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Unit 2 Clin Med III > L8: Anorectal disease > Flashcards

L8: Anorectal disease Flashcards

1
Q

The lower 4 cm of the rectum contains

A

anal sinus
anal column
anal crypt
anal gland

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2
Q

Pectinate line aka

A

dentate line

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3
Q

Red flags that need an ASAP referral to GI/Colorectal

A

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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4
Q

Who gets hemorrhoids?

A

Common, M=F, 45-65 years

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5
Q

Hemorrhoids are…

A

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

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6
Q

Hemorrhoid grading

A

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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7
Q

Which kind of hemorrhoids hurt?

A

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

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8
Q

Hemorrhoids presentation

A 
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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9
Q

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

A

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

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10
Q

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

A

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

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11
Q

Indications for hemorrhoidectomy

A

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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12
Q

Conservative management of hemorrhoids

A

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

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13
Q

Nitroglycerin ointment

A

antispasmodic for hemorrhoids, anal fissure

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14
Q

After conservative management fails, your hemorrhoid patient should get

A

Office-based procedures (nonsurgical)

Internal hemorrhoids

  1. Rubber-band ligation (banding) (most common for symptomatic internal)
  2. Infrared coagulation
  3. Sclerotherapy

External hemorrhoids
Excision of thrombosed external hemorrhoid

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15
Q

Management for all grades of hemorrhoids

A 
Lifestyle mods
Increased fluid 
Increased fiber (dietary/bulk laxatives)
Toilet habits
Sitz baths→ lukewarm water bath 2-3x/day
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16
Q

Hemorrhoid grade: painless bleeding, no prolapse

A

Grade I

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17
Q

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

A

Grade II

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18
Q

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

A

Grade III

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19
Q

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

A

Grade IV

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20
Q

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

A

Pruritis Ani

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21
Q

Pruritis ani presentation

A

Intense itching + burning

Circumferential erythematous & irritated perianal skin

22
Q

Pruritis ani management

A 
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
23
Q

Witch hazel

A

Topical astringent for pruritis ani

24
Q

Zinc oxide

A

Topical barrier for pruritis ani

25
Q

Perianal skin tags could be caused by

A

Sequelae of thrombosed external hemorrhoids, Crohn’s

26
Q

Treatment of perianal skin tags

A

Not usually indicated
Interfere with hygiene or cause perianal discomfort→ refer for excision
Usure of diagnosis→ referral/biopsy

27
Q

Why doesn’t an anal fissure heal well? Where is it most common and why?

A

distal to dentate line (painful)→ spasm of the anal sphincters→ decreased blood flow→ prevents healing

Posterior midline most common→ lowest blood supply

28
Q

Causes of anal fissure

A

Primary causes→ Local trauma to anal canal, passage of stools, foreign body

Secondary causes→ Crohn, malignancy, HIV

29
Q

Anal fissure presentation

A

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

30
Q

Anal fissure management

A

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

31
Q

Who gets topical lidocaine gel because the pain is really bad?

A

Anal fissures

32
Q

A perianal abscess is an infected/obstructed _____

A

crypt gland

could be a manifestation of Crohns

33
Q

A chronic perianal abscess could progress to

A

fistula

34
Q

Perianal abscess management

A

+/- CT/MRI→ determine extent

Incision + Drainage +/- abx

Post op→ sitz baths, adequate fluid + fiber

35
Q

An anorectal fistula goes from _____ (internal opening) to ________ (external opening)

A

internal: anal canal
external: perianal area

36
Q

Causes of anorectal fistulas

A

Crohns
Radiation proctitis
Diverticulitis

37
Q

Anorectal fistula presentation

A

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

38
Q

Management of an anal fistula

A

Complex or recurrent fistula→ MRI pelvis
IBD concern→ Colonoscopy
Mainstay therapy→ fisulotomy→ unroofing the fistula tract to allow healing

39
Q

Anal condylomas are ______ caused by ______

A

Cauliflower like clusters

HPV

40
Q

Anal condyloma treatment

A

Removal or destruction of visible lesions
Topical Podofilox
Topical Imiquimod cream
Office treatment→ Trichloroacetic acid
Surgical removal→ follow-up intervals to assess for recurrence

41
Q

Risk of anal cancer

A

HPV
HIV
receptive anal intercourse
anorectal condyloma

42
Q

Most common type of anal cancer

A

Squamous cell cancer

43
Q

Anal cancer presentation

A

+/- 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

44
Q

Anal cancer management

A

Biopsy + scope/imaging to determine extent
Chemoradiotherapy
Surgery

45
Q

Pelvic floor disorder→ rectal tissue protrudes through anus

Risk: +/- chronic constipation, straining, multiparity, prior pelvic surgery

A

Rectal prolapse

46
Q

Rectal prolapse presentation

A

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

47
Q

Rectal prolapse management

A

+/- Defecography/ Anorectal manometry
Prevent constipation
Increase fiber, fluid
Consult colorectal surgery→ repair (mainstay of tx)

48
Q

Fascia weakens→ rectum to bulge into
vagina

Causes: +/- vaginal childbirth, increasing age, increasing BMI

A

Rectocele

49
Q

Rectocele presentation

A

+/- apply pressure on vagina /rectum/ perineum to defecate
Pelvic pressure, Sexual dysfunction
Constipation, Fecal incontinence
Rectovaginal exam→ bear down→ bulge

50
Q

Rectocele management

A

Unsure→ defecography
Expectant management, non-surgical options, surgery:
Pelvic floor muscle training
Pessary

Unit 2 Clin Med III (9 decks)

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