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Clinical Med III > Exam 2 - Anorectal Disease > Flashcards

Exam 2 - Anorectal Disease Flashcards

1
Q

What are some anorectal complaints that are red flags and should prompt referral to a GI/colorectal specialist?

A
  • Unintentional weight loss
  • Iron Deficiency Anemia
  • Personal or FH of IBD or CRC
  • Persistent anorectal bleeding or anorectal symptoms despite adequate treatment of a suspected benign condition
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2
Q

Hemorrhoids are normal vascular structures that arise from a fibrovascular cushion to protect the anal canal and help maintain continence. When do these hemorrhoids become symptomatic?

A

Become symptomatic when supporting structures of hemorrhoidal tissue (anal cushions) deteriorate

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3
Q

What is the difference between external and internal hemorrhoids?

A

External - distal to dentate line (painful)

Internal - proximal to dentate line (painless)

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4
Q

What are the different classifications of internal hemorrhoids?

A
  • Grade I: Bulge in anal canal without prolapse
  • Grade II: Prolapse that reduces spontaneously
  • Grade III: Prolapse that requires manual reduction
  • Grade IV: Chronic prolapse, irreducible
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5
Q

What is the clinical presentation associated with hemorrhoids?

A
  • Bleeding with bowel movements, usually bright red
  • Possible sensation of perianal fullness (prolapse)
  • Possible pruritis (“pruritis ani”)
  • Possible perianal pain and palpable “lump” if thrombosed
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6
Q

What are some dietary and lifestyle modifications for the management of symptomatic hemorrhoids?

A
  • Fluid and fiber (dietary/bulk laxatives such as Benefiber and Metamucil)
  • Toilet habits
  • Sitz bath
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7
Q

What are some conservative management options symptomatic hemorrhoids?

A
  • Stool softeners
  • Tucks pads
  • Short course of corticosteroid creams or suppositories
  • Nitroglycerin ointment
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8
Q

What are some office-based procedure options for management of symptomatic hemorrhoids?

A

Appropriate for patients refractory to conservative medical therapies

Internal hemorrhoids:

  • Rubber-band ligation
  • Infrared coagulation
  • Sclerotherapy

External hemorrhoids:
- Excision of thrombosed hemorrhoid

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9
Q

What is the most commonly used technique for the treatment of symptomatic bleeding internal hemorrhoids?

A

Rubber band ligation

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10
Q

When should hemorrhoidectomy be considered?

A
  • Persistent symptoms despite conservative measures or office-based procedures
  • Symptomatic grade III hemorrhoids
  • Grade IV internal hemorrhoids
  • Patients with extensive pain from thrombosed external hemorrhoids
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11
Q

What recommendation should all patients with hemorrhoids be counseled on?

A

Adequate fiber and fluid intake

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12
Q

What is the management for pruritus ani?

A
  • Eliminate offending agent
  • Proper hygiene (gentle cleansers, avoid aggressive wiping and overzealous hygiene, Sitz bath)
  • Keep region dry
  • Eliminate dry clothing
  • Topical astringent (witch hazel) or topical barrier (zinc oxide)
  • Short course of topical steroid cream appropriate for severe skin eruptions
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13
Q

The following description is consistent with what diagnosis?

  • Outgrowth of normal skin around the anus
  • Loose, flesh-colored, pedunculated tissues
A

Perianal skin tags

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14
Q

What is the management for perianal skin tags?

A

Treatment not usually indicated however, patients seek referral for excision if tags interfere with hygiene or cause perianal discomfort

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15
Q

What is an anal fissure?

A

Linear tear, or split, in the lining of the anal canal distal to the dentate line that causes spasm of the anal sphincters

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16
Q

What is the most common cause of severe anorectal pain?

A

Anal fissure

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17
Q

What are primary causes of anal fissures?

A
  • Local trauma to the anal canal
  • Passage of large hard stools
  • Foreign body
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18
Q

What are secondary causes of anal fissures?

A
  • Crohn Disease
  • Malignancy
  • HIV/AIDS
19
Q

What is the clinical presentation associated with anal fissures?

A
  • Severe pain during and often persisting after defecation described as “passing glass” or “sitting on a knife”
  • Bright red blood on toilet paper or streaking on the stool
20
Q

What is the management for anal fissures?

A
  • Adequate fiber and fluid
  • Proper anal hygiene
  • Sitz bath
  • Stool softeners
  • Topical analgesics: lidocaine gel
  • Topical vasodilators: Nifedipine or Nitroglycerin ointment (reduces spasm and increases blood flow)
  • If chronic/refractory, may require surgery (sphincterotomy in patients with low risk of developing fecal incontinence)
21
Q

What is the pathophysiology of a perianal abscess?

A
  • Originates from obstructed/infected anal crypt gland
  • Chronically, can progress to form a fistula
  • Can be associated with Crohn Disease
22
Q

What is the clinical presentation associated with perianal abscess?

A
  • Localized anal or rectal pain
  • Erythematous, palpable, tender, fluctuant mass with surrounding edema
  • Possible inguinal lymphadenopathy
23
Q

What is the management of a perianal abscess?

A
  • Incision and drainage
  • Possible antibiotics in appropriate patients
  • Postoperative treatment of Sitz bath and adequate fluid/fiber intake
24
Q

What other disorders are anorectal fistulas associated with?

A

Crohn Disease, radiation proctitis, diverticulitis

25
Q

What is the clinical presentation associated with anorectal fistulas?

A
  • Chronic drainage of blood or pus and occasionally stool from fistula
  • Rectal pain, itching, swelling, fever
  • Palpable cord beneath the skin between anus and abscess opening
26
Q

What diagnostic studies should possibly be ordered for anorectal fistulas?

A
  • MRI pelvis for complex or recurrent fistula

- Colonoscopy if concern for IBD

27
Q

What is the management of a anorectal fistula?

A

Surgical (fistulotomy) is mainstay therapy

28
Q

What is the cause of anal condyloma?

A

HPV

29
Q

What is the clinical presentation associated with anal condyloma?

A
  • Asymptomatic, may be pruritic

- Cauliflower like appearance, in clusters or single entities

30
Q

What is the management for anal condyloma?

A
  • Removal or destruction of visible lesions
  • Topical Podofilox
  • Topical Imiquimoid cream
  • Office treatment with Trichloroacetic acid
  • Surgical removal
31
Q

What are the majority of anal cancers?

A

Squamous cell cancers

32
Q

In what populations is the incidence of anal cancer increased?

A
  • Practicing receptive anal intercourse
  • History of anorectal condyloma
  • History of HPV, HIV
33
Q

What is the clinical presentation associated with anal cancer?

A
  • Anorectal pain, sensation of rectal mass
  • Possible rectal bleeding
  • Perianal skin irritation
  • Hard, friable or ulcerating internal or external lesions
  • Possible anal warts
  • Inguinal lymphadenopathy
34
Q

How is anal cancer diagnosed?

A

Biopsy + scope/imaging to determine extent

35
Q

What is the management of anal cancer?

A
  • Chemoradiotherapy

- Surgery

36
Q

What is the clinical presentation associated with rectal prolapse?

A
  • Constipation/fecal incontinence
  • Incomplete bowel evacuation, seepage
  • “mass” protruding through anus
  • Strain to reproduce
  • DRE: mucosa of rectal wall may feel floppy or loose with redundant tissue
37
Q

What is the mainstay treatment for rectal prolapse?

What other recommendations should be made?

A

Surgical repair by colorectal surgeon is the mainstay treatment

Prevent constipation, increase fiber/fluid

38
Q

What are possible causes of rectal prolpase?

A
  • Chronic constipation
  • Straining
  • Multiparity
  • Prior pelvic surgery
39
Q

What is a rectocele?

A

Occurs when fascia weakens and allows rectum to bulge into vagina

40
Q

What are potential causes of a rectocele?

A
  • Vaginal childbirth
  • Increasing age
  • Increasing BMI
41
Q

What clinical presentation is associated with rectocele?

A
  • Pelvic pressure
  • Constipation
  • Fecal incontinence
  • Sexual dysfunction
  • Patient bears down and you may see bulge of rectum into vagina on rectovaginal exam
  • Possible need to apply pressure on vagina, rectum or perineum to defecate
42
Q

If you are unsure of rectocele diagnosis, what other study could you order?

A

Defecography

43
Q

What is the management for a rectocele?

A
  • Surgery
  • Pelvic floor muscle training
  • Pessary

Clinical Med III (12 decks)

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