hernias, anal diseases Flashcards
external hemorrhoids
- distal to dentate line
- covered by modified squamous epithelium
- somatic pain receptors
- painful, esp when thrombosed
internal hemorrhoids
- proximal to dentate line
- viscerally innervated
- not sensitive to pain, touch, temp
how are external hemorrhoids classified?
- no classification system
how are internal hemorrhoids classified?
- graded I - IV
grade I internal hemorrhoid
- seen on anoscopy
- may bulge into lumen
- does not prolapse below dentate line
grade II internal hemorrhoid
- prolapse out of anal canal with BM or straining
- reduce spontaneously
grade III internal hemorrhoid
- prolapse out of anal canal with BM and straining
- requires manual reduction
grade IV internal hemorrhoid
- irreducible
- may strangulate
hemorrhoid risk factors
- advanced age
- diarrhea
- pregnancy
- pelvic tumors
- prolonged sitting
- straining, chronic constipation
- anticoagulation
clinical manifestations of hemorrhoids
- many asymptomatic
- almost always painless bleeding assoc with BM
- BRBPR
- fecal incontinence
- sensation of fullness in perianal area
- irritation or itching
- painful when thrombosed
diagnosis of hemorrhoids
- good hx and PE
- anoscopy
- DRE
external hemorrhoid management
- hydrocortisone rectal creams or suppositories
- astringants or protectants
- anesthetics
- excision and clot evacuation if thrombosed < 72 hours
internal hemorrhoid management
- rubber band ligation
- sclerotherapy
- hemorrhoidectomy
types of hemorrhoidectomies
- conventional- high post of complications, low recurrence
- hemorrhoidal artery ligation- low post op complications, high recurrence
- stapled- mod post op complication and recurrence
pain management s/p hemorrhoid surgery
- almost always have pain due to spasm of internal sphincter
- PO NSAIDs
- avoid opioids d/t constipation
who is most commonly effected by anal fissures?
- infants
- middle aged people
primary causes of anal fissures
- constipation
- diarrhea
- vaginal delivery
- anal sex
secondary causes of anal fissures
- crohn’s
- granulomatous disease
- malignancy
- infectious diseases
sx of anal fissures
- anal pain at rest
- exacerbated by BM
- anal bleeding
- longitudinal tears
- chronic fissures are less painful, have raised edges
acute vs chronic anal fissures timeline
- acute < 8 weeks
- chronic > 8 weeks
management of anal fissures
- fiber, stool softners, laxatives
- sitz bath
- topical analgesics and vasodilators
- sphincterectomy
- botox
- fissurectomy
- anal advancement flap
anal abscess
- acute infection of anal crypt gland
anal fistula
- chronic anal abscess
- abscess ruptures or is drained -> epithelialize track forms -> connects abscess to perirectal skin
ischiorectal anal abscess
- penetrates through external anal spincter into ischiorectal space
- seen on exam
intersphincteric anal abscess
- between internal and external sphincters
- usually dont cause skin changes
- found on DRE
supralevator anal abscess
- may originate from pelvic or crypt gland infections
- severe perianal pain, fever
- sometimes urinary retention
- no obvious external findings
- usually need CT to dx
- can cause sepsis
clinical manifestation of anal abscesses
- severe, constant pain
- fever, malaise
- purulent rectal drainage if ruptured
- indurated, erythematous, tender, fluctuant
diagnosis of anal abscess
- hx, PE
- DRE
- CT
- transperitoneal or endorectal US
management of anal abscess
- drainage*
- perianal and ischiorectal drained through skin
- perirectal and intersphincteric drained in OR
- supralevator drainage depends
- +/- abx
clinical presentation of anal fistula
- non-healing anorectal abscess after drainage
- intermitten rectal pain
- malodorous perianal drainage
- perianal skin excoriated and inflamed
- external opening and palpable cord possible
classification system for anal fistulas
- park system
park type 1 fistula
- intersphincteric
- starts at dentate line and ends at anal verge
park type 2 fistula
- transphincteric
- tracks through external sphincter into ischiorectal fossa
park type 3 fistula
- supraspincteric
- originates in anal crypt and terminates in ischiorectal fossa
parks type 4 fistula
- extrasphincteric
- high in anal canal
- terminates in skin overlying buttock
diagnosis of anal fistulas
- hx and PE
- imaging for complex fistula- esp if assoc with crohn’s
what is goodsall’s rule used for
- determining how anal fistulas track
goodsall’s rule for external openings posterior to line through ischial spines
- tracks in curvilinear fashion
goodsall’s rule for external openings anterior to line through ischial spines
- tracks in radial fashion
pilonidal disease
- infection of skin and subq tissue in upper part of natal cleft
- found just below sacrum
- pores get damaged -> collect debris and hair -> become infected -> tract formation
risk factors for pilonidal disease
- overweight/ obesity
- local trauma
- sedentary lifestyle, prolonged sitting
- deep natal cleft
- family hx
acute sx of pilonidal disease
- mild- severe pain while sitting
- drainage
- fever, malaise
- tender red mass
chronic sx of pilonidal disease
- recurrent persistent gluteal pain
- drainage
- tender red mass
- usually reoccur 2-3 X a year
treatment for pilonidal disease
- I & D
- local anesthesia
- pack with gauze
- possible recurrence
- dont usually require abx
- primary closures, off midline closures, z- plasty, v-y flap
types of groin hernias
- inguinal- more common
- femoral- assoc with more complications
types of abdominal wall or ventral wall hernias
- incisional
- umbilical
risk factors for groin hernias
- hx of hernia or prior repair
- older age, male, caucasian
- chronic cough or constipation
- abdominal wall injury
- smoking
- family hx
what causes congenital groin hernias?
- failure of processus vaginalis to close
direct groin hernia
- protrude medial to inferior epigastric vessels in hesselbach’s triangle
indirect groin hernia
- protrude at internal inguinal ring
femoral hernias
- protrude through femoral ring
clinical manifestation of groin hernias
- bulge in groin
- heaviness or dull discomfort usu at end of day or with standing
- mod-severe pain with incarceration or strangulation
- on R side 2/3 of time
treatment for groin hernias
- definitive treatment- surgical repair
- uncomplicated- elective repair
- complicated- emergent surgery
- truss of pt is not surgical candidate
hernia strangulation
- ischemia and necrosis
hernia incarceration
- trapping of hernia contents
spigelian and parastromal hernias
- abdominal wall hernias
- occur off midline
types of abdominal wall hernia’s
- epigastric
- umbilical
- spigelian
- parastromal
- incisional
mesh onlay
- above fascia
mesh inlay
- between fascia
mesh sublay
- between rectus muscles and peritoneum
mesh underlay
- intraperitoneum
