WCS 62 anal pain Flashcards
(51 cards)
1
Q
degrees for internal hemorrhoids
A
1: not prolapse out of anal canal, only seen by proctoscope
2: prolapse out, reduced spontaneously
3: manual reduction
4: cannot be reduced
2
Q
history ask for what associated symptoms in anal pain
A
- bleeding (and characteristic and duration?)
- discharge blood or purlent
- prolapse
- perianal mass
- pruritis ani
- incontinence
3
Q
socrates for anal pain
A
site onset character: sharp dull burning; radiation associated: bowel movements, activity, bleeding time course: constant intermittent exacerbation: bowel movements? acitivity? severity
4
Q
p/e for anal pain
A
general exam abdom exam perianal exam DRE proctoscopy
5
Q
investigations for anal pain
A
- dx, severity, anatomy, exclude proximal bowel problems
- flexible sigmoidoscopy
- Transrectal USG
- MRI for complicated abscess/ fistula
- barium enema
- defecography
- fistulogram
anorectal manometry - electromyogram
- pudendal nerve latency test
6
Q
use of transrectal usg
A
- rectal ca staging
- assess sphincter muscle in fecal incontinence
- assess complex fistula
7
Q
external vs internal hemorrhoids
A
external distal to dentate line
squamous epithelium cf columnar epithelium, with nerve endings and painful
8
Q
etiology of hemorrhoids
A
constipation straining pregnancy low fibre diet fam history
9
Q
symptoms presented in internal hemorrhoids
A
bleeding prolapse mucus pruritis (pain only when thrombosis, prolapse)
10
Q
treatment for internal hemorrhoids
A
nonoperative
- diet modification
- sitz bath for prolapsed hemorrhoids
(- ointments and suppositories)
office operative
- banding
- sclerotherapy
- infrared coagulation
surgical
- stapled hemorrhoidopexy
- transanal hemorrhoidal artery devascularization
- hemorrhoidectomy
11
Q
indications for surgical hemorrhoidectomy
A
- 4th degree
- mixed internal external
- failure of other treatment
- patient preference
- in conjunction with another procedure
12
Q
complications for hemorrhoidectomy
A
- bleeding
- urine retention
- pain
- fecal impaction
- infection
- anal tags
- anal stenosis
- incontinence
13
Q
complications for stapled hemorrhoidopexy
A
- rectal perforation
- severe pelvic sepsis
- rectovaginal fistula
- more recurrence than conventional hemorrhoidectomy
14
Q
what is stapled hemorrhoidopexy
A
- stapling device to remove ring of rectal mucosa and submucosa
- create mucosal anastomosis above the dentate line
- hemorrhoidal tissues pulled back into anal canal from prolapse
- interruption of blood supply to hemorrhoids
15
Q
what is transanal hemorrhoidal artery devascularization
A
- reduce blood flow to hemorrhoids by locating and stitching close the vessels supplying hemorrhoids by anal USG
16
Q
what is anal fissure
A
split in the anoderm at dentate line more likely in the posterior midline
17
Q
what structures are associated with chronic fissure
A
- sentinel pile
- hypertrophic papilla
- visualization of internal sphincter muscles at the base of the fissure
18
Q
causes of anal fissure
A
hard stool
- tight internal anal sphincter
- ischemia of the overlying anoderm at the posterior midline
19
Q
if there are multiple anal fissures and in atypical positions what do you suspect
A
- IBD
- TB
- syphilis
- HIV
- CMV
20
Q
presentation of anal fissure
A
- pain on defecation
- fresh rectal bleeding
21
Q
how do you diagnose anal fissure
A
clinical inspection without rectal exam and proctoscopy
22
Q
treatment for anal fissures
A
non-operative
- bulk agents
- stool softeners
- topical anesthetics
- topical agents to reduce internal sphincter pressure (nitroglycerin, CCB, botulinum toxin)
operative
- lateral internal sphincterotomy
23
Q
anorectal abscess etiology
A
- cryptoglandular infection
- IBD
- TB
- actinomycosis
- foreign body
- surgery
- malignancies
24
Q
anorectal abscess presentation
A
- pain
- swelling
- drainage
- constipation
- urinary difficulties
25
- pain
- swelling
- drainage
- constipation
- urinary difficulties
anorectal abscess
26
- pain on defecation
| - fresh rectal bleeding
anal fissure
27
location of anorectal abscesses
(descending order of occurrence)
- ischioanal
- perianal
- intersphincteric
- supralevator
28
treatment for anorectal abscess
- incision and drainage of abscess
| - antibiotics for severe cellulitis, valvular disease, prosthetic valves, immunosuppression
29
what is anal fistula
abnormal tract communicating rectum or anal canal
30
cause of anal fistula
cryptoglandular infection
31
location of anal fistula
- intersphincteric
- transphincteric
- extrasphincteric
- suprasphincteric
32
presentation of anal fistula
- drainage
- pain, decrease with drainage
- bleeding
- swelling
- external opening
- induration with cord like structure on PR
33
how to diagnose fistulas
- PR clinical exam induration with cord like structure
| - MRI for complicated high fistula, recurrent fistula
34
treatment for fistulas
fistulotomy/fistulectomy for simple low fistula
complicated high/transphincteric fistula with a lot of muscle involved
- seton
- endorectal advancement flap
- anal fistula plug
- LIFT ligation of intersphincteric fistula tract
35
complications for fistula treatments
- incontinence
| - recurrence
36
complication for pruritis ani
secondary infection
| excoriation
37
causes for pruritis ani
```
personal hygiene
diet
systemic diseases
dermatogical conditions
neoplasm
infection
psychogenic
drugs
diarrhoea
idiopathic
```
38
what is rectal prolapse
full thickness circumferential protrusion of rectum through anal sphincters
39
what is rectal internal prolapse
rectum intussuscepts but does not pass beyond anus
40
anatomical abnormalities in rectal prolapse
```
Rectal intussusception
Deep cul de sac
Loss of rectal fixation
Redundant sigmoid
Levator ani diastasis
Patulous anal sphincter
Pudendal neuropathy (stretched nerve incontinence)
```
41
causes of rectal prolapse
constipation
parity
neurological disorders
childhood: cystic fibrosis, whooping cough, developmental abnormalities, malnutrition
42
rectal prolapse clinical presentation
```
Incontinence
Constipation
Protrusion
Bleeding
Discharge
Sensation of incomplete emptying
Rectal pressure/tenesmus
```
43
treatment for rectal prolapse
abdominal repair
- rectal fixation by suture or mesh
- sigmoid resection
- proctectomy
- combo rectal fixation and sigmoid resection
- laparoscopic ventral mesh rectopexy
perineal repair
- full thickness resection
- mucosal resection with muscular reefing
- anal encirclement
- concomitant sphincter repair and/or levator reinforcement
44
anal margin cancers
- SCC
- basal cell ca
- kaposi's sarcoma
45
anal neoplasms
- epidermoid ca
| - melanoma
46
risk factors for epidermoid ca of anal canal
anal intercourse
std
hpv
47
pilonidal sinus
A pilonidal sinus (PNS) is a small hole or tunnel in the skin. It may fill with fluid or pus, causing the formation of a cyst or abscess. It occurs in the cleft at the top of the buttocks.
48
treatment of pilonidal sinus
- incision and drainage of abscess
- wide excisison of sinus to fascia
- z-plasty, myocutaneous flap for complex and recurrent disease
- meticulous hair control
49
causes of fecal incontinence
- perineal soiling (pseudoincontinence)
- overflow incontinence
- diarrhea
- sphincter injury (obs, surgical, traumatic)
- congenital
- pelvic floor denervation
50
ix for fecal incontinence
- anal manometry
- defecography
- electromyography
- pudendal nerve latency
- anal usg
51
tx for fecal incontinence
medical
- diet and medication to change stool consistency and transition time
- colonic irrigation
- biofeedback
surgical
- anorectal muscle repair by overlapping sphicteroplasty, post anal repair
- neosphincter procedure: dynamic graciloplasty, artificial sphincter
- sactal nerve stimulation
- diversion
- continent colonic conduit
