1. Project: Ghana Emergency Medicine Collaborative Document Title: Emergency Management of Ano-Rectal Disorders Author(s): Joseph H. Hartmann (University of Michigan), DO 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1

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3. WikipedianProlific, Wikimedia CommonsWikimedia Commons 3

4. Hemorrhoids Symptoms – itching, pain, bleeding, protrusion External hemorrhoids – asymptomatic unless thrombosed Internal hemorrhoids – –Bleeding – typically bright red on stool – but not mixed in stool –Protrusion – soiling / mucus discharge incarcerated/strangulated 4

5. Hemorrhoids Pathogenesis –Inadequate dietary fiber –Prolonged sitting on comode –Chronic straining –Prolonged sitting (occupational) –Medical conditions causing increased venous pressure Pregnancy, ascites, pelvic tumor 5

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8. Thrombosed Hemorrhoids External – most common –Acute onset anal pain –Palpable perianal mass Internal – far less common –Pain –Pressure –Bleeding 8

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12. Gray’s Anatomy, 20 th edition, Wikimedia CommonsWikimedia Commons 12

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20. Hemorrhoids - treatment Medical –Sitz baths –Increased dietary fiber –Stool softener –OTC topical agents / suppositories –Prescription topical agents / suppositories Anusol / Anusol HC 20

21. Hemorrhoids - treatment Surgical –Sclerotherapy (injection of phenol in oil or hypertonic salt solution causing thrombosis of vessels and sclerosis of connective tissue) –Cryotherapy –Rubber band technique –Bipolar diathermy –Direct-current electrotherapy –Infrared photocoagulation –Surgical excision 21

22. Rectal Prolapse (Procedentia) Passage (herniation) of a portion or all of rectal mucosa thru external anal sphincter Type I – false procedentia –Partial / mucosal prolapse less than 2 cm long –Produces radial folds Type II – true procedentia –Complete / full thickness rectal wall extrusion –Extends 2 – 5 cm –Produces circular / concentric folds 22

23. Dr. K.-H. Günther, Klinikum Main Spessart, Lohr am Main, Wikimedia CommonsWikimedia Commons 23

24. Rectal Prolapse Increased intra-abdominal pressure –Chronic constipation, protracted coughing, forceful vomiting Diarrheal disease Cystic fibrosis Malnutrition Pelvic floor weakness 24

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30. Leonard Portal Mark, St. Bartholomew’s Hospital Archives & Museum, London, UK, Wellcome ImagesWellcome Images 30

31. Anal Fissure (fissure-in-ano) Split in squamous epithelium at or just inside the anal verge (efface anal canal) Sharp cutting anal pain with defecation that is relieved in-between defecations Sentinel skin tag ( sentinel pile) present Occurs in midline –posteriorly (90% male and 75% female) Predominately noted in young adults 31

32. Armin Kübelbeck, Wikimedia CommonsWikimedia Commons 32

33. Jonathanlund, Wikimedia CommonsWikimedia Commons 33

34. Anal Fissure Treatment –Sitz baths –Topical analgesics –Surgery for chronic lesions or intractable pain –Diminish resting anal sphincter pressure Nitroglycerin or calcium channel blocking agents 34

35. Cryptitis (Papilitis) Inflammation of mucosal lining over crypts (? passage of hard stools) Predisposes to inflamation of anal glands leading to abscess formation and possible eventual fistula formation Characterized by –Anal pain exacerbated with defecation – +/- bleeding and/or pruritis –Tender swollen crypts on palpation 35

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38. Cryptitis Treatment –Sitz baths –Warm rectal irrigation –Bulk laxatives –Proctofoam HC 38

39. Ano-rectal Abscess Originates from infected anal glands at dentate line Perianal Ischiorectal (buttocks) Intersphincteric (fluctuance in lumen) Supralevator (CT diagnosis) Horseshoe / deep posterior anal space –bilateral ischiorectal space abscess 39

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43. Ano-rectal Abscess Symptoms – dull aching, throbbing pain worse before defecation and persists between defecations Treatment –Incision and drainage –Antibiotics if Extensive cellulitis Diabetes Valvular heart disease Immunosuppression 43

44. Anal Fistula Uncommon in general population –Anorectal malignancy –Leukemia –Radiation proctitis –Actinomycosis –Lymphogranuloma venereum –Inflammatory bowel disease (Crohn’s) 44

45. Marc A Levitt, Alberto Peña. Anorectal malformations. Orphanet Journal of Rare Diseases. 2, 33. 2007, Wikimedia CommonsWikimedia Commons 45

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48. Venereal Proctitis Characterized by pruritis, discharge, mild – moderate pain or irritation, tenesmus Usual etiologies –Viral Herpes simplex type 2 Human immunodeficiency virus Papillomavirus (condylomata accuminata) –Bacterial Neisseria gonorrhea Chlamydia trachomatis Treponema pallidum (condylomata lata –secondary syphillis) 48

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