Anorectal Emergencies
Presented by M. Brendan Munn
Calgary Resident Teaching Rounds
May 13 2010
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
[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
Thanks and Credits
Arun Abbi for his clinical wisdom
Mike Su for his foreign body expertise
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Brainstorm :
5 ED Triage Complaints
10 Anorectal Disorders
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Brainstorm :
5 ED Triage Complaints
Bleed
Pain
Itch
Lump
Discharge
Incontinence
Obstruction
10 Anorectal Disorders
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
All underwent survey, inspection, anoscopy, DRE
870 patients, GI clinic referrals
63 non-benign conditions
Hemorrhoids
74%
268 no disease
Pruritis Ani
59%
13%
539 benign anal disease (BAD) Fissure
Thrombosed
Fistula
31.2% of BAD had multiple causes
significant sx :
POS = soreness, weeping
NEG = AP, diarrhea
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
5%
1%
Anatomy Review
Rectum
Peritoneum
Pectinate Line
Anal Glands
Anal Canal
Nerve Fibers
Muscles
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
[Google Quotable #2]
“flatulence is being blamed for bringing a hospital patient's operation to a fiery end.”
History
AMPLE
Associated Sx
Pain Hx
Bowel and Bladder Hx
Bleed Hx
Perforation Hx
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Case 1 : Bleeding
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Complete Anorectal Examination
Inspection
DRE
Anoscopy
Metal Ruler
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Complete Anorectal Examination
Inspection
DRE
Anoscopy
Metal Ruler
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Management of Anal Fissures
Conservative
W
A
S
H
warm sitz
analgesia
stool softening
hygiene
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Classification of Hemorrhoids
Theories
External
Internal
Grading
I - no prolapse
II - spont reduces
III - manually reduces
IV - irreducible
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Management of Hemorrhoids
Conservative
Surgical
(Ext, Gr I and II)
(Gr III and IV)
W
A
S
H
Minimally Invasive > Excision
Rubber Band Ligation is best
Antibiotics if foul
Acutely Thrombosed External
may benefit from thrombectomy
warm sitz
analgesia
stool softening
hygiene
Topical Nifedipine
or NTG; Botox
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Case 2 : PITA
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
[Google Quotable #3]
“embarrassing question… let’s say I got something stuck up my bum.”
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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
The Usual and Unusual Suspects
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
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
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Approach to Rectal FB in ED
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Approach to Rectal FB in ED
Voluntary?
Object(s)?
High or Low?
Perforation?
CSART, GA
#, perforation risk
DRE
exam, 3 views, CBC
for ED management MUST be 3D
Dull, Distal and Directly visualized
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
“get a small pair of hands, ideally not yours”
[Google Quotable #4]
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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
Perianal and Rectal Trauma
Blunt (Minority) or Penetrating (Majority)
GSW, Lacerations predominate
Can be intra or extraperitoneal
Signs:
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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
Case 3 : Swollen Bum
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Anal Abscesses
Blocked and infected anal gland
E. Coli, S. Aureus, Fecal Anaerobes
50% become fistulas
Spectrum of disease
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Abscess Classification
supralevator
intersphincteric
perianal
ischiorectal
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Fistulas
Parks classification
Consider associated medical conditions
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
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
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Rectal Prolapse
Classification
Internal
Mucosal
Full Thickness
Treatment
Stool softeners
Defecogram / Barium
Surgery
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Case 4 : Itchy
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Pruritis Ani
Perianal irritation
Commonly fecal soiling
Remove irritant
Good hygiene practices
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Bibliography
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS
Questions?
CALGARY EMERGENCY MEDICINE TEACHING ROUNDS