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Block D - Digestion and Metabolism > Pathology -- Anorectal Disorders > Flashcards

Pathology -- Anorectal Disorders Flashcards

1
Q

3 anorectal disorders

A
  • Hemorrhoidal disease
  • Fissures
  • Anorectal abscess and fistula-in-ano
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2
Q

Define a hemorrhoid

A

A sinusoid “cushion” consisting of ARTERIAL and venous blood (even though they look blue) that lines the anal canal

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3
Q

Function of hemorrhoids

A
  • Contribute ~15% to consistence
  • Engorge when abdominal pressure increases
  • May prevent injury to anodern by hard stools
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4
Q

Describe the characteristics of internal hemorrhoids

A
  • Above the dentate, in the anal canal
  • Visceral innervation, insensate
  • Supplied by branches of superior/middle rectal arteries
  • Derived from endoderm
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5
Q

Describe the characteristics of external hemorrhoids

A
  • Near the anal verge
  • Anodren: somatic innervation from the pudendal nerve, sensate
  • Inferior rectal arteries
  • Derived from ectoderm
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6
Q

6 differential diagnoses for hemorrhoids

A
  • Rectal prolapse
  • Anal fissure (sentinel pile)
  • Neoplasms (anal cancer)
  • Condylomas (warts)
  • Crohn’s/IBD
  • Infections
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7
Q

Position of internal hemorrhoids anatomically

A
  • Left lateral
  • Right antero-lateral
  • Right postero-lateral
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8
Q

Location of external hemorrhoids

A

Lining the perianal skin

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9
Q

Presentation of external hemerrhoids

A
  • Very painful
  • Patients report a tender, pea-sized lump
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10
Q

Consequence of external hemerrhoids

A

Rather than prolapsing, can THROMBOSE

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11
Q

6 signs and symptoms of hemorrhoids

A
  • Bleeding – Bright red blood per rectum (BRBPR)
  • Anal pain
  • Tenesmus
  • Perianal mass
  • Urgency to defecate (i.e. immediately)
  • Itch (pruritus ani)
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12
Q

Why might a patient present with anal pain if they have hemorrhoids

A

Burnign due to irritation fo the anoderm

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13
Q

3 characteristics of BRBPR

A
  • Streaking stools or toilet paper
  • Dripping into bowl (NOT mixed)
  • Often find an association with hard stools, constipation, straining
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14
Q

Describe the classiciation of internal hemorrhoids

A
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15
Q

5 treatments/advice on treatment for internal hemorrhoids

A

Depends on grade:

  • Stool bulking/softeners; warm sitz bath
  • NO creams/ suppositories
  • AVOID straining, prolonged pressures (like reading on toilet)
  • Rubber bang ligation/ scleropathy/ infrared coagulation (Gr 2, 3)
  • Surgical excision (Gr 3, 4)
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16
Q

Treatments for external hemorrhoids

A
  • If thrombosed <48 h: surgical excision (do not INCISE them)
  • If >48h: warm sitz baths, stool softeners, bulkers. Clot will reabsorb with time
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17
Q

Describe surgical excision of hemorrhoids

A

Removal of hemorrhoidal bundles with closure of mucosa

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18
Q

Potential consequence of surgical excision for hemorrhoids

A

Excess removal can cause anal stenosis

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19
Q

Importance of recurrence prevention post-surgical excision of hemorrhoids

A
  • High fiber diet
  • Adequate water intake
  • Proper toileting habits
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20
Q

Define an anal fissure

A

A linear tear in the anoderm, distal to the dentate line

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21
Q

Presentation of anal fissure (4)

A
  • Extremely painful – burning/tearing, usually associated with a hard BM (can also occur with diarrhea)
  • Pain happens during the movement, then lasts a few minutes (note: chronic = possibly lasts for hours)
  • Bright red bleeding
  • Potentially cannot perform DRE (too painful)
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22
Q

Define an acute anal fissure

A

A symple tear in the anoderm

23
Q

Define a chronic anal fissure (3)

A
  • After 8 - 12 weeks the edges scar
  • Inflames, edematous
  • Signs of chronic inflammation: hypertrophied anal papillus sentinel piles (“skin tag”)
24
Q

Location of anal fissure

A

Typically in anterior or posterior midline

  • 75% posterior
  • 25% anterior (women more often)
  • 3% can have both
25
Q

Group of people most commonly affected by anal fissures

A

Young patients (20s and 30s), with women experiencing posterior anal fissures more often

26
Q

What if the anal fissure is located OFF the midline?

A

Need to think of other diagnoses

  • Crohn’s disease/ulcerative colitis
  • Anorectal trauma
  • Infections: HIV/AIDS, syphilis, TB, gonorrhea/chlamydia
  • Neoplasms: leukemia, lymphoma
27
Q

5 steps in the pathophysiology of an anal fissure

A
  1. Hypertonic internal anal sphincter & spasm (–> sustained, resting hypotonia)
  2. Relative ischemia in anterior and posterior midlines
  3. Passage of hard stool or multiple, high floow BMs (i.e. diarrhea) –> tear
  4. Ischemia prevents healing
  5. Pain = patients do not want to pass BM –> more constipation + more pain

(Vicious cycle)

28
Q

23ways to treat anal fissures non-surgically

A

Break the cycle of pain/constipation:

  • Stool bulking agents (fiber/psyllium, water)
  • Sitz baths
  • Topical anesthetics
29
Q

Why can sitz baths treat anal fissures

A

Warmth promotes relaxation of sphincter, cleans and soothes

30
Q

Topical anesthetic for anal fissure

A

Topical nifedipine 0.5% x 1 month

31
Q

What is topical nifedipine?

A

Calcium channel blocker to promote relaxation of smooth muscle / internal anal sphincter

32
Q

2 surgical options to treat anal fissures

A
  • Botox injections
  • Surgical sphincterotomy
33
Q

Define surgical sphincterotomy

A

Cutting part of the internal sphincter to release tension and promote blood flow

34
Q

Potential risks of surgical sphincterotomy

A

Temporary changes in fecal continence with <0.1% having permanent incontinence

35
Q

Define fistula

A

An abnormal connection between 2 epithelialized surfaces

36
Q

Define sinus

A

A connection to a cavity from an epithelialized surface

37
Q

Define fistula-in-ano

A

An abnormal connection between the anal canal (or distal rectum) and the perianal skin

38
Q

What lines the anal canal?

A

8 - 16 anal crypts/glands

39
Q

Function of anal crypts and glands

A

Secrete mucous to help pass stool, provide lubrication to anus

40
Q

Location of anal glands

A

Most are located in submucosa, some extend to the conjoined muscle or even to the intercphincteric area

41
Q

Most common cause of infection and abscess formation in anorectal region

A

Cryptoglandular obstruction

42
Q

Most common abscess of anorectal region

A

Perianal

43
Q

5 types of anorectal abscesses

A
  • Perianal
  • Ischioanal
  • Intersphincteric
  • Supralevator
  • Submucosal
44
Q

7 causes of anorectal abscesses

A
  • Cryptoglandular obstruction
  • IBD
  • Infection
  • Trauma
  • Surgery
  • Neoplasms
  • Radiation
45
Q

3 infections that can cause anorectal abscesses

A
  • Tuberculosis
  • Actinomycosis
  • Lymphogranuloma venereum
46
Q

3 surgeries that can cause anorectal abscesses

A
  • Episiotomy
  • Hemorrhoidectomy
  • Prostatectomy
47
Q

3 neoplasms that can cause anorectal abscesses

A
  • Carcinoma
  • Leukemia
  • Lymphoma
48
Q

4 presenting symptoms of anorectal abscesses

A
  • Perianal pain, swelling, redness
  • Tenderness to touch
  • Sometimes drain spontaneously – reports of pus
  • Intersphincteric abscess wont be seen, but is so painful that DRE cannot be performed
49
Q

6 treatments/ advice for treatments for anorectal abscesses

A
  • Incision and drainage (surgeon)
  • NO packing
  • NO role of antibiotics, except:
    • Severe cellulitis
    • Systemic signs of inflammation
    • Comorbidities
  • Warm sitz bath
  • Stool bulking/softening
  • Analgesia (non-narcotic)
50
Q

Possible consequence of draining an anorectal abscess

A

40 - 50% of tracts will persist and form a fistula

51
Q

Characteristic features of fistula-in-ano

A
  • Persistent, intermittent, sanguino-purulent drainage from a hole (punctum) in the skin
  • Patients complain of staining underwear, intermittent abscesses that rupture and drain, sometimes pain
52
Q

5 characterizations of fistula-in-ano

A
  • A = subcutaneous
  • B = intersphincteric
  • C = Trans-sphincteric
  • D = Supra-sphincteric
  • E = Extra-sphincteric
53
Q

3 general treatment options for fistula-in-ano

A
  • Consult a surgeon
  • Anoscopy to try to identify the internal opening
  • Low-fistulas are generally layed open
54
Q

3 treatments for trans-, extra- ,supra- sphincterics

A
  • Placement of a seton
  • Tissue glue
  • Fistula plugs

NOTE: risk of incontinence if muscle is cut

Block D - Digestion and Metabolism (29 decks)

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