nothing

1. nothing

2. nothing

3. Common Anorectal Conditions Garrett Meyers Faculty Development Fellow

4. Objectives • Explored visual diagnosis of common benign anorectal conditions • Discussed optimal management strategies

5. SetAnsDistrib Clicker Check -1 HideAns • I am a medical student • Resident • Staff • Other [Default] [MC Any] [MC All]

7. When do we need to refer?

8. Case #1 A 38 year old male presents to your clinic complaining of 2 months of anal pruritus, intermittent bright red blood noted on the toilet paper, and pain.

10. nothing Which statement is false concerning this patient? 1 HideAns • Excision is likely to be of benefit • Conservative measures should be initiated • Fiber supplementation is associated with improvement • Topical analgesics are indicated 19 2 4 [Default] [MC Any] [MC All] 1

11. Your Treatment Plan What is “conservative” therapy?

12. Conservative Therapy • Sitz Baths • Stool softeners • Fiber supplementation • Topical therapy

15. nothing Which statement is false concerning this diagnosis? 1 no • Hemorrhoidectomy benefit drops after 72 hours • Conservative management is unlikely to be of benefit • Malignancy may be comorbid 12 6 7 [Default] [MC Any] [MC All] 0

17. 62 year old male referred for colonoscopy for persistent bleeding despite conservative treatment.

18. nothing Which statement is false concerning this diagnosis? 1 HideAns • This diagnosis is the most common cause of rectal bleeding • Rubber band ligation is the most effective treatment • Surgical excision has better remission rates for grade 3 and higher • Excision is associated with decreased pain and complications 2 1 4 [Default] [MC Any] [MC All] 17

19. Case #2 A 38 year old female presents to your clinic complaining of over one year of anal itching. She has worked to self-manage without success.

20. nothing Which statement is false concerning pruritus ani? 1 no • It has a broad differential diagnosis • It may be radicular in nature • Topical steroids should be avoided • Antibacterial soap is effective 0 5 8 [Default] [MC Any] [MC All] 11

21. Case #3 A 26 year old male presents complaining of anal pain. He notes constipation, with recent BM’s including a feeling of passing “shards of glass.” He notes small bright red blood after BM’s.

22. Case #3

23. nothing Diagnosis? 1 no • Anal Fissure • Hemorrhoid • Fistula-in-ano • Abscess • Proctitis 24 0 1 [Default] [MC Any] [MC All] 0

24. nothing Which fissure therapy has not been shown to be effective? 1 no • Conservative measures • Topical sildenafil • Topical nitroglycerin • Botox • Topical diltiazem 0 9 0 [Default] [MC Any] [MC All] 7

25. nothing Which requires referral? 1 no • Chronic fissure • Non-midline fissure • Fissure with chronic constipation • Adjacent skin tag 16 7 0 [Default] [MC Any] [MC All] 0

30. Case #4 23 year old AD male with a painful anal mass

31. nothing Diagnosis? 1 HideAns • Anal Fissure • Hemorrhoid • Fistula-in-ano • Abscess • Proctitis 0 0 0 [Default] [MC Any] [MC All] 26

32. nothing Which is a true statement for this diagnosis? 1 HideAns • Antibiotics are necessary • Conservative therapy will lead to resolution • This diagnosis requires referral • Acute onset with minimal exam findings is concerning 1 3 1 [Default] [MC Any] [MC All] 18

33. Case #5 23 year old male with a painless anal mass.

34. nothing Which is false concerning this diagnosis? 1 no • No topical treatment has been shown to have superior efficacy • Anoscopy should be performed • Biopsy for persistence • Home treatment is not recommended 6 6 2 [Default] [MC Any] [MC All] 9

35. Case #6 A 26 year old male presents complaining of anal pain, occasional discharge, and a sensation of swelling.

36. Case #6

37. nothing Diagnosis? 1 no • Anal Fissure • Hemorrhoid • Fistula-in-ano • Abscess • Proctitis 0 0 0 [Default] [MC Any] [MC All] 0

38. nothing Which is true regarding treatment? 1 no • All fistulas should be referred for surgical evaluation • MRI or ultrasound may help define the lesion • Posterior position is concerning • Abscess formation is uncommon 0 0 0 [Default] [MC Any] [MC All] 0

40. 62 year old female with a complaint of recent constipation, straining, and an anal mass.

41. 28 year old male with nocturnal diarrhea and chronic weight loss.

42. What is the most important piece of advice for this patient?

43. 27 year old male with recent rectal pain, intermittent bloody stools, urgency, tenesmus, and lower abdominal pain.

44. A 52 year old male presents with sudden onset anal pain which lasts for several seconds up to minutes. It often occurs at night. He is unable to identify a trigger. Exam is unremarkable except for increased anal sphincter tone.

45. Take-home points • Consider malignancy • Know, use, love conservative measures

46. Questions