29. What is the most common clinical presentation of a pilonidal sinus?

Show answer
Pain and swelling in the sacrococcygeal region, which typically are associated with a (sometimes several) chronic draining sinus tract.

30. Is pilonidal disease acquired or congenital?

Show answer
Acquired. Hair follicles in the midline sacrococcygeal area enlarge and become infected, resulting in an abscess.

31. How is acute pilonidal abscess treated?

Show answer
Incision and drainage (like a fistula in ano, it is necessary to excise the whole tract).

32. What is the definitive therapy for pilonidal disease?

Show answer
Excision of the entire pilonidal cavity and associated sinus tracts down to the fascia with primary or delayed closure.

33. What theory explains the rarity of pilonidal disease after age 40 years?

Show answer
Changes in body habitus.

References
BIBLIOGRAPHY
1. Beck DE, Wexner SD (eds): Fundamentals of Anorectal Surgery. Philadelphia, W.B. Saunders, 1998.
2. Cho DV: Endosonographic criteria for an internal opening of fistula-in-ano. Dis Colon Rectum 42:515-518, 1999.
3. Cintron JR, Park JJ, Orsay CP, et al: Repair of fistulas-in ano using fibrin adhesive: Long-term follow-up. Dis Colon Rectum 43:944-949, 2000. Medline Similar articles
4. Corman ML: Anal fistula. In Corman ML: Colon and Rectal Surgery, 4th ed. Philadelphia, Lippincott-Raven, 1998, pp 238-271.
5. Hodgkin W: Pilonidal sinus disease. J Wound Care 7:481-483, 1998. Medline Similar articles
6. Law WL, Chu KW: Triple rubber band ligation for hemorrhoids: Prospective randomized trial of local anesthetic injection. Dis Colon Rectum 42:363-366, 1999. Medline Similar articles
7. Park JJ, Cintron JR, Orsay CP, et al: Repair of chronic anorectal fistulae using commercial fibrin sealant. Arch Surg 135:166-169, 2000.
8. Sentovich SM: Fibrin glue for all anal fistulas. J Gastrointest Surg 5:158-161, 2001. Medline Similar articles Full article

1. What aspect of the initial patient encounter is most important in the diagnosis of anorectal disease?

Show answer
Clinical history, including duration of complaints, exacerbating or alleviating issues, precipitating events, dietary and bowel habits, and current or previous treatments. This may not sound glamorous, but you will never encounter a more grateful patient than one whose rectal problem you have solved.

2. What is the most common cause of painless, bright red blood per rectum? Show answer
Internal hemorrhoids.

3. What are the proximal and distal anatomic landmarks of the anal canal? What is its average length?

Show answer
The anal canal starts at the anorectal junction (which is the upper border of the internal sphincter muscle or puborectalis muscle) and ends at the anal verge. The average length is only 3-4 cm. The midpoint of the anal canal is called the dentate line.

4. What is the anatomic and surgical significance of the dentate line?

Show answer
The dentate line is the location of the anal crypts that drain the intramuscular and intersphincteric anal glands, which are the site of anorectal abscesses and fistulas in ano. Above the dentate line, the anal canal receives visceral innervation (involuntary control), is covered by columnar epithelium, and is the origin of internal hemorrhoids. Below the dentate line, the anal canal receives somatic innervation (voluntary control), is lined with squamous epithelium, and is the location of external hemorrhoids.

5. What is the most common cause of anorectal abscess?

Show answer
Ninety percent result from cryptoglandular infection.

6. What are the four potential anorectal spaces used to classify anorectal abscesses?

Show answer

1. Perianal (area of the anal verge)
2. Ischiorectal (area lateral to the external sphincter muscles, extending from the levator ani muscles to the perineum)
3. Intersphincteric (area between the internal and external sphincter muscles, continuous inferiorly with the perianal space and superiorly with the rectal wall)
4. Supralevator (area superior to the levator ani muscles, inferior to the peritoneum, and lateral to the rectal wall)

7. Define fistula in ano.

Show answer
A fistula is an abnormal communication between any two epithelial-lined surfaces. The internal opening of the fistula in ano involves the anoderm at the dentate line, whereas the external orifice is located at the anal margin.

8. What is the incidence of fistula in ano after appropriate surgical incision and drainage of acute anorectal abscesses?

Show answer
50%.

9. What is the most important factor leading to the successful surgical eradication of anorectal abscesses or fistulas?

Show answer
You must know anorectal anatomy, including the potential spaces (just memorize the answers to questions 4 and 6).

10. What is Goodsall’s rule?

Show answer
The location of the internal opening of an anorectal fistula is based on the position of the external opening. An external opening posterior to a line drawn transversely across the perineum originates from an internal opening in the posterior midline. An external opening, anterior to this line, originates from the nearest anal crypt in a radial direction.

11. What is the most important determinant of successful surgical treatment of fistula in ano?

Show answer
Identification of the internal openings.

12. What is a seton?

Show answer
A seton is a heavy suture placed through the fistulous tract that is then serially tightened, allowing slow, controlled transection of the sphincter. The associated fibrous reaction maintains sphincter integrity. Although associated pain is a limiting factor in its use, the technique can effectively change a high fistula into a low fistula with minimal risk of incontinence.

13. What is the role of fibrin glue in the management of anal fistula?

Show answer
Theoretically, the use of fibrin sealant represents an attractive alternative to the morbidity of operative treatment. However, although preliminary results support a marked decrease in postoperative pain and discomfort, 1-year recurrence rates are often > 50%.

14. What is the most common location for idiopathic anal fissure?

Show answer
90% are posterior, and 10% are anterior.

15. What are the most common symptoms of anal fissure?

Show answer
Tearing anal pain and bleeding with bowel movements.

16. What is the underlying pathophysiology of fissure in ano?

Show answer
Local trauma to the anal canal, internal anal sphincter dysfunction, and ischemia.

17. What is the differential diagnosis for anal fissure, especially if atypical in location?

Show answer
Anorectal abscess, thrombosed hemorrhoid, inflammatory bowel disease, or malignancy.

18. How do you best diagnose anal fissure?

Show answer
By clinical history and visual inspection-not by digital examination or anoscopy (which serves only to turn a friendly patient into an irate one).

19. What are the nonoperative treatment options?

Show answer
High-fiber diet; stool-bulking agents; increased hydration; frequent, warm sitz baths; and topical agents containing anti-inflammatory agents, local anesthetics, and vasodilators (nitroglycerin).

20. What is the most common operation performed to treat intractable fissure in ano?

Show answer
Fissurotomy with lateral internal anal sphincterotomy.
KEY POINTS: ANAL FISSURE

1. Ninety percent of idiopathic anal fissures are posterior and 10% are anterior.
2. The most common symptoms are tearing anal pain and bleeding with bowel movements.
3. The diagnosis involves visual inspection-not by digital exam or anoscopy.
4. Nonoperative treatment includes high-fiber diet, warm sitz baths, and topical agents containing anti-inflammatory agents, local anesthetics, and vasodilators.
5. The most common operation is a fissurotomy with lateral internal anal sphincterotomy.

21. What are hemorrhoidal tissues, and what are their normal functions?

Show answer
Hemorrhoids are cushions of vascular tissue that contribute to anal continence and protect the sphincter mechanism during defecation. Hemorrhoids are not veins, but sinusoids. Bleeding originates from presinusoidal arterioles, thus explaining the bright red arterial color.

22. What are the most common causes of pathologic hemorrhoids?

Show answer
Constipation, prolonged straining, pregnancy, and internal sphincter dysfunction.

23. What is the most important difference between internal and external hemorrhoids?

Show answer
Whereas internal hemorrhoids are located above the dentate line with visceral innervation, external hemorrhoids are located below the dentate line with somatic innervation. Ablation of internal hemorrhoids causes a pressure sensation with an urge to defecate, but a similar approach to external hemorrhoids causes excruciating pain.

24. What are the most common complaints associated with pathologic internal hemorrhoids?

Show answer
Bleeding, mucus discharge, and prolapsing tissue.

25. What are the most common complaints associated with external hemorrhoids?

Show answer
Pain, inflammation, thrombosis, and difficulty with anal hygiene.

26. Are there any treatment options for symptomatic internal hemorrhoids based on identifiable physical characteristics?

Show answer
Yes. Treatment is based on the degree of prolapse:

Grade 1: None
Grade 2: Spontaneous reduction
Grade 3: Manual reduction
Grade 4: Unreducible

27. How are patients with symptomatic grades 2 and 3 and occasionally grade 4 internal hemorrhoids treated?

Show answer
Diet and stool bulking, rubber band ligation, injection sclerotherapy, cryotherapy, infrared photocoagulation, anal dilatation, or electrocautery.

28. What is the last-resort treatment for recalcitrant symptomatic internal hemorrhoids or combined internal and external hemorrhoids?

Show answer
Operative hemorrhoidectomy.

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1. What is imperforate anus?

Show answer
It is a congenital defect in which the opening of the anus is absent or misplaced, usually fistulizing anteriorly to the perineum or genitourinary (GU) tract. Anorectal malformations range from slight anterior malpositioning of the anus to complex cloacal deformities. Children with anorectal malformations commonly have other congenital anomalies, such as the VACTERL association.

2. What is the VACTERL association?

Show answer

V Vertebral defects
A Anorectal malformations
C Cardiac anomalies
T Tracheoesophageal fistula
E Esophageal atresia
R Renal anomalies
L Limb defects

The incidence of renal anomalies increases with the severity of the imperforate anus-from 10% with low lesions to 75% with high lesions.

3. How do you determine the severity of the defect in boys?

Show answer
The key is whether the boy has a high or low lesion. Low lesions are characterized by a fistula to the perineum somewhere along the midline raphe between the anus and the urethral meatus. After 24 hours, most infants with low lesions demonstrate meconium at the fistula. Other signs of a low lesion include white “pearls” along the raphe or a raised loop of skin, the so-called bucket-handle deformity. Boys with high lesions typically have flat buttocks without a good buttocks crease and may have meconium at the urethral meatus or apparent on urinalysis.

4. How is the lesion assessed in girls?

Show answer
Most affected girls (> 90%) have a rectovestibular or rectovaginal fistula, which usually can be determined by careful perineal examination. Girls with cloacal deformities (i.e., one orifice) have a high incidence of GU obstruction such as hydrocolpos or bladder obstruction. In low lesions, the anal opening is displaced anteriorly on the perineum. The normal location of the anus is halfway between the vaginal orifice and the coccyx.

5. How are infants with anorectal malformations treated?

Show answer
Infants with high lesions should be managed initially with a sigmoid colostomy and later with a pull-through procedure called posterior sagittal anorectoplasty. Infants with low lesions usually can be managed with immediate anoplasty or dilatation and delayed repair.

6. What is a posterior sagittal anorectoplasty (PSARP)?

Show answer
PSARP is a procedure performed through a longitudinal incision in the midline of the perineum, which permits visualization of the pelvic musculature and sphincters and clear exposure of the rectum and fistula. After closure of the fistula, the rectum is repositioned within the sphincteric muscle complex, and a neoanus is created.

7. What are the results after surgical reconstruction?

Show answer
Continence, defined as voluntary bowel movements with no soiling, depends on the type of lesion. Continence approaches 100% for low lesions but is rare with the highest lesions such as cloaca deformities in girls or bladder-neck fistulas in boys. Constipation is present in almost 50% of patients but is more frequent with the simpler defects.
KEY POINTS: IMPERFORATE ANUS

1. Imperforate anus is a congenital defect in which the opening of the anus is absent or misplaced, usually fistulizing anteriorly to the perineum or genitourinary tract.
2. Infants with high lesions should be managed initially with a sigmoid colostomy and later with a pull-through procedure called posterior sagittal anorectoplasty.
3. Infants with low lesions usually can be managed with immediate anoplasty or dilatation and delayed repair.

References
BIBLIOGRAPHY
1. deVries PA, Pena A: Posterior sagittal anorectoplasty. J Pediatr Surg 17:638-643, 1982. Medline Similar articles
2. Jones NM, Humphreys MS, Goodman TR, et al: The value of anal endosonography compared with magnetic resonance imaging following the repair of anorectal malformations. Pediatr Radiol 33:183, 2003. Medline Similar articles
3. Kluth D, Lambrecht W: Current concepts in the embryology of anorectal malformations. Semin Pediatr Surg 6:180-186, 1997. Medline Similar articles
4. Pena A: Anorectal malformations. Semin Pediatr Surg 4:35-37, 1995. Medline Similar articles
5. Pena A, Hong A: Advances in the managemant of anorectal malformations. Am J Surg 180:370-376, 2000.
6. Sarin YK, Sinha A, Gupta A: High anorectal malformation in boys: Need for clarity of definition and management. J Pediatr Surg 37:1637, 2002. Medline Similar articles

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1. Describe the treatment of a patient who presents with lower gastrointestinal (GI) bleeding.

Show answer
Treatment begins with the ABCs (airway, breathing, circulation). Place two large-bore intravenous (IV) catheters in the upper extremities. Obtain hemoglobin and hematocrit levels, blood type, and cross-match. A Foley catheter should be placed to help monitor volume status.

2. What is the next step in evaluating the patient?

Show answer
A nasogastric tube should be placed to rule out an upper GI source. If the aspirate is bilious, the examiner can be fairly certain that the source is distal to the ligament of Treitz. However, if the aspirate reveals no bile, the patient may still be bleeding in the duodenum with a competent pylorus.

3. What are the two most common causes of massive lower GI bleeding?

Show answer
Diverticular hemorrhage (diverticulosis) and bleeding vascular ectasias. Diverticular disease was previously thought to be the most common cause of lower GI bleeding, but vascular ectasias are now quite frequent.
4. What are the other causes of blood per rectum? Show answer

* Colon cancer
* Polyps
* Ischemic colitis
* Infectious colitis
* Inflammatory bowel disease
* Anorectal disorders (e.g., hemorrhoids, fissure)
* Meckel’s diverticulum

5. After a thorough history and physical examination, what is the first step toward identifying the specific site of bleeding?

Show answer
Anoscopy and rigid proctosigmoidoscopy to rule out anorectal fissures and an extraperitoneal source.

6. Name four options for localizing lower GI bleeding.

Show answer

1. Tagged red blood cell scan
2. Sulfur colloid scan
3. Angiography
4. Colonoscopy

7. Discuss the differences between sulfur colloid scan and tagged red blood cell (RBC) scan.

Show answer
The sulfur colloid scan can be accomplished quickly and detects bleeding as minimal as 0.1 mL/min. The radiolabeled sulfur colloid is cleared quickly by the liver and spleen, which may obscure the bleeding site if it is located in the hepatic or splenic flexure. The test is complete within 20 minutes of administration of the radionuclide.
The tagged red blood cell scan requires a 60-minute delay while the autologous RBCs are labeled with isotope. The test detects bleeding as slow as 0.5 mL/min. Because the tagged cells stay in the patient’s system, it is also helpful in identifying the source when the patient is bleeding intermittently. The study takes at least 2 hours.

8. What is the role of angiography?

Show answer
Angiography detects bleeding rates of 0.5-1.0 mL/min but only if the patient is actively bleeding. When a bleeding site is identified, the angiographic appearance may provide further insight into the cause of the bleeding. Whereas diverticular bleeding is often seen as extravasation of contrast, vascular ectasias may be identified by a vascular tuft or early filling vein.

9. What therapeutic options are available with angiography?

Show answer
(1) Infusion of vasopressin (Pitressin) into a selected vessel and (2) embolization of the bleeding vessel.
KEY POINTS: LOWER GI BLEEDING

1. The most common causes of massive lower GI bleeding are diverticular hemorrhage and bleeding vascular ectasias.
2. The most common cause of lower GI bleeding in children is Meckel’s diverticulum.
3. After a thorough history and physical exam, the first steps in identifying the specific site of bleeding are anoscopy and rigid proctosigmoidoscopy.
4. Tagged red blood cell scan, sulfur colloid scan, colonoscopy, and angiography are four options for localizing lower GI bleeding.
5. Indications for surgery include patients who have received 6 U of blood without resolution of bleeding and patients who continue to bleed after vasopressin or embolization.

10. Which patients should have angiographic embolization of the bleeding site?

Show answer
Most surgeons believe that embolization should be reserved for patients who are poor operative risks in that a 15% complication rate is associated with the procedure. Patients may perforate or develop a stricture as a result of bowel wall ischemia.

11. What is the role of vasopressin infusion?

Show answer
Vasopressin is only a temporizing measure. Control of the bleeding with vasopressin allows time for resuscitation and essentially converts an emergent case into an urgent one. Vasopressin occasionally may be used as the only treatment for diverticular bleeding. If the patient has a repeated episode of bleeding after weaning from vasopressin, the surgeon must decide between embolization and surgery.

12. Do lower GI hemorrhages ever spontaneously resolve?

Show answer
Spontaneous resolution occurs in 75% of patients with vascular ectasias and 90% of patients with diverticular bleeding.

13. What are the indications for operative intervention?

Show answer
When the patient has received 6 units of blood (two thirds of the patient’s blood volume in 24 hours) without resolution of bleeding. Any patient who continues to bleed or has recurrent bleeding after vasopressin or embolization should undergo resection.

14. What is the role of blind subtotal colectomy in the management of patients with massive lower GI bleeding?

Show answer
Blind subtotal colectomy is limited to the small group of patients in whom a specific bleeding source cannot be identified. The procedure is associated with a 16% mortality rate. Younger patients tend to tolerate the procedure better than elderly patients. Older patients often suffer with severe diarrhea, urgency, and incontinence. However, blind segmental colectomy is associated with an even higher mortality rate (40%) and a 50% rebleeding rate.

15. What is the most common cause of lower GI hemorrhage in the pediatric population?

Show answer
Meckel’s diverticulum.

References
BIBLIOGRAPHY
1. American Society for Gastrointestinal Endoscopy: The role of endoscopy in the patient with lower gastrointestinal bleeding. Gastrointest Endosc 48:685-688, 1998.
2. Belaiche J, Louis E, D’Haens G, et al: Acute lower gastrointestinal bleeding in Crohn’s disease: Characteristics of a unique series of 34 patients. Belgian IBD Research Group. Am J Gastroenterol 94:2177-2181, 1999. Full article
3. Cynamon J, Atar E, Steiner A, et al: Catheter-induced vasospasm in the treatment of acute lower gastrointestinal bleeding. J Vasc Interv Radiol 14:211-216, 2003. Medline Similar articles
4. Gunderman R, Leef JA, Lipton MJ, Reba RC: Diagnostic imaging and the outcome of acute lower gastrointestinal bleeding. Acad Radiol Suppl 2:S303-S305, 1998.
5. Mallant-Hent RC, Van Bodegraven AA, Meuwissen SG, Manoliu RA: Alternative approach to massive gastrointestinal bleeding in ulcerative colitis: Highly selective transcatheter embolization. Eur J Gastroenterol Hepatol 15:189-193, 2003. Medline Similar articles Full article
6. So JB, Kok K, Hgoi SS: Right-diverticular disease as a source of lower gastrointestinal bleeding. Am Surg 65:299-302, 1999. Medline Similar articles
7. Wilcox CM, Clark WS: Causes and outcome of upper and lower gastrointestinal bleeding: The Grady Hospital experience. South Med J 92:44-50, 1999. Medline Similar articles