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Anorectal Emergencies

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Presentation on theme: "Anorectal Emergencies"— Presentation transcript:

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

2 Objectives [Google Quotable #1] 1. Review anatomy
“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.” Objectives 1. Review anatomy 2. Discuss common anorectal emergencies 3. Clear the cache wouldn't it be nice if these patients read the internet before they came in? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 2

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

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

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 Hemorrhoids % Pruritis Ani % Fissure % Thrombosed % Fistula % Limitation: Not our population Interestingly anal pain or discomfort non-sig difference, with 33.7% w BAD and **28.6% w no disease!!! bleeding 58 and 53% (NSS) CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 6

7 Rectum Anatomy Review Peritoneum Pectinate Line Anal Glands Anal Canal
Nerve Fibers Muscles Anatomy Review rectal canal 12cm anal canal 4cm, pectinate / dentate line bw Intra and retroperitoneal anal glands in pect line -- lubricate, abscess Nerves canal stratified epithelium innervated rectum mucosa not voluntary and involuntary muscles Muscles external - voluntary striated, prevents defecation at wrong time internal - involuntary smooth, fills rectal ampulla puborectalis and levator ani replexively empty rectum via coord peristal CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 7

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

9 Case 1 : Bleeding CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 9

10 Complete Anorectal Examination Inspection
DRE Anoscopy Metal Ruler Folds - no skim reading DRE -- no finger no findy Anoscopy CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 10

11 Complete Anorectal Examination Inspection
DRE Anoscopy Metal Ruler Google search : “normal anus” CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 11

12 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Fissure Characteristic presentation = pain with defecation, outlet bleed. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 12

13 Management of Anal Fissures
Conservative W warm sitz A analgesia S stool softening H hygiene Surg consult if recurrent despite therapy CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 13

14 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Skin tags and hemorrhoids Characteristic presentation = pain, itch, bleeding CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 14

15 Classification of Hemorrhoids
Theories External Internal Grading I - no prolapse II - spont reduces III - manually reduces IV - irreducible Theories Thomson WH. The nature of haemorrhoids. Br J Surg 1975;62: Nisar 2003 Acheson 2008 triradiate lumen lined by three endovascular cushions Fragmentation of connective tissue with age and hard stools = desc straining produces cushion engorgement causes: incompetence of valves, straining, inc IAP, portal dz, sphincter hypertrophy blood supply sup / med / inf hemorrhoidal a.s and v.s mid and sup v. drain to portal system, inf drain to ivc CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 15

16 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Roid rage CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 16

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 thrombosed may incise1% xylo, elliptical incision and evaccautery prntape buttocks w pad x8h for pressure special pops pregnancy no surg until term unless unbelievable conservative in HIV and active crohn's SCOPE for age >50 or RF colon Ca should we be doing thrombectomies in ED? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 17

18 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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19 Case 2 : PITA CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 19

20 [Google Quotable #3] “embarrassing question… let’s say I got something stuck up my bum.” On further questioning may have a potato in his rear CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 20

21 Rectal Foreign Bodies 78% are the result of sexual activity Fun Facts
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 russian case series (biriukov 2000) 99% male Another study states Males predominate 35:1 must ask directly CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 21

22 The Usual and Unusual Suspects
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 Upper right hand bizarre corner -- frozen pigs tail and kangaroo tumour bottom right combo corner CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 22

23 Approach to Rectal FB in ED
What are some of the things you would want to know? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 23

24 Approach to Rectal FB in ED
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 May convert high to low -- wait, sedate, endoscope, bimanual, laparascopic Retrospective review of 48 patients found 2/3 removed in ED Beware of radiolucent FBs CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 24

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

26 Removal in ED 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 It went past the verge once! Tenaculum, care with sharp objects Unconventional examples: laser apple, Local description in schon and weinstein (rarely used) pudendal and **intersphincteric Be creative! Magnets, glue, suction darts, obs vacuum, forceps, plaster of paris Very low complication rate with outpt d/c following scope CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 26

27 Perianal and Rectal Trauma
Blunt (Minority) or Penetrating (Majority) GSW, Lacerations predominate Can be intra or extraperitoneal Signs: Does not include obstetric trauma Moore EE, Cogbill TH, Malangoni MA, et al: Organ injury scaling II: pancreas, duodenum, small bowel, colon and rectum. J Trauma 30:1427, 1990 Again sexual assault considerations Grade I — Hematoma: Contusion or hematoma without devascularization                    Laceration: Partial-thickness Grade II — Laceration ≤50 percent circumference Grade III — Laceration >50 percent circumference Grade IV — Full-thickness laceration with extension into the perineum Grade V — Devascularized segment CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 27

28 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 Does not include obstetric trauma Moore EE, Cogbill TH, Malangoni MA, et al: Organ injury scaling II: pancreas, duodenum, small bowel, colon and rectum. J Trauma 30:1427, 1990 Again sexual assault considerations Grade I — Hematoma: Contusion or hematoma without devascularization                    Laceration: Partial-thickness Grade II — Laceration ≤50 percent circumference Grade III — Laceration >50 percent circumference Grade IV — Full-thickness laceration with extension into the perineum Grade V — Devascularized segment CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 28

29 Case 3 : Swollen Bum CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 29

30 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 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 31

32 Abscess Classification
supralevator intersphincteric Planes dictate locations Describe muscles Perianal ischiorectal (induration on rectal exam intersphincteric (exquisite tenderness, no ext signs) supralevator (uncommon, more pelvic pain) Submucosal -- not shown perianal ischiorectal CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 32

33 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 A perianal abscess should be treated in a timely fashion by incision and drainage (grade B) Antibiotics are an unnecessary addition to routine incision and drainage of uncomplicated perianal abscesses. (grade A) tape buttock outward After drainage tape pad w compression between buttocks CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 33

34 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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35 Fistulas Parks classification Consider associated medical conditions
Anorectal malignancy Actinomycosis Lymphogranuloma venereum Radiation proctitis Leukemia CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 35

36 Fistulas Parks classification Management
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 Fistulas Anorectal malignancy Actinomycosis Lymphogranuloma venereum Radiation proctitis Leukemia CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 36

37 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
A - superficial B - intersphincteric C - transsphincteric D - suprasphincteric E - extrasphincteric CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 37

38 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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39 Rectal Prolapse Classification Internal Mucosal Treatment
Full Thickness Treatment Stool softeners Defecogram / Barium Surgery Radial folds vs concentric rings Thought to be a spectrum of disease -- straining and connective tissue degradation Incontinence and mucous Surgical treatment CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 39

40 Case 4 : Itchy CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 40

41 Pruritis Ani Perianal irritation Commonly fecal soiling
Remove irritant Good hygiene practices Contact dermatitis and pinworm also possible CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 41

42 Bibliography CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 42

43 Questions? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS 43


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