FI Flashcards by R R

6 components necessary to maintain anal continence

stool consistency
bowel transit
rectal capacity/compliance
rectal sensation/sampling reflex
pelvic floor muscle integrity
competent anal sphincters

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Internal anal sphincter

how think is it?
how much does it contribute to the resting tone?

70%

external anal sphincter provides 30% of the resting

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What innervates the external anal sphincter

inferior rectal branch of the pudendal nerve

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what is a normal anorectal angle at rest?

95 degrees

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what is a normal anorectal angle during a voluntary contraction?

75 degree

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what is a normal anorectal angle with BM?

110 - 130 degrees

loss of puborectalis impression
funneling of anorectum

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MRI for FI

describe the scoring of levator ani injuries on MRI?

Each side is scored separately on a scale of 0 to 3

0 = no defect
3= complete loss

0-3 is minor
4-6 is major

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What supplies motor innervation to the puborectalis?

sacral plexus S3, S4 and inferior rectal nerve

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what mediates the sympathetic innervation of the IAS?

postganglionic fibers of hypogastric n.

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what nerves mediates the parasympathetic innervation of the IAS?

preganglionic fibers of the sacral n.

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describe the hemorrhoid grading system.

Internal - above the dentate line

grade I- no bleeding without prolapse
grade II- prolapse with spontaneous reduction
grade III- prolapse with manual reduction
grade IV- incarecated, irreducible prolapse

external - below dentate line

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describe the components of the digital rectal exam

-resting tone
-voluntarily squeeze lasting 5 sec.
Valsalva to assess relaxation of puborectalis
-involuntary contraction with cough
-pain, fissures, hemorrhoids,
-consistency of the stool
-assess for enterocele with valsalva
-masses or lesions

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How does Loperamide
work?

opiod recepter agonist–> decreases activity of myenteric plexus in small intestines–>this causes smooth muscle relaxation which increases water absorption

-it also inhibits gastrocolic reflex

Treats diarrhea

2-8mg dose

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does loperamide cross the BBB?

SE of loperamide

dry mouth, constipation

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Could SNM work for someone with anal sphincter tear?

yes, studies included patients with tears up to 120 degrees.

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OASI repair
suture type?
abx?
bowel regimen?

PDS or other absorbable
cefazolin
laxitives.

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Name the Rome III criteria to dx constipation

2 or more of the following:
-straining at least 25% of BM
-hard stool at least 25% of BM
-sensation of anorectal blockage at least 25% of the time
-manual maneuvers for BM at 25% of the time
-fewer than 3 BM per week
-insufficient criteria for IBS

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how is a transit study performed?

-24 markers in on tablet
-x-ray on day 5
-At least 80% should have been expelled
-if more than 6 markers are left, then its either slow transit or obstruction

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How many grams of fiber is recommended per day?

20-35g

How does fiber work to increase stool volume?

stool is mostly bacteria, fiber provides a substrate to increase bacteria growth, thereby increases the volume of stool

undigested fiber absorbs fluid

Name three categoroies of laxitives

bulk laxatives like fiber
osmotic laxatives like mag citrate or polyethylene glycol,
3, stimulant laxatives like senna and biscodyl
pharmacotherapy- refer to GI

how do you dx dyssynergia?

MR defecography
digital rectal exam

what is the bubble test for fistula?

put water in the vagina and push air into the rectum. you will see bubbles in the vagina

classification of Fistula

-high
-midlevel
-low

-small vs large

high- apical
midlevel-above the sphincter
low-involves sphincter or distal

small is <2.5 cm
large >/= 2.5cm

You dx a RVF in office. What is your next step in evaluation? Imaging?

Needs BX to rule out cancer. -either referral for scope with bx or perform your own. or send the tract for pathology when excised in the OR. -CT A/P with and without contrast -MR enterography

Describe the steps to RVF repair.

1. Inspection- sphincter involved or not 2. incision-inverted U on the posterior vagina or proctoepisiotmy 3. Mobilization and visualization of the relevant muscles: rectal mucosa, internal anal sphincter, levator ani muscles, external anal spinchter, transverse perenei, bulbocavernous 4. Tension free Reapproximation of the rectal mucosa, levator ani muscles, end to end sphincteroplasty. -bulbocavernosous transposition flap or gracilis flap 5. Skin closure. U or Z flap

What kind of post op restrictions would you give for post RVF repair?

pelvic rest no lunges no prolonged sitting Diet- low residue diet with stool softener

What is a low residue diet?

low fiber avoid raw fruits and veggies, avoid whole grains, legumes, popcorn

Give some examples of insoluble fiber. Why does the type of fiber matter?

green leafy vegetables, whole grains, whole wheat insoluble fiber attracts water into the intestines to increase stool frequency and help with constipation

Give some examples of soluble fiber. Why does the type of fiber matter?

fruits, oats, beans, Dissolves in water to form a gel and slow motility, Helps with diarrhea Metamucil-psyllium fiber

How many grams of fiber is considered a high fiber diet?

25-35 grams

How much water should one be drinking per day?

32-50 oz per day

Components of a digital rectal exam

1. sphincter resting tone and squeeze, symmetry 2. length- 3-4 cm 3. strength of puborectalis 4. angle of anorectal angle 5. elevation of the perineum during voluntary squeeze which shows integrity of the rectal vaginal septum 6. Valsalva to assess relaxation of the puborectalis

What information can you gather from an anal manometry?

1. anal canal length 2. anal sphincter pressure with rest and squeeze 3. rectal sensation and compliance 4. presence or absense of RAIR 5. Balloon expulsion test (<60s)

What are the components of the RAIR reflex?

rectoanal inhibitory reflex relaxation of the IAS when the rectum is distended so you can sample the stool 1. Rectum distends 2. Anal sampling - IAS relaxes >25% drop in resting pressure 3. IAS re-engages to 2/3 of resting pressure 4. EAS engages to keep the stool in

risk factors for FI

advanced age diarrhea urinary incontinence vaginal deliveries sphincter injury obesity pelvic rad diabetes (metformin) IBS/IBD

Patient presents with fecal seepage. What dietary change do you recommend and why does this work?

stool bulking bc bulkier stool can trigger the RAIR reflex which engages the external anal sphincter and allows for stool sampling.

4 sub types of rectal dyssynergia

Type 1: good valsalva with paradoxical anal sphincter squeeze Type 2: no valsalva with paradoxical anal sphincter squeeze Type 3: good valsalva with absent or little anal sphincter relaxation Type 4: poor valsalva with absent or little anal sphincter relaxation

you get anal manometry on a patient and the RAIR is absent. What is your next step?

recommend biopsy to rule out Hirschsprung

list the diagnostic criteria for defecatory dyssynergia

1. dx of constipation or IBS-C 2. Manometry or EMG evidence of dyssynergia pattern 3. abnormal balloon, defecography, transit study

Describe the sequence of events for normal defecation.

1. sensory preception of stool 2. rectal distention 3. contract diaphragm, abd, rectum 4. relax EAS 5. relax puborectalis muscles

treatment for rectal dyssynergia

-PFPT with biofeedback -stress management -fiber, water, exercise

name insoluble fiber supplement

citrucel

linaclotide MOA SE

MOA- GC-C agonist- binds to receptor in the intestines, increased fluid in GI tract, leading faster colonic transit SE- FI, fecal urgency

Compare sphincteroplasty to SNM for FI

sphincteroplasty initial improvement 85% 5-10 years, 50% with fair improvement SNM 86% after at least 50% improvement 40% have no FI at 3 years.

risk of FI if they have a second OASI what if they have a third OASI?

13% 24%

Q cyrptoglandurla abscess in the anal canal -tumor necrosis enarteritis obliterans -keratinization of epithelial tract