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The Rectum and You. Robert Theobald III, D.O. Vein Associates P.A. Napolean. Jimmy Carter. George Brett. Hemorrhoids. Cushions of tissue and varicose veins located in and around the rectal area Usually swollen and inflamed due to precipitating factors

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The rectum and you l.jpg

The Rectum and You

Robert Theobald III, D.O.

Vein Associates P.A.

Hemorrhoids l.jpg

  • Cushions of tissue and varicose veins located in and around the rectal area

  • Usually swollen and inflamed due to precipitating factors

  • Factors include constipation, diarrhea, pregnancy, straining, aging, and anal intercourse

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  • Approximately 89% of all Americans at some time in their lives

  • Over 2/3 of healthy people report having hemorrhoids

  • Hemorrhoids tend to become worse over the years, never better, unless intervention ensues

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  • They are located both inside and above the anus (internal) or under the skin around the anus (external)

  • Hemorrhoids arise from congestion of internal and/or external venous plexuses around the anal canal

  • Are classified into four degrees

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  • 1st Degree: Bleeding occurs, but do not prolapse outside the anal canal

  • 2nd Degree: Prolapse outside the anal canal upon defecation, but retract spontaneously

  • 3rd Degree: Require manual reduction after prolapse

  • 4th Degree: Can not be reduced, because of strangulation

  • This is a medical emergency!

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  • The major drainage of the hemorrhoidal plexus is through the superiorhemorrhoidal vein, which drains into the inferior mesenteric vein and the portal system

  • Hemorrhoidal veins have no valves

  • Valveless veins exert maximal pressure at the lowest point

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  • Any process that impairs venous return will promote stasis

  • Can be produced by either systemic or by portal venous hypertension (CHF or cirrhosis)

  • Intra-abdominal pressure also impairs venous return (ascites, exercise, pregnancy, straining, and tumors)

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3rd Degree Prolapse

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4th Degree Prolapse

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  • The most significant symptom is rectal bleeding!

  • Usually bright red

  • Internal hemorrhoids are NOT painful

  • Bleeding can be significant because of an arteriovenous fistula formation in plexus

  • Other symptoms are prolapse, pruritis, and perianal edema

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Hemorrhoid Treatment

  • Treatment starts conservatively

  • Hydrocortisone Cream 2.5%

  • Anusol HC Suppositories

  • Rubber-Band Ligation

  • Sclerotherapy (5% phenol)

  • Infra-Red Coagulation

  • Surgery

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Thrombosed External Hemorrhoids

  • Thrombosed hemorrhoids are an acute and very painful problem that develops rapidly

  • Typically a perianal mass develops which is painful to palpate (and look at)

  • The lesion is due to sudden clot formation in one of the subcutaneous or submucosal veins

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Thrombosed External Hemorrhoids

  • The diagnosis is easy to make by the violet discoloration of the lesion

  • The overlying tissue is tense and shiney

  • Treatment is with excision of the clot

  • The body will eventually reabsorb the clot, but might takes weeks

  • Easier to excise after a few days

  • Adherence may occur if not excised within a few days

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  • A perianal abscess is a collection of pus in one of the anatomic spaces of the anal region

  • The perianal anatomy is defined by the sphincter and the levator ani muscles

  • The Iliococcygeus, Pubococcygeus, and Puborectalis

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  • Abscesses can be classified according to location

  • Perianal, Supralevator, Intersphincteric

  • The most common location is perianal

  • It results from a blockage of the anal glands located just outside the anus

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  • According to the crypto-glandular theory, they often develop from cryptitis which may be associated with an enlarged papillae in the anal canal

  • It starts as a cellulitis with only swelling and erythema

  • Finally, the infecting organisms burrow in the anal glands producing the abscess

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  • The microorganisms are not specific or unique

  • They are usually polymicrobial

  • More than 90% will include E. coli

  • Other organisms include streptococci, staphylococci, and a variety of anaerobic bacteria

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  • The patient will present with fever, local inflammation, and pain

  • The initial manifestation is fever followed by pain

  • In 24-48 hours a fluctuant mass will appear

  • An abscess in the intramuscular space may be difficult to diagnose and treat

  • Clinical assumption is needed to treat appropriately

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  • Treatment consists of surgically draining the infected cavity

  • A cruciate incision is made to allow pus to drain for a few days

  • Sometimes a catheter is left in the incision to assure adequate drainage

  • A fistulous tract can arise if the abscess is not treated properly

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  • Most fistulas begin as an anorectal abscess

  • Anal fistulas is an abnormal passage or communication between the interior of the anal canal or rectum and the skin surface

  • Rarer forms may communicate with the vagina, large bowel, and bladder

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  • Are usually a purulent discharge and drainage of pus or stool near the anus

  • Can irritate the outer tissues causing itching and discomfort

  • Pain occurs when fistulas become blocked and abscesses recur

  • Flatus may also escape from the tract

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  • Fistulas can be difficult to diagnosis

  • A probe must be passed between the opening of the skin’s surface and the interior opening

  • Goodsall’s Rule can be helpful

  • Other causes include tuberculosis, inflammatory bowel disease, and cancer

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  • Fistulas last until surgically removed

  • Excision of the complete tract is called a fistulectomy

  • Sometimes a seton is placed in the tract to elicit an inflammatory reaction in the tissue resulting in closure

  • 80% success rate with surgery

  • Remicade (infliximab) for persistent disease

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  • An anal fissure is a tear causing a painful linear ulcer at the margin of the anus

  • Can cause itching, pain, or bleeding

  • 80% of fissures occur in the posterior midline

  • 15% of fissures occur in the anterior midline

  • 5% of fissures occur either right or left lateral

    • Fissures that occur laterally think of Crohn’s, tuberculosis, lymphoma, leukemia, anal cancer, syphilis, and trauma

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  • When an anal fissure is suspected, physical examination is diagnostic

  • The exam may be difficult due to pain and sphincter spasm

  • The triad consists of a sentinel skin tag, a fissure and a hypertrophied papilla

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  • Treatment for superficial fissures includes Anusol HC or Canasa (mesalamine) suppositories

  • If suppositories don’t heal fissure, then nitroglycerin cream 0.2% is used (headaches are major side-effect)

  • If not responding to pharmacotherapy or chronic fissure, then surgery is recommended

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  • Surgery consists of a fissurectomy and sphincterotomy

  • Helps the fissure to heal by preventing pain and spasm which interferes with healing

  • 90% of patients will improve with the surgery

  • Very small chance of anal incontinence

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Pilonidal Cysts

  • The term pilonidal was derived from the Latin pilus meaning hair and nidus meaning nest

  • The pathogenesis is unknown, but the most common theory is that they are a result of an embryonic malformation and results in a remnant of a neurocanal

  • Men are more likely than women to have the cysts at a ratio of 4 to 1

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Pilonidal Cysts

  • Infection of a pilonidal cyst is most commonly seen between puberty and age 30

  • Hair growth and secretion of sebaceous glands reach their peak

  • Some suggest that trauma to the gluteal area to be an important predisposing factor

  • In WWI it was known as Jeep Rider’s Disease

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Pilonidal Cysts

  • Unless they become infected or inflamed, they are asymptomatic

  • When a cyst becomes infected, an abscess can develop, usually lateral or superior to the gluteal cleft and over the coccyx

  • As the process becomes chronic, a fistula develops and creates a sinus tract

  • Diagnosis can be made with pilonidal pores which are 2 or more openings located between the gluteal cleft

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Pilonidal Cysts-Treatment

  • The only way to cure pilonidal cysts is surgery

  • The first episode can be treated with antibiotics (Keflex or Augmentin)

  • If recurrent, then surgery is performed

  • Open-technique is most successful

  • Other techniques include closed, marsupialization, and Z-plasty

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Condylomata Acuminata

  • Condylomata Acuminata (anal or perianal warts) are the most common sexually transmitted disease of the anus and rectum

  • Human papillomavirus (HPV) is responsible

  • Over 40 subtypes of HPV

  • Most common 6 and 11

  • 16, 18, 31, and 32 are associated with squamous cell carcinoma

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Condylomata Acuminata

  • CDC reports a 500% increased in the incidence from 1981; 1/7 Americans

  • Are epithelialized, raised wartlike lesions that arise alone or more often in groups

  • They can range from a few millimeters to a cauliflower-like lesion

  • Can occur in combination with genital lesions

  • Mode of transmission is sexual intercourse, auto-inoculation may occur

  • Rarely bleed or painful, mostly pruritis

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Condylomata Acuminata

  • Although perianal condylomata can be seen in women and heterosexual men, typically the patients are homosexual males

  • CDC reports that 60-70% of homosexual men have condylomata

  • Women have increased risk of cervical carcinoma with HPV infection

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Condylomata Acuminata

  • Successful therapy requires accurate diagnosis and eradication of all warts

  • All patients undergo anoscopy and genital examination

  • Once identified, there are many different treatments depending on disease progression

  • Each treatment has advantages and disadvantages

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Condylomata Acuminata

  • The treatment options consist of excisional, destructive, immunotherapy, and chemotherapy

  • Condylomata can be excised either in the office with local anesthesia or in the operating room

  • Preservation of the anoderm and anal canal mucosa to minimize pain and healing time

  • The rate of recurrance is less than 10%

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Condylomata Acuminata

  • Podophyllin is a resin that is cytotoxic to condylomas and very irritating to normal skin

  • Can not be applied to anal canal lesions

  • Local complications include necrosis, fistula, and anal stenosis

  • Electrocautery, Cryotherapy, and Lasers are also used with frequency

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Condylomata Acuminata

  • Two therapies that are more commonly practiced today are interferon injections and Aldara (imiquimod) cream

  • Both therapies are very potent with many side-effects

  • LFT’s should be checked routinely with interferon injections

  • Aldara should be used every other day, because it can burn normal tissue and make it necrotic

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Pruritis Ani

  • More common in males than females

  • Symptoms include itching, burning, and irritation

  • Close examination of the perianal area is required; ulcerations and excoriation

  • Can be associated with other diseases

    • Infections (fungal, parasitic, bacterial)

    • Irritants (soaps, coffee, ETOH, detergents)

    • Dermatologic (psoriasis, dermatitis, pemphigus)

    • Systemic disease (diabetes, SLE, liver dx)

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Pruritis Ani

  • Treatment

    • Avoiding the offending agents

    • Creams (analpram lotion/cream 2.5%)

    • Topical Steroids

    • Corona ointment (lanolin/bees wax based)

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Anal Cancer

  • Very uncommon cancer, accounting for only 4% of all cancers of the lower GI tract

  • Anal cancer is on the rise due to individuals with HPV

  • The majority of patients are women in their seventh decade who present with bright red bleeding and pain

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Anal Cancer

  • Anal cancer is often curable

  • 3 major factors include site, size, and differentiation

  • Squamous cell carcinomas make up the majority of all primary cancers of the anus

  • The others are adenocarcinoma, verrucous carcinoma, and malignant melanoma

  • Colorectal cancers are primarily adenocarcinoma

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Anal Cancer-Treatment

  • Surgery is a common way to diagnose and treat anal cancer

  • Local resection takes out only the cancer, it spares the internal anal sphincter muscle

  • Abdominoperineal resection (APR) removes the anus and the lower part of the rectum by cutting into the abdomen and the perineum

  • With an APR, the patient will have a colostomy

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Anal Cancer-Treatment

  • Radiation therapy and Chemotherapy are used together to shrink tumors

  • All anal cancers respond very well to this combination therapy

  • APR is now an unnecessary surgery for anal cancer, but still very common for distal rectal carcinoma

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Levator Syndrome

  • More commonly called Proctalgia fugax

  • It is episodic rectal pain caused by spasm of the levator ani muscles

  • A spasm is situated in the rectum approximately 10-15 cm above the anus

  • The pain or spasm is related to sitting for long periods of time

  • Pain is described as a sharp, knife-like, twisting inside the rectum

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Levator Syndrome

  • Physical examination is usually normal

  • Emotional factors, sexual activity, or fatigue can trigger an attack

  • Can also be triggered by an injury to coccyx or lower back

  • Structural deviations of the lumbro-sacral area, sacro-iliac, coccyx, and supportive structures are also causes

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  • A fracture or dislocation of the coccyx should be reduced by bi-manual manipulation

  • Levator ani tenderness will readily respond to OMT

  • Digital stretching of the ischiococcygeus tends to relax the entire structure, usually on the left lateral side