GI lecture 7 Anorectal Disease

pilonidal cyst

cyst containing hair and skin debris that develops along the coccyx near the cleft, 5cm from the anus

pilonidal cyst onset

15-24 yo

pilonidal cyst symptoms

pain over the lower spine at the gluteal cleft, erythema and warmth over the skin, localized swelling, pain w sitting, drainage of pus, fever (uncommon)

pilonidal cyst treatment

removal of hair (laser), I&D w packing if infected, 1st gen cephalosporins + metronidazole, maybe sx

recurrence common

repetitive ___ pressure can cause hemorrhoidal disease

downward

internal hemorrhoids locations

right anterior, right posterior, left lateral

external hemorrhoids

arise from inferior hemorrhoidal veins below dentate line

covered w squamous epithelium of anal canal or perianal region

hemorrhoids risk factors

pregnancy, chronic constipation, obesity, prolonged sitting/standing, anal intercourse, low-fiber diet

external hemorrhoids symptoms

usually asymptomatic

become painful when thrombosed or acutely irritated

may be highly pruitic and associated skin tags

internal hemorrhoids form

above dentate line

internal hemorrhoids symptoms

bright red bleeding (MC)

usually painless, may cause anal discomfort by depositing irritants on perianal skin

grade 1 internal hemorrhoids

bleeding but no prolapse

grade 2 internal hemorrhoids

early protrusion, reduces spontaneously

grade 3 internal hemorrhoids

more advanced protrusion, requires digital reduction

grade 4 internal hemorrhoids

irreducible hemorrhoidal disease

hemorrhoid general treatment

high fiber, high fluids diet (20-30g fiber, 1.5-2L water daily)

avoid straining or lingering on the toilet

regular physical exercise

sitz bath

stool softeners

stage 1-3 hemorrhoid treatment

topical anesthetics/steroids (lido-hydrocortisone)

topical vasoconstrictors (phenylephrine)

topical astringents (witch hazel)

sclerotherapy

ultroid treatment (causes shrinking)

rubber band ligation

hemorrhoid stage 3-4 w severe bleeding treatment

hemorrhoidectomy if no conservative measures or severe prolapse/strangulation

rectal prolapse

full-thickness protrusion of the rectum beyond the anal sphincter

90% of cases occur in

women

rectal prolapse risk factors

multiparity, hx of pelvic sx, elevated BMI, chronic diarrhea or constipation, connective tissue disorder, neurologic disease

rectal prolapse presentation

sensation of rectal mass

minor symptoms of fecal incontinence

rectal prolapse treatment

conservative measures in pts w minor prolapse or are poor sx candidates

rectopexy

resection of the prolapsed rectum and folding/tightening of the muscle wall

fecal incontinence

involuntary loss of stool or flatus

almost 1/2 of nursing home pts

fecal incontinence causes

fecal impaction, sx or traumatic injury, rectal prolapse, neuro disorders, chronic diarrhea states, dementia, impaired mobility, poor access to toilet facilities

fecal incontinence diagnosis

often w hx alone

anal endoscopic ultrasound if necessary to eval sphincter anatomy and defects

fecal incontinence treatment

mild- conservative therapy (fiber supplement, loperamide up to 4x daily)

sphincter disruption- sx repair, sacral nerve stimulation

sphincter defect- transanal infection of dextranomer in stabilized hylaruonic acid

anal fissures caused by

stretching of anal mucosa or increased sphincter tone

anal fissures presentation

marked discomfort w bowel movements

anal fissures MC location

posterior midline

if not on midline- think Crohn's, HIV/AIDS, syphilis, or anal carinoma

sentinel tag

scar tissue over tear seen in anal fissures

need ___ to examine anal fissures

anesthesia - painful!!

anal fissure treatment

sitz bath, high fiber & fluid diet, topical anesthetics

chronic fissures- topical sphincter relaxants (nitro or diltiazem gel), botulism toxin injection, lateral internal sphincterotomy

perianal abscess caused by

infection of anal glands that track toward the skin

perianal abscess presentation

perianal pain and swelling

erythema, fluctuance, swelling

perianal abscess treatment

prompt I&D

augmentin q12h or cipro q12h + flagyl q8h for significant cellulitis or immunocompromised status

pts w hx of perianal abscess may develop

anal fistula w persistent rectal discharge

anal fistula are MC in

men

multiple or atypical fistulas should raise suspicion for

Crohn disease

anal fistula presentation

feeling of a "boil" several weeks post abscess drainage

anal fistula treatment

sx to repair sinus tract, prevents recurrent infections

MC anal cancer

squamous cell carcinoma

anal cancer risk factors

female gender, HPC (MC), low CD4 counts, anal intercourse, HIV, genital warts, smoking

anal cancer s&s

rectal bleeding, anorectal pain/sensation of mass, constipation, diarrhea, discharge, pruritis, tenesmus

anal cancer PE

may appear as visible mass, bleeding, anal warts, flat pigmented lesions, ulcerations

anal cancer testing

biopsy

chest, abdominal, pelvic CT scan for staging

PET scan

CEA markers not routine

Anal cancer treatment

chemoradiotherapy is preferred bc it preserved anal sphincter

local excision if lesion is

anal cancer treatment response should be re-evaluated

every 8-12 weeks after chemoradiation is completed

DRE every 3-6 months for 5 years

CT/PET scan annually for 3 years

anal cancer prevention

HPV vaccine

poor prognostic factors for anal cancer

palpable, clinically positive lymph node and males

anal margin tumors are [more/less] favorable than canal tumors

more

upper GI bleed

occurs proximal to the ligament of treitz

mortality rate of upper GI bleed

higher in patients >60yo and in hospitalized patients

upper GI bleeds causes

peptic ulcer disease, portal hypertension, Mallory-Weiss tear, vascular anomaly, gastric neoplasm, erosive gastritis, erosive esophagitis

upper GI bleed presentation

hematemesis (bright red or coffee grounds), melena (black, tarry, foul smelling if chronic), hematochezia , pallor, orthostatic hypotension, signs of hypovolemia, ecchymosis, petechiae, organomegaly, abd tendernesss/mass, ascites

melena occurs after

50-100mL of blood

hemtochezia occurs after

>1000 mL of blood

upper GI bleed diagnosis

vital signs for signs of hypovolemia

NG tube placement

endoscopy (gold standard)

stool guiac, CBC, CMP, coag profile, blood type and cross

lower GI bleed

bleeding from colon and anorectum distal to ligament of trietz

lower GI bleed often occurs in

elderly

lower GI bleed often presents w

painless hematochezia

lower GI bleed common causes

diverticulosis, internal hemorrhoids, fissure, IBD, ischemic colitis, infectious colitis, colon cancer, colonic angiodysplasia (common >60)

lower GI bleed symptoms

melena, hematochezia

orthostatic changes not common

signs of rectosigmoid or anal bleed

brown stool mixed or streaked w blood

signs of colonic bleed

large volume bright red stool

signs of ascending colon or small intestine bleed

maroon stool

signs of diverticular bleed

painless large volume bleeding

lower GI bleed diagnosis

NG tube w aspiration, endoscopy to r/o upper GI bleed (if pt has hematochezia and hemodynamic compromise)

anoscopy and sigmoidoscpy

colonoscopy (gold standard)

angiogram to determine site and infuse vasoconstricters

nuclear scintipgrahy to determine site

nuclear scintigraphy is less accurate if

bleeding is slow or intermittent

lower GI bleed initial treatment

stabilize, blood replacement, and triage if needed

consider d/c of antiplatelets/anticoags if taking any

lower GI bleed treatment after stabilizing

therapeutic colonoscopy - administer epi, cautery, or endoclips

intra-arterial embolization

emergency sx- usually for diverticular hemorrhage or angioectasia

hernia

protrusion, bulge, or projection of an organ/part of an organ through the body wall

abdominal herniation are some of MC hernias

abdominal hernia classification

ventral, groin/inguinal, pelvic

hernia risk factors

male (8-10x)

age (0-5 and 75-80yo)

family history

impaired collagen metabolism

inguinal hernia patho

congenital- failure of processus vaginalis to close

acquired- weakening or disruption of the fibromuscular tissues of the body wall allowing contents to protrude

inguingal hernia classification

indirect (MC)- goes through inguinal canal

direct- does not go through inguinal canal

femoral (less common but higher risk of strangulation)

inguinal hernia symptoms

asymptomatic if small

bulge sensation, heaviness, or dull discomfort

groin pain that worsens w cough or strain

groin pain or fullness that resolves w lying down

inguinal hernia PE

bulge in groin- palpation along external inguinal ring when having pt bear down

severe pain w inguinal hernia sugests

strangulation or necrotic tissue

inguinal hernia diagnosis

primarily H&P

pelvic ultrasound (test of choice)

CT w/o contrast

MRI

hernia treatment

observe if asymptomatic/minimal syptoms

consider open vs laparoscopic repair