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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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slide1

Presented by M. Brendan Munn

Calgary Resident Teaching Rounds

May 13 2010

Anorectal Emergencies

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide2

[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

slide3

Thanks and Credits

Arun Abbi for his clinical wisdom

Mike Su for his foreign body expertise

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide4

Brainstorm :

5 ED Triage Complaints

10 Anorectal Disorders

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide5

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

slide6

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

slide7

Rectum

Peritoneum

Pectinate Line

Anal Glands

Anal Canal

Nerve Fibers

Muscles

Anatomy Review

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide8

[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

slide9

Case 1 : Bleeding

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide10

Complete Anorectal Examination

Inspection

DRE

Anoscopy

Metal Ruler

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide11

Complete Anorectal Examination

Inspection

DRE

Anoscopy

Metal Ruler

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide13

Management of Anal Fissures

Conservative

W warm sitz

A analgesia

S stool softening

H hygiene

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide15

Classification of Hemorrhoids

Theories

External

Internal

Grading

I - no prolapse

II - spont reduces

III - manually reduces

IV - irreducible

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide17

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

slide19

Case 2 : PITA

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide20

[Google Quotable #3]

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

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide21

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

slide22

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

slide23

Approach to Rectal FB in ED

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide24

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

slide25

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

[Google Quotable #4]

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide26

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

slide27

Perianal and Rectal Trauma

Blunt (Minority) or Penetrating (Majority)

GSW, Lacerations predominate

Can be intra or extraperitoneal

Signs:

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide28

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

slide29

Case 3 : Swollen Bum

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide31

Anal Abscesses

Blocked and infected anal gland

E. Coli, S. Aureus, Fecal Anaerobes

50% become fistulas

Spectrum of disease

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide32

Abscess Classification

supralevator

intersphincteric

perianal

ischiorectal

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide33

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

slide35

Fistulas

Parks classification

Consider associated medical conditions

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide36

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

slide39

Rectal Prolapse

Classification

Internal

Mucosal

Full Thickness

Treatment

Stool softeners

Defecogram / Barium

Surgery

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide40

Case 4 : Itchy

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide41

Pruritis Ani

Perianal irritation

Commonly fecal soiling

Remove irritant

Good hygiene practices

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide42

Bibliography

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS

slide43

Questions?

CALGARY EMERGENCY MEDICINE TEACHING ROUNDS