Physician Assistant Exam: Rectal Conditions

The rectum and anus can be sources of Physician Assistant Exam (PANCE) questions. Many of these conditions affecting the rectum and anus are also painful, so when someone says something is “a pain in the butt,” it’s not just an expression.

Patients with hemorrhoids

Hemorrhoids may be external or internal. The ones that can hurt — and the ones that you can see on examination — are the external hemorrhoids. They’re distal to (below) the pectinate (or dentate) line. Symptoms can include pain with defecation, anal pruritus, and irritation around the affected area. The most common symptom is hematochezia.

Internal hemorrhoids, or hemorrhoids originating above the pectinate line, come in four degrees. Mild cases either bleed or descend with bleeding but go back to their original positions after the acute flare is over. The more advanced grades of internal hemorrhoids may be visible after bowel movements and need to be reduced. A grade 4 hemorrhoid is the worst and may be visible to the naked eye.

Treatment depends on the grade. The lower grades get more conservative treatment, including diet modification and hydration. Higher grades may need topical anesthetic preparations or specialized suppositories. Surgical intervention is an option if other measures are unsuccessful.

Fecal impactions

As a medical professional, Rich has had to do his share of manual disimpactions for fecal impaction. It’s not a pretty sight. The stool consists of this hard ball-like material, almost looking clay-like. The goal is not to let the stool get to this state.

Many people will discuss their bowel issues with you. Common symptoms of a fecal impaction you may hear about are abdominal pain, distention, and bloating. They may say that they “can’t pass gas.”

Usually the fecal material is confined to the colon, but an impaction can affect much of the large intestine and, on rare occasions, the small intestine. Left untreated, the person risks colon perforation, necrosis of the rectal tissue, and ulcers of the rectal tissue. Note that a colon fully distended by fecal material can cause urinary symptoms as well.

The treatment usually involves digital disimpaction as well as enemas. Other therapies take longer and aren’t valuable when the impaction needs to be removed immediately.

The fecal impaction is often due to constipation that has gotten worse and worse. Remember that constipation is usually having 3 or fewer bowel movements per week. In addition, it can be tremendously difficult to move the bowels (leading to straining) and/or there can be a sense of not being fully empty.

Common causes of constipation can include opioid pain medications, calcium channel blockers, hypothyroidism, and electrolyte problems such as hypokalemia and hypercalcemia that can slow down bowel motility. Neuropathic disorders like diabetic gastroparesis can also be contributory.

A colonic malignancy can present with constipation and incomplete emptying. When other differential diagnoses are excluded and the constipation persists, you need to think of a colonic malignancy and order a colonoscopy.

The treatment can consist of dietary changes such as increased fiber, stool softeners, and laxative agents that can clean out the stool.

Rectal cancer

The risk factors for rectal cancer are somewhat similar to the risk factors for colon cancer. These include older age, tobacco use, a diet higher in fat, a family history of cancer, and human papillomavirus (HPV) infection.

Signs and symptoms of colon cancer can include hematochezia and/or blood mixed with the stool. The patient may also have obstructive symptoms, especially if the mass is large enough to obstruct the rectal lumen. Other type B constitutional symptoms, including weight loss, can also occur, depending on the extent and spread of the cancer.

Sometimes an initial hint of this condition is the palpation of a mass during a digital rectal examination. The diagnosis is confirmed by a sigmoidoscopy.

The treatment of the rectal cancer often depends on the stage of the cancer. Early-stage cancers are more confined to the rectum and have no lymph node involvement. Early stages can be treated with surgical resection. For Stage II and higher, chemotherapy and radiotherapy may be considered. Common sites of metastasis include the lungs and the liver. Stage IV cancer is consistent with metastasis.

Perirectal abscess

A perirectal abscess can be a painful experience. The person often presents with rectal pain and fever. Another possible symptom is constipation, and sometimes drainage from the abscess is present. Often, you can palpate a mass on examination.

The etiology of the abscess is usually bacterial in nature. Common causative organisms include Staphylococcus and E. coli. All abscesses require surgical intervention, with an incision and drainage (I&D) recommended. If left unattended, a fistula can form. And that’s no fun, either.

Anal fissures

An anal fissure is a small tear in the anal canal. Risk factors include constipation, improper hygiene, and any condition that causes intestinal straining, such as the birth of a child. For test purposes, if you see a question concerning anal fissures, Crohn’s disease should be in your differential diagnosis.

The key point to remember with anal fissures is that you need to worry about the anal sphincter as well. If you don’t relax the contracted anal sphincter, the fissure may not heal.

Treatment can be medical or surgical. Common conservative therapies include more fiber in the diet and laxatives as needed. In addition, topical vasodilators such as nitro are sometimes enough to help the sphincter relax. If medication treatment fails, a sphincterotomy is often considered.

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