Reading around cases Flashcards
What do you need to do if pt comes in with rectal bleeding?
r/o colon CA: don’t just assume hemorrhoids (history, Ix)
What is a hemorrhoid?
normal vascular structures in anal canal: helps anus form seal
Common for them to become enlarged and inflamed
What are external hemorroids
Below dentate line
Somatic sensory innvervation
What are internal hemorroids?
Above dentate line (no somatic sensation)
Columns of rectal mucosa
What are the standard positions of hemorrhoids?
Right anterior, right posterior,
3, 7, 11
What is the clock orientation?
Lithotomy position
12 is anterior, 3 is pt left, 9 is pt right
What is the presentation of hemorrhoids?
Pain, bleeding, prolapse, itch [though Paun says itch is not a symptom]
External: Present as bulge or mass below dentate line
Internal: bleeding, protrusion
What history is important for hemorrhoids?
- nature of bleeding (surface, mixed, dripping)
- FHx colon CA
- constipation Hx (fibre, stooling, straining)
What are the grades of hemorrhoids?
1: bleeding, no prolapse
2: prolapse, spontaneously reduce
3: prolapse, need to be reduced manually
4: prolapse, incarcerated, cannot be reduced
What is the Exam for hemorrhoids?
Differentiate: Internal vs external
(Can you feel finger above hemorrhoid cushion? – can with external, can’t usually with internal)
Consider scope (rigid, or colonoscopy)
How are external hemorrhoids managed?
External: depends on duration
- manage pain and Sx (ice, NSAIDs, laxatives); if skin tag develops, can excise later
- can lance, if thrombosed and w/in 24h (unusual)
How are internal hemorrhoids managed?
Internal:
Grade 1-2: non-op. Increase dietary fibre
“Constipation is the enemy” – water, fibre, avoid straining
If symptoms resolve, leave
Procedures:
- banding
- injection
- photocoagulation
- hemorrhoidectomy
How is banding done, and what are the complications?
Banding: only for internal. Band around hemorrhoid. Can be outpt – minimal discomfort (test with suction on mucosa first to ensure above lined).
Complications:
- pain
- urinary retention
- perianal sepsis (rare)
What are the indications for hemorrhoidectomy? Pros/cons?
Rare.
- persistent prolapsing hemorrhoids (perineum looks like a bunch of grapes – so many skin tags etc)
- uncontrolled bleeding (eg young man with Hb of 60)
Overall, very painful, but very effective.
What is an anal fissure?
split or tear in anoderm (sensitive skin below dentate line)
Likely due to tear with constipation
What is the clinical presentation of anal fissure?
bleeding (BRBPR, on TP or in bowel, not mixed in stool, usually immediately after BM; like with hemorrhoids)
- *pain**
- defining characteristic
- burning, at time of BM, can last for minutes to hours after
- pt may fear BM – even stop eating to prevent BM
Chronic: most marked in 1st wk or two; chronic, pain becomes duller.
What is the natural history of most anal fissures?
w/ proper treatment, acute anal fissure will heal within a few weeks (1-2w)
What is the history of chronic anal fissure?
Doesn’t heal, pain & inflammation continues, and internal sphincter spasms
What will you find on exam?
DRE exquisitely painful (tell pt you know it will be sore but you won’t hurt them)
Inspection:
- sphincter spasm
- may see sentinel tag
- may see fissure (post midline, or anywhere)
DRE:
- may feel spasm
- may feel specific area of tenderness
If you can do a full rectal exam on someone, with no pain, pretty good indication they don’t have an anal fissure!
What is the DDx from fissure?
- Hemorrhoids
- Anal or low rectal CA
NOT: anal fistula!
What is the difference in clinical presentation between anal fissure and anal fistula?
Fissure: pain, bleeding
fistula: swelling, discharge
Remember that these are very different: some med students mix them up!
What is the management of acute anal fissure?
Acute:
- relieve pain
- treat constipation (get soft BM)
- get fissure to heal
so:
- analgesics
- stool softeners, laxatives
- Sitz baths
What is the management of acute anal fissure?
Key: spasm (which stops normal healing)
So: make it relax.
Chemical, neurological, and __ sphincterotomy
Chem: induces muscle to relax. Topical. App 6-8x /d
- glyceril trinitrate (0.1%), diltiazem (2%)
What is the difference between internal and external anal sphincters?
Internal sphincter spasms. Involuntary. Always on, unless having BM
(External: voluntary – so eg to stop self from having BM)
What is a chemical anal sphincterotomy?
Chemical: 1st line.
Induces muscle to relax. Topical. App 6-8x /d
- glyceril trinitrate (0.1%), diltiazem (2%)
a/e:
- h/a, lightheadness (better with diltiazem)
6w-3mo
Should see some response
What is a neurological anal sphincterotomy?
2nd line (though could be 1st)
Botulinum toxin in intersphinctery groove
Very effective – also temporary (wears off after 2-3mo)
May be incontinent to gas or even liquid in first few days
What is a surgical anal sphincterotomy sphincterotomy?
Third line:
Lateral internal sphincterotomy
cut in anoderm laterally
Forces sphincter to relax
Can –> incontinence (frank incontinence rare, but some impairment common-ish). Pros: relief is immediate.
What should you do after treating for fissure?
See the pt in follow up!
Want to avoid: Treat for fissure …. never see again … and turns out they had anal CA
Also, want to remind them to avoid constipation! Bc that can –> fissure again.
What is an anal fistula?
Classic story:
- swelling, redness, around anal canal; ED Dx as abscess
- red fluctuant mass, I&D, home with dressings
If abscess: heals. If not: wound gets smaller, starts to close, but doesn’t all the way
Swelling and drainage
Sometimes pain with infection
Pain, swelling, and discharge
Classic picture really is swelling and draining
What is a fistula?
Abnormal communication between two epithelialized surfaces
Where does a naturally arising anal fistula start?
The dentate line
What is the most common type of anal fistula?
Inter-sphincteric fistula (approx 40%)
Goes between internal and external sphincters, and exits medial to external sphincter, near anus
What is the second-most-common type of anal fistula?
Trans-sphincteric fistula (approx 30%)
Goes through both sets of sphincter muscles
What is the third-most-common type of anal fistula?
Supra-sphincteric fistula (approx 20%)
Goes through internal sphincter, tracks along external, then exits out above puborectalis
What is the least common type of anal fistula?
Extrasphincteric fistula
Not naturally occurring (10%)
May be due to radiation, or Crohn’s
This 10% may not have opening on dentate line
What is Goodsall’s rule?
Fissures that begin anteriorly will have straight course and exit anteriorly (run radially). Fissures that begin posteriorly will begin in the midline and have a curved tract (arcing from midline more laterally)
(Med students get asked this a lot!)
What is the basic anatomy of an anal fistula?
Internal opening, tract, external opening.
What history should you ask when assessing anal fistula?
History to ask: - bowel habit - bleeding - previous surgery in the area - PMHX of bowel issues or IBD, Crohns; also FHx (want to know if eg radiation)
Typical: normal bowel habit, no bleeding, no previous Hx of problems, just this swelling that’s draining fluid
What should you look for in a pt with ?anal fistula on exam?
- WL, anemia (r/o CA, bleed)
- abdo exam
- locate external opening (likely site with some drainage)
- assess for active infection (fluctuant, inflammatory signs)
- rectal exam (assess for induration – can palpate tract, potentially abscess)
What characterizes simple vs complex anal fistulas?
Simple:
- 1st time, no prev surgery
- 1 ext opening, low in anal canal, no signs of sepsis
Complex:
- previous operations, multiple external openings (multiple tracts), previous disease
- if sepsis: OR ASAP, to drain
- if not: MRI ( + St Mark’s diagram – draw out tracts)
What is the first step in performing surgery for anal fistula?
Run probe through tract. Estimate how much muscle is above the fistula tract.
How big are the anal sphincter muscles?
4cm in man, 3cm in women
larger at back, smaller at front
What is a Seton suture?
Suture that loops through fistula and is left temporarily. Allows it to drain. (Buys some time.)
What is the biggest risk of fistula surgery?
Incontinence
Consider asking pt in initial assessment about whether they are continent to gas (more sensitive)
What is one non-operative option for management of anal fistula?
Indwelling seton: stays, facilitates drainage
What is the operative management of
low lying (does not involve external sphincter): primary fistulotomy high lying (involves external sphincter): - staged fistulotomy, with Seton. Spares muscle. - new: LIFT (ligation of intersphincteric fistula tract)
