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Anorectal Outlet Sources

Anorectal Outlet Sources. Giuseppe Gagliardi, MD Mario Pescatori, MD, FRCS Coloproctology Unit, Rome Villa Flaminia. Acute bleeding:anorectal causes. More common Less common Hemorrhoids Rectal varices Post-surgical Angiodysplasya Post-polypectomy* SRU

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Anorectal Outlet Sources

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  1. Anorectal Outlet Sources Giuseppe Gagliardi, MD Mario Pescatori, MD, FRCS Coloproctology Unit, Rome Villa Flaminia

  2. Acute bleeding:anorectal causes More commonLess common Hemorrhoids Rectal varices Post-surgical Angiodysplasya Post-polypectomy* SRU Radiation proctitis* Stercoral ulcer Neoplasms Dieulafoy IBD Aneurysms Trauma*

  3. Treatment of hemorrhoidal bleeding Rubber band ligation vs excisional hemorrhoidectomy: no difference for bleeding symptoms Cochrane 2005 Bleeding after RBL 25% patients taking warfarin 7% NSAID 2.9% patients taking neither Iyier DCR 2004 Hemorrhoidectomy with Ligasure in anticoagulated patients Lawes Colorectal Dis 2004

  4. Treatment of hemorrhoidal bleeding Morar Cardiovasc Intervent Radiol 2006

  5. Bleeding after hemorrhoid treatment Reactionary: technical errors incidence 1% PPH vs excisional hemorrhoidectomy (for PPH 1.8-44% reoperation 25-90%) Secondary: after 6-11 days incidence 2.4-6%. Treatment: Anal packing 15% rebleed Hemostatic sponge Rectal Foley Adrenaline injections Rectal irrigation 12% don’t stop Chen DCR 2002 Suturing required in 7%-40% followed by late complications in 15% Mazier Semin Colon Rectal Surg 1990 ? role of micronized flavonoids

  6. Rectal Varices Incidence in portal hypertension 44-90% > in viral cirrhosis Chawla Gut 1991 Bleed in 10%-37%, independent from Child’s classification Treatment Octreotide Oversewing/stapling Sclerotheraphy TIPPS vs TIPPS + embolization 42 vs 28% rebleed Vangeli J Hepatology 2004 Venus shunts Resective surgery contraindicated

  7. Anorectal tumors Is resection necessary for palliation? Local recurrence After surgery clinical improvement in 78%(curative) 40%(palliative), in the long term 63% and 88%% and develop symptoms Miner Ann Surg Oncol 2003 EXTR and re-XRTshort term palliation for non-metastatic, bleeding palliated Mohiuddin Cancer 2002 EXRT+hyperthermia 72% immediate palliation Juffermans Cancer 2003 Brachytheraphy 60-90% response for bleeding Hoskins Radiother Oncol 2004 Metastatic disease EXRT 90% of patients with metastastic disease palliated until death Crane Int J Radiat Oncol Biol Phys. 2001 Long term palliation in 75% with (repeated) APC Gevers Gastrointest Endosc 2000

  8. Anorectal Tumors Surgery indicated for palliation in patients with > 6 months life expectancy Fazio J Gastrointest Surg 2004 Resection and anastomosis in patients with metastatic disease Moran Arch Surg 1987 Hartmann vs Abdominoperineal to avoid perineal wound sepsis and pain Heah DCR 1997 Local excision equivalent palliation Chen J Gastrointest Surg 2001 Anorectal melanoma Presents with bleeding, beware of amelanotic lesions Treatment is surgical Survival and recurrence not dependent on surgical strategy (LE=APR) Yeh ASCRS 1995

  9. Anorectal bleeding:IBD Acute Fulminant Colitis In pre-pouch era 20% of acute bleedings underwent proctectomy In emergency IRA for bleeding 18% rebleed from rectum but massive bleeding rare Robert Am J Surg 1990 Emergency IPAA with low morbidity Ziv DCR 1994; Ham DCR 1994 Emergency IPAA higher septic and obstructive complications Penna DCR 1993 Medical theraphy, rectal foley, adrenaline, endoscopic, embolization* *Mallant-Hent Eur J Gastroenterol Hepatol 2003 Crohn’s Bleeding from left colon ulcer Medical 60% endoscopic 20% surgery 20% Balaiche AJG 1999

  10. Rectal Ulcer Dieulafoy, Acute hemorrhagic rectal ulcer, aspecific ulcer ESRD, NSAID Stercoral ulcer Frequency underestimated (1.7-5% in autopsy) Elderly, bedridden, constipated Pressure ulcer of necrosis, fecaloma Sigmoid=perforation Rectum=bleeding Aspecific chronic and acute inflammation Solitary rectal ulcer Treatment Sclerotheraphy1, clipping, cauterization, APC, suturing, embolization2, surgery 1Matsushita Gastrointestinal Endoscopy 1998 2Dobson Cardiovascular and Interventional Radiology 1999

  11. Angiodysplasya Klippel-Trenaunay Rubber Bleb Nevus Syndrome Hemangioma capillary arterio-venous cavernous Treatment Sclerotherphy, APC, endoscopic banding, EXRT Surgery: LAR, mucosectomy and coloanal sleeve anastomosis Londono-Schimmer BJS 1994

  12. Conclusions Rigid sigmoidoscopy and rectal washout should be part of the work-up of patients presenting with bright red blood per rectum Some of the causes are rare and require specialist input in tertiary care centers Most of anorectal acute bleedings can be controlled without laparotomy Embolization of rectal arteries carries low morbidity

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