Rectum and Anal Pathology Flashcards
Define anal fissure
Acute longitudinal tear or a chronic ovoid ulcer in the squamous epithelium of anal canal
what is the pathophys of anal fissure?
- Anal fissures result from laceration by a hard or large stool, w/ 2° infection
- Trauma (i.e. anal intercourse) is a rare cause
- May cause internal sphincter spasm, ↓ blood supply & perpetuating the fissure
What are the sxs of anal fissures?
- Posterior midline but may occur in the anterior midline
A. Pain
B. Bleeding w/ bm
How are anal fissures dxed?
- Dx is made by inspection
A. Unless findings suggest a specific cause, no further studies required
B. Exam must be gentle but w/ adequate spreading of buttocks to allow visualization - Anoscopy
How are anal fissure treated?
- Stool Softeners
- Bulking Agents
- Sitz baths
- Protective Ointments (Zinc Oxide)
- Topical Nitroglycerin Ointment/Nifedipine Cream
A. Vasoconstrict - Botulinum Toxin Type A injection
A. Relaxes sphincter tone & ↓ maximal resting anal pressure - Surgery (internal anal sphincterotomy)
What is an anorectal abscess?
- Localized collection of pus in perirectal spaces
- Located in various spaces surrounding the rectum
- May be superficial or deep
What concomittant dz can cause anorectal abscess?
Crohn’s disease (especially of the colon) sometimes causes anorectal abscess
What infectious agents may be within the abscess?
Mixed infection w/ Escherichia coli, Proteus vulgaris, Bacteroides, streptococci, & staphylococci predominating
What are the sxs of anorectal abscesses?
- Pain
- Perianal swelling
- Redness
- Tenderness
- Deeper abscesses may be less painful but cause toxic symptoms (fever, chills, malaise)
- May be no perianal findings, but DRE may reveal a tender, fluctuant swelling of rectal wall
- Sometimes fever is the only symptom
What anorectal abscesses do not require imaging?
Patients who have a pointing cutaneous abscess, a normal digital rectal examination, & no signs of systemic illness do not require imaging
What anorectal abscesses do require imaging?
- Rarely examination under anesthesia or CT
A. Those with any findings suggestive of a deeper abscess or Crohn’s disease should have an examination under anesthesia at the time of drainage - Higher (supralevator) abscesses require CT to determine the intra-abdominal source of sepsis
How is anorectal abscess treated by I&D?
- Prompt incision & adequate drainage required & should not wait until the abscess points.
- Warm-water cleansing, Analgesics, Stool softeners, and High-fiber diet (WASH regimen)
When is anorectal abscess treated by abx?
- Antibiotics for high-risk patients
A. Febrile, neutropenic, DM, cellulitis
-Ciprofloxacin 500 mg IV q 12 h + Metronidazole 500 mg IV q 8 h,
-Ampicillin/Sulbactam 1.5 g IV q 8 h - Antibiotics are not indicated for healthy patients w/ superficial abscesses, but Deb still puts them on abx
What is an anorectal fistula?
Tube-like track w/1 opening in anal canal & other usually in perianal skin
What is the etiology of anorectal fistula?
- Fistulas arise spontaneously or occur 2° to drainage of a perirectal abscess
- Predisposing causes include Crohn’s Dz & TB
- Most fistulas originate in the anorectal crypts
- Others may result from diverticulitis, tumors, or trauma
What are the sxs of anorectal fistula?
- Hx of recurrent abscess followed by intermittent or constant discharge is common
- Discharge material is purulent, sero-sanguinous, or both
- Pain may be present if infected
- A cordlike tract can often be palpated
- A probe inserted into tract can determine the depth & direction & locate primary opening
How are anorectal fistulas dxed?
- Diagnosis is by examination
2. Colonoscopy should follow to R/O Crohn’s Dz
How are anorectal fistulas treated?
- Surgery- entire tract is unroofed & converted into a “ditch“
- Partial division of the sphincters may be necessary
A. Stool incontinence may occur - Alternatives to conventional surgery include advancement flaps, biologic plugs, & fibrin glue instillations into the fistulous tract
- If diarrhea or Crohn’s disease is present, fistulotomy is contraindicated because of delayed wound healing
- IV Infliximab (Remicade) is very effective in closing fistulas caused by Crohn’s disease
What are hemorrhoids? Differentiate between external and internal.
- Swollen & inflamed veins around the anus or in the lower rectum
A. External hemorrhoids are located under the skin around the anus
B. Internal hemorrhoids develop in the lower rectum
- May prolapse, through the anus.
- Severely prolapsed hemorrhoids may protrude permanently & require Tx
Who mc presents with hemorrhoids?
- About 75% of population will have hemorrhoids at some point in their lives
- Most common among adults 45-65 yr
- Common in pregnant women
What are the sxs of internal and external hemorrhoids?
- Bright red blood on stool, on toilet paper, or in the toilet bowl after BM
- Internal hemorrhoids that are not prolapsed are usually not painful
A. Prolapsed hemorrhoids often cause pain, discomfort, & anal itching - Thrombosed external hemorrhoids cause bleeding, painful swelling, or a hard lump at anus
A. Excessive straining, rubbing, or cleaning around anus may make symptoms worse: Itching & irritation - Sx’s resolve w/in a few days
- Some people w/ hemorrhoids never have sx’s
How are hemorrhoids dxed?
- Diagnosis usually clinical & based on H & P
2. Anoscopy or colonoscopy on occassion
How are hemorrhoids treated non-surgically?
- High-fiber diet
- Bulk stool softener (Colace) or fiber supplement (Metamucil or Citrucel)
- 6-8 8 oz glasses of water QD
- Exercising to prevent constipation
- OTC creams & suppositories may also relieve sx’s
- Stool softener prn
How are hemorrhoids treated surgically?
- Surgical Management
A. Rubber band ligation—Rubber band placed around base of the hemorrhoid starving it of circulation
B. Sclerotherapy—Chemical solution injected into blood vessel to shrink hemorrhoid
C. Infrared coagulation—Heat used to shrink the hemorrhoid tissue
D. Resection—Hemorrhoidectomyif other Tx fails
What is pilonidal dz?
Acute abscess or chronic draining sinus in the presacro-coccygeal area
Who is mc to get pilonidal dz?
- 4X more likely in males than females
- More common in hirsute & obese individuals
- Rare in those > 40 yr
What are the sxs of pilonidal cysts?
- Noninfected cyst may not cause symptoms
Infected cyst causes pain, redness, & swelling - Painful, fluctuant area at the sacro-coccygeal cleft
What is the tx for pilonidal cyst?
- I&D of acute abscess
- Antibiotics if cellulitis present
A. 1st generation Cephalosporin (Keflex) + Metronidazole (Flagyl) - If underlying immunosuppression, high risk for endocarditis, methicillin-resistant Staphylococcus aureus (MRSA), or concurrent systemic illness
A. Antibx + surgical management - Chronic condition requires follicle removal & unroofing of sinus tract
What is fecal impaction?
- Fecal impaction is a large mass of hard, retained stool
2. Generally occurs in the rectum but also may occur higher in the colon
What are potential complications of fecal impaction?
- Urinary tract obstruction & infection
- Spontaneous perforation of colon
- Stercoral ulcer, where mass has pressed on the colon
- Fecaliths (hard stony mass of feces in the intestinal tract)
A. May develop & lead to appendicitis - More proximal impaction generally indicates neoplasm
What are the sxs of fecal impaction?
- Abdominal pain
- Rectal discomfort
- Anorexia
- Nausea & Vomiting
- Headache & general illness
- Incontinence of small amounts of water & semi-formed stool may occur as leakage passes impaction
- Rock-hard stool felt in the rectal vault on exam
- Abdominal mass may be palpated
How is fecal impaction dxed?
- DRE w/ pain meds (tramadol injection)
2. Sigmoidoscopy or barium enema (BE) may be needed to confirm a more proximal impaction
How is fecal impaction treated?
- Break up impaction digitally
- Mineral Oil enema
- Pay close attention to bowel habits & dehydration
- Patient education/diet changes
What is proctitis?
Inflammation of the lining of the rectum
What causes proctitis?
- STD’s
- Non-STD infections (Salmonella, Shigella)
- Trauma
- Inflammatory Bowel Dz
- Radiation Tx
- Antibiotics
What are the sxs of proctitis?
- Tenesmus (rectal fullness, urge)
- Hematochezia
- Rectal pain
- Rectal discharge (blood, mucus)
- Loose stools
- Abd cramping
How is proctitis dxed?
- History
- Exam
- Anoscopy
- Colonoscopy
- Cultures
What is the goal of treatment for proctitis?
- Reduce symptoms
- Treat infection
- Reduce inflammation
- Heals 4-6 weeks
- Remission Treatment
How is mild proctitis treated?
- Topical Mesalamine (Rowasa enema /Canasa supp): anti-inflammatory med
- Antiviral
- Antibiotics
How is moderate proctitis treated?
- Steroids
2. Immune System Suppressors
