rectum

anal fistula

An anal fistula occurs when a structure or pathway forms between the intestine and another adjacent structure. It is most commonly a complication of perirectal abscess. Fistula tracts are categorized by anatomic location and include intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. Patients with anal fistula will complain of anal irritation and itching, drainage from the anus that is bloody or pus-filled, or urinary symptoms if the fistula involves the bladder. Anal fistulas are associated with Crohn disease, which is an inflammatory condition of the bowel. Physical exam may reveal an internal fistula opening, however, this is difficult to assess without anal relaxation, which is often achieved only with anesthesia. Patients with signs and symptoms of an acute infectious process should be treated promptly with intravenous antibiotics and urgent surgical consultation. Those who have no indication of acute infection can be evaluated by a surgeon in the outpatient setting. Surgical intervention using a seton or a fistulotomy is often a definitive treatment, although recurrence rates are high with complex fistulas.

Anal Fissure Patient presents with r PE Diagnosis is made by Treatment is If fissures are located ___, search for pathologic etiologies

Anal Fissure Patient presents with rectal pain and bleeding that occurs with or shortly after defecation PE will show fissure located in the posterior midline Diagnosis is made by visual inspection Treatment is stool softeners, protective ointments, sitz baths, topical nitroglycerin or nifedipine If fissures are located laterally, search for pathologic etiologies

anal fissure

Anal fissure is a common cause of pain and rectal bleeding. A fissure is a laceration of the midline of the posterior or anterior anal canal. These fissures typically occur after trauma to the area, which is typically due to a hard bowel movement and most commonly occurs in infants and middle-aged adults. Patients describe pain that is worse during or just after a bowel movement and characterize the pain as sharp and knife-like. Some patients may describe the pain as like "passing glass." The fissure can cause bleeding during bowel movements. Physical exam will reveal an area that appears to be lacerated if there is an acute anal fissure present. A fissure can also be chronic, appearing more fibrous and having edges that appear raised. Diagnosis is clinical and based on history and physical exam alone. Avoiding constipation and straining with bowel movements helps prevent anal fissures from occurring. Treatment includes fiber supplementation and increasing fluid intake to soften bowel movements and prevent constipation. Warm sitz baths after bowel movements can help reduce anal spasm and pain. Topical medications, such as nitroglycerin, hydrocortisone, and diltiazem, provide relaxation of the sphincter. Botulinum toxin injection can provide relief from sphincter spasm while the fissure heals but can cause fecal incontinence that is typically reversible after several months. Surgical repair is reserved as a last option because of the risk of irreversible fecal incontinence that occurs in 3-5% of patients. Surgical repair is typically reserved for patients who have had symptoms for longer than 8 weeks and have failed other treatments.

What is the recommended age to start screening for colorectal cancer according to the U.S. Preventive Services Task Force?

Answer: 50 years grade A recommendation. 45 years grade B recommendation.

What medications should be prescribed to the patient after incision and drainage of a perianal abscess?

Answer: Antibiotics, stool softeners, and analgesics.

When should surgical treatment for anal fissures be considered?

Answer: For refractory cases or if symptoms last longer than 8 weeks.

What is the classification of internal hemorrhoids called?

Answer: Goligher classification.

What is the most common type of anal fistula?

Answer: Intersphincteric.

What is the surgical repair of an anal fissure called?

Answer: Lateral internal sphincterotomy.

What patient populations are more at risk of developing fecal incontinence after surgical intervention?

Answer: Multiparous women, older patients, and patients with preexisting fecal incontinence.

What position should a patient be in to perform an examination for hemorrhoids?

Answer: Prone or left lateral position.

Above what anatomical landmark do internal hemorrhoids form?

Answer: The dentate line.

Hemorrhoids Sx: PE:Internal: External: Tx:

Hemorrhoids Sx: discomfort and itching in the anal region, if thrombosed may also report pain PE:Internal: proximal to the dentate lineExternal: distal to the dentate line Tx: lifestyle modifications, sitz baths, analgesic creams, rubber band ligation, sclerotherapy, surgical excision

hemorrhoids

Internal hemorrhoids are a normal anatomical part of the anal canal. These hemorrhoids consist of connective tissue, smooth muscle fibers, and terminal branches of the rectal arteries and veins providing normal closure and pressures in the anal canal. They are located in the right anterior, right posterior, and left lateral areas of the canal and arise from the superior hemorrhoidal cushion. External hemorrhoids are veins located below the dentate line and are superficial vessels covered with squamous epithelium. Both types of hemorrhoids become dilated with increased venous pressure. This pressure can be caused by constipation and straining with bowel movements, pregnancy, or obesity, and creates distention of these veins that can result in rectal bleeding with or without discomfort. Internal hemorrhoid tissue is not as sensitive as external hemorrhoid tissue. At first, internal hemorrhoids may cause rectal bleeding with bowel movements but, otherwise, may be asymptomatic. Prolapsed internal hemorrhoids manifest as purple nodular structures protruding from the anus on physical exam. These are typically nontender unless there is an associated thrombosis.

perianal abscesses

Perianal abscesses typically arise from the anal crypt gland at the dentate line. There are 8 to 10 of these glands around the anal canal, and when one of them becomes infected, the collection of pus fills subcutaneous tissues or intersphincteric planes. Men are more likely to present with this condition than women. The mean age at presentation is 40 years. These patients will present with pain in the anal area. Physical exam will reveal swelling, tenderness, induration, and fluctuance to varying degrees. Patients may have constitutional symptoms of infection, including fatigue, fever, or general malaise. If the abscess is not treated with prompt incision and drainage, patients can develop complications such as fistula or sepsis. The incision is made in the skin as close to the anal verge as possible. Imaging is typically not necessary unless there is suspicion of a deep anorectal abscess. CT or MRI will demonstrate evidence of deeper fluid collections and the involvement of adjacent structures if the infection has spread. Antibiotics should be prescribed to all patients with perianal abscess to reduce the risk of fistula formation.

Pilonidal Abscess tx

Pilonidal Abscess I&D Consider antibiotics Refer to surgery

pilonidal disease

Pilonidal disease is a chronic glandular inflammation due to blocked hair follicles that occurs along the superior and inferior gluteal cleft. The disease is chronic, as opposed to the acute inflammation of hair follicles in folliculitis, because pits form in the subcutaneous space along the natal cleft. These pits draw in debris from the skin (e.g., hair and dirt), which results in extension of the subcutaneous pocket. Pilonidal abscesses occur when the subcutaneous collection of fluid becomes infected. Pilonidal disease is more common in men. Patients with pilonidal disease may present with an acutely infected pilonidal abscess or chronically draining pits along the superior and inferior gluteal cleft that extend cephalad. This presentation is different from anorectal abscesses and fistulas, where the tracts typically extend to the rectum. The diagnosis of pilonidal disease is made clinically since there is no laboratory or diagnostic imaging that is specific to the disease. Patients with pilonidal abscesses should be treated with incision and drainage. Other manifestations of pilonidal disease should be treated conservatively initially, since the natural course of the disease typically leads to self-resolution. Individuals with a severe initial presentation or those who fail conservative management should be considered for surgical removal of the pilonidal tracts.

A 30-year-old man with a history of constipation presents with severe tearing anal pain on defecation. He notices bright red bloody streaks on the stool each time he defecates. On exam, an elliptical lesion is noted on the posterior midline of the anus. Which of the following is the most likely diagnosis?

anal fissure Anal fissures are elliptical or linear lesions that are found in the lining of the anal canal, distal to the dentate line. They are most commonly found on the posterior midline, although they can also occur laterally, in which case they may be associated with leukemia, Crohn disease, tuberculosis, HIV, or other granulomatous diseases. Common causes of an anal fissure include constipation, straining, vaginal delivery, diarrhea, or anal sex. Patients typically present with severe tearing anal pain on defecation, which may or may not be accompanied by hematochezia. Anal pain is precipitated by anal sphincter spasm and may last minutes to hours. Bright red blood may be seen on the stool or toilet paper. Anal fissures can be acute (present for < 8 weeks) or chronic (lasting more than 8 weeks). On physical exam, an acute anal fissure has a clean edge and appears as a "paper cut" to the anal mucosa, while a chronic anal fissure has an indurated, hypertrophied edge, often exposing the underlying sphincter muscle. The initial goal of management for anal fissures is to relax the anal sphincter and soften the stools to prevent further trauma so the lesion can have time to heal. Fiber, stool softeners, and increased hydration can accomplish this goal. Sitz baths three times daily can also improve the healing of anal fissures by relaxing the sphincter and increasing blood flow to the anus. Anal fissures that persist despite conservative treatment can be treated with topical nitroglycerine or nifedipine ointment or topical analgesics such as topical lidocaine. Bleeding can be stopped with topical styptics, such as silver nitrate and gentian violet solution. Patients with refractory chronic anal fissures and anal fissures that occur laterally should be referred to a colorectal specialist for further evaluation and surgical management.

A 23-year-old man presents with anorectal discharge for two weeks. Three weeks ago, he had a painful right-sided perianal mass that he "popped" with his fingers. The pain has continued, and two weeks ago, he noticed pus and blood on toilet paper after each bowel movement. He has no medical or surgical history. His vitals are normal. On examination, there is a subcutaneous nodular structure at the right perianal region with minimal overlying erythema, and on rectal examination, a small amount of pus is expressed with palpation of the right lateral anal canal. The remainder of his physical exam is normal. What is the most likely diagnosis?

anal fistula Anal fistula is an abnormal communication between the anus and the perirectal skin, most commonly resulting from drainage of an anorectal abscess. Anal glands function in evacuating feces by secreting mucous into individual crypts of an anal valve. Anal valves connect the inferior borders of the columns of Morgagni to semilunar folds of epithelium at the dentate line of the anus, where columnar epithelium transitions to squamous epithelium. Anal glands are positioned between the internal and external anal sphincter muscles and may become obstructed, leading to infection and abscess formation. Over one-half of anorectal abscesses either recur or develop a chronic epithelialized tract (anal fistula). The Parks classification categorizes anal fistulas based on their relation to the anal sphincter muscles. Intersphincteric fistulas result from perianal abscesses, transsphincteric fistulas result from ischiorectal abscesses, and suprasphincteric fistulas result from supralevator abscesses. Extrasphincteric fistulas open high up in the rectum and are located proximal to the dentate line. Superficial fistulas are submucosal and do not involve any of the sphincter muscles. Anorectal infections most commonly occur in the third or fourth decade of life, and men are more frequently affected (one theory for male predominance is androgen conversion in the anal glands). Other risk factors for anorectal infection include rectal mucosal laceration (obstetric trauma, rectal instrumentation, or foreign body), pelvic radiation exposure, and Crohn disease. Common symptoms of an anal fistula include chronic drainage of pus and stool from the skin opening, rectal pruritus, and intermittent rectal pain that occurs with defecation or sitting. The diagnosis is made clinically on examination or by intraoperative fistulotomy. On physical exam, the perianal skin may show erythema, induration, and excoriations. The external opening of the fistula may be tender with expressible discharge, and a cord may be palpated from the external opening to the anal canal. The main treatment is fistulotomy, which involves unroofing the fistula tract and allowing the fistula to heal by secondary intention. Staged fistulotomy uses a seton stitch that allows progressive sphincteric muscle division, as opposed to partial sphincterotomy, which is more likely to precipitate incontinence.

A 34-year-old woman presents with a urinary tract infection. She has had recurrent UTIs in the past 2 months. Each time, a urine culture has demonstrated E. coli growth. She complains of foul-smelling urine and has noted anal irritation and bloody drainage from the anus at times. Which one of the following in her past medical history would be most consistent with the suspected diagnosis?

crohn disease

A 45-year-old man presents to his primary care physician with complaints of intermittent rectal bleeding. The patient states he occasionally sees bright red blood on the toilet paper after a bowel movement. He denies pain and states this happens most often when he is constipated. The patient has a history of constipation, and his diet consists mostly of fast food. On physical exam, there are no external abnormalities of the anus. Digital rectal exam is normal and hemoccult is negative. With anoscopy, you visualize two purplish bulges in the anterior rectum. Which of the following is the most appropriate next step in management?

fiber supplementation Altered venous drainage of the anus causes the venous plexus and connecting tissue to dilate, leading to hemorrhoids. This dilation then creates an outgrowth of anal mucosa from the rectal wall. Internal hemorrhoids occur above the dentate line in the rectum and are painless. External hemorrhoids occur below the dentate line and can become painful when swollen or thrombosed. Hemorrhoids are more prevalent in patients aged 45 to 65 years. Risk factors include straining with constipation, obesity, pregnancy, chronic diarrhea, anal intercourse, pelvic floor dysfunction, and a low-fiber diet. Patients with internal hemorrhoids often report bright red, painless bleeding present as streaks of blood on stool. Patients can also present with prolapse, soiling, or itching. External hemorrhoids present similarly but become painful when thrombosed. Physical exam should include an abdominal and rectal exam, and the rectal exam should include evaluation with the patient at rest and bearing down. Exam findings can include obvious prolapse, masses, tenderness, or fluctuance. Internal hemorrhoids are less likely to be palpated unless they are large or prolapsed. Anoscopy can be used to visualize internal hemorrhoids, which look like purplish bulges. Endoscopic evaluation is reserved for patients older than 40 years, patients younger than 40 years who do not respond to treatment, patients with a personal or family history of colon cancer or inflammatory bowel disease, and patients with any red flags such as weight loss, abdominal pain, fever, or anemia. First-line conservative treatment includes fiber supplementation, high-fiber diet, increased water intake, warm sitz baths, and stool softeners. Topical nitroglycerin or nifedipine has also been shown to decrease pain. Office-based and surgical procedures such as closed hemorrhoidectomy are used to treat those refractory to medical therapies.

A 35-year-old man with a history of internal hemorrhoids presents with bright red bloody stools. He reports the presence of a lump protruding through the anal canal each time he defecates, coughs, or sneezes. He is able to manually reduce the lump. Which of the following is the classification of his hemorrhoids?

grade III internal hemorrhoids Hemorrhoids are varices of hemorrhoidal plexus that are found in the rectum and anus. Risk factors for hemorrhoids include advanced age, pregnancy, constipation, straining, and prolonged sitting. Hemorrhoids are classified as external, when they are located below the dentate line and covered by modified squamous epithelial cells, or internal, when they are located above the dentate line and covered by columnar cells. External hemorrhoids can occur anywhere in the anoderm but are typically only visible when they become thrombosed or swollen. Thrombosed external hemorrhoids appear as bluish or purplish lesions that are exquisitely tender to palpation. Patients with external hemorrhoids may complain of pain with sitting or wiping or bleeding from the lesions. Patients with internal hemorrhoids present with hematochezia or bright red blood on the toilet paper when wiping. Occasionally, internal hemorrhoids may prolapse through the anus, particularly during defecation. Prolapse can also occur with activities that increase intra-abdominal pressure, such as coughing, heavy lifting, pregnancy, or portal hypertension. Internal hemorrhoids can be classified into grade I, grade II, grade III, or grade IV based on the presence of bleeding and prolapse. Grade III internal hemorrhoids bleed and prolapse through the anal canal with defecation or when performing activities that increase intra-abdominal pressure and require manual reduction after bowel movements. A physical exam may show a bulging purplish-blue anal mass, particularly when the hemorrhoid is prolapsed. A digital rectal exam may reveal ulcerated or indurated areas, masses, tenderness, or mucoid or bloody discharge. Anoscopy is necessary if bright red blood per rectum is present and may show rectal polyps, internal hemorrhoids, a neoplasm, or anal fissures. First-line treatment for hemorrhoids is lifestyle modification measures (increase in dietary fiber, increased hydration, and sitz baths). Analgesic creams containing corticosteroids or astringents may provide temporary relief but are not curative. Referral to a colorectal specialist is indicated in the following instances: failure of conservative treatment, persistent patient discomfort, prolapse, or symptoms lasting more than 4 to 6 weeks. The specialist may seek surgical management, which may include injection with a sclerosing agent such as phenol, rubber band ligation, or sclerotherapy.

A 51-year-old man presents with anal pain and bleeding. He states these symptoms have been ongoing for the past 10 weeks and are affecting his activities of daily living. He has tried topical treatments, including topical hydrocortisone and diltiazem, without relief. He describes the pain as "knife-like" and worse with bowel movements. Physical exam reveals an area in the posterior midline of the anus that appears like a small laceration. Surgical intervention is being considered. Which of the following is a major concern with this type of surgery?

irreversible fecal incontinence

A 44-year-old man presents with pain in the anal area that began 2 days ago and has been gradually worsening. He denies any rectal bleeding or itching. He also denies any constipation or changes in bowel movements, although he states having a bowel movement today was extremely painful. Physical exam reveals a tender, fluctuant mass that is erythematous to the right of the anus and involves the anal verge. Which of the following is the best next step in managing this patient's care?

perform incision and drainage

A 29-year-old man presents to clinic with buttock pain and fluid drainage that started 1 week ago. Visual inspection reveals a tender, red, and fluctuant mass in the sacrococcygeal region, approximately 6 cm cephalad to the rectum. The patient states this same lesion has occured on several occasions in the same location. What is the most likely diagnosis?

pilonidal abscess

A 38-year-old woman with no past medical history presents complaining of severe pain with defecation that lasts for about 1-2 hours after passing a bowel movement. The patient reports she has also noticed some bright red blood on her toilet paper. Her exterior anorectal exam reveals a small tear in the lining of the anus. What is the most common location of this patient's diagnosis?

posterior midline The patient in the vignette has an anal fissure, which is the most common cause of severe anorectal pain. A fissure is a tear or split of the lining of the anal canal. Patients commonly complain of pain while passing a bowel movement, which is often described as feeling as if they are "passing glass" or "passing a knife," followed by pain anywhere from a minute to a couple of hours after passing the bowel movement. Patients will also commonly report either bright red blood on their toilet paper or drips of blood in the toilet bowl. Fissures are most commonly located at the posterior midline of the anus followed by the anterior midline. If there are multiple fissures or if fissures are located on the lateral aspect of the anus, then atypical causes should be considered, such as Crohn disease, ulcerative colitis, tuberculosis, leukemia, HIV, cancer, or syphilis. These patients should then be referred to a specialist for further management. Treatment is aimed towards softening the stool by increasing fiber intake to prevent further trauma so the lesion can heal. Sitz baths multiple times per day are also recommended to encourage relaxation of the anal sphincter and increase blood flow to promote healing. Topical medications, such as 0.2% nitroglycerine or nifedipine, can also be used.

A 47-year-old woman presents with complaints of bleeding with bowel movements for the past 2 days and a sensation of fullness in the anal area. The symptoms began after straining with a bowel movement. Physical exam reveals a purple, nodular protrusion from the anus. From what anatomical location did this issue likely arise?

superior hemorrhoidal cushion