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Anorectal disorders

This is a video on anorectal disorders. This presentation was created with Google Slides Images were created or adapted from Wikimedia Commons. ADDITIONAL TAGS: Anorectal disorders Fecal incontinence Hemorrhoids Anal fistula Anal fissure Pilonidal cyst Rectal prolapse Anal cancer Perianal abscess By Waterced - http://digestive.niddk.nih.gov/ddisea..., CC BY-SA 4.0, https://commons.wikimedia.org/w/index... Fecal incontinence Def: recurrent uncontrolled passage of fecal material ( 10 mL) for 1 month in people 3 years old Dx: Clinical, history. Consider flexible sigmoidoscopy or anoscopy. Definitive test is manometry Tx: medical (fiber or other bulking agents), biofeedback (muscle strengthening, control exercises), injections (dextranomer/hyaluronic acid), or surgery Hemorrhoids Dilation of the submucosal layer (purple or blue bulge) within the anorectum Risk factors: constipation, old age, straining, prolonged sitting (increased venous hypertension) Sx: bleeding (BRBPR=internal), itching, burning/pain (external), asymptomatic (40%) Dx: usually clinical. Best test is anoscopy Tx: dietary changes (hydration, fiber, stool softeners, reduced fat/alcohol); regular exercise; sitz bath; topical steroids + anesthetics → internal hemorrhoid ligation → surgery (hemorrhoidectomy) By WikipedianProlific and Mikael Häggström - File:Hemorrhoid.png by WikipedianProlific, CC BY-SA 3.0, https://commons.wikimedia.org/w/index... Fecal incontinence Pathophys: occlusion of anal crypt gland → bacterial overgrowth → formation of abscess (collection of pus) near the anus. Risk factors: Crohn’s, diabetes, steroids Sx: discomfort when wiping → severe pain +/- systemic signs (fever). Red, tender, fluctuant mass on the skin. Tx: I&D. Systemic abx decrease recurrent and fistula formation (given to high risk patients with diabetes, systemic illness [fever, cellulitis]) By McortNGHH - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index... Perianal abscess Anorectal fistula (fistula in ano) Abnormal communication between epitheliaized surface of anal anal and external peranal skin. Caused by chronic inflammation (perianal abscess, IBD, cancer, radiation, infxn) Sx: discharge (pus, serous fluid, fecal matter, +/-blood, +/- foul smelling); skin maceration; itching If infected → pain, swelling, fever Dx: clinical. +/- imaging: fistulogram, MRI, endosonography. Tx: manage inflammation. Surgery (fistulotoma) helps, but they can recur (from residual fistula tracts). By McortNGHH - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index... Anal fissure Mucosal tear. Can be caused by: tight sphincter + large caliber stool; prolonged diarrhea; anal sex; IBD; malignancy Sx: pain with defection; BRBPR. Tear visible on exam, usually on posterior midline anus, +/- skin tag at distal end Tx: sitz bath, topical lidocaine, nitroglycerin paste, botulism to relax sphincter, fiber. Surgically release tension (lateral internal sphincterotomy) Infected follicle on the lower back (butt crack) creates a cyst. Occurs with hairy back/butt and prolonged sitting (often makes 15-30 years old, obese, sedentary, deep gluteal clefts). Sx: pain (worse with bending down), fluctuant mass 4-5 cm above the anus in intergluteal region. +/- drainage (mucoid, pus, blood). Dx: clinical Tx: drain and resect; also excise sinus tracts. By Jonathanlund - Own work, CC BY-SA 4.0, https://commons.wikimedia.org/w/index... Risk: age 40; multiparous women; prior pelvic surgery; constipation, straining; stroke, dementia Sx: straining, fecal incontinence, abd pain/discomfort. Digital maneuver required to pass stool. Exam: Mass protruding through anus, increases in size with Valsalva. concentric rings = full-thickness prolapse Dx: clinical Tx for small prolapse: medical (fiber, hydration); biofeedback (pelvic floor strengthening) Tx for large prolapse: surgery (rectopexy) A. full thickness external rectal prolapse. Circumferential arrangement of folds B. mucosal prolapse. Radial folds By https://www.ncbi.nlm.nih.gov/pmc/, Public Domain, https://commons.wikimedia.org/w/index... Anal cancer Cancer that arises in the anus; usually squamous cell carcinoma Risk: HPV, smoking, HIV/AIDs, receptive anal sex Sx: Pain, pressure in the anus; change in bowel habits; bleeding, itching, discharge Dx: anal pap for high risk patients; biopsy Tx: Nigro protocol (5-fluorouracil and mitomycin and medical radiation); resection if necessary By Dr. K.-H. Günther, Klinikum Main Spessart, Lohr am Main, CC BY 3.0, https://commons.wikimedia.org/w/index...