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Block B > WCS 62 anal pain > Flashcards

WCS 62 anal pain Flashcards

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

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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
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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
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4
Q

p/e for anal pain

A 
general exam
abdom exam
perianal exam
DRE
proctoscopy
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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
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6
Q

use of transrectal usg

A
  • rectal ca staging
  • assess sphincter muscle in fecal incontinence
  • assess complex fistula
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7
Q

external vs internal hemorrhoids

A

external distal to dentate line

squamous epithelium cf columnar epithelium, with nerve endings and painful

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8
Q

etiology of hemorrhoids

A 
constipation
straining
pregnancy
low fibre diet
fam history
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9
Q

symptoms presented in internal hemorrhoids

A 
bleeding
prolapse
mucus
pruritis
(pain only when thrombosis, prolapse)
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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
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11
Q

indications for surgical hemorrhoidectomy

A
  • 4th degree
  • mixed internal external
  • failure of other treatment
  • patient preference
  • in conjunction with another procedure
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12
Q

complications for hemorrhoidectomy

A
  • bleeding
  • urine retention
  • pain
  • fecal impaction
  • infection
  • anal tags
  • anal stenosis
  • incontinence
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13
Q

complications for stapled hemorrhoidopexy

A
  • rectal perforation
  • severe pelvic sepsis
  • rectovaginal fistula
  • more recurrence than conventional hemorrhoidectomy
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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
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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
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16
Q

what is anal fissure

A

split in the anoderm at dentate line more likely in the posterior midline

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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
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18
Q

causes of anal fissure

A

hard stool

  • tight internal anal sphincter
  • ischemia of the overlying anoderm at the posterior midline
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19
Q

if there are multiple anal fissures and in atypical positions what do you suspect

A
  • IBD
  • TB
  • syphilis
  • HIV
  • CMV
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20
Q

presentation of anal fissure

A
  • pain on defecation

- fresh rectal bleeding

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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
Q
  • pain
  • swelling
  • drainage
  • constipation
  • urinary difficulties
A

anorectal abscess

26
Q
  • pain on defecation

- fresh rectal bleeding

A

anal fissure

27
Q

location of anorectal abscesses

A

(descending order of occurrence)

  • ischioanal
  • perianal
  • intersphincteric
  • supralevator
28
Q

treatment for anorectal abscess

A
  • incision and drainage of abscess

- antibiotics for severe cellulitis, valvular disease, prosthetic valves, immunosuppression

29
Q

what is anal fistula

A

abnormal tract communicating rectum or anal canal

30
Q

cause of anal fistula

A

cryptoglandular infection

31
Q

location of anal fistula

A
  • intersphincteric
  • transphincteric
  • extrasphincteric
  • suprasphincteric
32
Q

presentation of anal fistula

A
  • drainage
  • pain, decrease with drainage
  • bleeding
  • swelling
  • external opening
  • induration with cord like structure on PR
33
Q

how to diagnose fistulas

A
  • PR clinical exam induration with cord like structure

- MRI for complicated high fistula, recurrent fistula

34
Q

treatment for fistulas

A

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
Q

complications for fistula treatments

A
  • incontinence

- recurrence

36
Q

complication for pruritis ani

A

secondary infection

excoriation

37
Q

causes for pruritis ani

A 
personal hygiene
diet
systemic diseases
dermatogical conditions
neoplasm
infection
psychogenic
drugs
diarrhoea
idiopathic
38
Q

what is rectal prolapse

A

full thickness circumferential protrusion of rectum through anal sphincters

39
Q

what is rectal internal prolapse

A

rectum intussuscepts but does not pass beyond anus

40
Q

anatomical abnormalities in rectal prolapse

A 
Rectal intussusception
Deep cul de sac
Loss of rectal fixation
Redundant sigmoid 
Levator ani diastasis
Patulous anal sphincter
Pudendal neuropathy (stretched nerve  incontinence)
41
Q

causes of rectal prolapse

A

constipation
parity
neurological disorders
childhood: cystic fibrosis, whooping cough, developmental abnormalities, malnutrition

42
Q

rectal prolapse clinical presentation

A 
Incontinence
Constipation
Protrusion
Bleeding
Discharge
Sensation of incomplete emptying
Rectal pressure/tenesmus
43
Q

treatment for rectal prolapse

A

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
Q

anal margin cancers

A
  • SCC
  • basal cell ca
  • kaposi’s sarcoma
45
Q

anal neoplasms

A
  • epidermoid ca

- melanoma

46
Q

risk factors for epidermoid ca of anal canal

A

anal intercourse
std
hpv

47
Q

pilonidal sinus

A

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
Q

treatment of pilonidal sinus

A
  • incision and drainage of abscess
  • wide excisison of sinus to fascia
  • z-plasty, myocutaneous flap for complex and recurrent disease
  • meticulous hair control
49
Q

causes of fecal incontinence

A
  • perineal soiling (pseudoincontinence)
  • overflow incontinence
  • diarrhea
  • sphincter injury (obs, surgical, traumatic)
  • congenital
  • pelvic floor denervation
50
Q

ix for fecal incontinence

A
  • anal manometry
  • defecography
  • electromyography
  • pudendal nerve latency
  • anal usg
51
Q

tx for fecal incontinence

A

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

Block B (4 decks)

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