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Flashcards in Anorectal Dz Deck (30)
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1
Q

Anal Fissures

  • definition
  • causes
  • most commonly found where?
  • clinical presentation
  • PE
A

Def: painful linear tear or crack in the distal anal canal.

Causes:

  • trauma to anal canal
  • defication
  • straining
  • constipation
  • Most commonly occur in the 12 or 6 o clock area.
  • if tear found in 3 or 9 oclock think crohns.
  • Clinical Presentation:
  • C/O severe tearing pain during defication
  • mild hematochezia (blood on stool or toilet paper

PE: confirmed by visual insepction of the anus

  • acute: crack in the epithelium
  • chronic: fibrosis and development of a skin tag.
2
Q

Anal Fissure:

-Tx

A

First line: fiber supplements, stool softeners, and sitz baths

Second line:

  • 0.4% nitroglycerin ointment BID for 6-8wks (decreases spasm, helps increase blood flow to the area)
  • botulinum toxin (inject into anal sphincter)
  • Internal anal sphincterotomy
3
Q

Perianal abscess

  • what is this?
  • MC type?
  • causes
  • risk factors
  • presentation
A

What: anal glands at the base of the rectum become infected. Appears as a boil like swelling near the anus.

MC type: Perianal abscess

Cause: anal fissures, anal fistulas, hemorrhoids, blocked anal glands

Risk factors:

  • colitis
  • inflamm bowel dz
  • DM2
  • PID

Presentation:

  • constant throbbing pain that is worse when sitting
  • swelling and redness around the anus
  • painful bowel movements
  • discharge of pus around the anus
  • deeper abscesses:
  • -fever
  • -chills
  • -malaise
4
Q

Perianal abscess:

  • lab studies
  • tx
A

Labs: wound cultures and I&D

Tx: I&D

  • packing and return in 24hrs
  • sitz bath 3x/day and after bowel movements
  • f/u in 2-3wks for wound eval.
  • **DONT give ABX.
5
Q

Anal Fistula:

  • aka
  • results from what?
  • etiology
  • clinical presentation
  • PE
  • Tx
A

aka: fistula-in-ano

results from : previous or current anal abscess

Etiology:

  • anorectal abscess
  • crohns
  • radiation proctitis

Presentation:

  • hx of drained abscess
  • anorectal pain
  • purulent drainage and irritation from the skin

PE:

  • identification of the external opening that drains pus, blood, or stool
  • DRE may express pus or stool from the opening

Tx:

  • fistulotomy
  • complex fistulas:
  • -fibrin glue
  • -fistula plug
6
Q

Pruritis Ani

  • what is this?
  • causes
  • PE
  • Tx
  • Prevention
A

What:

  • perianal itching or discomfort
  • itch-scratch-itch cycle; skin becomes excoriated and 2ndry infections occur

Causes:

  • idiopathic
  • hygiene related
  • fistulas/fissures
  • fecal incontinence
  • parasites
  • lichens sclerosis

PE:

  • inspection of the area may reveal anal excoriations and erythema
  • hygiene issues
  • chronic issues show thickened or leathery skin
  • anoscopy

Tx:

  • treat underlying cause
  • avoid spicy acidic foods
  • after BM clean with unscented wipes
  • place gauze or cotton ball next to anal opening
  • talcum powder
  • use zinc oxide or hydrocortisone ointment.
7
Q

Rectal Prolapse:

  • aka
  • what is this?
  • MC gender and age?
  • sx
  • causes
  • dx
  • tx
A

aka: rectal procidentia

What: painless protrusion of the rectum through the anus

MC in older adults w/ hx of constipation and weak pelvic floor muscles.
More common in women over 50*

Sx:

  • feeling a bulge or apperance of reddish colored mass that extends outside the anus
  • pain in the anus or rectum?
  • leakage of blood or stool

Cause:

  • chronic constipation of diarrhea
  • straining during BM
  • weakness of anal sphincter
  • damage to nerves

Dx

  • anal EMG
  • anal monometry
  • anal ultrasound
  • colonoscopy
  • proctosigmoidoscopy

Tx

  • 1st use stool softeners and pushing the fallen tissue back up into the anus by hand
  • surgery: abdominal repair, rectal repair
  • Recovery: 3-5 days w/ complete recovery in 3mo
8
Q

Pilonidal Cyst

  • what is this?
  • cause
  • MC in what age and gender?
  • risk factors
  • clinical presentation
  • tx
A

What: cyst near the natal cleft that often contains hair or skin debris

Cause:
-when hair punctures the skin and becomes imbedded

MC in hair young men

Risk:

  • sitting for long periods of time
  • obesity
  • local trauma/irritation

Clinical presentation:

  • pain
  • erythema and swelling of the skin
  • drainage of foul smelling pus or blood from opening of the skin

Tx:

  • 1st I&D cyst; may need to leave open or pack
  • if recurrent will need surgical cyst removal
  • abx if worried about cellulitis; 1st gen cephalosporin(cefazolin) plus flagyl
9
Q

Hemorrhoids

  • what is this?
  • types
  • classification
  • cause
A

What: dilated veins of the hemorrhoidal plexus in the lower rectum

Types:
-external(below adente line) and internal

Classification:

  • Grade 1: hemorrhoids do not prolapse
  • grade 2: hemorrhoids prolapse on defecation and reduce spontaneously (slinky)
  • Grade 3: hemorrhoids prolapse on defication and must be reduced manually
  • Grade 4: hemorrhoids are prolapse and cannot be reduced manually

Cause:

  • pregnancy
  • frequent heavy lifting
  • repeated straining during defication
  • constipation
10
Q

Hemorrhoids:

  • clinical presentation
  • dx
  • tx
A

Presentation:

  • asymptomatic
  • external: painful and purplish swelling, rarely ulcerate and cause minor bleeding, swelling lasting a few weeks, itchiness around anus, may become thrombosed.
  • internal: bleeding after defication, blood on stool or TP, mucous and fecal incontinence, itchiness, strangulated hemorrhoids may be very painful.

Dx:

  • Anoscopy
  • sigmoidoscopy or colonoscopy

Tx:

  • stool softeners/fiber
  • sitz baths after BM
  • anesthetic ointments
  • 2nd line is banding if conservative tx is unsuccessful
  • 3rd line: surgical removal
11
Q

Hernias

  • what is this?
  • types
  • MC type in adults
A

What:

  • a protrusion, bulge, or projection of an organ or part of an organ through the body wall that normally contains it
  • normally harmless
  • if strangulated the hernia becomes medical emergency

Types:

  • inguinal (direct and indirect)
  • umbillical
  • incisional/ventral
  • epigastric
  • femoral
  • spigelian

MC type in adults is inguinal hernia

12
Q

Inguinal hernia

  • MC in which gender?
  • what is this?
  • risk factors?
A

MC in men

What: weak area in the inguinal canal where the spermatic cord or round ligament exits the abdoment.

Risk factors:

  • hx of hernia or repair
  • chronic cough or constipation
  • abdominal wall injry
  • smoking
13
Q

What are the two types of inguinal hernias? Which type is most common?
Describe each.

A

Indirect and Direct.

Indirect is MC.

IndirecT: hernia protudes throught the internal inguinal ring, hernia sac is located lateral to the inferior epigastric artery. sometimes the hernia will protrude into the scrotum. (some bowel contents can go into the scrotum and you can hear bowel sounds)

Direct: protrude medial to the inferior epigastric vessels within the hesselbachs triangle. rarely protrude into the scrotum

14
Q

What are the barriers of the Hesselbach triangle?

A

Laterally: inferior epigastric artery

Medially: rectus abdominus

Inferiorly: inguinal ligament

15
Q

Femoral Hernia:

  • located where?
  • MC in which gender?
  • high chance of what?
A

Located: inferior to the inguinal ligament and protrudes through the femoral ring

MC in women

High chance of strangulation

16
Q

Inguinal Hernia:

  • clinical presentation
  • PE
  • Dx
  • Tx
A

Presentation::

  • painless bulge in the groin or scrotum
  • groin discomfort or pain
  • swelilng of tugging in the groin
  • sudden pain, n/v you would need to be concerned with strangulated hernia

PE:

  • bulge in groin is MC
  • pt stand and ask them to cough or valsalva
  • reducible or irreducible
  • Strangulated: irreducible, painful to palpation, N/V. may appear ill w/ or w/o fever.
  • if you cant reduce it then they need to be referred to general surgery.

Dx:

  • hx and exam
  • if not apparent then initial study is groin ultrasound
  • CT/MRI

Tx:

  • non-surgical: watchful wiating, or TRUSS
  • Surgical: open repair, laparoscopic repair. Use mesh or keyhole mesh.
17
Q

Umbilical Hernia

  • what is this?
  • MC in who?
  • cause
  • presentation
  • tx
A

What: outward bulging of the lining of the abd or abdominal organs around the belly button

MC in infants

Cause:

  • muscle through which the umbilical cord passes doesnt close completely after birth
  • obesity
  • multiple pregnancies
  • fluid in abd cavity (ascites)
  • previous abd surgery

Presentation:

  • soft swelling or bulge near the umbilicus
  • more noticeable when baby cries, coughs, strains
  • adults cause abd discomfort, bulgind with strain or coughing
  • Can be strangulated

Tx: surgery +/- mesh

18
Q

Incisional/ventral hernia

-cause

A

Cause: abd surgery causes a flaw in the abd wall that must heal on its own, this weakness may lead to hernia
-iatrogenic

19
Q

Epigastric hernia

  • What is this?
  • risk factors
A

What: hernia that develops in the epigastrum between the breast bone and the belly button.

Risk factors:
-obesity and pregnancy

20
Q

Spigalian Hernia:

  • aka
  • what is this?
  • MC occur where?
  • sx
  • dx
  • tx
A

aka: lateral/ventral hernia

What: hernia through the spigelian fascia, high chance of strangulation

MC occur on the right side of the rectus abdominus

Sx:
-intermittent mass, localized pain or N/V

Dx:
-US

Tx:
-surgery is treatment of choice

21
Q

Gastrointestingal acute abd

-what are the 4 types of pain experienced with this?

A

Visceral: from abd viscera, respond to sensations of distention and muscular contraction. Pain is vague, dull, nauseating
Innervated by autonomic nerves

Somatic Pain:
-from parietal peritoneum, respond to irritation from infection, chemical, and inflamm process, pain is shartp and well localized. Innervated by somatic nerves

Reffered pain:
-pain perceived distant from its source

Peritonitis:

  • inflamm of peritoneal cavity
  • most serious cause is perforation of GI tract
  • causes fluid shift into the peritoneal cavity and bowel, leasds to severe dehydration and electrolyte problems.
22
Q

Acute Abd: Appendicitis

-sx

A

Sx: anorexia, and vague periumbilical discomfort that develops into RLQ pain

urinary sx and diarrhea

23
Q

Acute Abd: Biliary dz

-sx

A

sx: acute cholecystitis c/o RUQ or epigastric pain
Pain may radiate to shoulder or back
-n/v and anorexia

Murphys sign present: positive for cholecystitis. Place hand mid clavicular and inferior to costal margin. Ask pt to breath out and upon inspiration push gently down into abd, if positive pt should wince and you should feel gallbladder. Must do this on the left side w/o eliciting a rxn for murphy sign to be positive.

24
Q

Acute Abd: Pancreatitis

-sx

A

Sx: pain is steady in upper abd, bandlike radiation to the back is common

  • n/v comm
  • paint often reaches maximum intensity within 10-20minutes
25
Q

Acute Abd:
-diverticular dz; sx

  • peptic ulcer dz; sz
  • Incarcerated hernia; what is this? sx
  • IBD;sx
  • IBS;sx
A

diverticular dz: LLQ pain, n/v, +/- change in bowel habits

Peptic ulcer dz: Epigastric pain, indigestion, reflux sx

Incarcerated hernia: hernia of bowel leading to bowel obstruction, cause severe pain and require immediate surgical consultation.

IBD:
pain, bleeding, perforation, bowel obstruction, fistula, abscess formation, toxic megacolon

IBS: sx persist for 3mo over a one year period. Abd pain associated with change in stool frequency or consistency

26
Q

Acute abd:

  • features of high risk abd pain
  • what piece of hx must be obtained in women 12-50
A

High risk features:

  • greater than 65 yo
  • immunocompromised
  • alcoholism
  • CV dz
  • major comorbidities, CA
  • prior surgery or recent GI instrumentation
  • early pregnancy

Pain characteristics:

  • sudden onset
  • maximal at onset
  • pain then subsequent vomiting
  • constant pain of less than 2 days duration

Exam findings:

  • tense or rigid abd
  • involuntary gaurding
  • signs of shock
  • signs of peritonitis

women of childbearing age pregnancy status must be determined.

27
Q

What dz are MC found:

  • RUQ
  • Epigastric
  • LUQ
  • Right umbilical
  • umbilical
  • left umbilical
  • RLQ
  • suprapubic
  • LLQ
A

RUQ: gallstones, stomach ulcer, pancreatitis

Epigastric: stomach ulcer, heartburn/indigestion, pancreatitis, gallstones/epigastric hernia

LUQ: stomach ulcer, duodenal ucler, biliary colic, pancreatitis

Right umbilical: kidney stones, urine infection, constipation, lumbar hernia

Umbilical: pancreatitis, early appendicitis, stomach ulcer, IBD, Small bowel, umbillical hernia

Left umbilical: kidney stones, diverticular dz, constipation, IBD

RLQ: appendicitis, constipation, pelvic/groin pain, inguinal hernia

suprapubic: UTI, appendicitis, diverticular dz, IBD, pelvic pain

LLQ: Diverticular dz, pelvic/groin pain, inguinal hernia

28
Q

carnets sign, how do yo perform this? what is a positive/negative result?

WHat is psoas sign?

A

Carnets sign: pt lift head and shoulder from exam table to tense abd muscles.

Positive: with head and shoulder raise there is increased pain of the abd indicating that the source is the abd wall.

Negative: with head and shoulder raise there is decreased pain of the abd indicating that the source is intra-abdominal

psoas sign:
-pt actively flexes hip; if pain this indicates + test suggesting peritoneal irritation.

29
Q

Acute Abd:

-dx

A

dx:
- urine pregnacy for all women of child bearing ages
- Serum lipase, serum amylase if suspecting pancreatitis
- plain xrays (helpful for bowel obstruction, bowel perforation, radiopaque FB
- US; biliary tract dz, ectopic pregnancy, appendicitis in children, AAA
- CT: study of choice for undifferentiated abd pain. w/ oral and IV contrast

30
Q

What is the Test of choice for each of the following quadrants:

  • RUQ
  • LUQ
  • LLQ
  • RLQ
  • suprapubic
A

RUQ: US is test of choice, HIDA scan is better

LUQ: endoscopy, us, CT

LLQ: CT with oral and IV contrast

RLQ: CT IV contrast

Suprapubic pain: US