42. The Tail End of Things Flashcards
He will only ask questions about Fissure, Fistula, and Pilonidal disease/hidradenitis supprativa so I just made FCs on those subjects!
Describe the Bristol Stool Chart. What does each Type indicated about quality of stool?
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.
General description of a fissure?
Like a paper cut in the anus. If the pt has severe pain, it is likely a fissure.
Identify:
External sphincter, internal sphincter, fissure, fistula, enlarged papule, hemorrhoid
Anatomy: identify the dentate line, renal columns/crypts?
Specific treatments for Fissure-in-Ano? (lifestyle, medical tx, surgery)
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)
Specific treatments for Abscesses/fistula?
initial I&D
Seton/staged treatment
fibrin glue
fistula plug
endorectal advancement flap
LIFT procedure
Fissure: epidemiology? genders? age?
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
Fissure: symptoms?
-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
Fissure: more complete definition?
What is cause?
- 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.
Fissure: most common location?
Posterior midline (90%)
Second most common: anterior midline
due to lessened anodermal blood supply –> more prone to ischemia
Left pic: identify fissure, hypertrophied papillae, skin tag
R: fissure has exposed what fibers?
L pic: hypertrophied papilla at top, fissure in middle, sentinal skin tag at bottom
R: break in anoderm, exposed muscle fibers
Identify skin tag, muscle fibers, hypertrophied papillae
Phys exam of fissure: at what point have you made the dx?
Once you see the fissure, you can stop! no more exam needed. be gentle!
What if the patient doesn’t tolerate your physical exam for anal fissure?
Have to examine under anesthesia.
Is this fissure new or chronic?
CHronic
(fissure at 6:00; note skin tag at 2, external hemorrhoid at 11)
can tell due to white fibers that represent scarring.
If there is a fissure in the lateral anal canal, is this likely to be primary or seondary to something else?
Most likely due to something else. Crohn’s and HIV are most common causes of secondary anal fissures
Fissure treatment: Lifestyle option. What do we recommend? does it work?
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.
Fissure treatment: medical management option. what do we recommend?
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
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?
Ask about compliance (hard for pts to comply with frequency of Sitz baths and application of topicals)
Next step is Botox injection.
Botox injection: what does it bind?
How long does it last?
Binds to pre-synaptic cholinergic nerve terminals. Causes muscle paralysis.
Lasts a few months.
Your anal fissure patient fails medical therapy (baths, topicals, Botox). next step is surgery.
what is the gold standard?
How effective?
side effects?
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….
Apparently we should know this anatomy.
Also, what do internal hemarrhoids do? (what is their purpose)?
Internal hemrrhoids serve to keep mucus in the proximal canal.
What is a fistula in general? what is an anal fistula?
Fistula: abnormal communication between 2 epithelial lined surfces.
Anal fistula: classified by relationship to anal sphincter. See blelow. Terms: intersphicteric, transphincteric, extra-sphincteric, suprasphincteric
what is the relationship between an anal abscess and an anal finsula?
An abscess can develop into a fistula.
Anal fistula: what are the surgical options?
Seton drain
Endorectal advancement flap repair
Fibrin glue
Anal fistula plug
LIFT procedure
Seton drain for anal fistula repair: describe the procedure?
advantages?
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.
Anal fistula repair: Fibrin Glue option. what is the ideal fistula for this procedure?
what is the procedure?
pros/cons?
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)
anal fistula repair: fistula plug option. describe procedure?
efficacy?
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
Pilonodal disease: one possible presentation?
22 yo athletic dartmouth student, referred from dick’s house, for painful intermittently draining area in intergluteal cleft.
Pilonidal disease: where does it usually present?
how does this happen?
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)
