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Anorectal Emergencies

Presented by M. Brendan Munn Calgary Resident Teaching Rounds May 13 2010. Anorectal Emergencies. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS. [Google Quotable #1].

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Anorectal Emergencies

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

  2. [Google Quotable #1] “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 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  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 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

  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 74% Pruritis Ani 59% Fissure 13% Thrombosed 5% Fistula 1% CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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

  8. [Google Quotable #2] History 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

  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

  12. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  13. Management of Anal Fissures Conservative W warm sitz A analgesia S stool softening H hygiene CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  14. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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

  16. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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

  18. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  19. Case 2 : PITA CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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

  21. Rectal Foreign Bodies 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

  22. The Usual and Unusual Suspects 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 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 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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

  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 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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

  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 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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

  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 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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

  30. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  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

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

  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 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  34. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  35. Fistulas Parks classification Consider associated medical conditions CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  36. 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 CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  37. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  38. CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  39. Rectal Prolapse Classification Internal Mucosal Full Thickness Treatment Stool softeners Defecogram / Barium Surgery CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  40. Case 4 : Itchy CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  41. Pruritis Ani Perianal irritation Commonly fecal soiling Remove irritant Good hygiene practices CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  42. Bibliography CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

  43. Questions? CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

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