Exam 2 - Anorectal Disease Flashcards
What are some anorectal complaints that are red flags and should prompt referral to a GI/colorectal specialist?
- 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
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?
Become symptomatic when supporting structures of hemorrhoidal tissue (anal cushions) deteriorate
What is the difference between external and internal hemorrhoids?
External - distal to dentate line (painful)
Internal - proximal to dentate line (painless)
What are the different classifications of internal hemorrhoids?
- 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
What is the clinical presentation associated with hemorrhoids?
- 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
What are some dietary and lifestyle modifications for the management of symptomatic hemorrhoids?
- Fluid and fiber (dietary/bulk laxatives such as Benefiber and Metamucil)
- Toilet habits
- Sitz bath
What are some conservative management options symptomatic hemorrhoids?
- Stool softeners
- Tucks pads
- Short course of corticosteroid creams or suppositories
- Nitroglycerin ointment
What are some office-based procedure options for management of symptomatic hemorrhoids?
Appropriate for patients refractory to conservative medical therapies
Internal hemorrhoids:
- Rubber-band ligation
- Infrared coagulation
- Sclerotherapy
External hemorrhoids:
- Excision of thrombosed hemorrhoid
What is the most commonly used technique for the treatment of symptomatic bleeding internal hemorrhoids?
Rubber band ligation
When should hemorrhoidectomy be considered?
- 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
What recommendation should all patients with hemorrhoids be counseled on?
Adequate fiber and fluid intake
What is the management for pruritus ani?
- 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
The following description is consistent with what diagnosis?
- Outgrowth of normal skin around the anus
- Loose, flesh-colored, pedunculated tissues
Perianal skin tags
What is the management for perianal skin tags?
Treatment not usually indicated however, patients seek referral for excision if tags interfere with hygiene or cause perianal discomfort
What is an anal fissure?
Linear tear, or split, in the lining of the anal canal distal to the dentate line that causes spasm of the anal sphincters
What is the most common cause of severe anorectal pain?
Anal fissure
What are primary causes of anal fissures?
- Local trauma to the anal canal
- Passage of large hard stools
- Foreign body
What are secondary causes of anal fissures?
- Crohn Disease
- Malignancy
- HIV/AIDS
What is the clinical presentation associated with anal fissures?
- 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
What is the management for anal fissures?
- 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)
What is the pathophysiology of a perianal abscess?
- Originates from obstructed/infected anal crypt gland
- Chronically, can progress to form a fistula
- Can be associated with Crohn Disease
What is the clinical presentation associated with perianal abscess?
- Localized anal or rectal pain
- Erythematous, palpable, tender, fluctuant mass with surrounding edema
- Possible inguinal lymphadenopathy
What is the management of a perianal abscess?
- Incision and drainage
- Possible antibiotics in appropriate patients
- Postoperative treatment of Sitz bath and adequate fluid/fiber intake
What other disorders are anorectal fistulas associated with?
Crohn Disease, radiation proctitis, diverticulitis
What is the clinical presentation associated with anorectal fistulas?
- 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
What diagnostic studies should possibly be ordered for anorectal fistulas?
- MRI pelvis for complex or recurrent fistula
- Colonoscopy if concern for IBD
What is the management of a anorectal fistula?
Surgical (fistulotomy) is mainstay therapy
What is the cause of anal condyloma?
HPV
What is the clinical presentation associated with anal condyloma?
- Asymptomatic, may be pruritic
- Cauliflower like appearance, in clusters or single entities
What is the management for anal condyloma?
- Removal or destruction of visible lesions
- Topical Podofilox
- Topical Imiquimoid cream
- Office treatment with Trichloroacetic acid
- Surgical removal
What are the majority of anal cancers?
Squamous cell cancers
In what populations is the incidence of anal cancer increased?
- Practicing receptive anal intercourse
- History of anorectal condyloma
- History of HPV, HIV
What is the clinical presentation associated with anal cancer?
- 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
How is anal cancer diagnosed?
Biopsy + scope/imaging to determine extent
What is the management of anal cancer?
- Chemoradiotherapy
- Surgery
What is the clinical presentation associated with rectal prolapse?
- 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
What is the mainstay treatment for rectal prolapse?
What other recommendations should be made?
Surgical repair by colorectal surgeon is the mainstay treatment
Prevent constipation, increase fiber/fluid
What are possible causes of rectal prolpase?
- Chronic constipation
- Straining
- Multiparity
- Prior pelvic surgery
What is a rectocele?
Occurs when fascia weakens and allows rectum to bulge into vagina
What are potential causes of a rectocele?
- Vaginal childbirth
- Increasing age
- Increasing BMI
What clinical presentation is associated with rectocele?
- 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
If you are unsure of rectocele diagnosis, what other study could you order?
Defecography
What is the management for a rectocele?
- Surgery
- Pelvic floor muscle training
- Pessary
