EOR GI part 8- anal disease Flashcards
What are the causes of an anal fistula?
Usually anal crypt/gland infection (usually perianal abscess)
What are the s/sx of an anal fistula?
Perianal drainage Perirectal abscess Recurrent perirectal abscess Diaper rash Itching
What dz should be considered with an anal fistula?
Crohn’s dz
How is the dx of an anal fistula made?
Exam
Proctoscope
What is Goodsall’s rule?
Fistulas originating anterior to a transverse line through the anus will course straight ahead and exit anteriorly, whereas those exiting posteriorly have a curved tract
What is the management of anorectal fistulas?
Define the anatomy
Marsupialization of fistula tract
Wound care: routine sitz baths and dressing changes
Seton placement if fistula is through the sphincter muscle
What is a seton
Thick suture placed through fistula tract to allow slow transection of sphincter muscle
Scar tissue formed will hold the sphincter muscle in place and allow for continence after transection
How do you find the internal rectal opening of an anorectal fistula in the OR?
Inject hydrogen peroxide (or methylene blue) in external opening- then look for bubbles (or blue dye) coming out of internal opening
What is a sitz bath?
Sitting in a warm bath (usually done after bowel movement and TID)
Perirectal abscess
Abscess formation around the anus/rectum
S/sx of perirectal abscess
Rectal pain
Drainage of pus
Fever
Perianal mass
How is the dx of perirectal abscess made?
Physical/digital exam reveals perianal/rectal submucosal mass/fluctuance
What is the cause of perirectal abscess?
Crypt abscess in dentate line with spread
What is the tx for perirectal abscess?
As with all abscesses (except simple liver amebic abscess) drainage, sitz bath, anal hygiene, stool softeners
What is the indication for postop IV abx for drainage in perirectal abscess?
Cellulitis
Immunosuppression
DM
Heart valve abnormality
Anal fissure
Tear or fissure in the anal epithelium
What is the most common site of anal fissures?
Posterior midline (comparatively low blood flow)
What is the cause of anal fissures?
Hard stool passage
Hyperactive sphincter
Dz process
S/sx of anal fissures?
Pain in the anus Painful (can be excrutiating) bowel movement Rectal bleeding Blood on toilet tissue after bowel movement Sentinel tag Tear in the anal skin Extremely painful rectal exam Sentinel pile Hypertrophic papilla
What is a sentinel pile?
Thickened mucosa/skin at the distal end of an anal fissure that is often confused with a small hemorrhoid
Whatis the anal fissure triad for a chronic fissure?
Fissure
Sentinel pile
Hypertrophied anal papilla
What is the conservative tx for anal fissures?
Sitz baths Stool softeners High fiber diet Excellent anal hygiene Topical nifedipine Botox
What dz process must be considered with a chronic anal fissure?
Crohn's dz Anal CA Sexually transmitted dz Ulcerative colitis AIDS
What are the indications for surgery in anal fissures?
Chronic fissure refractory to conservative tx
What is one surgical option for an anal fissure?
Lateral internal sphincterotomy- cut the internal sphincter to release it from spasm
What is the rule of 90% for anal fissures?
90% occur posteriorly
90% heal with medical tx alone
90% of pts who undergo an LIS heal successfully
Hemorrhoids
Engorgement of the venous plexuses of the rectum, anus, or both; with protrusion of the mucosa, anal margin, or both
Why do we have healthy hemorrhoidal tissue?
It is thought to be involved with fluid/air continence
S/sx of hemorrhoids?
Anal mass/prolapse
Bleeding
Itching
Pain
What type of hemorrhoids, internal or external, is painful?
External, below the dentate line
If a pt has excruciating anal pain and hx of hemorrhoids, what is the likely dx?
Thrombosed external hemorrhoid (treat by excision)
What are the causes of hemorrhoids?
Constipation/straining
Portal hypertension
Pregnancy
What is an internal hemorrhoid?
Hemorrhoid above the proximal dentate line
What is an external hemorrhoid?
Hemorrhoid below the dentate line
What are the three hemorrhoid quadrants?
Left lateral
Right posterior
Right anterior
First degree hemorrhoid
Hemorrhoid that does not prolapse
Second degree hemorrhoid
Prolapses with defecation but returns on its own
Third degree hemorrhoid
Prolapses with defecation or any type of Valsalva maneuver and requires active manual reduction
Fourth degree hemorrhoid
Prolapsed hemorrhoid that cannot be reduced
What is the tx for hemorrhoids?
High-fiber diet Anal hygiene Topical steroids Sitz baths Rubber band ligation Surgical resection for large refractor hemorrhoids Infared coagulation Harmonic scalpel
What is a closed versus open hemorrhoidectomy?
Closed closes the mucosa with sutures after hemorrhoid tissue removal
Open leaves mucosa open
What are the complications of hemorrhoidectomy?
Exsanguination
Pelvic infection
Incontinence
Anal stricture
What condition is a contraindication for hemorrhoidectomy?
Crohn’s dz
Classically, what must be ruled out with lower GI bleeding believed to be caused by hemorrhoids?
Colon CA
