Page 441 - TNFlipTest

Toronto Notes 2019
Anorectum
General Surgery and Thoracic Surgery GS39
Anorectum
Hemorrhoids
Etiology
• vascularandconnectivetissuecomplexesformaplexusofdilatedveins(cushion) • internal:superiorhemorrhoidalveins,abovedentateline,portalcirculation
• external:inferiorhemorrhoidalveins,belowdentateline,systemiccirculation
Risk Factors
Internal hemorrhoid
Middle rectal vein
Always rule out more serious causes (e.g. colon CA or anal canal cancer) in a person with hemorrhoids and rectal bleeding
Band ligation can be done as outpatient
External hemorrhoids will often recur
• increasedintra-abdominalpressure:chronicconstipation,pregnancy,obesity,portalHTN,heavylifting
Clinical Features and Treatment
• internalhemorrhoids
■ engorged vascular cushions usually at 3, 7, 11 o’clock positions (patient in lithotomy position) ■ painless rectal bleeding, anemia, prolapse, mucus discharge, pruritus, burning pain, and rectal
fullness
◆ 1st degree: bleed but do not prolapse through the anus
– treatment: high fibre/bulk diet, sitz baths, steroid cream, parmoxine (Anusol®), rubber band ligation, sclerotherapy, and photocoagulation
◆ 2nd degree: bleed, prolapse with straining, and spontaneous reduction – treatment: rubber band ligation, and photocoagulation
◆ 3rd degree: bleed, prolapse, and requires manual reduction
– treatment: same as 2nd degree, but may require closed hemorrhoidectomy
◆ 4th degree: bleed, permanently prolapsed, and cannot be manually reduced – treatment: closed hemorrhoidectomy
• externalhemorrhoids
■ dilated venules usually mildly symptomatic
◆ pain after bowel movement, associated with poor hygiene
◆ medical treatment: dietary fibre, stool softeners, steroid cream (short course), parmoxine
(Anusol®), and avoid prolonged straining ■ thrombosed hemorrhoids are very painful
◆ resolve within 2 wk, may leave excess skin = perianal skin tag
◆ treatment: consider surgical decompression within first 48 h of thrombosis, otherwise medical
treatment
Table 17. Signs and Symptoms of Internal vs. External Hemorrhoids
Figure 19. Hemorrhoids
Inferior rectal vein
Dentate line
External hemorrhoid
Internal Hemorrhoids
Painless BRBPR
Rectal fullness or discomfort Mucus discharge
Anal Fissures
Definition
External Hemorrhoids
Sudden severe perianal pain Perianal mass
• tearofanalcanalbelowdentateline(verysensitivesquamousepithelium)
• 90%posteriormidline,10%anteriormidline
• ifoffmidline:considerotherpossiblecausessuchasIBD,STIs,TB,leukemia,oranalcarcinoma • repetitiveinjurycycleafterfirsttear
■ sphincter spasm occurs preventing edges from healing and leads to further tearing ■ ischemia may ensue and contribute to chronicity
Etiology
• localtrauma:constipation,irritation,diarrhea,vaginaldelivery,analintercourse
• secondaryto:Crohn'sdisease,granulomatousdiseases,malignancy,communicablediseases • furthertearingbyinternalanalsphincterspasmandhypertonicity
Clinical Features
• acutefissure
■ very painful bright red bleeding especially after bowel movement, sphincter spasm on limited DRE ■ treatment is conservative: stool softeners, bulking agents, and sitz baths (heals 90%)
• chronicfissure(analulcer)
■ triad: fissure, sentinel skin tags, and hypertrophied papillae ■ treatment
◆ stool softeners, increased fibre intake, and sitz baths
◆ topical nitroglycerin or calcium channel blocker (nifedipine): increases local blood flow,
promotes healing, and relieves sphincter spasm
◆ lateral internal anal sphincterotomy (most effective): relieves sphincter spasm to increase blood
flow and promote healing; reserved for medically-refractory cases due to 5% chance of fecal
incontinence
◆ alternative treatment: botulinum toxin A: inhibits release of acetylcholine (ACh), reducing
sphincter spasm
© Shelley Wall 2003