Anorectal Dz - Gardner

females

Anal Cancer •2.5% of GI Malignancies •8300 new cases/year •Risk factors -________ (m or f) -HPV infection -Multiple sexual partners -Anal receptive intercourse -Smoking -Genital warts -HIV Infection

chemoradiation, surgical

Anal Cancer •Treatment for Anal SCCA -Combined _____________ - this is because it is very rare to find it early enough -Salvage surgery (APR (abdominal perineal resection) this will require a colostomy) -Local excision in select patients (small, superficial disease) •Treatment for Adenocarcinoma Rectum/Anus -__________ Resection (APR or Low Anterior Resection) -Chemoradiation

inguinal

Anal Cancer •Tumors from below dentate line tend to metastasize to superficial and deep __________ nodes. •Survival is dependent on size and nodal status (5-year survival): -T1 - 86 percent -T2 - 86 percent -T3 - 60 percent -T4 - 45 percent -N0 - 76 percent -Node positive - 54 percent

squamous, columnar

Anal Cancer •________ Cell versus Rectal Cancer which arises from ___________ epithelium (this is done with excisional/punch biopsy) •Symptoms -Bleeding usually minimal -Pain usually mild (due to slow growth) -Mass •Signs -One lesion, maybe satellite lesions -Friable, ulcerated, bloody -Hard, gritty, usually flatter (not anything like anal warts)

distal, relaxation, internal, spasm

Anal Fissure-Pathophysiology •An anal fissure is a tear in the lining of the anal canal ________ to the dentate line. •The majority of anal fissures are caused by failure of ___________ of the __________ anal sphincter, the sphincter is in ________. •Anal fissures can also be seen in patients with Crohn's disease, tuberculosis, and leukemia.

1-2, internal, sphincterotomy, 14

Anal Fissures Surgical Treatment •After ___-___ months of medical therapy •Lateral _________ Anal ________________ (96% healing) -cut the muscle about as long as the fissure is •Incontinence Risk -Overall ~ ___% -Flatus incontinence ~ 9% -Soilage/Seepage ~ 6% -Incontinence to stool > 1%

12, 6, chronic

Anal Fissures •Anal fissures usually occur in the ___ and ___ o'clock positions, if in other positions, think of other causes (IBD, HIV, TB, CA or syphilis) -"the vast majority are in the posterior midline" •If not treated promptly, anal fissures may become _________ and require surgical management. (time related)

sentinel, tag

Anal Fissures •Generally accompanied by a "_________ pile"; a small fleshy skin ____ at the end of the tear.

strain, sitz, nifedipine, nitroglycerine

Anal Fissures •The goal of treatment is the ability to pass soft stools without _________ •Fiber supplements, stool bulking agents/Stool Softeners •______ baths for acute discomfort (warm water will ease pain) •EMLA cream for severe pain •Topical Vasodilators: 0.2 - 0.3% _____________ 2 to 4 times a day or 0.2 - 0.4% _______________ bid. (Smooth muscle relaxers)

HPV, direct, transmission

Anal Warts •Condyloma Acuminata •Due to ____ (acronym for cause) (probably a test question) •Common - ~200/100,000 population •Transmission is by _______ contact - read sexual in adults •Lesions are soft papules or plaques •Lesions need not be present for ____________ to occur •Malignant transformation is rare (but it is a risk factor for anal cancer) •Diagnosis is made clinically or by biopsy •Worse in immunosuppressed patients

creams, sexual

Anal Warts Treatment •Patient applied topical ________ -Efficacy 35-80% (this essentially means we don't really know how well it works...huge range and we can't really control how well the patient does this treatment at home. No real downside to trying) -Treatment time is in weeks and is intermittent -Requires motivated, compliant patient -May cause irritation -May weaken condoms and diaphragms and may interfere with _______ activity (creams can weaken condoms/diaphragms)

electrocautery

Anal Warts Treatment •Provider applied treatments -Cryotherapy -_______________ (gardner's preference) -Trichloroacetic acid -Excision -CO2 Laser •Higher success rates •May still recur •More aggressive the treatment, higher risk of scarring and dysfunction •Next line treatments include Podophyllin resin, Topical 5 FU and others -if you ever take something off, send it to pathology -rule of thumb: the more options for treatment, then the less likely any is going to work well

crypt, bacterial, abscess, fistula

Anorectal Abscess •A perianal abscess represents an infection of the soft tissues surrounding the anal canal, with formation of a discrete abscess cavity. •This infection usually begins with an infected anal _____ gland when it becomes obstructed with inspissated debris, which permits ___________ growth and ___________ formation •_______ may then develop from this area of infection

e.coli, perianal, ishiorectal

Anorectal Abscess •Common organisms causing anorectal abscess include: -___.______ and other enteric gram negatives -Bacteroides species and other anaerobes -Staphlococcus species and other skin flora •Anorectal abscesses may be: (locations) -_________ (60%) -____________ (20%) -Intersphincteric (5%) or supralevator (4%)

pain, bleeding, mass, duration, fever

Anorectal Disease Symptoms and Signs used to differentiate between processes THE BIG THREE •______ •___________ •______ SECONDARY •__________ of process •_______

side, bent, relax, circumference, prostate

Anorectal Exam •On their _____ with top leg _____ •Allow the sphincter time to ______ •Use a well lubricated, gloved finger •Feel entire _______________ of the wall •Feel the entire ___________ (for males)

difficult, suction seal, lithotomy

Anorectal Foreign Bodies •Diagnosis usually not too difficult to make. •Important to know what the FB is, and how it is oriented. Do not make the problem worse. •Typically _____________ to remove, or else patient would have already done that. •Often a "_________ ________" is present which makes removal more difficult -Patient in ____________ position -Relax the sphincter with anesthesia, regional or general -Introduce air into the colon/rectum above the FB •May need a laparotomy and colotomy

crohn's, malignancy

Anorectal fistulas can develop in patients without abscess in a variety of other disorders including : •_______ disease and Ulcerative colitis •Anorectal __________ •Radiation proctitis •Rectal foreign bodies •Leukemia

reducible, painful, tangential, circular

Classification-Internal Hemorrhoids Painful •Grade IV: The hemorrhoids are prolapsed and NOT _________. Typically ___________, but not always (ischemic type pain). Grade IV Hemorrhoids vs Prolapse •Hemorrhoids have ___________ lines. •Rectal prolapse has concentric or _________ lines.

prolapse, bleeding, spontaneously, manually

Classification-Internal Hemorrhoids Painless: •Grade I: The hemorrhoids do not _________, present with bright red _________. -not a bad idea to do a colonoscopy because it could present along with something more serious (i.e. rectal cancer) •Grade II: The hemorrhoids prolapse upon defecation but reduce ________________ -can also bleed -can also complain of itching and burning in grade 2 and 3 due to prolapse •Grade III: The hemorrhoids prolapse upon defecation and must be reduced ________

asymptomatic, mild, severe

Clinical Presentation of Pilonidal Dz •____________ disease: a painless cystic lesion lined with hair or sinus opening located at the top of the gluteal cleft (no need to do anything at this point. Just warn the patient of symptoms in the future) •_____ Pain or Irritation: Due to pressure from a non-infected cyst or drainage from a sinus •________, acute pain: From an abscess •+Fever, usually with abscess and/or cellulitis.

chronic, acute

Clinical Presentation of a Pilonidal Cyst Duration •_________ Disease: persistent drainage from a sinus or sinuses connecting to the pilonidal cyst itself. -One or more sinus openings will typically be seen, and drainage of mucoid or frankly purulent material may be present •______ Disease: Typically due to an abscess. -About half of patients will present with acute abscess and about half with a more chronic process

all, older

Diagnosis of Symptomatic Hemorrhoids •Physical examination, including Digital Rectal Exam (DRE) •Confirmation by flexible sigmoidoscopy, anoscopy, or colonoscopy should be performed in ___ patients. •Colonoscopy is generally recommended in _______ patients to exclude more serious underlying disease (eg, malignancy).

straight, curved, 3, curved, posterior

Goodsall's Rule -Goodsall's rule is a guideline for internal opening & path of fistula track & aids in RX. -Fistulas can be described as anterior or posterior relating to a line drawn in the coronal plane through ischial spines across the anus - called transverse anal line -Anterior fistulas - have a __________ track into the anal canal -Posterior fistulas - have a __________ tack with their internal opening lying in the posterior midline of the anal canal -An exception to the rule - anterior fistulas lying more than ___cm from the anus, which may have a ________ track (similar to posterior fistulas) that opens into the __________ midline of the anal canal

above, below

Hemorrhoids •Normal vascular structures in the anal canal, comprised of arteriolar, venous and smooth muscle elements- present in everyone! •It is only when they become symptomatic that lay people generally believe that they have "hemorrhoids". •They are external or internal based upon whether they are below or above the dentate (pectinate) line. Internal is _______ the dentate line External is _______ the dentate line (typically only caused by thrombosis)

clinically, high

Making the Diagnosis of Pilonidal Dz •Pilonidal cysts are diagnosed ___________. •When a patient presents with an acutely inflamed mass near the top of (superior to) the gluteal (natal) cleft, the likelihood that it is an infected pilonidal cyst is extremely _____. •Typically, the mass is very painful, and it may or may not have drained spontaneously.

ligation

OR Treatment of Hemorrhoids Only indicated after conservative treatment has failed. Options include: -Rubber band _______ --This is best used with an internal hemorrhoid because there are less nerves above dentate line so it is less painful. External would be super painful -Infrared coagulation -Sclerotherapy -Cryosurgery Figures A-E depict rubber-banding of internal hemorrhoids A&B: the hemorrhoid is grasped C&D the rubber band is applied E: the banded hemorrhoid

age, pregnancy, tourniquet

Pathophysiology-Hemorrhoids •The development of symptomatic hemorrhoids has been associated with: -Advancing ____: facilitates prolapse -_____________: decreased venous return? -Pelvic tumors -Prolonged sitting on the toilet- __________ effect -Straining/ Chronic constipation? Poor evidence •The cause of symptomatic external hemorrhoids is not completely understood

posterior, anterior, laceration, raised, white

Physical Exam-Anal fissure •Spread the buttocks apart gently, looking carefully in the: -___________ midline (most common location) -____________ midline (second most common location) •Patients are often too uncomfortable to tolerate a digital rectal examination or anoscopy. •An acute fissure appears as a fresh __________ •Chronic fissure has _______ edges exposing the _______, horizontally oriented fibers of the internal anal sphincter at its base

teens, 30, males, cyst, abscess, sinus

Pilonidal Disease •Commonly encountered young adults, most commonly in their ______ to ___'s, with 3-4x more ______ (m or f). Why? -the problem is with HAIR. The end of the hair will poke into the skin and form a pocket. Will find a nest of hair here •Pilonidal disease generally presents as a _____, __________, or one or more ______ tracts (tunnel from cyst to the outside surface of the skin) in the upper part of the gluteal (natal) cleft (butt crack). •Pilonidal disease is important economically both in terms of its direct and indirect costs

30, fistula, healing, defecation, excoriated

S/S of Anorectal Fistulas •~___% of patients with Anorectal abscess will develop a ______ in anorectal area. - warn them of s/s •"Non-__________" anorectal abscess following drainage, or with chronic drainage and a pustule-like lesion in the perianal or buttock area. •Discomfort during ___________, which is usually much less severe than in patients with fissures •Perianal skin may be __________ and itchy •Fistulas complicating Crohn's disease may be accompanied by associated bowel symptoms; diarrhea and abdominal pain

blueberry

Signs and Symptoms-Hemorrhoids External Hemorrhoids •Acute •Thrombosed •Painful, very painful •Typically solitary 1-1.5 cm in size •Look like a _________ stuck to the anus. •Firm, but not red. •Located on the anal verge.

fluctuance, indurated, pain, toxicity

Signs of Anorectal Abscess •Area of _____________ or a patch of erythematous, indurated skin overlying the perianal or ischiorectal area. •Fluctuant and ___________ mass on DRE -Pain on DRE may limit exam •Deeper (more proximal) abscesses may have no findings other than ______ and systemic ___________, and the abscess is only seen on CT scan.

bowel movement, constipation, blood

Symptoms of Anal Fissures •Exquisite pain during a ________ _________, with the pain lasting several minutes to hours afterward and recurring with every BM. -The patient commonly becomes afraid or unwilling to have a BM, leading to a cycle of worsening _____________, harder stools, and more anal pain. •About 70% note a little bright red _________ on the toilet paper or streaking the stool. (only a very little amount) -Occasionally, a few drops may fall in the toilet bowl, but significant bleeding does not usually occur with an anal fissure

pain, constant, pruritus, fullness, systemic, purulent

Symptoms-Anorectal Abscess? •Severe ______ in the anal area -Dull and __________ (duration) may worsen with a BM -Also worsens with movement or sitting •________ and anal _______ •__________ symptoms such as fever and malaise are common. •_________ drainage may be noted if the abscess has begun to drain spontaneously.

surgeon, location, sphincter

Treatment of Fistula •If anorectal fistula is suspected, the patient should be referred to a _________ for further care. •The surgical management of the anorectal fistula depends on -__________ of the fistula in relation to the external anal sphincter -Amount of the _________ complex involved with the fistulous tract

fistulotomy, seton, tightened

Treatment of Fistula •Superficial fistulas that affect less than a third of the sphincter complex may be treated by ____________. •Deeper fistulas, supra-sphincteric, are treated with a cutting _______. •A cutting seton is a loop of silk or vascular loop that goes through the fistula tract and out the anus. The ends are fastened together and the seton is _____________ every few days as it "cuts" it's way through the subcutaneous tissue.

hemorrhoidectomy, 4, 3, painful

Treatment of Hemorrhoids Surgical ________________ •Grade ___ Hemorrhoids and large Grade ___ Hemorrhoids. •Very rarely indicated for Grade I and II hemorrhoids. •A very _______ surgery post-op. •Risks including bleeding, infection, anal stenosis IMPORTANT -Grade 4 hemorrhoid will usually be very swollen. If you can reduce the swelling (using sugar) then you may be able to reduce the hemorrhoid and make the surgery more elective

conservative, bleeding, pruritus

Treatment of Hemorrhoids •____________ treatment measures are successful for most patients with Grade I and II Hemorrhoids. -If __________-Fiber supplementation, stool softeners, laxatives, exercise -If __________/irritation-variety of analgesic creams, hydrocortisone suppositories (use these for a max of a week), and warm sitz baths. -Hot water -Hot water -Hot water --(these are very soothing and can make it feel better)

fistula, low, GNR

Treatment of Peri-rectal Abscess •Other anorectal abscesses require operative drainage under general anesthesia due to their deep location. •One of the most concerning complications of perianal abscess is __________ formation. The most important predictor of fistula formation is the type of organisms cultured. -Abscesses associated with skin flora infection (Staph) have a very _____ risk of fistula, whereas 40% of those with _____ (acronym) infection will have a fistula.

perianal

Treatment of Perianal Abscess •I&D of superficial ________ abscesses can be accomplished in the ED or office with local anesthetics by an experienced clinician. •An incision is made over the area of fluctuance. (don't just do a punch hole, you need to have a big enough hole to make sure you can get your finger in to break up loculations) •Pus is collected and sent for culture. •Gentle pressure is used to remove all purulent material. •The cavity is irrigated and swept with a finger to remove loculations •The abscess cavity is loosely packed with iodophor gauze. (want this to heal by secondary intention i.e. healing from the inside - out)

surgical, antibiotics, metronidazole

Treatment-Anorectal Fistula •___________ treatment is usually required in patients with symptomatic anorectal fistulas, with the exception being patients with Crohn's disease. •Patient with Crohn's disease-treatment of the underlying Crohn's disease and __________ is the modality of choice. Surgery usually exacerbates fistula formation in a patient with Crohn's. Antibiotic of choice is ________________, with or without Ciprofloxacin.

72, excision, analgesics, sitz, spontaneous

Treatment-Painful thrombosed external hemorrhoids •Within ___ hours from onset of sx: -_________ of the entire hemorrhoid (favored procedure) -Lancing and evacuation of the clot •After 72 hours from onset of sx: -Oral and topical __________, stool softeners, and _____ baths may provide adequate relief until ____________ resolution occurs

True

True or False Abscess forms in the intersphincteric space and spreads to other adjacent potential spaces. cyclical pattern -Glandular secretion stasis ->infection & suppruration -> abscess formation -> anal crypt obstruction

True

True or False Anal Warts •Symptoms -Bleeding (very minimal) -Pain/Irritation (typically not very painful) -Mass - Soft, plush -relatively asymptomatic •Signs -Multiple discrete lesions -Not ulcerated -Not friable -Soft

True

True or False Anorectal Anatomy Muscles -Internal sphincter is smooth muscle which means we cannot control it -External sphincter is skeletal muscle from the levator ani and is voluntary control Epithelium -Dentate line in the rectum with the anal glands. Play a role in anal abscesses Vascular Supply -Most of the rectum gets blood from inferior mesenteric artery -Anus and distal rectum get blood from the external iliac artery -Very rich blood supply, pretty hard to lose supply to cause ischemia of rectum Nerve Supply

True

True or False Anorectal Disease •Foreign Bodies •Infection/Abscess •Fistula •Fissure •Hemorrhoids •Cancer •Warts/Skin Lesions

True

True or False Anorectal Foreign Bodies •Do not be judgmental •Never let the patient or family know you are shocked or disturbed. •Do not laugh or joke about anything in the nurse's station.

True

True or False Anorectal Physiology How does IT (pooping) happen? Nerve supply to muscles -Smooth muscle - autonomic -skeletal muscle - conscious control -Nerves help to differential between solids, liquids, and gas -Pressure in rectum causes relaxation of internal sphincter and you can then choose to relax the external

True

True or False Differential Diagnosis-Hemorrhoids •Most laypersons and many practitioners attribute all perianal symptoms to hemorrhoids- be vigilant for other causes! •Anal fissures •Condyloma •Rectal prolapse •Anal cancer •Crohn's disease

True

True or False Hemorrhoids Do you have hemorrhoids? -everybody does (just the name of the venous plexus in the anus) The "Go-To" diagnosis for all anal disease.

True

True or False Other Symptoms of Hemorrhoids •Pruritis (itching) •Burning •Soiling

True

True or False with regard to Gardner's surgery lecture Post Procedure Perforation -Pain, tachycardia -Acute abdominal x-ray series - specifically upright CXR --want to look between the right hemidiaphragm and liver. Look for free air here -CT scan if xrays are negative or non-diagnostic

surgical, waiting, incision, drainage, metronidazole, 1st

Tx of Infected Pilonidal Cyst -Chronic and symptomatic - _______ excision (difficult to close up afterward and long healing process -Chronic and asymptomatic - watchful ________ •Acute treatment: simple _________ and __________ (I&D) -Overall cure rate of 45% •ABX are not indicated unless significant cellulitis. If needed, ____________ and a ___ generation cephalosporin should provide reasonable coverage (G+ and anaerobes) •Surgical excision is required for removal of cysts and sinus tracts, after the acute infection has resolved.

CT, contrast, incision, drainage, insufficient, malfunction

Work-Up and Treatment of Deep (proximal) Anorectal Abscess •Imaging may be necessary for dx, ____ scan with ___________ would be the modality of choice. MRI and U/S may also be used. •___________ and _________ of the abscess is essential, antibiotic therapy alone is ________________. •Delay in drainage increases the risk of permanent sphincter __________, fistula formation and extends soft tissue damage.