delay in diagonsis can lead to necrotizing infection. esp in immune compromised pt’s
What is best tx for rectal abscess?
surgical drainage under local anesthesia
if larger and more complex best in OR
In a supralevator abscess it is important to ______ when treating?
identify and tx the process causing the abscess as well as relieve abscess with surgical drainage
Are Abx required for a perianal abscess?
No unless the pt has DM
Offending agent of pilonidal abscess is almost always____?
hair
t/f pilondal abscess is NOT an anorectal abscess?
true
tx for Pilonidal abscess
surgical excision (last resort) keep area hair free
What are some of the treatable causes of perianal pruritis?
infection
dermatitis
hemorrhoids
How can you determine the possibility of a treatable cause of perianal pruritis
KOH smear, Bx
DRE
Anoscope
What agents should be avoided in a pt who c/o perianal pruritis
caffiene spicy food citrus peppermint tomato ETOH smoked/cured foods
What might cause fecal incontinence?
childbirth rectal prolapse episiotomy prior anal surgery prior pelvic radiation physical trauma
What is the definition of fecal incontinence
loss of stool
If fecal incontinence is accompanied by unawareness of the situation what should you consider?
loss of central awareness s/a dementia, CVA, MS
Periopheral nerve injury d/t spinal cord injury, aging, diabetes
tx for fecal incontinence?
fiber avoid caffeine cotton ball to soak up leakage resolve underlying hemorrhoids, diarrhea etc. kegal, anal wink sacral nerve stim artificial bowel/sphincter
What is the only way to tx a full thickness rectal prolapse?
surgically
What is the best way to examine a pt with rectal prolapse?
with them sitting on toilet
MC form of rectal Ca?
adenocarcinoma
RF for rectal ca?
Age
smoking
Fam hx colorectal ca?
High fat diet from primarily animal sources
sx of rectal ca?
tenesmus
hematochezia
pelvic pain
enlarged inguinal lymph nodes
Diagnostics for Rectal Ca?
CT to eval loacal and possible disseminated dz
Bx
Tx for Rectal Ca?
chemo, surgery for refractory or recurrent dz
What is more common in the US Rectal ca or Anal ca?
Rectal Ca more common
What is the MC associated dz of anal ca?
HPV
