ICL 18.4: Hemorrhoids, Fissures, Prolapse, Abcesses Flashcards
what are the top 10 anorectal complains?
- hemorrhoids
- hemorrhoids
- hemorrhoids
- hemorrhoids
- hemorrhoids
- fissure-in-ano
- fistula-in-ano
- condyloma acuminatum
- abscess
- pilonidal disease
what’s the difference between internal vs. external hemorrhoids?
external = squamous regular skin –> painful
internal = mucosa of rectum –> not painful
both are bulging of blood vessels!! the type of skin is what differentiates and also the external hemorrhoids are super painful while internal hemorrhoids bleed a lot more
what are the grades of internal hemorrhoids?
grade I = protrudes into the anal canal but does not prolapse
grade II = prolapses but reduces spontaneously
grade III = prolapses and requires manual reduction
grade IV = irreducible prolapse
none of these are emergencies
how do you prevent hemorrhoids?
- fiber
- water
- pramoxine + steroid cream
how do you treat hemorrhoids?
grade II and III you can do local treatment and banding
grade III and IV you do surgical excision or stapling treatment for prolapsing hemorrhoids
what is banding a hemorrhoid?
you only with internal hemorrhoids
you literally put a rubber band around the hemorrhoid which cuts off the hemorrhoids blood supply which causes it to wither and drop off painlessly in a few days
what is an excisional hemorrhoidectomy?
you excise the hemorrhoid and sew the defect closed
what are the complications of hemorrhoid surgery?
- PAIN
- swelling
- fecal impaction due to administering narcotics + anal pain so you hold your poop
- bleeding 5%
- reoperation for bleeding 1%
- mucus drainage
- stenosis/stricture if you take too much skin and then they can’t have a BM
what condition looks like hemorrhoids but aren’t actually them?
- rectal prolapse
it looks a lot like prolapsed hemorrhoids!!
you can tell the difference because rectal prolapse is circular while prolapsed hemorrhoids are radial lines
rectal prolapse can be treated with sugar for 30 minutes which pulls all the water and edema out of the tissue to reduce it and then you can push it back in; this does NOT work for hemorrhoids obviously lol
- anal condyloma
- cancer (biopsy margins)
what surgery do you do to treat full thickness prolapse?
- Altmyer procedure is when you cut off the prolapsed rectum down to the anus to the edge of the dentate line and it’s painless and patients can go home the next day
pelvic floor physical therapy is needed after to strengthen it and prevent recurrence
- internal surgery and take the redundant part of the rectum and sigmoid where you attach the colon to the posterior pelvis; do this in younger people because it has lower recurrence rates
what are anal fissures? what causes anal fissures?
a tear in the anoderm! this causes your internal anal sphincter to not want to open anymore and closes up so then when you try to have a BM moving forward, the fissure tears more since the sphincter doesn’t want to open
causes:
1. postpartum
- chronicity
how do you treat anal fissures?
- fluid
- fiber
- nitroglycerine cream to help sphincter relax
- CCB which help muscles in internal anal sphincter to relax
- botox = paralyzes internal anal sphincter to allow stool to pass
- dilation
- lateral internal sphincterotomy (cut a little but not too much to the point you cause incontinence)
what causes perianal accesses?
we think it’s from infections of the anal columns that then drip into the anal crypts and cause external accesses
what is the number 1 cause of anal abscess?
cryptoglandular disease!
the abscess can be perianal, ischiorectal, intersphincteric, or supralevator
how do you treat an abscess?
anesthetize –> open wide –> drain
you don’t want to pack it because it can cause the infection to stick around
dont give antibiotics unless DM patient
what are the outcomes of abscess surgical removal??
- cure
- fistula!!
- recurrance
- incontinece
- necrotizing fasciitis = crepitano, watery discharge
what are the causes of fistulas?
- cryptoglandular
- poor initial care; were just treated with antibiotics
- misdiagnosis
when you think someone has a fistula, what other things should also be in the differential?
- hydradenitis
- Crohn’s disease
- dysplasia
- leukemia/lymphoma
- HIV
how do you diagnose a fistula?
- Goodsall’s rule = posteriorly it’s a curved canal and anteriorly it’s a straight line from the cryptoglandular junction
- digital rectal exam
- US, fistulogram, MRI
how do you treat fistulas?
put in a seton! that’s where you put a probe through to find the opening of the fistula on the inside of the anus and then put a rubber band in to allow the abscess to drain
what are some of the outcomes of fistula treatment surgery?
- incontinence (if you mess up and cut something you’re not supposed to)
- recurrence
- Crohn’s patients have complications and you can’t get the seton’s out and end up needing a colostomy
what is pilonidal disease?
hair follicles of the natal cleft –> in between the butt cheeks above the anus, the hairs rub together and you can get an abscess or sinus and when you open it up there’s a huge hair ball
they present as an abscess, sinus or recurrent or complex disease
common in young men who have hair buttcracks
how do you treat pilonidal disease?
- antibiotics
- cut it open and get the hair out and then leave it open so that it heals; allow for it to scar so hair doesn’t grow back!
it’ll come back if there’s hair regrowing in the area so you have to always shave it
what is the most common cause of condylomata?
aka warts!!
HPV!
6 and 11 most common but 16 and 18 are cancer causing
how do you prevent condylomas?
creams
cut them off
but its a virus and is still in your system so they can come back
what are the risk and outcomes of condylomas?
- high recurrence rate
- malignant transformation
- HIV & transplant patients at higher risk (~60 fold)
biopsy the lesion, serotype if possible, schedule a repeat exam
how do you treat anal cancer?
squamous NOT adenovirus like rectal!!
usually non-operative unlike rectal cancer
nitro protocol = 5-FU and mitomycin-C with radiation completely gets rip of the cancer! you only operate for recurrence or non-regression
what is pruritus ani?
itchy butt
excoriated diaper rash
it gets worse because then people start to over clean because they think they’re dirty and it really just makes the itch worse
what are the 3 main medical causes of acute anorectal pain?
- thromboses external hemorrhoids
not worse with BM, no bleeding, obvious lesion left later, right anterior or right posterior
- perianal abscess
not worse with BM, no bleeding, tender, indurated mass, may be subtle, fever
- anal fissure
worse with bowel movement, usually with bleeding, usually midline, may have sentinel tag
what is proctitis?
inflammation of the rectum causing discomfort or bleeding with possible discharge of pus or mucus
anus may also be involved
what are the causes of proctitis?
- STDs
- non-sexually transmitted infections like B-hemolytic strep, amoebic dysentry
- UC or Crohn’s disease
- tuberculosis
- AIDS
- radiation proctitis
- noxious agents
