Hernias and Anal Disorders Flashcards
Where do hemorrhoids arise from
ateriovenous connective tissue
What are hemorrhoids? What is the function?
normal vascular structures in the anal canal that help with the passage of stool
External hemorrhoids
distal to the dentate line
Internal hemorrhoids
proximal to the dentate line
Mixed hemorrhoids
both proximal and distal to the dentate line
Grading system is used for what type of hemorrhoids
internal
Grade I
visualized on anoscopy, may bulge into lumen but do not prolapse below dentate line
Grade II
prolapse out of the anal canal with BM or straining but reduce spontaneously
Grade III
prolapse out of the anal canal with BM and straining and requires manual reduction
Grade IV
irreducible and may strangulate
Where are hemorrhoids located
submucosal layer in the lower rectum
Are internal hemorrhoids painful? Why
No because they are viscerally innervated
Are external hemorrhoids painful? Why
Yes because they are covered by modified squamous epithelium which contain somatic pain receptors
What is the clinical manifestation always associated with hemorrhoids
painless bleeding with BM
Other possible clinical manifestations of hemorrhoids
- BRBPR
- fecal incontinence
- itching or irritation of perianal skin
- sensation of fullness in perianal area
When are hemorrhoids most painful
when they thrombos
What do internal hemorrhoid bundles look like on anoscopy? Prolapsed internal hemorrhoids? Thrombosed external hemorrhoids?
internal bundles- bulging purpleish-blue veins
prolapsed internal- dark pink, glistening, sometimes tender
thrombosed- acutely tender, purpulish- blue color due to clot inside them
Three main categories for external hemorrhoid treatment
- irritation or puritis
- astringents and protectants
- anesthetics
What is used to treat irritation or puritis with hemorrhoids
hydrocortisone cream or suppositories
What is used as astringents and protectants in patients with hemorrhoids
- witch hazel
- zinc oxide topical paste
What anesthetics are used for patients with hemorrhoids
benzocaine, dibucaine, pramoxine
How do you treat thrombosed external hemorrhoids
> 72 hours- conservative measures because clot contracts and lessens sx
<72 hours- excision and clot evacuation
What do you have to do when removing a clot from a thrombosed external hemorrhoid
make a large incision so the clot does not reform
Rubber band ligation is treatment for what
grade II or III internal hemorrhoids (most common used for bleeding symptomatic hemorrhoids)
How does rubber band ligation work
rubber band is shot onto the hemorrhoid and it strangulates it so the hemorrhoid falls off
When is sclerotherapy treatment indicated for hemorrhoid treatment
grade I and II bleeding internal hemorrhoids
What are the sclerosing agents used in sclerotherapy
all injectable
- pehnol
- sodium morrhiuate
- quinine
What are the three types of hemorrhoidectomies
Conventional- removed using scalpel, scissors or electrosurgical device
Stapled- excises part of anal mucosa
Hemorrhoidal artery ligation- doppler guided
USED FOR INTERNAL
Where are most anal fissures located
posterior midline
Primary causes of anal fissures
TRAUMA
- constipation
- diarrhea
- vaginal delivery
- anal sex
Secondary causes of anal fissures
- chrons disease
- granulomatous disease (sarcoid, TB)
- malignancy
- infections disease (HIV, chlamydia, syphilis)
When is an anal fissure considered chronic
lasts longer than 8 weeks
How do anal fissures start
tear in the anoderm withing the distal half of the anal canal
Clinical presentation of anal fissures
- anal pain at rest
- longitudinal tear (may look like paper cut)
What differentiates a chronic anal fissure from n acute anal fissure
chronic fissures have raised edges and are not as painful
Medical management of anal fissures
- fiber
- stool softener/laxative
- sitz bath
- topical analgesics
- topical vasodialtors (nifefipine/nitroglycerine)
Surgical management of anal fissures
-spincterectomy (lateral inte rnal sphincter) -botox injection -fissureectomy -anal advancement flap
Most common cause of anal abscess
obstructed crypt gland
What is the chronic phase of an anal abscess
fistula
What is a perianal abscess
abscess that transverses into the perianal skin
What is a perirectal abscess
abscess that transverses into another location other than perianal skin
Ishiorectal abscess
penetrates through external anal sphincter into ishiorectal space
How does an ishiorectal abscess present
diffuse, tender, indurated and fluctuant area withing the buttocks
Interspincteric abscess
located in the interspincteric groove between the internal and external sphincters
How are interspincteric abscesses found
DRE
Where does a supralevator abscess originate from
pelvic infection or crypt gland infection
How does a patient with a supralevator abscess present
severe perianal pain, fever, urinary retention
What is needed to diagnose a supralevator abscess
CT
Clinical manifestations of anal abscesses
- constant pain
- fever, malaise
- purulent rectal drainage is abscess has begun to drain
- indurated, erythematous, fluctuant mass
Treatment of anal abscess
surgical drainage
Which abscess can be drained through a simple skin incision
perianal, ischiorectal, supralevator is extends from ischiorectal space
Which abscess have to be drained in the OR
perirectal, interspincteric, supralevator if from a pelic infection
ABX for anal abscesses. When do you use them?
augmentin or cipro plus metronidazole
use if pt has DM, sepsis, fake heart valves or is immunosuppresssed
Clinical presentation of anal fistula
- nonhealing anorectal abscess following drainage
- rectal pain with BM, sitting and activity
- malodorous perianal drainage
Intersphincteric fistula
starts at the dentate line and ends at anal verge
Parks type 1
Transphincteric fistula
tracks through the external sphincter into ishiorectal fossa
Parks type 2
Suprasphincteric fistula
originates at anal crypt and terminates in ishiorectal fossa
Parks type 3
Extrasphincteric fistula
high in the anal canal, terminates in the skin overlying the buttocks
Parks type 4
Superficial fistula
does not involve any sphincter muscle
When is imaging done with anal fistulas
when complex or associated with chrons disease
Abdomen pelvis CT
Management of anal fistula
SURGERY
- fistulotomy
- fibrin sealant
- fistulotomy and seatons
- advancement flap
- advancement flap with fibrin seal
Goodsalls rule
all fistula tracts with openings posterior to transverse anal line travel in a curvilinear fashion and all tracts anterior to the line travel in a radial fashion
What is pilonidal disease
infection of the skin and SQ tissue in the upper part of the natal cleft
What are some risk factors for pilonidal disease
- obesity
- sedentary lifestyle
- trauma
- deep natal cleft
- family history
How does pilonidal disease occur
damage to hair follicles and opening of pores or pits–> debris collects in the opening and leads to infection–>form tracts
Presentation of acute pilonidal disease
- intergluteal pain while sitting
- drainage
- fever, malaise if untreated
- tender, red mass
Presentation of chronic pilonidal disease
- recurrent gluteal pain
- drainage
- tender, red mass
How do you treat pilonidal disease
I&D
or
surgical management for chronic (excision, primary closure, off midline closure, Z plasty, V-Y advancement flap)
When do you give ABX to a patient with pilonidal disease. And what do you give?
- surrounding cellulitis
- high risk endocarditis
- immunosuppression
- dirty wound
Cefazolin plus metronidazole
What types of hernias are considered groin hernias
inguinal and femoral
What types of hernias are considered abdominal wall/ventral hernias
incisional and umbilical
What is a hernia
protrusion, bulge or projection of an organ through a body wall which normally contains in
What is the most common type of groin hernia
inguinal
Which type of groin hernia presents with more complications
femoral
What are some risk factors for hernias
- hx of hernia or prior repair
- male sex
- Caucasian
- abdominal wall injury
- family hx
Etiology of hernias
congenital or acquired
What is a direct hernia
protrude medial to interior epigastric vessels within hesselbach’s triangle
What is an indirect hernia
protrude at the internal inguinal ring
What is a femoral hernia
protrudes through femoral ring
What makes up Hesselbach’s triangle
inferior epigastric A&V
inguinal ligament
rectus abdominus
Clinical manifestations of hernias
- bulge in the groin
- heaviness or dull discomfort in the groin
How should you preform the physical exam if you suspect a patient has a hernia
with the patient standing
What is incarceration
trapping of hernia contents within the hernia sac such that reducing them back into the abdomen is not possible
What is strangulation
result of incarceration–> ischemia and necrosis of the hernia contents
Management of hernia
SURGERY
What is the only non surgical management for hernias
a truss for men
like a jockstrap, holds everything up
What are the surgical approaches to repairing hernias
- open
- laparoscopic
- open tension free mesh
- open primary tissue approximation non mesh
Which hernias are ventral hernias
epigastric and umbilical
Which hernias occur off the midline
spigelian and parastromal
What causes incisonal hernias
previous surgery
Repair of an umbilical hernia <2cm
simple sutures with or without mesh
Repair of incisional hernia <2cm
mesh
Repair of ventral hernias between 2-10cm
MESH required
What classifies a hernia as a large hernia
hernia >10cm, difficult to repair
What are the two categories of mesh
synthetic or biologic
What are the 4 locations mesh can be placed during hernia repair
onlay: placed above fascia
inlay: between fascia
sublay: between rectus muscles and peritoneum (lap only)
underlay: intraperitoneum
What type of surgery is done for complex or large hernias
component separation surgery
need to advance the muscle with the mesh
What is recurrence of hernias typically due to
- improper placement or fixed mesh
- open repair
- simple suture repair
