L8: Anorectal disease Flashcards by Jeri Sheldon (AZ PA Mast 20)

The lower 4 cm of the rectum contains

anal sinus
anal column
anal crypt
anal gland

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Pectinate line aka

dentate line

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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

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Who gets hemorrhoids?

Common, M=F, 45-65 years

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Hemorrhoids are…

A normal vascular structure. They’re symptomatic when the anal cushions deteriorate

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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

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Which kind of hemorrhoids hurt?

External hemorrhoids, as they’re distal to the dentate line. Internal hemorrhoids are painless.

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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

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If your patient has hemorrhoid pattern bleeding, you have to…

AT LEAST get them sigmoidoscopy to rule out other anorectal pathology
Colonoscopy better

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Your hemorrhoid pattern bleeding patient def needs a colonoscopy if….

IBD or malignancy
(constitutional symptoms,
anemia, change in BMs, FH IBD/CRC)

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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

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Conservative management of hemorrhoids

Stool softeners
+/- Topical agents→ symptomatic relief
→ Tucks Pads
→ Short course of corticosteroid creams or suppositories
+/- Antispasmodic agents→ Nitroglycerin ointment

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Nitroglycerin ointment

antispasmodic for hemorrhoids, anal fissure

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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

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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

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Hemorrhoid grade: painless bleeding, no prolapse

Grade I

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Hemorrhoid grade: painless bleeding, perianal itching, prolapses with straining, reduces spontaneously

Grade II

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Hemorrhoid grade: painless bleeding, perianal itching, swelling, staining/soilage with mucus/feces. Prolapse with straining but must be reduced with manual pressure

Grade III

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Hemorrhoid grade: Pain, bleeding, swelling, soilage, non-reducable prolapse, chronic inflammatory changes

Grade IV

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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

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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