S09C88 - Anorectal disorders

Question 1

Anorectal abscess

Answer 1

• pathophys: obstruction of an anal gland
• perianal abscess is only anorectal absces that can be adequately treated in the ED, rest need surgery
• packing if placed, should be loose and removed in 24h

Question 2

Tenesmus

Answer 2

=straining with the urge to defecate

Question 3

Proctitis

Answer 3

• inflm of rectal mucosa
• cause: radiation, autoimmune, vasculitis, ischemia, infxs dz
• condylomata tx: podophyllum has high recurrence rates, best to do laser ablation, cry, electrocautery, immunotherapy, surgical excision 0 risk of scc
• gonorrhea - can have no Sx to having profuse yellow bloody d/c PR
• chlamydial infxn: can have a LGV variety (lymphogranulomatous)(tropics), LGV causes painful ulcers, unilateral lymphn node, flulike illness, scarrring, abscess, fistulas
• syphili: chancre at he anal verge or canal (may look like a fissure however chancre is assoc with ymphadenopathy)
• herpessevere anorectal pain, vesicles coalesce and rupture to tender ulcers

Question 4

Procititis

Answer 4

• stool softeners, sitz baths, hygience, pain meds
• Abx: septra (isospora), flagyl (entamoeba, giardia), azithromycin (campylobacter), acyclover, fluoroquinolones (Salmonella, shigella)

Question 5

Rectal prolapse:

Answer 5

3 groups:

1. prolapse involving rectal mucosa only
2. prolapse invovlign all layers of rectum (complete)
3. intususception of the upper rectum into and through the lower rectum so that the mucosal apex of the intussusception nearly extends to the anus (incomplete)

Question 6

Mucosal prolapse

Answer 6

-usually occurs distal to dentate line and extends only a few cm beyond the anal verge

Question 7

Complete prolapse

Answer 7

• may extend 15cm from verge
• anus apperas normal in contrast to a mucosal prolapse in which the anal edges appear everted
• there will be a thick mucosal wall with decreased tone on DRE
• red, ball-like mass

Question 8

Rectal prolapse: Tx

Answer 8

• children: Sedate and reduce with slow steady pressure, then treat for constipation, do a DRE and refer for further eval
• adults: gentle continous pressure with thumbs on inside and fingers on outside, then DRE, then refer for scope and repaire, if ++ edema then sprinkle granulated sugar over the prolapse and wait 15mins then try

Question 9

Anorectal tumors

Answer 9

Tumors distal to dentate line - anal margin neoplasms

• SCC, BCC, bowen dz, paget dz, melanoma
• low-grade, slow to metastasize (except melanoma)

Anal canal neoplasms

• adenocarcinoma, transitional carcinoma, melanoma, kaposi sarcoma, villous adenoma,
• more virulent, metastasizes, poor prognosis

Question 10

Rectal FB

Answer 10

• do xray for position and also for free air (don’t forget to look for free air along the psoas muscle for retroperitoneal perf)
• if FB removed and conerned for injury, pt should be observed for 12h, perf may occur, rectal/anal lacs may need repair
• for large FB a perianal block may be required, inject at 6 and 12 o’clock positions, then place index finger of L hand into anus and inject 5mL into each quadrant along the internal sphincter muscle
• if vacuum develops by FB, insert foley past object and inject air

Question 11

Pruritus Ani

Answer 11

• DDx: fissure, fistula, hemorrhoid, prolapse, canacer, atopic dermatitis, lichen planus, psoriasis, seborrheic dermatitis, anal margin neoplasms, DM, pemphigus, lymphoma
• causes: infxs, pinworms, candida, fecal contamination, irritants, synthetic tight clothing
• tx: treat underlying d/o, metamucil to thicken stools, sitz baths 15mins TID, zinc oxide, fungicidal cream for secondary fungal infxns, 1% HCT for allergic component of inflm

Question 12

Pilonidal sinus

Answer 12

• midline, over sacrum and coccyx
• always MIDLINE
• sinus formed from ingrown hair
• ddx: TB and syphilitic granulomas, furuncles, fungal infxn, sacral osteomyelitis
• complication: infxn, carcinoma, SCC
• acute tx: I+D, then refer to surgery

Question 13

Hidradenitis Suppurativa

Answer 13

• blocked hair follicles and sweat glands, superficial fistuals and abscesses, do not originate at the dentate line
• chronic inflm, edema, tissue induration, fibrosis, scarring
• tx: drain abscesses, oral clinda, oral rifampin/clinda, retinoids, NSAIDs, immunosuppression

Question 14

Rectovaginal fistulas

Answer 14

• Sx: flatulence, malodorous d/c, stool from vagina, air or stool in urine or rectal urine
• CT/MRI to confirm
• causes: gyne surgery or FB, pelvic irradiation, local infxn, congenital, gyne cancer, leukemia, IBD