GI- Anorectal Disorders

Where does the anal canal start?

Dentate line; junction of colorectal and anal mucosa

Where does the anal canal end?

Anal verge; junction of anal mucosa and perianal skin

The internal sphincter is composed of _____ & the external sphincter is composed of _____

involuntary circular muscle ; voluntary striated muscle

What causes the urge to defecate?

progressive distension of rectum → continuous inhibition of internal sphincter & relaxation of external sphincter

Anorectal inflammation, infection, or ischemia is referred to as ______

Proctitis

What are chronic/acute engorgements or tissue prolapses into the anal canal that are part of normal anatomy to protect sphincter muscle & ensure closure of anal canal?

Hemorrhoids

What maintains resting internal anal pressure to ensure continence & minimizes trauma during BMs?

hemorrhoids

What type of hemorrhoid?

• vascular cushion

• located above dentate line (insensate)

• lines w/ rectal or transitional mucosa

internal hemorrhoid

What type of hemorrhoid?

• vascular complexes

• underlie highly vascular anal tissue

• located below dentate line

external hemorrhoids

What type of hemorrhoid?

• viscerally innervated and usually not painful

• not well understood; likely due to increased pressure in abdominal cavity

internal hemorrhoid

What type of hemorrhoid?

• readily visible on PE

• thrombosis → acute onset of severe perianal pain

  • skin tags may occur w/ resolution of thrombosis

external hemorrhoid

How might increased venous pressure affect hemorrhoids?

become symptomatic → distension, engorgement & possible bleeding

What are possible causes of hemorrhoids?

prolonged straining, prolonged sitting, constipation, low fiber, heavy weights, pregnancy, age, etc

What classification of hemorrhoid?

• no prolapse

• just prominent blood vessels

1st degree

What classification of hemorrhoid?

• prolapse upon bearing down but spontaneously reduced

2nd degree

What classification of hemorrhoid?

• prolapse upon bearing down and requires manual reduction

3rd degree

What classification of hemorrhoid?

• prolapsed and cannot be manually reduced

4th degree

What are symptoms of hemorrhoids?

pruritic, dull burning pain (external), prolapsed tissue, BRBPR, fecal incontinence, recurrent protrusion

What is the workup for hemorrhoids?

PE- DRE, anoscopy, proctoscopy, flexsigmoidoscopy, colonoscopy

What are the conservative treatment measures for hemorrhoids?

high fiber diet (> 25gm/day), inc fluids, stool softeners, Sitz baths, hydrocortisone-lido cream, proctofoam, anusol, witch hazel pads

What are procedural treatment options for hemorrhoids?

rubber band ligation (grades 1-3),

sclerotherapy (liver dz/immunocomp/anticoag pt)

infrared coagulation

hemorrhoidectomy (4th degree)

excision if all else fails

Which procedure is good for grade 3, requires narcotics post-op and has longer post-op pain & delayed return to normal activity?

conventional hemorrhoidectomy

Which procedure is better for grades 2-4, & involves a circular stapling device excising prolapsed tissue?

stapled hemorrhoidopexy

Which procedure uses an anoscope w/ u/s to locate the 6 branches of the superior rectal artery to ligate, has NO excision, less post-op pain (NSAIDs for pain relief)?

transanal hemorrhoidal dearterialization

What are possible complications of hemorrhoidectomies?

fecal incontinence w/ injury to anal sphincter, bleeding, infx, severe pain, urinary retention, anal stenosis

What condition?

• rupture of vein at anal margin → clot in SC tissue

• pt complains of painful rectal lump

• PE: tense, tender, bluish mass covered with/ skin

thrombosed external hemorrhoid

How soon does a patient w/ a thromboses external hemorrhoid need to be treated for evacuation to be successful?

< 48 hrs from sx onset

What is the treatment for thrombosed external hemorrhoids?

clot evacuation & excision

conservative: warm sitz bath, high fiber diet, stool softeners

What conditions should an anal fissure off the midline arouse suspicion for?

Chrons, HIV/AIDS, cancer

What condition?

• split or tear in anal mucosa, occurs midline, distal to dentate line

• range from involving only epithelium to entire thickness of mucosa

Anal fissure

Who is at an increased risk of anal fissures?

IBD, post partum women, elderly

A mature ulcer (chronic anal fissure) is associated with what?

skin tag (sentinel pile) & hypertrophied anal papilla

What are possible causes of anal fissures?

vigorous stretching of canal during large firm BM, childbirth, Crohn’s, anal intercourse, digital/FB insertion, previous anorectal surgery

What is the pathogenesis of an anal fissure?

anodermal tearing exposes internal splinter muscle → inc tension → muscle spasm → prevents sphincter relaxation → further tearing, deepening, & spasm → persistent spasm creates degree of ischemia that further delays healing

what are symptoms of anal fissures?

severe tearing/burning/throbbing pain (esp during BM), hard stool from pt ignoring urge to defecate, constipation, bright red bleeding w/ defecation

What is the goal of treatment for anal fissures?

relieve pain, constipation, spasms & reduce resting anal sphincter pressure to encourage healing

What are treatment options for anal fissures?

stool softeners

high fiber diet

topical nitroglycerine ointment

bulking agents

hydrocortisone supp or cream

surgery rarely needed

Who are anorectal abscesses & fistulas more common in?

men; 3rd-5th decade

What conditions are anorectal abscesses associated with?

Crohn’s, immunocomp (DM, HIV), malignancy, constipation/diarrhea, infx, trauma, prior radiation

Where do anorectal abscesses arise from?

the 6-14 anal glands; lie at/near area bt int & ext sphinters

drain through int sphinters → crypts at dentate line

When would an infection occur with anorectal abscesses?

occluded crypt; edema from trauma adjacent inflammatory processes

What condition?

• abnormal fluid filled cavity in anorectum; can extend up/down through anal tissues

  • develops when crypt does not empty the anal canal / stool enters instead

  • results from surrounding infx

• PE- DRE: erythema, flatulence, edema

• sx: throbbing continuous perianal pain

anorectal abscess

What is the treatment for anorectal abscess?

I&D + abx

What condition?

• communication bt abscess w/ identifiable opening within anal canal’ frequently at dentate line

• purulent drainage → pruritus, tenderness, pain

• frequently noted after drainage of abscess

anorectal fistula

What conditions are anorectal fistulas associated with?

Crohn’s, lymphogranuloma venereum, rectal cancer

What is the treatment for anorectal fistulas?

I&D, fistulotomy, broad spectrum abx, sitz bath

Who are pilonidal diseases most common?

caucasian males, peak 16-21 y/o

What is the patho of pilonidal disease?

acquired in hirsute individuals

natal cleft hair follicle infected → rupture into surrounding tissues → abscess

What condition?

• abscess in sacrococcygeal cleft w/ resultant sinus tract development

• painful fluctuant area

• small midline pits or abscess near midline of sacrum, coccyx

• +/- abscess

• chronic draining sinuses w/ hair protruding from pits

Pilondidal cyst

What is the treatment for pilonidal disease?

surgical I&D → unroofing (removal of granulation tissue & hair by curettage)

What is the treatment for chronic draining pilonidal cysts or failure to heal after 3 months?

excision of midline pits & hair removal

marsupialization- excision w/ open packing

What is another name for anal / genital warts?

Condylomata Acuminata

What virus invades superficial layers of anogenital region during sexual contact, causing anal warts?

HPV

What age has the highest prevalence of HPV?

16-25

What condition?

• generally asx but can be pruritic, painful, or friable

• soft pink - brown lesions in cauliflower like clusters

Anal warts

What is the treatment for anal warts?

topical podofilox, imiquimod, or sinecatechins

cryotherapy, podophyllin, bi/trichloroacetic acid, or laser surgery

What types of HPV is most commonly documented with malignant transformation?

16 & 18

What types of HPV account for 90% of genital warts?

6 & 11

What vaccine covers 9 total strains of HPV to prevent anal warts & cancer?

Gardisil