L8: Anorectal disease Flashcards
The lower 4 cm of the rectum contains
anal sinus
anal column
anal crypt
anal gland
Pectinate line aka
dentate line
Red flags that need an ASAP referral to GI/Colorectal
Unintentional weight loss
Fe deficiency anemia
Personal or family history of IBD or colorectal cancer
Persistent anorectal bleeding or anorectal symptoms despite adequate treatment of a suspected benign condition
Who gets hemorrhoids?
Common, M=F, 45-65 years
Hemorrhoids are…
A normal vascular structure. They’re symptomatic when the anal cushions deteriorate
Hemorrhoid grading
Grade I: Bulge in anal canal w/o prolapse
Grade II : Prolapse, reduces spontaneously
Grade III: Prolapse, manual reduction
Grade IV: Chronic prolapse, irreducible
Which kind of hemorrhoids hurt?
External hemorrhoids, as they’re distal to the dentate line. Internal hemorrhoids are painless.
Hemorrhoids presentation
Bleeding with BM, usually bright red \+/- fecal incontinence \+/- mucoid discharge \+/- pruritus Thrombosed→ acute perianal pain and palpable “lump” Prolapse→ sensation of perianal fullness
If your patient has hemorrhoid pattern bleeding, you have to…
AT LEAST get them sigmoidoscopy to rule out other anorectal pathology
Colonoscopy better
Your hemorrhoid pattern bleeding patient def needs a colonoscopy if….
IBD or malignancy
(constitutional symptoms,
anemia, change in BMs, FH IBD/CRC)
Indications for hemorrhoidectomy
Persistent symptoms despite conservative measures or office-based procedures
Symptomatic grade III hemorrhoids
Grade IV internal hemorrhoids
Extensive pain from thrombosed external hemorrhoids
Conservative management of hemorrhoids
Stool softeners
+/- Topical agents→ symptomatic relief
→ Tucks Pads
→ Short course of corticosteroid creams or suppositories
+/- Antispasmodic agents→ Nitroglycerin ointment
Nitroglycerin ointment
antispasmodic for hemorrhoids, anal fissure
After conservative management fails, your hemorrhoid patient should get
Office-based procedures (nonsurgical)
Internal hemorrhoids
- Rubber-band ligation (banding) (most common for symptomatic internal)
- Infrared coagulation
- Sclerotherapy
External hemorrhoids
Excision of thrombosed external hemorrhoid
Management for all grades of hemorrhoids
Lifestyle mods Increased fluid Increased fiber (dietary/bulk laxatives) Toilet habits Sitz baths→ lukewarm water bath 2-3x/day
Hemorrhoid grade: painless bleeding, no prolapse
Grade I
Hemorrhoid grade: painless bleeding, perianal itching, prolapses with straining, reduces spontaneously
Grade II
Hemorrhoid grade: painless bleeding, perianal itching, swelling, staining/soilage with mucus/feces. Prolapse with straining but must be reduced with manual pressure
Grade III
Hemorrhoid grade: Pain, bleeding, swelling, soilage, non-reducable prolapse, chronic inflammatory changes
Grade IV
Often develops from local irritation of skin and resultant inflammation
Mechanical→ prolapsing tissue, fecal incontinence/soiling, inadequate hygiene→ excess sweat, mucous, or stool between the buttocks
Pruritis Ani
Pruritis ani presentation
Intense itching + burning
Circumferential erythematous & irritated perianal skin
Pruritis ani management
Eliminate offending agent Proper hygiene Gentle cleansers (water only, mild soap) Avoid aggressive wiping and overzealous hygiene Sitz baths Keep region dry Eliminate tight clothing Topical astringent→ witch hazel Topical barrier→ zinc oxide Severe skin eruptions→ Short course of topical steroid cream
Witch hazel
Topical astringent for pruritis ani
Zinc oxide
Topical barrier for pruritis ani
Perianal skin tags could be caused by
Sequelae of thrombosed external hemorrhoids, Crohn’s
Treatment of perianal skin tags
Not usually indicated
Interfere with hygiene or cause perianal discomfort→ refer for excision
Usure of diagnosis→ referral/biopsy
Why doesn’t an anal fissure heal well? Where is it most common and why?
distal to dentate line (painful)→ spasm of the anal sphincters→ decreased blood flow→ prevents healing
Posterior midline most common→ lowest blood supply
Causes of anal fissure
Primary causes→ Local trauma to anal canal, passage of stools, foreign body
Secondary causes→ Crohn, malignancy, HIV
Anal fissure presentation
Most common cause of severe anorectal pain
Severe pain during, after defecation
“like passing glass” “sitting on a knife”
Bright red blood on toilet paper or streaking on the stool
Tear in the anodermal tissue, minimal edema, erythema, or
bleeding may be seen
Anal fissure management
Adequate fiber and fluid, Proper anal hygiene, Sitz baths, Stool softeners
Topical analgesic: lidocaine gel
Topical vasodilators: Nifedipine or Nitroglycerin ointment → reduces spasm and increases blood flow
Chronic/refractory + low risk of fecal incontinence→ sphincterotomy
Who gets topical lidocaine gel because the pain is really bad?
Anal fissures
A perianal abscess is an infected/obstructed _____
crypt gland
could be a manifestation of Crohns
A chronic perianal abscess could progress to
fistula
Perianal abscess management
+/- CT/MRI→ determine extent
Incision + Drainage +/- abx
Post op→ sitz baths, adequate fluid + fiber
An anorectal fistula goes from _____ (internal opening) to ________ (external opening)
internal: anal canal
external: perianal area
Causes of anorectal fistulas
Crohns
Radiation proctitis
Diverticulitis
Anorectal fistula presentation
Chronic drainage of blood or pus, +/- stool from fistula, rectal pain, itching, swelling, fever
+/- Excoriated or inflamed perianal skin
Palpable cord under skin between anus + abscess opening
+/- visualize External opening→ examine under anesthesia
Management of an anal fistula
Complex or recurrent fistula→ MRI pelvis
IBD concern→ Colonoscopy
Mainstay therapy→ fisulotomy→ unroofing the fistula tract to allow healing
Anal condylomas are ______ caused by ______
Cauliflower like clusters
HPV
Anal condyloma treatment
Removal or destruction of visible lesions
Topical Podofilox
Topical Imiquimod cream
Office treatment→ Trichloroacetic acid
Surgical removal→ follow-up intervals to assess for recurrence
Risk of anal cancer
HPV
HIV
receptive anal intercourse
anorectal condyloma
Most common type of anal cancer
Squamous cell cancer
Anal cancer presentation
+/- rectal bleeding, anorectal pain, sensation of rectal mass
+/- anal warts, perianal skin irritation, hard, friable, or ulcerating internal or external lesions
Palpate for inguinal LAD
Anal cancer management
Biopsy + scope/imaging to determine extent
Chemoradiotherapy
Surgery
Pelvic floor disorder→ rectal tissue protrudes through anus
Risk: +/- chronic constipation, straining, multiparity, prior pelvic surgery
Rectal prolapse
Rectal prolapse presentation
Constipation/fecal incontinence
Incomplete bowel evacuation, seepage
Mass protruding through anus
Exam: strain to reproduce, protruding circumferential mucosa tissue
DRE→ mucosa of rectal wall is floppy/loose with redundant tissue
Rectal prolapse management
+/- Defecography/ Anorectal manometry
Prevent constipation
Increase fiber, fluid
Consult colorectal surgery→ repair (mainstay of tx)
Fascia weakens→ rectum to bulge into
vagina
Causes: +/- vaginal childbirth, increasing age, increasing BMI
Rectocele
Rectocele presentation
+/- apply pressure on vagina /rectum/ perineum to defecate
Pelvic pressure, Sexual dysfunction
Constipation, Fecal incontinence
Rectovaginal exam→ bear down→ bulge
Rectocele management
Unsure→ defecography
Expectant management, non-surgical options, surgery:
Pelvic floor muscle training
Pessary
