Internal Medicine EXIMIUS

ANORECTAL DISEASE AND COMMON ANORECTAL DISORDERS 2021

Michael Razote, MD SEPT 21, 2019

DIVERTICULAR DISEASE - Surgery for complicated diverticulitis

◦ Control sepsis, eliminate complications, removing
- Diverticulosis: saclike herniation diseased segment, and restoring intestinal continuity
- True and false/pseudodiverticulum
- Left and sigmoid colon, Asian 70% are in right and cecum COMMON DISEASES OF THE ANORECTUM
- Patients >80 y/o (mean age of 50 y/o)
- Most are asymptomatic and 20% are symptomatic
 RECTAL PROLAPSE
- Prevalence: male = females
◦ Circumferential, full thickness protrusion of the rectal
PATHOGENESIS wall through the anal orifice.
◦ Break in the integrity of colonic wall at the point of vasa ◦ Women > men
recti ◦ Pelvic floor disorders, CF, Ehler Danlos, Solitary rectal
◦ Higher amplitude of contractions and high fat content of ulcer syndrome, Congenital hypothyroidism,
stool Hirsprung’s disease, Dementia, mental retardation,
◦ Compression and erosion of vasa recti leads to bleeding and Schizophrenia.
and perforation ◦ Anal mass, bleeding per rectum, and poor perianal
◦ Chronic low grade inflammation hygiene
◦ Constipation and incontinence
PRESENTATION, EVALUATION AND MANAGEMENT OF ◦ Cystoproctoscopy and colonoscopy
DIVERTICULAR BLEEDING ◦ Treatment:
- Stool bulking agents and fiber
 HEMORRHAGE (20%) supplementation
◦ HTN, atherosclerosis, NSAID, ANS ASA - Surgical correction
◦ Self-limited and bowel rest
◦ Lifetime rebleeding risk of 25%  FECAL INCONTINENCE
◦ Colonoscopy, CT angiogram, and RBC scan ◦ Passage of faecal material for at least 1 month in an
◦ Coil embolization, segmental resection, and selective individual with a developmental age of at least 4
infusion of vasopressin years
◦ Unstable patient and had been transfused with 6 unit ◦ Women > 65 y/o
PRBC should undergo surgery (segmental or subtotal) ◦ Multiparty
◦ Obstetric injury to the pelvic floor (prolonged labour,
PRESENTATION, EVALUATION AND MANAGEMENT OF forceps, and episiotomy).
DIVERTICULITIS ◦ Injury to the external anal sphincter and pudendal
nerve.
- Acute uncomplicated ◦ Incontinence to flatus and seepage of liquid stool
◦ Fever, anorexia, llq pain, obstipation (minor) or inability to control solid stool (major)
- Diverticular perforation and peritonitis/pericolonic abscess ◦ DX: History and PE, anal manometry, pudendal nerve
- Leucocytosis terminal motor latency, and endoanal UTZ
- Air-fluid level on LLQ ◦ TX: bulking up stool, biofeedback, overlapping
- Giant diverticulum in sigmoid colon sphincteroplasty, sacral neuromodulation.
- CT findings:
◦ Sigmoid diverticula, >4mm thickness of colonic wall,  HEMORRHOIDAL DISEASE
inflammation within the pericolic fat + collection of ◦ Nonselective for age and sex
the contrast material/fluid ◦ Risk factors: age, low fiber, high fat, straining
- Colonoscopy: ◦ External and internal hemorrhoids
◦ Exclusion of colorectal cancer ◦ Pain, bleeding and protrusion
◦ Fistula formation into cutaneous, vaginal, and vesicle. ◦ Anoscopy, colonoscopy or flexible sigmoidoscopy
◦ Excision, sitz bath, fiber and stool softeners
TREATMENT ◦ Banding and sclerotherpy
◦ Surgical management: excision hemorrhoidectomy,
- Asymptomatic transhemorrhoidal dearterialization and stapled
◦ Diet alteration (30g fiber/day) hemorrhoidectomy
◦ Smoking cessation
- Symptomatic uncomplicated  ANORECTAL ABSCESS
◦ Antibiotics and bowel rest ◦ Men>women
- Anti-inflammatory medications ◦ Third to fifth decade
- Probiotics ◦ Diabetes, IBD, hematologic disorders, and HIV
- Rifaximin ◦ Infection of anal glands resulting in abnormal fluid
collection in the anorectal region.

TRANSCRIBERS GROUP 1
 Internal Medicine EXIMIUS
ANORECTAL DISEASE AND COMMON ANORECTAL DISORDERS 2021
Michael Razote, MD SEPT 21, 2019

◦ Perianal pain and fever, dysuria and hematochezia

◦ Visible fluctuant area
◦ Leucocytosis
◦ CT, MRI, and colonoscopy
◦ Surgical drainage
◦ Antibiotics

 FISTULA IN ANO
◦ Associated with anorectal abscess, IBD, TB,
malignancy and radiation
◦ Communication of an abscess cavity with an
identifiable internal opening within the anal canal
◦ Classified as intersphicteric, transsphincteric,
suprashincteric, and extrasphincteric
◦ Constant drainage from the perianal region
associated with a firm mass
◦ Anoscopy
◦ Surgery (fistulotomy, ligation)
◦ Stool bulking agents narcotic analgesics, and SITZ
bath

 ANAL FISSURE
◦ 3rd to 5th decade
◦ Male = female
◦ Assoc. with constipation, diarrhoea, infection,
perianal trauma, and chrons disease.
◦ irritation and injury to anal canal increases resting
pressure of the internal sphincter resulting in
ischemia and fissure formation
◦ pain on defecation and relentless
◦ hematochezia
◦ anoscopy
◦ stool softener, dietary fiber, topical anesthetic,
glucocorticoid and sitz bath
◦ nifedipine and nitroglycerin ointment
◦ surgery

TRANSCRIBERS GROUP 2