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The Rectum and You

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

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  1. The Rectum and You Robert Theobald III, D.O. Vein Associates P.A.

  2. Napolean

  3. Jimmy Carter

  4. George Brett

  5. Hemorrhoids • 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

  6. Hemorrhoids • 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

  7. Hemorrhoids • 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

  8. Hemorrhoids-Classifications • 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!

  9. Hemorrhoids

  10. Hemorrhoids • 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

  11. Hemorrhoids • 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)

  12. 3rd Degree Prolapse

  13. 4th Degree Prolapse

  14. Hemorrhoids • 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

  15. Perianal Edema

  16. Hemorrhoid Treatment • Treatment starts conservatively • Hydrocortisone Cream 2.5% • Anusol HC Suppositories • Rubber-Band Ligation • Sclerotherapy (5% phenol) • Infra-Red Coagulation • Surgery

  17. Hemorrhoidectomy

  18. 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

  19. Thrombosed External Hemorrhoids

  20. 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

  21. Abscesses • 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

  22. Abscesses • 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

  23. Abscesses • 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

  24. Abscesses • 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

  25. Abscesses-Symptoms • 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

  26. Abscess

  27. Abscesses • 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

  28. Fistula • 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

  29. Fistula

  30. Fistula-Symptoms • 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

  31. Fistula • 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

  32. Crohn’s Fistula

  33. Fistula-Treatment • 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

  34. Fissures • 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

  35. Fissures • 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

  36. Fissures

  37. Fissures-Treatment • 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

  38. Fissures-Treatment • 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

  39. Auto-colonoscopy

  40. 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

  41. 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

  42. 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

  43. Pilonidal Cysts

  44. Pilonidal Cysts

  45. 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

  46. 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

  47. 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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