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Clin Med 3 > Hernias & Anal Disorders (Hemorrhoids, Fissure, Fistula, Abscess) > Flashcards

Hernias & Anal Disorders (Hemorrhoids, Fissure, Fistula, Abscess) Flashcards

1
Q

what are hemorrhoids?

A

normal vascular structures in the anal canal that arise from arteriovenous connective tissue

WE ALL HAVE HEMORRHOIDS

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2
Q

what do hemorrhoids help with?

A

the passage of stool - act as cushions

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3
Q

when do hemorrhoids become a disease/problem?

A

when they cause symptoms

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4
Q

what determines if hemorrhoids are internal or external?

A

above or below the pectinate line

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5
Q

hemorrhoids epidemiology

A

true prevalence unknown

equal M and F

<b>COMMON IN PREGNANCY</b>

peaks b/w 45-65 (development prior to 20 is rare)

40% are asymptomatic - internal hemorrhoids

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6
Q

where are external hemorrhoids?

A

distal to the pectinate line (dentate line)

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7
Q

where are internal hemorrhoids?

A

located proximal to pectinate line

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8
Q

which type of hemorrhoids has a grading system?

A

internal hemorrhoids (no widely used classification system for external hemorrhoids)

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9
Q

when trying to visualize internal hemorrhoids, what tool do you use?

A

anoscope

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10
Q

Grade I internal hemorrhoids means?

A

visualized on anoscopy may bulge into lumen, but do not prolapse below dentate line

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11
Q

Grade II internal hemorrhoids means?

A

prolapse out of the anal canal with bowel movement or straining but reduce spontaneously

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12
Q

Grade III internal hemorrhoids means?

A

prolapse out of the anal canal with bowel movement and straining and requires manual reduction

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13
Q

Grade IV internal hemorrhoids means?

A

irreducible and may strangulate

-can’t push back in

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14
Q

where are hemorrhoids located?

A

in the submucosal layer in the lower rectum

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15
Q

can internal and external hemorrhoids coexist?

A

YES! BOTH OFTEN COEXIST

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16
Q

which type of hemorrhoid NOT painful? innervation?

A

internal hemorrhoids are NOT sensitive to pain, touch or temp b/c they are VISCERALLY INNERVATED

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17
Q

why are external hemorrhoids painful?

A

b/c external hemorrhoids are covered by modified squamous epithelium which contains somatic pain receptors

they are painful especially with thrombosis (when they form a clot)

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18
Q

hemorrhoids risk factors

A

advanced age, diarrhea, pregnancy (increasing weight on pelvis), pelvic tumors, prolonged sitting, straining, chronic constipation, anticoagulation

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19
Q

hemorrhoids clinical manifestations

A
  • 40% of internal hemorrhoids are asymptomatic
  • ALMOST ALWAYS PAINLESS BLEEDING ASSOCIATED WITH BOWEL MOVEMENT (internal hemorrhoids)
  • BRBPR
  • fecal incontinence
  • sensation of fullness in perianal area
  • irritation or itching of perianal skin
  • pain associated with thrombosis (for external hemorrhoids)
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20
Q

pathophysiology of hemorrhoids

A

internal hemorrhoids - engorgement of venous plexus originating from superior hemorrhoid vein proximal to the pectinate line

external hemorrhoids - engorgement of venous plexus originating from inferior hemorrhoid veins distal to the pectinate line

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21
Q

hemorrhoids dx

A

hx

  • if pain with bowel movement and no thromboses hemorrhoid may be something else
  • fever, night sweats, weight loss -> may be colon cancer

PE
Anoscopy
DRE - should always do one

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22
Q

what do internal hemorrhoid bundles look like on anoscopy?

A

bulging purplish-blue veins

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23
Q

what do prolapsed internal hemorrhoids look like on anoscopy?

A

dark pink, glistening, sometimes tender

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24
Q

what do thromboses external hemorrhoids look like on anoscopy?

A

acutely tender, purplish-blue color

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25
Q

tx for irritation or puritus of hemorrhoids

A
  1. Hydrocortisone rectal creams (Anusol-HC, Preparation-H, Proctosol)
  2. Hydrocortisone rectal suppository
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26
Q

tx of hemorrhoids with astringents and protectants

A
  1. witch hazel - tucks, prep-H pads
  2. zinc oxide topical paste - Destine, Boudreaux’s butt paste

good for irritation or puritus

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27
Q

tx of hemorrhoids with anesthetics

A

good for external hemorrhoids b/c of pain

  1. benzocaine
  2. dibucaine
  3. pramoxine
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28
Q

do external hemorrhoids usually require surgery?

A

no!

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29
Q

tx for thrombosed external hemorrhoids >72 hours

A

> 72 hours - conservative measures - Clot organizes and contracts lessening six’s (will eventually absorb and get better)

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30
Q

tx for thrombosed external hemorrhoids <72 hours

A

excision and clot evacuation, but high recurrence so need to use wide surgical excision

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31
Q

what grade of internal hemorrhoids requires surgical excision?

A

Grade IV - irreducible and may strangulate

-start to have pain with Grave IV (grades 1-3 are painless bleeding)

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32
Q

internal hemorrhoids management

A

rubber band ligation - most common

sclerotherapy

hemorrhoidectomy

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33
Q

what is rubber band ligation?

A

tx of internal hemorrhoids

most commonly used technique for symptomatic bleeding of internal hemorrhoids

effective, easy, no complications

FOR GRADE II OR III

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34
Q

what is sclerotherapy for internal hemorrhoids management?

A

injectable sclerosant (inject sclerosant right into the hemorrhoids)

  • phenol in vegetable oil
  • sodium morrhuate
  • quinine

good for grades I and II bleeding internal hemorrhoids

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35
Q

what is hemorrhoidectomy?

A

tx of internal hemorrhoids

  1. conventional - remove hemorrhoids using scalpel, scissors or electrosurgical device
  2. stapled - excises a part of the anal mucosa
  3. hemorrhoidal artery ligation - hoppler guided

USED FOR ALL STAGE IV OR THOSE NO RESPONSE TO THE OTHER THERAPIES

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36
Q

what are anal fissures?

A

PAINFUL LINEAR TEAR/CRACK IN THE DISTAL ANAL CANAL

common benign anorectal diseases

common cause of anal pain and bleeding

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37
Q

anal fissures epidemiology

A

most often affects infants and middle-age individuals

vasty majority (90%) of anal fissures are located posterior midline

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38
Q

what are a majority of anal fissures (primary or secondary) and what are they caused by?

A

majority of anal fissures are primary

caused by local trauma:

  • constipation
  • diarrhea
  • vaginal delivery
  • anal sex
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39
Q

primary anal fissures are caused by what?

A

caused by local trauma:

  • constipation
  • diarrhea
  • vaginal delivery
  • anal sex
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40
Q

secondary anal fissures are caused by what?

A
  • crohn’s disease
  • granulomatous disease (sarcoidosis, TB)
  • malignancy
  • infectious diseases (HIV, Chlamydia, Syphilis)
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41
Q

pathology of anal fissures

A

start with a tear in the anoderm within the distal half of the anal canal

tear triggers cycles or recurring pain and bleeding - chronic

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42
Q

anal fissures clinical presentation

A
  • anal pain at rest
  • pain exacerbated by bowel movements causing pt to refrain from having BM leading to constipation
  • BRBPR - anal bleeding
  • longitudinal tear
  • chronic fissures have raised edges - not as painful
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43
Q

what classifies acute vs chronic anal fissures?

A

acute sx < 8 weeks

chronic > 8 weeks

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44
Q

where are most anal fissures located?

A

posterior midline

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45
Q

anal fissures dx

A
  • hx of anal pain brought on by BM and lasting hours after
  • associated with some bleeding
  • confirmed by PE (see a tear)
  • anoscopy not helpful (b/c see what is on the outside)
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46
Q

anal fissures medical management

A
  • fiber, stool softener/laxative (if pt has constipation)
  • sitz bath (keeps area clean)
  • topical analgesics
  • topical vasodilators (make it easier for stool to pass) - nifedipine, nitroglycerin
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47
Q

what topical vasodilators can you treat anal fissures with?

A

nifedipine or nitroglycerin

make it easier for stool to pass

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48
Q

anal fissures surgical management

A
  • Sphincterectomy - lateral internal sphincter (fecal incontinence is the major complication)
  • Botox injection - relaxes hypertonic anal sphincter
  • Fissurectomy - excision of anal skin affected
  • Anal advancement flap
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49
Q

what is a major complication of a spincterectomy when treating anal fissures?

A

fecal incontinence

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50
Q

what are the 2 types of anal abscesses?

A

perianal and perirectal abscesses

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51
Q

what is an anal abscess caused by?

A

infection most often from obstructed anal crypt gland (glands that help lubricate the anus for the passage of stool)

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52
Q

anal abscess vs anal fistula

A

anal abscess is acute phase

anal fistula is chronic phase

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53
Q

anal abscess epidemiology

A

men are 2x more likely to develop

mean age of 40 y/o

30-40% of pts w/ an abscess also have a fistula b/c didn’t seek care

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54
Q

what is a perianal abscess?

A

when abscess transverses into the perianal skin

55
Q

what is a perirectal abscess?

A

when abscess transverses into other spaces (not the perianal skin)

56
Q

what is the difference in management of perirectal and perianal abscesses?

A

different in the way they are drained

57
Q

classifications of anal abscesses (HINT: 3)

A
  1. ischiorectal (sischioanal)
  2. intersphincteric
  3. supralevator
58
Q

ischiorectal (ischioanal) anal abscess

A

penetrates thru the external anal sphincter into ischiorectal space (pt will have sx’s on the outside and you can see the abscess)

presents as a diffuse, tender, indurated and fluctuant area within the buttocks

drain thru the skin

59
Q

intersphincteric anal abscess

A

can’t feel on outside

located in the intersphincteric groove b/w the internal and external sphincters

usually don’t cause perianal skin changes

found on DRE

60
Q

supralevator anal abscess

A

found on DRE (can’t see on outside)

may originate from pelvic infection or crypt gland infection

patients present with severe perianal pain, fever, and sometimes urinary retention

may have fluctuant area on DRE

CT usually needed to establish dx

61
Q

patient presentation of supralevator anal abscess

A

severe perianal pain, fever, and sometimes urinary retention

62
Q

patient presentation of ischiorectal (ischioanal) anal abscess

A

diffuse, tender, indurated and fluctuant area within the buttocks

63
Q

anal abscess clinical manifestations

A
  • severe pain in the anal or rectal area that is worse with sitting
  • PAIN IS CONSTANT UNTIL ABSCESS IS DRAINED
  • pain not associated with bowel movement
  • fever, malaise (can turn into sepsis)
  • purulent rectal drainage if abscess has begun to drain
  • indurated area w/erythema, tenderness, and fluctuant (superficial)
  • fluctuant mass externally or on DRE (deeper)
64
Q

anal abscess dx

A
  • hx, PE
  • DRE
  • CT or transperitoneal or endorectal ultrasound if abscess is higher up in rectum
65
Q

what can happen if an undrained abscess isn’t drained?

A

can continue to expand and cause sepsis

66
Q

what is the Gold Standard tx for anal abscess?

A

surgical drainage

67
Q

how can a perianal abscess be drained?

A

through a skin incision

68
Q

how can a perirectal abscess be drained?

A

more complex than perianal and drained in OR

69
Q

how can an ischiorectal abscess be drained?

A

through a skin incision

70
Q

how can an intersphincteric abscess be drained?

A

through the rectum in the OR

71
Q

how can a supralevator abscess be drained?

A

through skin incision if abscess extends from ischiorectal space

in or through the rectum if from a pelvic infection

most often drained in the OR

72
Q

anal abscess tx

A

antibiotics

  • Augmentin
  • Cipro and Metronidazole

conflicting data on abc use but good to use on pts esp if DM, signs of sepsis, prosthetic valves

73
Q

what is an anal fistula?

A

chronic manifestation of an acute perirectal process that forms an anal abscess

abscess ruptures or is drained and an epithelialize track can form that connects the abscess to the perirectal skin

fistula-in-ano

74
Q

anal fistula epidemiology

A

adult males 2x more likely to develop

mean age at presentation is 40 y/o

75
Q

what is the most common cause of an anal fistula?

A

an infected anal crypt gland

76
Q

other (not most common) causes of an anal fistula?

A

crohn’s disease, infection caused by chlamydia, radiation proctitis (pelvic radiation), rectal foreign bodies, actinomycosis, obstetric injury

77
Q

anal fistula clinical presentation

A
  • usually present with a non healing anorectal abscess following drainage (get them drained, but don’t heal/reform)
  • intermittent rectal pain esp w/BM, sitting, and activity
  • malodorous perianal drainage
  • perianal skin excoriated and inflamed
  • external opening may be visualized
  • may feel a palpable cord leading to opening
78
Q

what is the usual presentation of a pt with an anal fistula?

A
  • usually present with a non healing anorectal abscess following drainage (get them drained, but don’t heal/reform)
  • malodorous perianal drainage
79
Q

how many classifications are there for anal fistulas? how many parks classifications?

A

5 classifications, 4 parks

80
Q

what is an intersphincteric anal fistula?

A

PARKS TYPE 1

starts at the dentate line and ends at anal verge

81
Q

what is a transphincteric anal fistula?

A

PARKS TYPE 2

tracks through the external sphincter into ishiorectal fossa

82
Q

what is a suprasphincteric anal fistula?

A

PARKS TYPE 3

originates at anal crypt and terminates in ishiorectal fossa

83
Q

what is an extrasphincteric anal fistula?

A

PARKS TYPE 4

high in the anal canal terminates in the skin overlying the buttocks

84
Q

what is a superficial anal fistula?

A

not in parks classification

DOES NOT INVOLVE ANY SPHINCTER MUSCLE

85
Q

anal fistula dx

A
  • characteristic findings
  • good history
  • imaging can be helpful with complex fistulas esp those associated with Crohn’s disease (do pelvic CT)
86
Q

what is the goal of surgical therapy of anal fistulas?

A

to eradicate the fistula while maintaining fecal continence

87
Q

what does the surgical approach of anal fistulas depend on?

A

depend on classification of anal fistula

follow GOODSALL’s rule (determines surgical management)

88
Q

what is GOODALL’s Rule and what does it say?

A

it determines the surgical management of anal fistulas

says that anterior anal fistulas go radially and posterior anal fistulas travel in a curvilinear fashion to the posterior midline

89
Q

what is the management of anal fistulas?

A
  • fistulotomy (cut open entire fistula and suture the sides)
  • fibrin sealant (seal up fistula)
  • fistulotomy and setons (scaring and tearing out fistula)
  • advancement flap (with fibrin seal)
90
Q

what is pilonidal disease?

A

abscess/cyst

infection of the skin and subcutaneous tissue in the upper part of natal cleft (gluteal cleft)

extends from just below the sacrum to the perineum

acute and chronic disease b/c recur if cut open

91
Q

pilonidal disease epidemiology

A

MC in white males, obese, prolonged sitting & local trauma

rare over the age of 45 and rare in children

21 years for men
19 years for women

men affected 2-4x more

92
Q

pilonidal disease risk factors

A
  • overweight/obesity
  • local trauma
  • sedentary lifestyle
  • prolonged sitting
  • deep natal cleft
  • family history
93
Q

pilonidal disease pathology

A
  • hair & inflammation are contributing factors
  • bending or sitting stretches natal cleft skin
  • damaging and breaking hair follicles and opening pore or pits
  • pores collect debris/hair and become infected
  • forms tracts
94
Q

pilonidal disease clinical presentation acutely

A

-variable (from asymptomatic to chronic inflammation and drainage)

acutely:

  • mild to severe intergluteal pain while sitting
  • drainage
  • fever, malaise with undrained abscess
  • tender, red mass
95
Q

pilonidal disease clinical presentation chronic

A
  • recurrent persistent gluteal pain
  • drainage
  • tender, red mass

***MOST OFTEN CHRONIC WILL HAVE GLUTEAL PAIN W/OUT TENDER RED MASS

96
Q

pilonidal disease dx

A

-clinical, hx, PE

differential pilonidal disease from perirectal disease

97
Q

pilonidal disease tx

A

I&D then pack with gauze

  • local anesthesia
  • but tend to recur

when recur -> excise

98
Q

are abx needed for pilonidal disease?

A
  • most simple acute abscess don’t need abx
  • use abx if surrounding cellulitis, high-risk endocarditis, immunosuppression, dirty wound

USE CEFAZOLIN PLUS METRONIDAZOLE

99
Q

what abx do you use for pilonidal disease?

A

cefazolin plus metronidazole (but only if surrounding cellulitis, high-risk endocarditis, immunosuppression, dirty wound)

100
Q

what are the 2 types of hernias?

A

groin hernias (inguinal and femoral)

abdominal wall or ventral (incisional and umbilical)

101
Q

what is a hernia?

A

protrusion of an organ thru a body wall which normally contains it

102
Q

which type of groin hernia is most common?

A

inguinal hernias are more common than femoral

103
Q

which type of groin hernia presents with more complications?

A

femoral hernias present with more complications b/c smaller area (incarceration, strangulation)

104
Q

groin hernias epidemiology

A

3rd leading cause of ambulatory care visits for GI complaints

more common in whites and males

women present at ages 60-79/men 50-69

indirect is the most common

105
Q

what is the most common type of inguinal hernia?

A

indirect inguinal hernia

106
Q

what type of groin hernia do old ladies most commonly get?

A

femoral hernias

107
Q

risk factors of groin hernias

A
  • hx of hernia or prior repair
  • older age
  • male
  • caucasian
  • chronic cough (b/c of pressure build up in abd cavity)
  • chronic constipation
  • abd wall injury
  • smoking
  • fam hx of hernia
108
Q

etiology of groin hernias

A

congenital - abnormal development in utero

acquired - wearing or disruption of the fibromuscular tissues of the body

109
Q

direct inguinal hernia?

A

protrude medial to inferior epigastric vessels w/in Hesselbach’s triangle

due to weakness in the floor of the inguinal canal

110
Q

indirect inguinal hernia?

A

protrude at the internal inguinal ring (lateral to the inferior epigastric artery)

MC type of hernia overall
MC in men

111
Q

femoral hernia?

A

protrude thru the femoral ring

112
Q

borders of Hesselbach’s triangle?

A

medial: rectus abdominis
lateral: inferior epigastric vessels
inferior: inguinal ligament

113
Q

groin hernias clinical manifestations

A
  • bulge in the groin
  • heaviness or dull discomfort int he groin usually at the end of the day or w/straining
  • mod-severe pain w/incarceration or strangulation
114
Q

where are a majority of hernias located?

A

2/3 of hernias are located on the right side

115
Q

groin hernias dx

A
  • hx
  • PE (best done while pt standing b/c of gravity)
  • males - finger in external ring
  • females - small hernias may need us to identify
116
Q

what is hernia incarceration?

A

trapping of hernia contents w/in the hernia sac such that reducing them back into the abdomen is not possible

SURGICAL EMERGENCY!!!

WILL LEAD TO STRANGULATION IF NOT TREATED

117
Q

what is hernia strangulation?

A

ischemic incarcerated hernias with systemic toxicity (irreducible hernia w/compromised blood supply)

ischemia and necrosis of the hernia contents

SURGICAL EMERGENCY!!!

118
Q

what is the treatment of choice for groin hernias?

A

definitive treatment is surgical repair (one of the most commonly performed operations)

119
Q

groin hernias tx triage

A

use to watch and wait if pt asymptomatic

complicated w/strangulation - 4-6 hrs of symptom onset

uncomplicated femoral & inguinal hernias w/or w/out six’s - elective repair recommended

120
Q

what is the only non-surgical approach to treating groin hernias?

A

a truss - similar to a jockstrap, holds things up

121
Q

types of abdominal wall hernias

A

epigastric, umbilical, spigellian, parastomal and incisional

122
Q

what are epigastric & umbilical hernias?

A

they are primary VENTRAL hernias

123
Q

spigellian and parastomal hernias occur where?

A

off midline

124
Q

incisional hernias due to what?

A

due to previous sugery

125
Q

umbilical hernia tx

A

<2 cm can be repaired with simple sutures w/or w/out mesh

REPAIRING W/MESH AS BETTER OUTCOMES

126
Q

incisional hernia tx

A

<2 cm recommended repair with mesh

127
Q

ventral hernias b/w 2-10 cm require what for tx?

A

a mesh

128
Q

hernias >10 cm tx

A

classified as larger hernias and difficult to repair

129
Q

types of mesh

A

synthetic or biologic (derived from human or animal tissue)

130
Q

mesh locations

A

onlay - placed above fascia

inlay - b/w fascia

sublay - b/w rectus muscles and peritoneum (LAP only)

underlay - intraperitoneum

LOCATION DETERMINED BY SIZE, PT, AND SURGEON

131
Q

what type of surgery for large or complex hernias >10 cm?

A

component separation surgery for large or complex hernias

open or lap

132
Q

recurrence of abdominal hernias

A
  • rate of recurrence depends on size and type of repair
  • RECURRENCE USUALLY D/T IMPROPER PLACEMENT OR FIXED MESH
  • lap repair associated w/reduced rates of recurrence
  • simple suture repairs associated w/extremely high recurrence
133
Q

is it better to have a mesh when repairing abdominal hernias?

A

yes!!! if just suture and don’t use mesh, then there is a high rate of recurrence!!!

Clin Med 3 (21 decks)

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