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Anorectal Disease. Anal Fissure

admin — Thu, 09 Jul 2009 07:25:48 +0000

ANAL FISSURE

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

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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?

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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?

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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.

Queries 5

admin — Mon, 21 Sep 2009 06:21:43 +0000

Anorectal Disease

admin — Thu, 09 Jul 2009 07:22:31 +0000

55 ANORECTAL DISEASE
Eric L. Sarin M.D., John B. Moore M.D.

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.

Queries 4

admin — Fri, 14 Aug 2009 18:13:50 +0000

Anorectal Disease. Hemorrhoids

admin — Thu, 09 Jul 2009 07:28:52 +0000

HEMORRHOIDS

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.

Anorectal Disease. Anorectal Abscess & Fistula In Ano

admin — Thu, 09 Jul 2009 07:24:17 +0000

ANORECTAL ABSCESS AND FISTULA IN ANO

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%.

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admin — Wed, 05 Aug 2009 06:42:54 +0000

Inflammatory Bowel Disease. Controversies

admin — Wed, 08 Jul 2009 20:42:53 +0000

CONTROVERSIES

17. Should all patients with enteroenteral fistulas secondary to Crohn’s disease have surgery when the fistula is discovered?

Show answer
For: Such patients ultimately do poorly, develop further intraperitoneal septic complications, and almost always require surgery.
Against: Many of these patients do well without operative treatment until they develop symptoms. It is fine to wait for symptoms.

18. Should all patients with ulcerative colitis that is documented for 10 years, whether the disease is active or not, undergo a colectomy to avoid the risk of carcinoma of the colon?

Show answer
For: The risk of colon cancer in ulcerative colitis increases by approximately 1% per year 10 years after the diagnosis.
Against: Using surveillance colonoscopy and biopsy, only patients whose colons show dysplastic changes need a colectomy.

19. Is ileorectal anastomosis an acceptable operation after colectomy for ulcerative colitis?

Show answer
For: The patients have reasonably normal bowel habits and avoid the complications associated with anal reconstructive procedures.
Against: At least 50% of patients eventually require reoperation for recurrence of disease. The remaining rectum also may be a site for the development of cancer.

20. Is standard (Brooke) ileostomy a good way to handle the terminal ileum after total colectomy for chronic ulcerative colitis?

Show answer
For: The complication rate is very low. More than 90% of patients lead satisfactory lives.
Against: Psychosocial and sexual problems are associated with the use of external appliances, particularly in the teenage group, among whom chronic ulcerative colitis is quite common.

21. Is the continent Kock pouch a good procedure after colectomy for chronic ulcerative colitis?

Show answer
For: It avoids use of an external appliance and is quite easy to manage.
Against: Approximately 25% of all patients who have a Kock pouch require a revision due to slippage of the valve mechanism, thus rendering the pouch incontinent.

22. Is an ileoanal anastomosis with a surgically constructed ileoanal reservoir a good operation after colectomy for chronic ulcerative colitis?

Show answer
For: It avoids external appliances or ostomies, so it is well accepted by patients. Currently, this is the most commonly performed operation after colectomy.
Against: It is more difficult technically to construct; thus, the complication rate is higher. The average number of bowel movements is five per day, and there may be soilage at night. Pouchitis remains a problem.

23. Do all ileal pouch anal anastomoses require a temporary diverting ileostomy?

Show answer
For: The diverting ileostomy protects the reservoir and its suture lines by diverting the fecal stream until it is healed, thus lowering the complication rate.
Against: The triple-stapled ileal pouch anal anastomosis has a low complication rate and low rate of small bowel obstruction. Thus, avoidance of the diverting ileostomy returns the patient to a functional life sooner.

References
BIBLIOGRAPHY
1. Duerr RH: The genetics of inflammatory bowel disease. Gastroenterol Clin North Am 31:63-76, 2002. Medline Similar articles
2. Farouk R: Functional outcomes after ileal pouch-anal anastomosis for chronic ulcerative colitis. Ann Surg 231:919-926, 2000. Medline Similar articles Full article
3. Fazio V: Current status of surgery for inflammatory bowel disease. Digestion 59:470-480, 1998. Medline
4. Heuschen UA, Hinz U, Allemeyer EH, et al: One- or two-state procedure for restorative protocolectomy: Rationale for a surgical strategy in ulcerative colitis. Ann Surg 234:788-794, 2001. Medline Similar articles Full article
5. Hurst RD, Michelassi F: Strictureplasty for Crohn’s disease: Techniques and long term results. World J Surg 22:359-363, 1998.
6. Present DH, Rutgeerts P Targan S, et al: Infliximab for the treatment of fistulas in patients with Crohn’s disease. N Engl J Med 340:1398-1405, 1999. Similar articles Full article
7. Solomon MJ, Schmitz M: Cancer and inflammatory bowel disease: Bias, epidemiology, surveillance, and treatment. World Surg 22:352-358, 1998. Full article
8. Stocchi L, Pemberton JH: Pouch and pouchitis. Gastroenterol Clin North Am 30:223-241, 2001. Medline Similar articles
9. Sugerman HJ: Ileal pouch anal anastomosis without ileal diverson. Ann Surg 232:530-541, 2000. Medline
10. Wolff BG: Factors determining recurrence following surgery for Crohn’s disease. World J Surg 22:364-369, 1998. Medline Similar articles Full article

Anorectal Disease. Pilonidal Sinus Disease

admin — Thu, 09 Jul 2009 07:32:17 +0000

PILONIDAL SINUS DISEASE

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

Imperforate Anus

admin — Sat, 11 Jul 2009 19:18:13 +0000

84 IMPERFORATE ANUS
Frederick M. Karrer M.D., Denis D. Bensard M.D.

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?

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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