Rectal disorders: hemorrhoids and fissures PP Week 4 Flashcards
rectum
lower 10- 15cm of the large intestine
anatomical anal canal
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
internal sphincter
subconsciously controlled so you don’t shit yourself
external sphincter
action is voluntary, it is highly innervated (vagal nerve)
both sphincters
are highly vascular
where the anal canal meets the rectum there is a ring of folds
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)
within the dentate lines are
anal crypts which are small tube like depressions opening into the anal canal
veins from rectum and anus drain into
the portal vein, which leads to the liver, and then to the general circulation
the lymph vessels of the rectum drain into
lymph nodes in the lower abdomen
the lymph of the anus drain into
the lymph nodes in the groin
rectal exam
inspect the skin around the anus for any abnormality, with a gloved finger- probe rectum clockwise for documentation
an anoscope or protoscope
3- 10 inch rigid viewing tubes- if you palpated something on the DRE that was abnormal, use this to visualize
sigmoidoscope
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
stop if
area in or around anus proves to be painful- use some type of anesthetic before continuing. ex anal ca
sometimes give what before a sidmoidoscopy to rid lower bowel of stool
cleansing enema
what may be obtained during sigmoidoscopy?
stool samples for microscopic examination and cultures
hemorrhoids
dilated, twisted (aka varicose) veins located in the wall of the rectum and anus
when do hemorrhoids occur
when veins in the rectum or anus enlarge; they may eventually bleed, may also develop a blood clot
internal hemorrhoids
above the boundary between the rectum and the anus (anorectal junction)
eternal hemorrhoids
below the anorectal junction
both internal and external hemorrhoids may
remain in the anus or protrude outside the anus
hemorrhoidal bleeding
bleeding is actually arterial
hemorrhoidal tissue is thought to contribute
to anal incontinence and functions as a compressible lining that provides complete closure of the anus
external hemorrhoids located
distal to dentate line
internal hemorrhoids located
proximal to dentate line
mixed hemorrhoids are located
both proximal and distal to dentate line
internal hemorrhoid classification**
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
most common cause of hemorrhoids
constipation
other causes of hemorrhoids
preggo, intreased intra- abdominal pressure (portal HTN, hep c, liver ca), hereditary, aging (d/t thinning of supportive tissue), prolonged straining
internal hemorrhoid-
portal venous system (heptasplenomegaly, hep c), not thrombosed
external hemorrhoid
systemic venous system; can become thrombosed with resultant bluish mass called external hemorrhoid
generalized sx of hemorrhoids
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
sx of internal hemorrhoids
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
prolapse internal hemorrhoid sx
edema and sphincteric spasm
prolapsed chronic internal hemorrhoid
constant soiling, very little pain
sx of external hemorrhoids
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
dx of internal or external hemorrhoids
is clinical; inspection, DRE, direct vision through anoscope and proctoscope
what position for DRE
prone, jack- knife position or lateral Sim’s position
location of hemorrhoids should be described according to their anatomic position
using a clockwise pattern
**since hemorrhoids are very common,
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
chronic anemia in the presence of a large but not bleeding hemorrhoid should provoke
a search for a polyp, cancer, or ulcer
treatment for hemorrhoids
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
treatment for internal hemorrhoids
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
treatment for external hemorrhoids
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
what should be done before a pt is subjected to a hemorrhoidectomy
proctoscopy and barium enema
surgical therapy
rubber band ligation, infared photocoagulation (laser), sclerotherapy or hemorrhoidectomy (only for symptomatic combined internal and external)
