anorectal emergencies presented by m. brendan munn calgary resident teaching rounds may 13 2010...

Anorectal EmergenciesPresented by M. Brendan MunnCalgary Resident Teaching RoundsMay 13 2010

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Objectives1. Review anatomy

2. Discuss common anorectal emergencies

3. Clear the cache


“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]

Thanks and Credits

Arun Abbi for his clinical wisdom

Mike Su for his foreign body expertise


Brainstorm : 5 ED Triage Complaints

10 Anorectal Disorders


Brainstorm : 5 ED Triage Complaints

10 Anorectal Disorders


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

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, diarrheaCALGARY EMERGENCY MEDICINE TEACHING ROUNDS

Hemorrhoids 74%

Pruritis Ani 59%

Fissure 13%

Thrombosed 5%

Fistula 1%

Anatomy Review


Rectum

Peritoneum

Pectinate Line

Anal Glands

Anal Canal

Nerve Fibers

Muscles

HistoryAMPLE

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.”


Case 1 : Bleeding


Complete Anorectal Examination

Inspection

DRE

Anoscopy

Metal Ruler



Management of Anal Fissures

Conservative

W warm sitz

A analgesia

S stool softening

H hygiene

Classification of Hemorrhoids


Theories

External

Internal

Grading

I - no prolapse

II - spont reduces

III - manually reduces

IV - irreducible


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

Case 2 : PITA



“embarrassing question… let’s say I got something stuck up my bum.”


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


Rectal Foreign Bodies

The Usual and Unusual Suspects


BottleJarGlassLight bulbTubeAppleBananaCarrotCucumberOnionParsnipPlantainPotatoeSalamiTurnipZucchiniAxe HandleStick Broom handleMiscellaneousDull KnifeIce Pick

Knife SharpenerMortar & PestleSpatula SpoonTin cupCandleFlashlightIron RodPenRubber tubeScrewdriverToothbrushWire SpringBalloonCondomInner TubeBaseballTennis ballBocce ballCandleboxSnuffboxBaby Powder Can

Cattle hornFrozen Pigs TailKangaroo TumorPlastic RodStoneToothbrush HolderToothbrush PackageWhip HandleGerbilGlass TubesJeweler’s SawOil CanPiece of Wood and PeanutUmbrella Handle Phosphorous Match Ends402 StonesToolbox2 Bars SoapBeer Glass and Preserving PotLemon and Cold Cream JarTobacco PouchMagazine


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


Approach to Rectal FB in ED


“get a small pair of hands, ideally not yours”


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


Removal in ED


Perianal and Rectal Trauma

Blunt (Minority) or Penetrating (Majority)GSW, Lacerations predominate

Can be intra or extraperitoneal

Signs:


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

Management3 views, CT, endoscopy, Gastrograffin

Admission, observation, serial exams

Irrigate and close lacerations, tetanus prophylaxis

Diverting colostomy if rectal perforation

Case 3 : Swollen Bum



Anal Abscesses

Blocked and infected anal gland

E. Coli, S. Aureus, Fecal Anaerobes

50% become fistulas

Spectrum of disease


perianal ischiorectal

supralevator

intersphincteric

Abscess Classification


Abscess Management

Perianal and IschiorectalDrainage 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


Fistulas

Parks classification

Consider associated medical conditions


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

ManagementOperative always except in Crohn’s

Setons for refractory cases


Rectal Prolapse

Classification

Internal

Mucosal

Full Thickness

TreatmentStool softeners

Defecogram / Barium

Surgery

Case 4 : Itchy



Pruritis Ani

Perianal irritation

Commonly fecal soiling

Remove irritant

Good hygiene practices


Bibliography

Questions?


anorectal emergencies presented by m. brendan munn calgary resident teaching rounds may 13 2010...

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