Mar1 M2-Anorectal disorders

Question 1

anal canal anatomy

Answer 1

endodermal lining, mucosa, tunica muscularis, no serosa bc extraperitoneal

Question 2

dentate (or pectinate) line function

Answer 2

separates endodermal mucosa of rectum and ectodermal derived tissue of perianal skin

Question 3

type of epithelium in anoderm compared to rectum

Answer 3

stratified squamous epithelium with a lot of nerves. very sensate. rectum is insensate

Question 4

anatomical and surgical anal canal

Answer 4

anatomical = pectinate line + anoderm
surgical anal canal = anal transition zone (right after rectum) (has hemorrhoid and internal sphincter + dentate line + anoderm (has external sphincter)

Question 5

internal anal sphincter

Answer 5

the circular muscle of the rectum that thickens (INVOLUNTARY control)

Question 6

external anal sphincter

Answer 6

SKELETAL muscle under VOLUNTARY control

Question 7

hemorrhoid def

Answer 7

sinusoid cushion with arterial and venous blood that is in the upper part of the anal canal (surgical). provide 15% of continence

Question 8

how to check end of anal canal physically

Answer 8

surgical anal canal is tight part. rectum is not tight

Question 9

when hemorrhoids function

Answer 9

increase in abd P = they engorge to fill the gap and prevent fecal loss and endoderm injury from hard stools

Question 10

crypts of Morgan fct + clinical

Answer 10

secrete mucous to help passage of stool. problem if are stuck

Question 11

internal hemorrhoids charact

Answer 11

above dentate line: insensate, visceral. come from branches of superior and middle rectal arteries. endoderm derived

Question 12

external hemorrhoids charact

Answer 12

near anal verge, on perianal skin. somatic, sensate. from inferior rectal artery (which branches from PUDENDAL) vessels. ectoderm derived.

Question 13

possible problems of external hemorrhoids

Answer 13

can get swollen if cough, deliver babt. can get thrombosed

Question 14

ddx of hemorrhoid (if see something protruding)

Answer 14

• anal fissure (the sentinel pile)
• rectal prolapse
• anal cancer skin
• condylomas
• IBD (Crohn’s)
• infection

Question 15

possible problem of internal hemorrhoid + position of hemorrhoids there

Answer 15

prolapse.
one left lateral
one right antero-lateral
one right postero-lateral

Question 16

symptoms of internal hemorrhoids

Answer 16

• BRBPR
• pain (irritation)
• tenesmus (feeling of incomplete evacuation)
• perianal mass
• urgency
• pruritus ani

Question 17

4 grades of internal hemorrhoids

Answer 17

1 = prominent vessels no prolapse
2 = prolapse, spontaneous reduction
3 = prolapse need manual reduction
4 = chronically prolapsed manual reduction ineffective

Question 18

internal hemorrhoid treatment

Answer 18

stool bulking, good water intake, no creams suppository, no prolonged pressure. surgical excision (if grade 3,4)

Question 19

external hemorrhoid treatment

Answer 19

-stool softeners if thrombosed for more than 48 hrs
-surgery if thromb for less 48 hrs
always stool bulking, good water intake

Question 20

anal fissure def and cause

Answer 20

linear tear in anoderm distal to dentate line

cause: passage of hard bowel mvmt
* may get chronic fissure (tear, spasms, healing cycle)

Question 21

charact of chronic anal fissure

Answer 21

inflamed, edematous, chronic inflam, hypertrophied.

ischemia prevents healing, cycle of constipation and spasm and pain, tears, scarring

Question 22

fissures where usually

Answer 22

posterior midline (75%), after that it’s anterior midline (25%)

Question 23

other causes of anal fissures

Answer 23

CD, UC, STDs, anorectal trauma, neoplasm (leukemia, lymphoma)

Question 24

anal fissure treatment

Answer 24

break cycle of constipation. stool bulkng (fiber, psyllium, water, topical anesthetics)

Question 25

medication for anal fissure

Answer 25

CCB nifedipine to relax internal sphincter

Question 26

extreme anal fissure treatments

Answer 26

injection of Botox (blocks AchR), sphincterotomy (surgical)

Question 27

sinus def

Answer 27

connection to a cavity from an epithelialized surface

Question 28

abscess def

Answer 28

collection of pus (dead WBC, bacteria, plasma)

Question 29

fistula-in-ano def

Answer 29

connection between anal canal (or distal rectum) and perianal skin)
*80% cryptoglandular, glocked infected with pus

Question 30

anal canal lined by crypts and glands for what reason

Answer 30

secrete mucous to help passage of stool

if prob in them, just burn or suture, don’t treat

Question 31

most common cause of infection and abcess formation (anorectal)

Answer 31

cryptoglandular obstruction

Question 32

most common location of abcess

Answer 32

perianal

Question 33

causes of anorectal abcess and fistula-in-ano + most important

Answer 33

• IBD (Crohn’s***)
• TB
• infections
• trauma
• sexual misadventures
• surgery
• cancer

Question 34

anorectal abcess presentation

Answer 34

perianal pain + signs of inflam, tenderness, can’t make DRE bc intersphincteric abcess

Question 35

Rx of anorectal abcess and fistula-in-ano

Answer 35

• drainage
• stool bulking
• analgesia (no narcotis bc constipate)
• NO packing (can damage sphincter nerves)
• NO Abx (except cellulitis, inflam, comorbidities)

Question 36

drainage of anorectal abcess prognosis

Answer 36

40-50% persist and form fistula. symptoms of puncture in skin, blood-stool mix from that hole

Question 37

general management of fistulas

Answer 37

• consult surgeon + after identify internal opening (note: ow-fistulas are generally layed open), do these
• *placement of seton, tissue glue, fistula plugs