Rectal

Question 1

What are the 3 anatomical features of the anorectal area?

Answer 1

Internal sphincter, external sphincter, and the dentate line

Question 2

What is significant about the dentate line?

Answer 2

It divides the nervous system

Above the dentate line (smooth muscle, no pain)

Below the dentate line (anoderm = pain!)

Question 3

A patient presents with pain and tearing sensation with bowel movements. They have also noticed hematochezia. What diagnosis are you thinking?

Answer 3

Anal fissure

Question 4

What is the most common cause of painful rectal bleeding?

Answer 4

Anal fissure

Question 5

What type of PE would you do in someone you suspect with an anal fissure?

Answer 5

Spread buttocks and can see a posterior anal fissure

Cannot do DRE due to pain

Question 6

How would you treat a patient with an anal fissure?

Answer 6

Bulking agents, stool softener, fluids, Sitz-baths, and Hydrocortisone ointments (anusol)

Question 7

What if a patient with anal fissures has failed conservative treatment?

Answer 7

Surgical = Internal anal sphincterotomy

Question 8

A patient presents with severe anal pain that is worse with sitting, coughing, and bowel movements. What diagnosis are you thinking?

Answer 8

anorectal abscess

Question 9

Where is the point of origin for anal abscesses?

Answer 9

Anal crypts with gland obstruction

Question 10

From the anal crypts, where can infection spread to?

Answer 10

Superficially to the external sphincter = perianal abscess

Question 11

You note on PE your patient has an abscess, what do you do next?

Answer 11

You could drain it, but you may want to get a CT scan to localize the abscess

Question 12

If your patient’s abscess was not localized, what is it known as?

Answer 12

anorectal fistula

Question 13

If it is a fistula, where does it usually go to?

Answer 13

From the crypt and tracks externally to the skin

Question 14

If a fistula opens anteriorly, where does it extend to?

Answer 14

Straight line

Question 15

If a fistula opens posteriorly, where does it extend to?

Answer 15

Curved line

Question 16

What might the patient complain of with a fistula?

Answer 16

Usually painless, with persistent/embarrassing drainage

Question 17

How would you treat an anal fistula?

Answer 17

Fistulotomy – healing via secondary intention

Question 18

What happens if the sphincter muscle is hit during a fistulotomy?

Answer 18

Fecal incontinence

Question 19

IF a patient presents with BRB during defecation that is painless, what would it most commonly be?

Answer 19

Internal Hemorrhoid

Question 20

If a patient presents with pain during defecation but no bleeding, what would it most commonly be?

Answer 20

External Hemorrhoid

Question 21

What is occurring during a hemorrhoid?

Answer 21

When cushions engorge during defecation to protect the canal, but with excessive straining and hard stool they become engorged and produce abnormal hemorrhoidal tissue.

Question 22

Which type of hemorrhoid is graded?

Answer 22

Internal

Question 23

What are the different gradings of internal hemorrhoids?

Answer 23

First – bleed

Second – bleed & prolapse but reduce spontaneously

Third – bleed, prolapse, manually reduce

Fourth – bleed & incarcerate

Question 24

How would you treat a grade 1 or 2 hemorrhoid?

Answer 24

Fiber, water, stool softener, cortisone (anusol HC)

Question 25

How would you treat a grade 3 or 4 hemorrhoid?

Answer 25

Excisional hemorrhoidectomy

Question 26

How would you treat an external hemorrhoid?

Answer 26

excision outside to remove the clot

Question 27

If a patient presents with painful, fluctulent, consistent pimple in the perianal area, what diagnosis are you thinking?

Answer 27

Pilonidal cyst

Question 28

What would you note on PE with a pilonidal cyst?

Answer 28

“halo”

Question 29

How would you initially treat and pilonidal cyst?

Answer 29

Surgical recommendation - I&D and Abx vs. surgery

Question 30

For a recurrent pilonidal cyst, what would the treatment be?

Answer 30

Sinus tract excision

Question 31

A patient presents with abdominal pain and cramping. They describe inability to pass stool over the past several days, but yesterday did have an increase in watery diarrhea with only a small amount of stool passing. What diagnosis are you thinking?

Answer 31

Fecal Impaction

Question 32

What is fecal impaction, how is it different than an obstruction?

Answer 32

A large mass of dry hard stool

Question 33

Who is at risk of fecal impaction?

Answer 33

Anyone with chronic constipation, on anticholenergics, narcotics, and antidiarrheal meds

Question 34

What would you note on PE with fecal impaction?

Answer 34

DRE reveals hard mass of dry stool in the rectal vault

Question 35

How would you initially treat this patient with fecal impaction?

Answer 35

Remove the impacted stool… manually

Question 36

What is the long term treatment for a fecal impaction?

Answer 36

Prevent constipation with stool softeners (Colace), fiber, and water

Question 37

In general, what are the recommendations for colorectal cancer screening?

Answer 37

Age 50 = colonoscopy every 10 years; annual fecal hemoccult testing

Question 38

What is it that we are looking for with a colonoscopy?

Answer 38

polyps

Question 39

What type of polyp are we most concerned about?

Answer 39

Adenomas – premalignant to colorectal cancer

Question 40

What are the subdivisions of adenoma polyps?

Answer 40

Tubular – pedunculated, and majority are adenomas, lowest risk Tubulovillous – moderate risk Villous – Sessile, highest risk.

Question 41

So when a polyp is seen on colonoscopy, what do you do?

Answer 41

Polypectomy