42. The Tail End of Things

Question 1

Describe the Bristol Stool Chart. What does each Type indicated about quality of stool?

Answer 1

Type 1: Separate hard lumps like nuts (hard to pass)

Type 2: sausage shaped but lumpy

Type 3: Like a sausage btu with lumps on the surface

Type 4: sausage or snake: smooth and soft

Type 5: Soft blobs with clean-cut edges

Type 6: Fluffy pieces with ragged edges: mushy stool

Type 7: watery, no solid pieces. entirely liquid.

Question 2

General description of a fissure?

Answer 2

Like a paper cut in the anus. If the pt has severe pain, it is likely a fissure.

Question 3

Identify:

External sphincter, internal sphincter, fissure, fistula, enlarged papule, hemorrhoid

Answer 3

Question 4

Anatomy: identify the dentate line, renal columns/crypts?

Answer 4

Question 5

Specific treatments for Fissure-in-Ano? (lifestyle, medical tx, surgery)

Answer 5

Lifestyle Modification: aimed at softening stool. Fiber + Fluids

Medical therapy: aimed at reducing sphincter spasms. Sitz baths, topical Nitroglycerine/Nifedipine, Botox inj.

Surgery: Laternal internal sphincterotomy (+ other options)

Question 6

Specific treatments for Abscesses/fistula?

Answer 6

initial I&D

Seton/staged treatment

fibrin glue

fistula plug

endorectal advancement flap

LIFT procedure

Question 7

Fissure: epidemiology? genders? age?

Answer 7

Common cause of painful defication! often mistaken for hemorrhoid.

M=F

Any age (even peds) but most common young and middle aged adults

RARE in elderly due to decr sphincter tone

Question 8

Fissure: symptoms?

Answer 8

-SHARP pain during/after defication. tearing, knife like, like passing a razor. fear of BMs.

-minor bleeding during and after BMs

• Sentinel skin tag (easy to confuse with hemorrhoid)
• may be drainage (fissure-fisula complex)

Should be able to diagnose based on history

Question 9

Fissure: more complete definition?

What is cause?

Answer 9

• Represents a traumatic injury (constipation, passage of large/hard stool)
• Linear (radial) tear in the anoderm (mucosa) of distal anal canal from dentate line to anal verge usually w. exposed internal anal sphincter muscle fibers

-Viscious cycle as below. Sphincter spasm is impt element.

Question 10

Fissure: most common location?

Answer 10

Posterior midline (90%)

Second most common: anterior midline

due to lessened anodermal blood supply –> more prone to ischemia

Question 11

Left pic: identify fissure, hypertrophied papillae, skin tag

R: fissure has exposed what fibers?

Answer 11

L pic: hypertrophied papilla at top, fissure in middle, sentinal skin tag at bottom

R: break in anoderm, exposed muscle fibers

Question 12

Identify skin tag, muscle fibers, hypertrophied papillae

Answer 12

Question 13

Phys exam of fissure: at what point have you made the dx?

Answer 13

Once you see the fissure, you can stop! no more exam needed. be gentle!

Question 14

What if the patient doesn’t tolerate your physical exam for anal fissure?

Answer 14

Have to examine under anesthesia.

Question 15

Is this fissure new or chronic?

Answer 15

CHronic

(fissure at 6:00; note skin tag at 2, external hemorrhoid at 11)

can tell due to white fibers that represent scarring.

Question 16

If there is a fissure in the lateral anal canal, is this likely to be primary or seondary to something else?

Answer 16

Most likely due to something else. Crohn’s and HIV are most common causes of secondary anal fissures

Question 17

Fissure treatment: Lifestyle option. What do we recommend? does it work?

Answer 17

Point is to optimize BMs – softer consistency – to minimize trauma.

**Fiber + fluids. **

Works…. but pt has to be compliant. This is a permanent lifestyle modification.

Question 18

Fissure treatment: medical management option. what do we recommend?

Answer 18

Point is to reduce internal sphincter spasms, and increase blood flow to anoderm.

Referred to as “Chemical Sphincterotomy”

• Sitz baths to incr blood flow
• Topical Nitro. He doesn’t like Nitro because it causes headaches.

**-Topical Nifedipine (Ca blocker): his treatment of choice. **

-injected botox into internal anal sphincter.

Overall success is about 2/3 of cases. Patients have to be compliant

Question 19

Your anal fissure patient has been on medical therapy (baths, topicals) for a few months and is not completely better. What do you ask? what is the next step?

Answer 19

Ask about compliance (hard for pts to comply with frequency of Sitz baths and application of topicals)

Next step is Botox injection.

Question 20

Botox injection: what does it bind?

How long does it last?

Answer 20

Binds to pre-synaptic cholinergic nerve terminals. Causes muscle paralysis.

Lasts a few months.

Question 21

Your anal fissure patient fails medical therapy (baths, topicals, Botox). next step is surgery.

what is the gold standard?

How effective?

side effects?

Answer 21

Lateral Internal Sphincterotomy

95% effective

10% of patients will have altered continence and incontinence sufflatus (cannot control farting). This is why we start with other optoins….

Question 22

Apparently we should know this anatomy.

Also, what do internal hemarrhoids do? (what is their purpose)?

Answer 22

Internal hemrrhoids serve to keep mucus in the proximal canal.

Question 23

What is a fistula in general? what is an anal fistula?

Answer 23

Fistula: abnormal communication between 2 epithelial lined surfces.

Anal fistula: classified by relationship to anal sphincter. See blelow. Terms: intersphicteric, transphincteric, extra-sphincteric, suprasphincteric

Question 24

what is the relationship between an anal abscess and an anal finsula?

Answer 24

An abscess can develop into a fistula.

Question 25

Anal fistula: what are the surgical options?

Answer 25

Seton drain

Endorectal advancement flap repair

Fibrin glue

Anal fistula plug

LIFT procedure

Question 26

Seton drain for anal fistula repair: describe the procedure?

advantages?

Answer 26

Seton = suture.

this procedure allows for scar tissue formation on either side of seton.

looks like you place a long suture through entire fistula. gradually tighten it. gradual sphincter division (??what does that mean?). Allows for fibrosis behind cut.

Adv: prevents recurrent abscess.

Question 27

Anal fistula repair: Fibrin Glue option. what is the ideal fistula for this procedure?

what is the procedure?

pros/cons?

Answer 27

Ideal patent has a straight, short fistula with no extensions.

INject the tract with fibrin, which forms fibrin plug. inject the fibrin to the point of the internal opening of the fistula.

Cons: may fail. Pros: if it fails, will do so in first 3months, and you haven’t lost anything but time and money (ie a failed fibrin glue procedure doesn’t damage anything)

Question 28

anal fistula repair: fistula plug option. describe procedure?

efficacy?

Answer 28

put in porcine collagen to obliterate internal opening.

allows fistula to scar over on the sphincter/canal side of things.

Efficacy only 50% but no damage done if it fails

Question 29

Pilonodal disease: one possible presentation?

Answer 29

22 yo athletic dartmouth student, referred from dick’s house, for painful intermittently draining area in intergluteal cleft.

Question 30

Pilonidal disease: where does it usually present?

how does this happen?

Answer 30

intergluteal cleft: usually far from verge (more than several centimeters away)

how: somehow a hair gets drawn into cleft and forms a pit –> infection.

(from wiki: ingrown hair, possibly more common at coccyx with prolonged sitting/pressure)