Hernias & Anal Disorders (Hemorrhoids, Fissure, Fistula, Abscess) Flashcards
what are hemorrhoids?
normal vascular structures in the anal canal that arise from arteriovenous connective tissue
WE ALL HAVE HEMORRHOIDS
what do hemorrhoids help with?
the passage of stool - act as cushions
when do hemorrhoids become a disease/problem?
when they cause symptoms
what determines if hemorrhoids are internal or external?
above or below the pectinate line
hemorrhoids epidemiology
true prevalence unknown
equal M and F
<b>COMMON IN PREGNANCY</b>
peaks b/w 45-65 (development prior to 20 is rare)
40% are asymptomatic - internal hemorrhoids
where are external hemorrhoids?
distal to the pectinate line (dentate line)
where are internal hemorrhoids?
located proximal to pectinate line
which type of hemorrhoids has a grading system?
internal hemorrhoids (no widely used classification system for external hemorrhoids)
when trying to visualize internal hemorrhoids, what tool do you use?
anoscope
Grade I internal hemorrhoids means?
visualized on anoscopy may bulge into lumen, but do not prolapse below dentate line
Grade II internal hemorrhoids means?
prolapse out of the anal canal with bowel movement or straining but reduce spontaneously
Grade III internal hemorrhoids means?
prolapse out of the anal canal with bowel movement and straining and requires manual reduction
Grade IV internal hemorrhoids means?
irreducible and may strangulate
-can’t push back in
where are hemorrhoids located?
in the submucosal layer in the lower rectum
can internal and external hemorrhoids coexist?
YES! BOTH OFTEN COEXIST
which type of hemorrhoid NOT painful? innervation?
internal hemorrhoids are NOT sensitive to pain, touch or temp b/c they are VISCERALLY INNERVATED
why are external hemorrhoids painful?
b/c external hemorrhoids are covered by modified squamous epithelium which contains somatic pain receptors
they are painful especially with thrombosis (when they form a clot)
hemorrhoids risk factors
advanced age, diarrhea, pregnancy (increasing weight on pelvis), pelvic tumors, prolonged sitting, straining, chronic constipation, anticoagulation
hemorrhoids clinical manifestations
- 40% of internal hemorrhoids are asymptomatic
- ALMOST ALWAYS PAINLESS BLEEDING ASSOCIATED WITH BOWEL MOVEMENT (internal hemorrhoids)
- BRBPR
- fecal incontinence
- sensation of fullness in perianal area
- irritation or itching of perianal skin
- pain associated with thrombosis (for external hemorrhoids)
pathophysiology of hemorrhoids
internal hemorrhoids - engorgement of venous plexus originating from superior hemorrhoid vein proximal to the pectinate line
external hemorrhoids - engorgement of venous plexus originating from inferior hemorrhoid veins distal to the pectinate line
hemorrhoids dx
hx
- if pain with bowel movement and no thromboses hemorrhoid may be something else
- fever, night sweats, weight loss -> may be colon cancer
PE
Anoscopy
DRE - should always do one
what do internal hemorrhoid bundles look like on anoscopy?
bulging purplish-blue veins
what do prolapsed internal hemorrhoids look like on anoscopy?
dark pink, glistening, sometimes tender
what do thromboses external hemorrhoids look like on anoscopy?
acutely tender, purplish-blue color
tx for irritation or puritus of hemorrhoids
- Hydrocortisone rectal creams (Anusol-HC, Preparation-H, Proctosol)
- Hydrocortisone rectal suppository
tx of hemorrhoids with astringents and protectants
- witch hazel - tucks, prep-H pads
- zinc oxide topical paste - Destine, Boudreaux’s butt paste
good for irritation or puritus
tx of hemorrhoids with anesthetics
good for external hemorrhoids b/c of pain
- benzocaine
- dibucaine
- pramoxine
do external hemorrhoids usually require surgery?
no!
tx for thrombosed external hemorrhoids >72 hours
> 72 hours - conservative measures - Clot organizes and contracts lessening six’s (will eventually absorb and get better)
tx for thrombosed external hemorrhoids <72 hours
excision and clot evacuation, but high recurrence so need to use wide surgical excision
what grade of internal hemorrhoids requires surgical excision?
Grade IV - irreducible and may strangulate
-start to have pain with Grave IV (grades 1-3 are painless bleeding)
internal hemorrhoids management
rubber band ligation - most common
sclerotherapy
hemorrhoidectomy
what is rubber band ligation?
tx of internal hemorrhoids
most commonly used technique for symptomatic bleeding of internal hemorrhoids
effective, easy, no complications
FOR GRADE II OR III
what is sclerotherapy for internal hemorrhoids management?
injectable sclerosant (inject sclerosant right into the hemorrhoids)
- phenol in vegetable oil
- sodium morrhuate
- quinine
good for grades I and II bleeding internal hemorrhoids
what is hemorrhoidectomy?
tx of internal hemorrhoids
- conventional - remove hemorrhoids using scalpel, scissors or electrosurgical device
- stapled - excises a part of the anal mucosa
- hemorrhoidal artery ligation - hoppler guided
USED FOR ALL STAGE IV OR THOSE NO RESPONSE TO THE OTHER THERAPIES
what are anal fissures?
PAINFUL LINEAR TEAR/CRACK IN THE DISTAL ANAL CANAL
common benign anorectal diseases
common cause of anal pain and bleeding
anal fissures epidemiology
most often affects infants and middle-age individuals
vasty majority (90%) of anal fissures are located posterior midline
what are a majority of anal fissures (primary or secondary) and what are they caused by?
majority of anal fissures are primary
caused by local trauma:
- constipation
- diarrhea
- vaginal delivery
- anal sex
primary anal fissures are caused by what?
caused by local trauma:
- constipation
- diarrhea
- vaginal delivery
- anal sex
secondary anal fissures are caused by what?
- crohn’s disease
- granulomatous disease (sarcoidosis, TB)
- malignancy
- infectious diseases (HIV, Chlamydia, Syphilis)
pathology of anal fissures
start with a tear in the anoderm within the distal half of the anal canal
tear triggers cycles or recurring pain and bleeding - chronic
anal fissures clinical presentation
- anal pain at rest
- pain exacerbated by bowel movements causing pt to refrain from having BM leading to constipation
- BRBPR - anal bleeding
- longitudinal tear
- chronic fissures have raised edges - not as painful
what classifies acute vs chronic anal fissures?
acute sx < 8 weeks
chronic > 8 weeks
where are most anal fissures located?
posterior midline
anal fissures dx
- hx of anal pain brought on by BM and lasting hours after
- associated with some bleeding
- confirmed by PE (see a tear)
- anoscopy not helpful (b/c see what is on the outside)
anal fissures medical management
- fiber, stool softener/laxative (if pt has constipation)
- sitz bath (keeps area clean)
- topical analgesics
- topical vasodilators (make it easier for stool to pass) - nifedipine, nitroglycerin
what topical vasodilators can you treat anal fissures with?
nifedipine or nitroglycerin
make it easier for stool to pass
anal fissures surgical management
- Sphincterectomy - lateral internal sphincter (fecal incontinence is the major complication)
- Botox injection - relaxes hypertonic anal sphincter
- Fissurectomy - excision of anal skin affected
- Anal advancement flap
what is a major complication of a spincterectomy when treating anal fissures?
fecal incontinence
what are the 2 types of anal abscesses?
perianal and perirectal abscesses
what is an anal abscess caused by?
infection most often from obstructed anal crypt gland (glands that help lubricate the anus for the passage of stool)
anal abscess vs anal fistula
anal abscess is acute phase
anal fistula is chronic phase
anal abscess epidemiology
men are 2x more likely to develop
mean age of 40 y/o
30-40% of pts w/ an abscess also have a fistula b/c didn’t seek care
what is a perianal abscess?
when abscess transverses into the perianal skin
what is a perirectal abscess?
when abscess transverses into other spaces (not the perianal skin)
what is the difference in management of perirectal and perianal abscesses?
different in the way they are drained
classifications of anal abscesses (HINT: 3)
- ischiorectal (sischioanal)
- intersphincteric
- supralevator
ischiorectal (ischioanal) anal abscess
penetrates thru the external anal sphincter into ischiorectal space (pt will have sx’s on the outside and you can see the abscess)
presents as a diffuse, tender, indurated and fluctuant area within the buttocks
drain thru the skin
intersphincteric anal abscess
can’t feel on outside
located in the intersphincteric groove b/w the internal and external sphincters
usually don’t cause perianal skin changes
found on DRE
supralevator anal abscess
found on DRE (can’t see on outside)
may originate from pelvic infection or crypt gland infection
patients present with severe perianal pain, fever, and sometimes urinary retention
may have fluctuant area on DRE
CT usually needed to establish dx
patient presentation of supralevator anal abscess
severe perianal pain, fever, and sometimes urinary retention
patient presentation of ischiorectal (ischioanal) anal abscess
diffuse, tender, indurated and fluctuant area within the buttocks
anal abscess clinical manifestations
- severe pain in the anal or rectal area that is worse with sitting
- PAIN IS CONSTANT UNTIL ABSCESS IS DRAINED
- pain not associated with bowel movement
- fever, malaise (can turn into sepsis)
- purulent rectal drainage if abscess has begun to drain
- indurated area w/erythema, tenderness, and fluctuant (superficial)
- fluctuant mass externally or on DRE (deeper)
anal abscess dx
- hx, PE
- DRE
- CT or transperitoneal or endorectal ultrasound if abscess is higher up in rectum
what can happen if an undrained abscess isn’t drained?
can continue to expand and cause sepsis
what is the Gold Standard tx for anal abscess?
surgical drainage
how can a perianal abscess be drained?
through a skin incision
how can a perirectal abscess be drained?
more complex than perianal and drained in OR
how can an ischiorectal abscess be drained?
through a skin incision
how can an intersphincteric abscess be drained?
through the rectum in the OR
how can a supralevator abscess be drained?
through skin incision if abscess extends from ischiorectal space
in or through the rectum if from a pelvic infection
most often drained in the OR
anal abscess tx
antibiotics
- Augmentin
- Cipro and Metronidazole
conflicting data on abc use but good to use on pts esp if DM, signs of sepsis, prosthetic valves
what is an anal fistula?
chronic manifestation of an acute perirectal process that forms an anal abscess
abscess ruptures or is drained and an epithelialize track can form that connects the abscess to the perirectal skin
fistula-in-ano
anal fistula epidemiology
adult males 2x more likely to develop
mean age at presentation is 40 y/o
what is the most common cause of an anal fistula?
an infected anal crypt gland
other (not most common) causes of an anal fistula?
crohn’s disease, infection caused by chlamydia, radiation proctitis (pelvic radiation), rectal foreign bodies, actinomycosis, obstetric injury
anal fistula clinical presentation
- usually present with a non healing anorectal abscess following drainage (get them drained, but don’t heal/reform)
- intermittent rectal pain esp w/BM, sitting, and activity
- malodorous perianal drainage
- perianal skin excoriated and inflamed
- external opening may be visualized
- may feel a palpable cord leading to opening
what is the usual presentation of a pt with an anal fistula?
- usually present with a non healing anorectal abscess following drainage (get them drained, but don’t heal/reform)
- malodorous perianal drainage
how many classifications are there for anal fistulas? how many parks classifications?
5 classifications, 4 parks
what is an intersphincteric anal fistula?
PARKS TYPE 1
starts at the dentate line and ends at anal verge
what is a transphincteric anal fistula?
PARKS TYPE 2
tracks through the external sphincter into ishiorectal fossa
what is a suprasphincteric anal fistula?
PARKS TYPE 3
originates at anal crypt and terminates in ishiorectal fossa
what is an extrasphincteric anal fistula?
PARKS TYPE 4
high in the anal canal terminates in the skin overlying the buttocks
what is a superficial anal fistula?
not in parks classification
DOES NOT INVOLVE ANY SPHINCTER MUSCLE
anal fistula dx
- characteristic findings
- good history
- imaging can be helpful with complex fistulas esp those associated with Crohn’s disease (do pelvic CT)
what is the goal of surgical therapy of anal fistulas?
to eradicate the fistula while maintaining fecal continence
what does the surgical approach of anal fistulas depend on?
depend on classification of anal fistula
follow GOODSALL’s rule (determines surgical management)
what is GOODALL’s Rule and what does it say?
it determines the surgical management of anal fistulas
says that anterior anal fistulas go radially and posterior anal fistulas travel in a curvilinear fashion to the posterior midline
what is the management of anal fistulas?
- fistulotomy (cut open entire fistula and suture the sides)
- fibrin sealant (seal up fistula)
- fistulotomy and setons (scaring and tearing out fistula)
- advancement flap (with fibrin seal)
what is pilonidal disease?
abscess/cyst
infection of the skin and subcutaneous tissue in the upper part of natal cleft (gluteal cleft)
extends from just below the sacrum to the perineum
acute and chronic disease b/c recur if cut open
pilonidal disease epidemiology
MC in white males, obese, prolonged sitting & local trauma
rare over the age of 45 and rare in children
21 years for men
19 years for women
men affected 2-4x more
pilonidal disease risk factors
- overweight/obesity
- local trauma
- sedentary lifestyle
- prolonged sitting
- deep natal cleft
- family history
pilonidal disease pathology
- hair & inflammation are contributing factors
- bending or sitting stretches natal cleft skin
- damaging and breaking hair follicles and opening pore or pits
- pores collect debris/hair and become infected
- forms tracts
pilonidal disease clinical presentation acutely
-variable (from asymptomatic to chronic inflammation and drainage)
acutely:
- mild to severe intergluteal pain while sitting
- drainage
- fever, malaise with undrained abscess
- tender, red mass
pilonidal disease clinical presentation chronic
- recurrent persistent gluteal pain
- drainage
- tender, red mass
***MOST OFTEN CHRONIC WILL HAVE GLUTEAL PAIN W/OUT TENDER RED MASS
pilonidal disease dx
-clinical, hx, PE
differential pilonidal disease from perirectal disease
pilonidal disease tx
I&D then pack with gauze
- local anesthesia
- but tend to recur
when recur -> excise
are abx needed for pilonidal disease?
- most simple acute abscess don’t need abx
- use abx if surrounding cellulitis, high-risk endocarditis, immunosuppression, dirty wound
USE CEFAZOLIN PLUS METRONIDAZOLE
what abx do you use for pilonidal disease?
cefazolin plus metronidazole (but only if surrounding cellulitis, high-risk endocarditis, immunosuppression, dirty wound)
what are the 2 types of hernias?
groin hernias (inguinal and femoral)
abdominal wall or ventral (incisional and umbilical)
what is a hernia?
protrusion of an organ thru a body wall which normally contains it
which type of groin hernia is most common?
inguinal hernias are more common than femoral
which type of groin hernia presents with more complications?
femoral hernias present with more complications b/c smaller area (incarceration, strangulation)
groin hernias epidemiology
3rd leading cause of ambulatory care visits for GI complaints
more common in whites and males
women present at ages 60-79/men 50-69
indirect is the most common
what is the most common type of inguinal hernia?
indirect inguinal hernia
what type of groin hernia do old ladies most commonly get?
femoral hernias
risk factors of groin hernias
- hx of hernia or prior repair
- older age
- male
- caucasian
- chronic cough (b/c of pressure build up in abd cavity)
- chronic constipation
- abd wall injury
- smoking
- fam hx of hernia
etiology of groin hernias
congenital - abnormal development in utero
acquired - wearing or disruption of the fibromuscular tissues of the body
direct inguinal hernia?
protrude medial to inferior epigastric vessels w/in Hesselbach’s triangle
due to weakness in the floor of the inguinal canal
indirect inguinal hernia?
protrude at the internal inguinal ring (lateral to the inferior epigastric artery)
MC type of hernia overall
MC in men
femoral hernia?
protrude thru the femoral ring
borders of Hesselbach’s triangle?
medial: rectus abdominis
lateral: inferior epigastric vessels
inferior: inguinal ligament
groin hernias clinical manifestations
- bulge in the groin
- heaviness or dull discomfort int he groin usually at the end of the day or w/straining
- mod-severe pain w/incarceration or strangulation
where are a majority of hernias located?
2/3 of hernias are located on the right side
groin hernias dx
- hx
- PE (best done while pt standing b/c of gravity)
- males - finger in external ring
- females - small hernias may need us to identify
what is hernia incarceration?
trapping of hernia contents w/in the hernia sac such that reducing them back into the abdomen is not possible
SURGICAL EMERGENCY!!!
WILL LEAD TO STRANGULATION IF NOT TREATED
what is hernia strangulation?
ischemic incarcerated hernias with systemic toxicity (irreducible hernia w/compromised blood supply)
ischemia and necrosis of the hernia contents
SURGICAL EMERGENCY!!!
what is the treatment of choice for groin hernias?
definitive treatment is surgical repair (one of the most commonly performed operations)
groin hernias tx triage
use to watch and wait if pt asymptomatic
complicated w/strangulation - 4-6 hrs of symptom onset
uncomplicated femoral & inguinal hernias w/or w/out six’s - elective repair recommended
what is the only non-surgical approach to treating groin hernias?
a truss - similar to a jockstrap, holds things up
types of abdominal wall hernias
epigastric, umbilical, spigellian, parastomal and incisional
what are epigastric & umbilical hernias?
they are primary VENTRAL hernias
spigellian and parastomal hernias occur where?
off midline
incisional hernias due to what?
due to previous sugery
umbilical hernia tx
<2 cm can be repaired with simple sutures w/or w/out mesh
REPAIRING W/MESH AS BETTER OUTCOMES
incisional hernia tx
<2 cm recommended repair with mesh
ventral hernias b/w 2-10 cm require what for tx?
a mesh
hernias >10 cm tx
classified as larger hernias and difficult to repair
types of mesh
synthetic or biologic (derived from human or animal tissue)
mesh locations
onlay - placed above fascia
inlay - b/w fascia
sublay - b/w rectus muscles and peritoneum (LAP only)
underlay - intraperitoneum
LOCATION DETERMINED BY SIZE, PT, AND SURGEON
what type of surgery for large or complex hernias >10 cm?
component separation surgery for large or complex hernias
open or lap
recurrence of abdominal hernias
- rate of recurrence depends on size and type of repair
- RECURRENCE USUALLY D/T IMPROPER PLACEMENT OR FIXED MESH
- lap repair associated w/reduced rates of recurrence
- simple suture repairs associated w/extremely high recurrence
is it better to have a mesh when repairing abdominal hernias?
yes!!! if just suture and don’t use mesh, then there is a high rate of recurrence!!!
