clin med exam 1: anorectal disease

etiology of internal hemorrhoids

subepithelial vascular cushions consisting of connective tissue, smooth muscle fibers, and arteriovenous communications between terminal branches of the superior rectal artery and rectal veins

located above dentae line

etiology of external hemorrhoids

arise from inferior hemorrhoidal veins and are covered with squamous epithelium

located below the dentae line

etiology of thrombosed external hemorrhoids

tense and bluish perianal nodule covered in skin; up to several centimeters in size

signs and symptoms of thrombosed external hemorrhoids

acute onset with severe pain

treatment for thrombosed external hemorrhoids

- warm sitz baths

- analgesics

- possible clot removal

etiology of hemorrhoids

engorgement and irritation of the perianal vasculature caused by extra pressure on the vessels

risk factors of hemorrhoids

- chronic constipation and straining

- obesity

- pregnancy

- prolonged sitting

- aging

- diarrhea

- anticoagulation or antiplatelet therapy

- low dietary fiber

- low fluid intake

signs and symptoms of hemorrhoids

- bleeding

- anal pruritus (itching)

- feeling of fullness or discomfort (with prolapsed hemorrhoids)

- mucoid discharge

- pain

- bright red blood per rectum

test for hemorrhoids (and what it shows)

external hemorrhoids:

- physical exam: shows visible protuberant purple nodules covered with mucosa, possible surrounding fissures, fistulas or dermatitis

internal hemorrhoids:

- anoscopy

- proctoscope

etiology of each hemorrhoid stage

1. hemorrhoids confined to anal canal

2. mucosal prolapse (bulging out) of hemorrhoids occurs during straining

3. prolapsed hemorrhoids can be manually reduced (manually pushed back in) after bowel movement

4. hemorrhoids remain chronically protruded

treatment for stage 1 and 2 hemorrhoids

- increase fluid intake

- increase fiber

- no straining (limit time on toilet)

treatment for stage 3 and 4 hemorrhoids

- increase fluid intake

- increase fiber

- no straining

- OTC topical preps (Preparation H, anusol, Tucks)

- suppositories (combo of emollients, anesthetics, vasoconstrictors, astringents, steroids)

treatment for refractory hemorrhoids

- sclerotherapy

- photoligation

- banding

- surgical excision (hemorrhoidectomy)

etiology of proctitis

inflammation of the lining of the rectum

caused by: IBD, bacterial infections, STIs (gonorrhea, chlamydia, syphilis, HSV, CMV) or perirectal radiation

risk factors of proctitis

immunocompromised patients (increased risk of STI proctitis)

signs and symptoms of proctitis

- painful defecation

- urgency

- tenesmus

- lower abdominal pain

- cramping

- painless bleeding

tests for proctitis

- proctoscopy

- sigmoidoscopy

- colonoscopy

- stool antigen tests

- blood tests

- anal swabs cultures

- viral cultures of vesicular fluid

- VDRL

- biopsy via colonoscopy

tests for proctitis: what do scope tests show (proctoscopy, sigmoidoscopy, colonoscopy)

inflammation

tests for proctitis: what can anal swab cultures and viral cultures show?

underlying STI

tests for proctitis: what can stool antigen tests show

underlying C. diff

tests for proctitis: what can VDRL tests show?

underlying syphilis

tests for proctitis: what can blood tests show

leukocytosis (underlying infection)

tests for proctitis: what can a biopsy show

autoimmune etiologies

treatment for proctitis

treat underlying condition

- infections: antibiotics followed by topical steroids if antibiotics don't resolve the infection

- autoimmune: topical mesalamine

etiology of anal fissures

linear or rocket shaped ulcers that are usually

etiology of primary anal fissures

caused by local trauma:

- chronic constipation

- vaginal delivery

- anal sex

- pregnancy

etiology of secondary anal fissures

caused by other diseases:

- Crohns

- TB

- sarcoid

- malignancy

- STDs

- HIV

risk factors of anal fissures

local trauma or underlying disease??

signs and symptoms of anal fissures

hallmark: extra tissue at the entrance of the anal canal called a sentinel pile or skin tag

- throbbing, intense anal pain that intensifies with defecation

- itching and burning

- blood when wiping

- laterally located fissures indicate IBD

(often mistaken for hemorrhoids but the pain is more intense with anal fissures)

test for anal fissures

not sure??

treatment for anal fissures

- increased fluids

- increased fiber

- Sitz baths

- topical analgesics (lidocaine gel)

- topical vasodilators (nifedipine or nitroglycerin)

- surgery (for refractory cases)

etiology of perianal abscess

pus filled cavity found near the anus or rectum that develop due to an acute infection of internal anal glands; as fluid accumulates in the gland, pressure increases, creating a fluid-filled pocket

risk factors of perianal abscess

adult men

signs and symptoms of perianal abscess

- constant pain in the perirectal area that does not correlate with a bowel movement

- fever

- malaise

test for perianal abscess (and what it shows)

physical exam: shows area of fluctuance over a patch of erythematous (red), indurated (hardened) skin

treatment for perianal abscess

- I&D (surgery)

- antibiotics given after surgery

etiology of anorectal fistula

abnormal epithelial track that connects the anus or rectum with the perirectal skin commonly caused by abscess; other causes: Crohn's disease, obstetric injury, radiation proctitis, rectal foreign bodies, infectious disease and malignancy

risk factors of anorectal fistula

- abscess

- Crohn's disease

- obstetric injury

- radiation proctitis

- rectal foreign bodies

- infectious disease

- malignancy

signs and symptoms of anorectal fistula

- pain

- defecation

- sitting

- activity

test for anorectal fistula (and what is shows)

physical exam:

- perianal skin often excoriated and inflamed

- tenderness

- drainage of purulent fluid

probe fistula to see how it tracks (but be careful)

MRI to visualize fistula

treatment for anorectal fistula

surgery

etiology of pilonidal disease

inflammation, infection, cyst, or abscess formation in the gluteal cleft caused by rubbing friction on the skin that leads to a hair follicle puncture re

risk factors of pilonidal disease

found on google (double check this info):

- tight clothing

- long periods of sitting

signs and symptoms of pilonidal disease

- asymptomatic

- acute pain

- drainage

test for pilonidal disease:

physical exam at the area

treatment for pilonidal disease

if abscess --> IND

if isolated cellulitis --> antibiotics

if recurrent --> surgical referral

etiology of hidradenitis suppurativa

chronic inflammatory condition involving follicles (folliculopilosebaceous units) that generally affects hairy areas of the body: axilla, groin, perianal, perineal and inframammory regions

Q: a 35 year old female presents to your clinic complaining of onset of severe mid-epigastric pain, weight loss, and vomiting following meals. Between meals she is asymptomatic. This has been going on for the past 2 years ever since she purposefully lost 25 lbs to attain a healthy weight for her height. Unfortunately she has continued to lose weight because of the postprandial pain and vomiting. On examination you notice a mid-epigastric bruit.

what is the diagnosis?

A.) aortic aneurysm

B.) atherosclerosis

C.) superior mesenteric artery (SMA) syndrome

D.) chronic pancreatitis

a 35 year old female presents to your clinic complaining of onset of severe mid-epigastric pain, weight loss, and vomiting following meals. Between meals she is asymptomatic. This has been going on for the past 2 years ever since since she purposefully lost 25 lbs to attain a healthy weight for her height. Unfortunately she has continued to lose weight because of the postprandial pain and vomiting. On examination you notice a mid-epigastric bruit.

C.) superior mesenteric artery (SMA) syndrome (also known as chronic mesenteric ischemia

:::::chronic mesenteric ischemia is associated with vague, crampy pain after a meal and thus patients may limit their food intake to avoid pain, which could lead to weight loss

:::::physical exam would show bruit because there is ischemia of the small intestine (supplied by the SMA)

Q: a fragile-appearing elderly man with temporal wasting. There is no JVD. The lungs are clear to auscultation. The heart sounds are regular, with no murmurs or gallops. The abdomen is protuberant with bulging flanks. Shifting dullness is present. There is a 2+ ankle edema bilaterally and scattered telangiectasias on skim examination. He has no asterixis. Which of the following findings would you expect to find on laboratory examination?

A.) elevated hemoglobin and HCT/hematocrit (17.5 g/dL and 55%)

B.) decreased platelet count of 80,000/mm3

C.) elevated serum albumin

D.) decreased PT/INR

a fragile-appearing elderly man with temporal wasting. There is no JVD. The lungs are clear to auscultation. The heart sounds are regular, with no murmurs or gallops. The abdomen is protuberant with bulging flanks. Shifting dullness is present. There is a 2+ ankle edema bilaterally and scattered telangiectasias on skim examination. He has no asterixis. Which of the following findings would you expect to find on laboratory examination?

:::::protuberant bulging abdomen, shifting dullness, peripheral edema and telangiectasias indicates ascites (most likely due to liver disease)

B.) decreased platelet count of 80,000/mm3

liver disease causes poor coagulation and increased bleeding, which is signified by a decreased platelet count

A???????

C.) elevated serum albumin

albumin is responsible for moving fluid into the vasculature (and out of the peritoneum and tissue). Ascites involves excess fluid in the peritoneal space is present he would have decreased albumin, not elevated because

D.) decreased PT/INR

pt/inr indicates prothrombin time (how fast a person clots). Liver disease causes poor coagulation and increased bleeding, so his clotting time would be increased not decreased

Q: regarding non-alcoholic fatty liver disease (NAFDL), or nonalcoholic steatohepatitis (NASH), all of the following are true except:

A.) it is frequently associated with one or more features of the metabolic or insulin resistance syndrome

B.) it is more common in women than men

C.) the histologic features can closely mimic those of alcoholic hepatitis

D.) it may lead to cirrhosis in a minority of patients

B.) it is more common in women than men

Q: in a patient with NAFLD, all of the following are appropriate actions except:

A.) obtain fasting lipid panel

B.) obtain fasting serum glucose

C.) recommend weight loss to get BMI to the normal range

D.) start ursodeoxycholic acid

D.) start ursodeoxycholic acid

ursodeoxycholic acid is an oral medication used to dissolve gallstones (it is not used for NAFLD)

Q: which of the following is true of mesenteric thrombosis and bowel ischemia?

A.) patients generally have guarding and rebound tenderness early in the course

B.) the pain is out of proportion to the examination and patients may have a normal initial examination

C.) a serum lactate level is helpful and specific for the diagnosis of bowel ischemia

D.) the best study to diagnose the disease entity is CT with contrast

B.) the pain is out of proportion to the examination and patients may have a normal initial examination

Q: which of the following is the most common adverse consequence of ERCP?

A.) pancreatitis

B.) contrast allergy

C.) perforation

D.) bleeding

E.) sepsis

A.) pancreatitis

ERCP scopes can cause irritation to the area of the GI tract that it is imaging, this irritation could produce inflammation

Q: which of the following is a marker for primary biliary cirrhosis