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Clin Med III Exam I > Hernias and Anal Disorders > Flashcards

Hernias and Anal Disorders Flashcards

1
Q

Where do hemorrhoids arise from

A

ateriovenous connective tissue

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2
Q

What are hemorrhoids? What is the function?

A

normal vascular structures in the anal canal that help with the passage of stool

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3
Q

External hemorrhoids

A

distal to the dentate line

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4
Q

Internal hemorrhoids

A

proximal to the dentate line

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5
Q

Mixed hemorrhoids

A

both proximal and distal to the dentate line

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6
Q

Grading system is used for what type of hemorrhoids

A

internal

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7
Q

Grade I

A

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

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8
Q

Grade II

A

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

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9
Q

Grade III

A

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

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10
Q

Grade IV

A

irreducible and may strangulate

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11
Q

Where are hemorrhoids located

A

submucosal layer in the lower rectum

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12
Q

Are internal hemorrhoids painful? Why

A

No because they are viscerally innervated

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13
Q

Are external hemorrhoids painful? Why

A

Yes because they are covered by modified squamous epithelium which contain somatic pain receptors

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14
Q

What is the clinical manifestation always associated with hemorrhoids

A

painless bleeding with BM

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15
Q

Other possible clinical manifestations of hemorrhoids

A
  • BRBPR
  • fecal incontinence
  • itching or irritation of perianal skin
  • sensation of fullness in perianal area
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16
Q

When are hemorrhoids most painful

A

when they thrombos

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17
Q

What do internal hemorrhoid bundles look like on anoscopy? Prolapsed internal hemorrhoids? Thrombosed external hemorrhoids?

A

internal bundles- bulging purpleish-blue veins

prolapsed internal- dark pink, glistening, sometimes tender

thrombosed- acutely tender, purpulish- blue color due to clot inside them

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18
Q

Three main categories for external hemorrhoid treatment

A
  • irritation or puritis
  • astringents and protectants
  • anesthetics
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19
Q

What is used to treat irritation or puritis with hemorrhoids

A

hydrocortisone cream or suppositories

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20
Q

What is used as astringents and protectants in patients with hemorrhoids

A
  • witch hazel

- zinc oxide topical paste

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21
Q

What anesthetics are used for patients with hemorrhoids

A

benzocaine, dibucaine, pramoxine

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22
Q

How do you treat thrombosed external hemorrhoids

A

> 72 hours- conservative measures because clot contracts and lessens sx

<72 hours- excision and clot evacuation

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23
Q

What do you have to do when removing a clot from a thrombosed external hemorrhoid

A

make a large incision so the clot does not reform

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24
Q

Rubber band ligation is treatment for what

A

grade II or III internal hemorrhoids (most common used for bleeding symptomatic hemorrhoids)

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25
How does rubber band ligation work
rubber band is shot onto the hemorrhoid and it strangulates it so the hemorrhoid falls off
26
When is sclerotherapy treatment indicated for hemorrhoid treatment
grade I and II bleeding internal hemorrhoids
27
What are the sclerosing agents used in sclerotherapy
all injectable - pehnol - sodium morrhiuate - quinine
28
What are the three types of hemorrhoidectomies
Conventional- removed using scalpel, scissors or electrosurgical device Stapled- excises part of anal mucosa Hemorrhoidal artery ligation- doppler guided USED FOR INTERNAL
29
Where are most anal fissures located
posterior midline
30
Primary causes of anal fissures
TRAUMA - constipation - diarrhea - vaginal delivery - anal sex
31
Secondary causes of anal fissures
- chrons disease - granulomatous disease (sarcoid, TB) - malignancy - infections disease (HIV, chlamydia, syphilis)
32
When is an anal fissure considered chronic
lasts longer than 8 weeks
33
How do anal fissures start
tear in the anoderm withing the distal half of the anal canal
34
Clinical presentation of anal fissures
- anal pain at rest | - longitudinal tear (may look like paper cut)
35
What differentiates a chronic anal fissure from n acute anal fissure
chronic fissures have raised edges and are not as painful
36
Medical management of anal fissures
- fiber - stool softener/laxative - sitz bath - topical analgesics - topical vasodialtors (nifefipine/nitroglycerine)
37
Surgical management of anal fissures
``` -spincterectomy (lateral inte rnal sphincter) -botox injection -fissureectomy -anal advancement flap ```
38
Most common cause of anal abscess
obstructed crypt gland
39
What is the chronic phase of an anal abscess
fistula
40
What is a perianal abscess
abscess that transverses into the perianal skin
41
What is a perirectal abscess
abscess that transverses into another location other than perianal skin
42
Ishiorectal abscess
penetrates through external anal sphincter into ishiorectal space
43
How does an ishiorectal abscess present
diffuse, tender, indurated and fluctuant area withing the buttocks
44
Interspincteric abscess
located in the interspincteric groove between the internal and external sphincters
45
How are interspincteric abscesses found
DRE
46
Where does a supralevator abscess originate from
pelvic infection or crypt gland infection
47
How does a patient with a supralevator abscess present
severe perianal pain, fever, urinary retention
48
What is needed to diagnose a supralevator abscess
CT
49
Clinical manifestations of anal abscesses
- constant pain - fever, malaise - purulent rectal drainage is abscess has begun to drain - indurated, erythematous, fluctuant mass
50
Treatment of anal abscess
surgical drainage
51
Which abscess can be drained through a simple skin incision
perianal, ischiorectal, supralevator is extends from ischiorectal space
52
Which abscess have to be drained in the OR
perirectal, interspincteric, supralevator if from a pelic infection
53
ABX for anal abscesses. When do you use them?
augmentin or cipro plus metronidazole use if pt has DM, sepsis, fake heart valves or is immunosuppresssed
54
Clinical presentation of anal fistula
- nonhealing anorectal abscess following drainage - rectal pain with BM, sitting and activity - malodorous perianal drainage
55
Intersphincteric fistula
starts at the dentate line and ends at anal verge Parks type 1
56
Transphincteric fistula
tracks through the external sphincter into ishiorectal fossa Parks type 2
57
Suprasphincteric fistula
originates at anal crypt and terminates in ishiorectal fossa Parks type 3
58
Extrasphincteric fistula
high in the anal canal, terminates in the skin overlying the buttocks Parks type 4
59
Superficial fistula
does not involve any sphincter muscle
60
When is imaging done with anal fistulas
when complex or associated with chrons disease Abdomen pelvis CT
61
Management of anal fistula
SURGERY - fistulotomy - fibrin sealant - fistulotomy and seatons - advancement flap - advancement flap with fibrin seal
62
Goodsalls rule
all fistula tracts with openings posterior to transverse anal line travel in a curvilinear fashion and all tracts anterior to the line travel in a radial fashion
63
What is pilonidal disease
infection of the skin and SQ tissue in the upper part of the natal cleft
64
What are some risk factors for pilonidal disease
- obesity - sedentary lifestyle - trauma - deep natal cleft - family history
65
How does pilonidal disease occur
damage to hair follicles and opening of pores or pits--> debris collects in the opening and leads to infection-->form tracts
66
Presentation of acute pilonidal disease
- intergluteal pain while sitting - drainage - fever, malaise if untreated - tender, red mass
67
Presentation of chronic pilonidal disease
- recurrent gluteal pain - drainage - tender, red mass
68
How do you treat pilonidal disease
I&D or surgical management for chronic (excision, primary closure, off midline closure, Z plasty, V-Y advancement flap)
69
When do you give ABX to a patient with pilonidal disease. And what do you give?
- surrounding cellulitis - high risk endocarditis - immunosuppression - dirty wound Cefazolin plus metronidazole
70
What types of hernias are considered groin hernias
inguinal and femoral
71
What types of hernias are considered abdominal wall/ventral hernias
incisional and umbilical
72
What is a hernia
protrusion, bulge or projection of an organ through a body wall which normally contains in
73
What is the most common type of groin hernia
inguinal
74
Which type of groin hernia presents with more complications
femoral
75
What are some risk factors for hernias
- hx of hernia or prior repair - male sex - Caucasian - abdominal wall injury - family hx
76
Etiology of hernias
congenital or acquired
77
What is a direct hernia
protrude medial to interior epigastric vessels within hesselbach's triangle
78
What is an indirect hernia
protrude at the internal inguinal ring
79
What is a femoral hernia
protrudes through femoral ring
80
What makes up Hesselbach's triangle
inferior epigastric A&V inguinal ligament rectus abdominus
81
Clinical manifestations of hernias
- bulge in the groin | - heaviness or dull discomfort in the groin
82
How should you preform the physical exam if you suspect a patient has a hernia
with the patient standing
83
What is incarceration
trapping of hernia contents within the hernia sac such that reducing them back into the abdomen is not possible
84
What is strangulation
result of incarceration--> ischemia and necrosis of the hernia contents
85
Management of hernia
SURGERY
86
What is the only non surgical management for hernias
a truss for men | like a jockstrap, holds everything up
87
What are the surgical approaches to repairing hernias
- open - laparoscopic - open tension free mesh - open primary tissue approximation non mesh
88
Which hernias are ventral hernias
epigastric and umbilical
89
Which hernias occur off the midline
spigelian and parastromal
90
What causes incisonal hernias
previous surgery
91
Repair of an umbilical hernia <2cm
simple sutures with or without mesh
92
Repair of incisional hernia <2cm
mesh
93
Repair of ventral hernias between 2-10cm
MESH required
94
What classifies a hernia as a large hernia
hernia >10cm, difficult to repair
95
What are the two categories of mesh
synthetic or biologic
96
What are the 4 locations mesh can be placed during hernia repair
onlay: placed above fascia inlay: between fascia sublay: between rectus muscles and peritoneum (lap only) underlay: intraperitoneum
97
What type of surgery is done for complex or large hernias
component separation surgery | need to advance the muscle with the mesh
98
What is recurrence of hernias typically due to
- improper placement or fixed mesh - open repair - simple suture repair

Clin Med III Exam I (9 decks)

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