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Anorectal Emergencies Presented by M. Brendan Munn Calgary Resident Teaching Rounds May 13 2010 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS.

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Presentation on theme: "Anorectal Emergencies Presented by M. Brendan Munn Calgary Resident Teaching Rounds May 13 2010 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS."— Presentation transcript:

1 Anorectal Emergencies Presented by M. Brendan Munn Calgary Resident Teaching Rounds May CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

2 Objectives 1. Review anatomy 2. Discuss common anorectal emergencies 3. Clear the cache CALGARY EMERGENCY MEDICINE TEACHING ROUNDS “The longer you take to tell the ER people what is wrong, the longer it will take for them to help you, so the easiest and best thing you can do is tell the ER people exactly what’s in there, how long it has been in there, and whether there is anything else that went in before or after it.” [Google Quotable #1]

3 Thanks and Credits Arun Abbi for his clinical wisdom Mike Su for his foreign body expertise CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

4 Brainstorm : 5 ED Triage Complaints 10 Anorectal Disorders CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

5 Brainstorm : 5 ED Triage Complaints 10 Anorectal Disorders CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Rectal Prolapse Proctalgia Fugax Anal Cancer Crohn's Disease Pruritis Ani Hidradenitis Suppuritiva Proctitis Familial Rectal Pain Hemorrhoids Fissures Abscess Fistula in Ano Rectal Foreign Body Trauma Pilonidal Sinus STIs Lump Incontinence Obstruction Bleed Pain Itch Discharge

6 All underwent survey, inspection, anoscopy, DRE 870 patients, GI clinic referrals 63 non-benign conditions 268 no disease 539 benign anal disease (BAD) 31.2% of BAD had multiple causes significant sx : POS = soreness, weeping NEG = AP, diarrhea CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Hemorrhoids 74% Pruritis Ani 59% Fissure 13% Thrombosed 5% Fistula 1%

7 Anatomy Review CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Rectum Peritoneum Pectinate Line Anal Glands Anal Canal Nerve Fibers Muscles

8 History AMPLE Associated Sx Pain Hx Bowel and Bladder Hx Bleed Hx Perforation Hx CALGARY EMERGENCY MEDICINE TEACHING ROUNDS “flatulence is being blamed for bringing a hospital patient's operation to a fiery end.” [Google Quotable #2]

9 Case 1 : Bleeding CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

10 Complete Anorectal Examination Inspection DRE Anoscopy Metal Ruler CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

11 Complete Anorectal Examination Inspection DRE Anoscopy Metal Ruler CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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13 Management of Anal Fissures Conservative W warm sitz A analgesia S stool softening H hygiene

14 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

15 Classification of Hemorrhoids CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Theories External Internal Grading I - no prolapse II - spont reduces III - manually reduces IV - irreducible

16 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

17 Management of Hemorrhoids Conservative (Ext, Gr I and II) W warm sitz A analgesia S stool softening H hygiene Topical Nifedipine or NTG; Botox Surgical (Gr III and IV) Minimally Invasive > Excision Rubber Band Ligation is best Antibiotics if foul Acutely Thrombosed External may benefit from thrombectomy

18 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

19 Case 2 : PITA CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

20 “embarrassing question… let’s say I got something stuck up my bum.” [Google Quotable #3]

21 Fun Facts 78% are the result of sexual activity More men than women Only 1/3 of patients admit to FB on arrival Largest was a stone 12 x 8.6 x 8.8 cm Longest 30 centimeter garden hose Best traveled 20cm vibrator 6mo world tour CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Rectal Foreign Bodies

22 The Usual and Unusual Suspects CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Bottle Jar Glass Light bulb Tube Apple Banana Carrot Cucumber Onion Parsnip Plantain Potatoe Salami Turnip Zucchini Axe Handle Stick Broom handle Miscellaneous Dull Knife Ice Pick Knife Sharpener Mortar & Pestle Spatula Spoon Tin cup Candle Flashlight Iron Rod Pen Rubber tube Screwdriver Toothbrush Wire Spring Balloon Condom Inner Tube Baseball Tennis ball Bocce ball Candlebox Snuffbox Baby Powder Can Cattle horn Frozen Pigs Tail Kangaroo Tumor Plastic Rod Stone Toothbrush Holder Toothbrush Package Whip Handle Gerbil Glass Tubes Jeweler’s Saw Oil Can Piece of Wood and Peanut Umbrella Handle Phosphorous Match Ends 402 Stones Toolbox 2 Bars Soap Beer Glass and Preserving Pot Lemon and Cold Cream Jar Tobacco Pouch Magazine

23 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Approach to Rectal FB in ED

24 Voluntary? CSART, GA Object(s)? #, perforation risk High or Low?DRE Perforation?exam, 3 views, CBC for ED management MUST be 3D Dull, Distal and Directly visualized CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Approach to Rectal FB in ED

25 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS “get a small pair of hands, ideally not yours” [Google Quotable #4]

26 Sedation ± Local Align axes Knee chest Valsalva *Direct visualization Foley provides traction breaks suction may use multiple 30 minute limit Post removal : Scope mucosa and observe/admit CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Removal in ED

27 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Perianal and Rectal Trauma Blunt (Minority) or Penetrating (Majority) GSW, Lacerations predominate Can be intra or extraperitoneal Signs:

28 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Perianal and Rectal Trauma Blunt (Minority) or Penetrating (Majority) GSW, Lacerations predominate Can be intra or extraperitoneal Signs: ecchymoses, subQ air, rectal bleed, peritonitis J Trauma 1990 : Organ Injury Scaling 1-5 Management 3 views, CT, endoscopy, Gastrograffin Admission, observation, serial exams Irrigate and close lacerations, tetanus prophylaxis Diverting colostomy if rectal perforation

29 Case 3 : Swollen Bum CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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31 Anal Abscesses Blocked and infected anal gland E. Coli, S. Aureus, Fecal Anaerobes 50% become fistulas Spectrum of disease

32 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS perianal ischiorectal supralevator intersphincteric Abscess Classification

33 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Abscess Management Perianal and Ischiorectal Drainage in ED w sedation Abx : immunocompromise, DM, cellulitis, high risk valve Culture not routinely used Radial ellipse or cruciate incision ± pack, f/u 24-48h Intersphincteric, Submucosal and Supralevator Operative Drainage

34 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

35 Fistulas Parks classification Consider associated medical conditions

36 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Fistulas Parks classification Consider associated medical conditions Malignancy, LGV, leukemia, Crohn’s, TB syphilis, rad tx Case series 458 Finnish fistulas 1/3 each IBD, trauma/surg, fissure/abscess MRI and US imaging modalities of choice Management Operative always except in Crohn’s Setons for refractory cases

37 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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39 Rectal Prolapse Classification Internal Mucosal Full Thickness Treatment Stool softeners Defecogram / Barium Surgery

40 Case 4 : Itchy CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

41 Pruritis Ani Perianal irritation Commonly fecal soiling Remove irritant Good hygiene practices

42 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS Bibliography

43 Questions? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS


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