Rectal disorders: hemorrhoids and fissures PP Week 4

Question 1

rectum

Answer 1

lower 10- 15cm of the large intestine

Question 2

anatomical anal canal

Answer 2

outlet of the digestive system, tube that is 3.8 cm long running from perianal skin of the buttock to the mucosal lining of the rectum

Question 3

internal sphincter

Answer 3

subconsciously controlled so you don’t shit yourself

Question 4

external sphincter

Answer 4

action is voluntary, it is highly innervated (vagal nerve)

Question 5

both sphincters

Answer 5

are highly vascular

Question 6

where the anal canal meets the rectum there is a ring of folds

Answer 6

called the the dentate line; it separates the anal canal and the rectum and dilineates where the nerve fibers end (below is innervated/ extremely sensitive to pain, above is not)

Question 7

within the dentate lines are

Answer 7

anal crypts which are small tube like depressions opening into the anal canal

Question 8

veins from rectum and anus drain into

Answer 8

the portal vein, which leads to the liver, and then to the general circulation

Question 9

the lymph vessels of the rectum drain into

Answer 9

lymph nodes in the lower abdomen

Question 10

the lymph of the anus drain into

Answer 10

the lymph nodes in the groin

Question 11

rectal exam

Answer 11

inspect the skin around the anus for any abnormality, with a gloved finger- probe rectum clockwise for documentation

Question 12

an anoscope or protoscope

Answer 12

3- 10 inch rigid viewing tubes- if you palpated something on the DRE that was abnormal, use this to visualize

Question 13

sigmoidoscope

Answer 13

longer, more flexible, can observe as much as 2 or more feet of the large intestine- would use if pt was having dark red stools

Question 14

stop if

Answer 14

area in or around anus proves to be painful- use some type of anesthetic before continuing. ex anal ca

Question 15

sometimes give what before a sidmoidoscopy to rid lower bowel of stool

Answer 15

cleansing enema

Question 16

what may be obtained during sigmoidoscopy?

Answer 16

stool samples for microscopic examination and cultures

Question 17

hemorrhoids

Answer 17

dilated, twisted (aka varicose) veins located in the wall of the rectum and anus

Question 18

when do hemorrhoids occur

Answer 18

when veins in the rectum or anus enlarge; they may eventually bleed, may also develop a blood clot

Question 19

internal hemorrhoids

Answer 19

above the boundary between the rectum and the anus (anorectal junction)

Question 20

eternal hemorrhoids

Answer 20

below the anorectal junction

Question 21

both internal and external hemorrhoids may

Answer 21

remain in the anus or protrude outside the anus

Question 22

hemorrhoidal bleeding

Answer 22

bleeding is actually arterial

Question 23

hemorrhoidal tissue is thought to contribute

Answer 23

to anal incontinence and functions as a compressible lining that provides complete closure of the anus

Question 24

external hemorrhoids located

Answer 24

distal to dentate line

Question 25

internal hemorrhoids located

Answer 25

proximal to dentate line

Question 26

mixed hemorrhoids are located

Answer 26

both proximal and distal to dentate line

Question 27

internal hemorrhoid classification**

Answer 27

graded according to the degree to which they prolapse from the anal canal
grade 1- viusualized on anoscopy and may buldge into the lumen but do not prolapse below dentate line
grade 2- prolapse out of the canal with defecation or with straining but reduce spontaneously
grade 3- prolapse out of the canal with defecation or straining, and will require manual reduction
grade 4- are irreducible and may strangulate

Question 28

most common cause of hemorrhoids

Answer 28

constipation

Question 29

other causes of hemorrhoids

Answer 29

preggo, intreased intra- abdominal pressure (portal HTN, hep c, liver ca), hereditary, aging (d/t thinning of supportive tissue), prolonged straining

Question 30

internal hemorrhoid-

Answer 30

portal venous system (heptasplenomegaly, hep c), not thrombosed

Question 31

external hemorrhoid

Answer 31

systemic venous system; can become thrombosed with resultant bluish mass called external hemorrhoid

Question 32

generalized sx of hemorrhoids

Answer 32

bleeding on stool or in toilet, mucosal protrusion, discharge, soiled underwear (d/t internal), sensation of incomplete evacuation, PAINLESS UNLESS THROMBOSED, bleeding from external is darker, thrombosed blood

Question 33

sx of internal hemorrhoids

Answer 33

pain not a usual feature until thrombosus, infection or erosion of the overlying mucosal surface. Most pts c/o BRBPR with a feeling of vague anal discomfort which is increased when hemorrhoid enlarges or prolapses

Question 34

prolapse internal hemorrhoid sx

Answer 34

edema and sphincteric spasm

Question 35

prolapsed chronic internal hemorrhoid

Answer 35

constant soiling, very little pain

Question 36

sx of external hemorrhoids

Answer 36

usually very painful because they lie under the skin, tender blue swelling at the anal verge d/t thrombosis of a vein in the external plexus (need not be associated with enlargement of internal veins). Spasm often occurs since the thrombus usually lies at the level of the sphinteric muscles

Question 37

dx of internal or external hemorrhoids

Answer 37

is clinical; inspection, DRE, direct vision through anoscope and proctoscope

Question 38

what position for DRE

Answer 38

prone, jack- knife position or lateral Sim’s position

Question 39

location of hemorrhoids should be described according to their anatomic position

Answer 39

using a clockwise pattern

Question 40

**since hemorrhoids are very common,

Answer 40

they must not be regarded as the cause of rectal bleeding or chronic hypochromic anemia until a through investigation has been made of the more proximal GI tract

Question 41

chronic anemia in the presence of a large but not bleeding hemorrhoid should provoke

Answer 41

a search for a polyp, cancer, or ulcer

Question 42

treatment for hemorrhoids

Answer 42

includes medical as well as surgical modalities- medical: stool bulking agents i.e. psyllium or methylcellulose, sitz bath (probably most effective topical treatment for relief of symptoms) most hemorrhoids respond to conservative therapies such as these

Question 43

treatment for internal hemorrhoids

Answer 43

if remain permanently prolapsed, best tx is surgery. Milder degrees of prolapse or enlargement with pruritis ani or intermittent bleeding can be successfully handled by banding or injection of sclerosing solutions

Question 44

treatment for external hemorrhoids

Answer 44

if acutely thrombosed, treated with incision, extraction of the clot and compression of the incised area following clot removal. No surgical procedure if there is acute inflammation of the anus, ulcerative proctitis, or UC

Question 45

what should be done before a pt is subjected to a hemorrhoidectomy

Answer 45

proctoscopy and barium enema

Question 46

surgical therapy

Answer 46

rubber band ligation, infared photocoagulation (laser), sclerotherapy or hemorrhoidectomy (only for symptomatic combined internal and external)