Pathology -- Anorectal Disorders Flashcards
3 anorectal disorders
- Hemorrhoidal disease
- Fissures
- Anorectal abscess and fistula-in-ano
Define a hemorrhoid
A sinusoid “cushion” consisting of ARTERIAL and venous blood (even though they look blue) that lines the anal canal
Function of hemorrhoids
- Contribute ~15% to consistence
- Engorge when abdominal pressure increases
- May prevent injury to anodern by hard stools
Describe the characteristics of internal hemorrhoids
- Above the dentate, in the anal canal
- Visceral innervation, insensate
- Supplied by branches of superior/middle rectal arteries
- Derived from endoderm
Describe the characteristics of external hemorrhoids
- Near the anal verge
- Anodren: somatic innervation from the pudendal nerve, sensate
- Inferior rectal arteries
- Derived from ectoderm
6 differential diagnoses for hemorrhoids
- Rectal prolapse
- Anal fissure (sentinel pile)
- Neoplasms (anal cancer)
- Condylomas (warts)
- Crohn’s/IBD
- Infections
Position of internal hemorrhoids anatomically
- Left lateral
- Right antero-lateral
- Right postero-lateral
Location of external hemorrhoids
Lining the perianal skin
Presentation of external hemerrhoids
- Very painful
- Patients report a tender, pea-sized lump
Consequence of external hemerrhoids
Rather than prolapsing, can THROMBOSE
6 signs and symptoms of hemorrhoids
- Bleeding – Bright red blood per rectum (BRBPR)
- Anal pain
- Tenesmus
- Perianal mass
- Urgency to defecate (i.e. immediately)
- Itch (pruritus ani)
Why might a patient present with anal pain if they have hemorrhoids
Burnign due to irritation fo the anoderm
3 characteristics of BRBPR
- Streaking stools or toilet paper
- Dripping into bowl (NOT mixed)
- Often find an association with hard stools, constipation, straining
Describe the classiciation of internal hemorrhoids
5 treatments/advice on treatment for internal hemorrhoids
Depends on grade:
- Stool bulking/softeners; warm sitz bath
- NO creams/ suppositories
- AVOID straining, prolonged pressures (like reading on toilet)
- Rubber bang ligation/ scleropathy/ infrared coagulation (Gr 2, 3)
- Surgical excision (Gr 3, 4)
Treatments for external hemorrhoids
- If thrombosed <48 h: surgical excision (do not INCISE them)
- If >48h: warm sitz baths, stool softeners, bulkers. Clot will reabsorb with time
Describe surgical excision of hemorrhoids
Removal of hemorrhoidal bundles with closure of mucosa
Potential consequence of surgical excision for hemorrhoids
Excess removal can cause anal stenosis
Importance of recurrence prevention post-surgical excision of hemorrhoids
- High fiber diet
- Adequate water intake
- Proper toileting habits
Define an anal fissure
A linear tear in the anoderm, distal to the dentate line
Presentation of anal fissure (4)
- Extremely painful – burning/tearing, usually associated with a hard BM (can also occur with diarrhea)
- Pain happens during the movement, then lasts a few minutes (note: chronic = possibly lasts for hours)
- Bright red bleeding
- Potentially cannot perform DRE (too painful)
Define an acute anal fissure
A symple tear in the anoderm
Define a chronic anal fissure (3)
- After 8 - 12 weeks the edges scar
- Inflames, edematous
- Signs of chronic inflammation: hypertrophied anal papillus sentinel piles (“skin tag”)
Location of anal fissure
Typically in anterior or posterior midline
- 75% posterior
- 25% anterior (women more often)
- 3% can have both
Group of people most commonly affected by anal fissures
Young patients (20s and 30s), with women experiencing posterior anal fissures more often
What if the anal fissure is located OFF the midline?
Need to think of other diagnoses
- Crohn’s disease/ulcerative colitis
- Anorectal trauma
- Infections: HIV/AIDS, syphilis, TB, gonorrhea/chlamydia
- Neoplasms: leukemia, lymphoma
5 steps in the pathophysiology of an anal fissure
- Hypertonic internal anal sphincter & spasm (–> sustained, resting hypotonia)
- Relative ischemia in anterior and posterior midlines
- Passage of hard stool or multiple, high floow BMs (i.e. diarrhea) –> tear
- Ischemia prevents healing
- Pain = patients do not want to pass BM –> more constipation + more pain
(Vicious cycle)
23ways to treat anal fissures non-surgically
Break the cycle of pain/constipation:
- Stool bulking agents (fiber/psyllium, water)
- Sitz baths
- Topical anesthetics
Why can sitz baths treat anal fissures
Warmth promotes relaxation of sphincter, cleans and soothes
Topical anesthetic for anal fissure
Topical nifedipine 0.5% x 1 month
What is topical nifedipine?
Calcium channel blocker to promote relaxation of smooth muscle / internal anal sphincter
2 surgical options to treat anal fissures
- Botox injections
- Surgical sphincterotomy
Define surgical sphincterotomy
Cutting part of the internal sphincter to release tension and promote blood flow
Potential risks of surgical sphincterotomy
Temporary changes in fecal continence with <0.1% having permanent incontinence
Define fistula
An abnormal connection between 2 epithelialized surfaces
Define sinus
A connection to a cavity from an epithelialized surface
Define fistula-in-ano
An abnormal connection between the anal canal (or distal rectum) and the perianal skin
What lines the anal canal?
8 - 16 anal crypts/glands
Function of anal crypts and glands
Secrete mucous to help pass stool, provide lubrication to anus
Location of anal glands
Most are located in submucosa, some extend to the conjoined muscle or even to the intercphincteric area
Most common cause of infection and abscess formation in anorectal region
Cryptoglandular obstruction
Most common abscess of anorectal region
Perianal
5 types of anorectal abscesses
- Perianal
- Ischioanal
- Intersphincteric
- Supralevator
- Submucosal
7 causes of anorectal abscesses
- Cryptoglandular obstruction
- IBD
- Infection
- Trauma
- Surgery
- Neoplasms
- Radiation
3 infections that can cause anorectal abscesses
- Tuberculosis
- Actinomycosis
- Lymphogranuloma venereum
3 surgeries that can cause anorectal abscesses
- Episiotomy
- Hemorrhoidectomy
- Prostatectomy
3 neoplasms that can cause anorectal abscesses
- Carcinoma
- Leukemia
- Lymphoma
4 presenting symptoms of anorectal abscesses
- Perianal pain, swelling, redness
- Tenderness to touch
- Sometimes drain spontaneously – reports of pus
- Intersphincteric abscess wont be seen, but is so painful that DRE cannot be performed
6 treatments/ advice for treatments for anorectal abscesses
- Incision and drainage (surgeon)
- NO packing
- NO role of antibiotics, except:
- Severe cellulitis
- Systemic signs of inflammation
- Comorbidities
- Warm sitz bath
- Stool bulking/softening
- Analgesia (non-narcotic)
Possible consequence of draining an anorectal abscess
40 - 50% of tracts will persist and form a fistula
Characteristic features of fistula-in-ano
- Persistent, intermittent, sanguino-purulent drainage from a hole (punctum) in the skin
- Patients complain of staining underwear, intermittent abscesses that rupture and drain, sometimes pain
5 characterizations of fistula-in-ano
- A = subcutaneous
- B = intersphincteric
- C = Trans-sphincteric
- D = Supra-sphincteric
- E = Extra-sphincteric
3 general treatment options for fistula-in-ano
- Consult a surgeon
- Anoscopy to try to identify the internal opening
- Low-fistulas are generally layed open
3 treatments for trans-, extra- ,supra- sphincterics
- Placement of a seton
- Tissue glue
- Fistula plugs
NOTE: risk of incontinence if muscle is cut
