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Back to medical school

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Back to medical school-anorectal disorders Ian Botterill, Dept Colorectal Surgery Leeds General Infirmary Wide variety of pathologies congenital / acquired benign ... – PowerPoint PPT presentation

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Title: Back to medical school


1
Back to medical school
  • -anorectal disorders

Ian Botterill, Dept Colorectal Surgery Leeds
General Infirmary
2
Wide variety of pathologies
  • congenital / acquired
  • benign / malignant
  • traumatic
  • infective / inflammatory
  • gender / age related

3
Common symptoms of ano-rectal disorders
  • bleeding
  • anal pain
  • itch
  • faecal leakage / hygiene problems
  • swelling
  • discharge

4
Examination
  • abdomen
  • groins (lymph nodes)
  • dermatoses

5
Ano-rectal examination
  • chaperoned
  • relaxed patient
  • left lateral
  • good light
  • knee elbow position
  • use pts hand to elevate right buttock
  • /- anoscopy in 1y care

6
Ano-rectal examination
  • External appearance -skin condition -swellings
    -soiling / discharge -perineal descent -scars
  • Digital examination -sphincter tone -squeeze
    pressure -cervix / prostate -coccyx -retrorect
    al space -rectocoele

7
Anatomy
8
Haemorrhoids
  • Symptoms - anal canal bleeding, pruritus,
    swelling, pain

9
Haemorrhoids
  • Classification - 1y bleed, do not
    prolapse - 2y prolapse reduce
    spontaeously - 3y prolapse require manual
    reduction - 4y prolase, not reducible

10
Cause of haemorrhoidal problems
  • altered bowel habit
  • raised intra-abdominal pressure
  • straining

11
Treatment of haemorrhoids
  • Diet -five helpings fibre / d
  • Out-patient -injection sclerotherapy -ban
    ding -photocoagulation

12
Surgical treatment
  • For 3rd / 4th degree haemorrhoids
  • Open haemorrhoidectomy
  • Closed haemorrhoidectomy
  • Ligasure haemorrhoidectomy
  • Stapled haemorrhoidopexy (PPH)

13
Results of haemorrhoidectomy
  • gt90 daycase
  • least initial pain -stapled
    haemorrhoidopexy -Ligasure haemorrhoiodectomy
  • quickest return to work -stapled
    haemorrhoidopexy -Ligasure haemorrhoidectomy
  • most costly PPH / ligasure
  • lowest recurrence (prolapse) conventional

14
Complications of haemorrhoidectomy
  • Local - stenosis - faecal leakage
    - recurence - bleeding -
    retention of urine
  • severe perineal sepsis (esp IDDM
    immunosuppressed)

15
Painful prolapsed haemorrhoids
  • natural history (worst pain days 3-7, then
    settles)
  • most resolve with conservative Rx - lactulose
    / topical anaesthetic creams / ice / paracetamol
    NSAIDs / relief of anal spasm (GTN or
    diltiazem) - failure to resolve gt
    haemorrhoidectomy - refer gangrenous or those
    that fail to settle
  • interval haemorrhoidectomy if still problematic

16
Anal skin tags
Sx anal swelling / hygiene problems Diagnosis
perineal examination alone Differential
Crohns disease / anal warts Rx reassurance /
excision
17
Rectal mucosal prolapse full thickness rectal
prolapse
18
Rectal mucosal prolapse
  • result of straining
  • associated with pruritus ani / mucous discharge
  • diagnosis _at_ anoscopy
  • Rx - dietary correction - advised to
    avoid straining at stool - injection
    sclerotherapy

19
Ano-rectal sepsis
Sx perineal pain (throbbing), possible prior
history of similar Exam tender fluctuant mass
/- discharge, may be toxic Beware diabetics
(risk of rapidly progressive infection
Fourniers gangrene) skin necrosis (possible
Fourniers gangrene) anal spasm throbbing pain
(inter-sphincteric abscess) Treatment ID
20
Fistula in ano
30-40 of all perineal sepsis once drained goes
on to develop a fistula 80-90 of perineal
sepsis that yielded enteric organisms will
develop a fistula
21
Fistula in ano
  • 95 cryptoglandular - ie origin in
    ano-rectal crypts at dentate line
  • 5 rarities - Crohns - TB -
    hidradenitis suppurativa - traumatic -
    malignancy - complicated diverticular
    disease - radiation - anastomotic leakage

22
Classification
Inter-sphincteric 70 Trans-sphincteric 25 Supr
a-sphincteric 5 Extra-sphincteric lt1
Simple v. complex
Complex -branching tracts / 2y
tracts -associated abscess -associated pathology
23
Goodsalls rule
External opening posterior to 3-9 oclock position
open in posterior midline of the anal
canal External opening anterior to 3-9 oclock
position open radially in the anal canal 80-90
accurate
24
Management of fistula in ano
Strike a balance between -cure of
fistula -prevention of further anorectal
abscess -preservation of continence
25
Management of fistula in ano
  • Divide tissues overlying track ( to allow healing
    by 2y intent) - lay open - cutting
    seton
  • Occlude internal opening provide external
    drainage - anal fistula plug -
    rectal or anal advancement flap
  • Prevention of further ano-rectal sepsis -
    draining seton

26
Anal fissure
  • focal linear deficiency of anal mucosa
  • posterior gt anterior
  • acute v. chronic -chronic IAS exposed , gt
    6/52, keratinisation
  • simple v. complex

27
Anal fissure
28
Anal fissure management
  • stool softeners
  • dietary advice
  • topical LA
  • chemical sphincterotomy -topical -injecte
    d
  • surgical sphincterotomy

29
Anal fissure surgery through the ages
  • anal stretch
  • lateral sphincterotomy
  • chemical sphincterotomy - topical -
    injectable

30
Anal fissure treatment
  • GTN 40-50 successful s/e severe
    headaches
  • Diltiazem 60-80 successful s/e nil
    generally
  • Botox 60-90 successful s/e transient
    minor leakage
  • Sphincterotomy 98 successful s/e 2
    passive leakage

31
Proctitis
  • Biopsy mandatory (with exception of prior prosate
    / cervical brachytherapy)
  • UC / Crohns / indeterminate / infective
  • Stool culture
  • Biopsy prior to starting suppositories
  • Suppositories often preferable to oral therapy

32
Pilonidal sinus / abscess
Abscess often deep-seated do not respond to
antibiotics
33
Pilonidal sinus disease
34
Z plasty
Uli Szymanovski Developed Z plasty wound closure
35
Rhomboid flap
Healing by 1y intention 90 of time as with Z
plasty
36
Healing by 2y intent
37
Healing using Vac Therapy
38
Perianal haematoma
  • Thromobosis of superficial haemorrhoidal veins
  • Discrete circular lump at / beyond anal verge
  • Incise drain

39
Pruritus ani
Night gt day Rule out coexistent dermatoses /
renal failure / liver disease If fungal disease
suspected gt skin scrapings Ano-rectal examination
proctoscopy. Treat ano-rectal pathology
(haemorrhoids / faecal incontinence / anal tags
etc).
40
Pruritus treatment
  • Avoid synthetic / tight underwear
  • Avoid perfumed soaps etc
  • Avoid scratching
  • Use hairdryer to dry skin
  • Avoid steroid creams
  • Treat anal pathology / diarrhoea
  • Dermatology involvement
  • Methylene blue injections gt 80 successful - s/e
    occasional cellulitis / ulcer / incontinence

41
Faecal incontinence - understand continence
first!
  • Brain / higher centres
  • Spinal cord
  • Reflex arcs
  • Pudendal nerves
  • Ano-rectal sensation sampling
  • Stool consistency
  • Rectal compliance
  • Anal sphincter complex

42
Faecal incontinence
  • Causation
  • Obstetric injury (8-30 sphincter injury rate at
    childbirth)
  • Post-surgical
  • Faecal impaction
  • Neuropathy / MS / Parkinsons
  • Poor mobility / impaired cognition
  • Diarrhoea
  • IBS / rectal non-compliance

43
Assessment of faecal incontinence
  • History
  • Examination
  • Endoanal USS (sphincter injury)
  • Anorectal manometry (rest squeeze strength)
  • Pudendal nerve terminal latency (sensation)

44
Assessment of incontinence
  • Cleveland clinic score - severity of
    soiling - frequency of soiling - use of
    pads - lifestyle disruption
  • History of back injury / neurolgical disorder
  • Urinary incontinence
  • Saddle anaesthesia

45
Treatment incontinence
  • dietary measures
  • treat diarrhoea / impaction / IBS
  • non-operative - collagen injections -
    anal plug
  • sacral nerve stimulation
  • sphincter repair
  • artificial sphincters
  • graciloplasty

46
Anal stenosis
  • Post-surgical
  • Cancer
  • Crohns
  • Previous chronic anal fissure
  • Radiation
  • Systemic sclerosis
  • Need EUA to assess all these

47
Anal cancer
Sx itch, bleeding, pain (if below dentate
line), swelling, ulcer, groin node Exam hard,
irregular, friable area. Groin nodes possible. ?
Coexists with anal warts Differential
haemorrhoids, anal fissure, anal warts,
STD Diagnosis EUA biopsy
48
Anal cancer -treatment
  • Chemo-radiotherapy
  • Ongoing perineal surveillance
  • Average local control 70
  • Average cure 70
  • Salvage surgery for recurrence - APER with
    rectus flap to perineum
  • Rarely is local excision alone sufficient

49
Hidradenitis suppurativa
Superficial fistulating condition assd with
chronic skin sepsis Axillae gt groins gt
perineum Clinical diagnosis (/- biopsy)
typically have disease elsewhere Rx drain sepsis
/ rotating antibiotics / infliximab / stop smokng
50
Anal papillae
Sx nil (asymptomatic finding
typically) Diagnosis at anoscopy Biopsy
rarely required Treatment leave alone
51
AIDS the perineum
  • Wide variety of pathology - fissures /
    abscesses / fistulae / infections / anal cancer
    / cutaneous lymphoma - florid warts -
    pruritus - incontience
  • General principle - suspect
    immunocompromise - culture / biopsy -
    avoid agresssive surgery - treat in
    conjunction with Infectious Diseases / Sexual
    Health

52
AIDS
HSV
53
Other perineal problems -pressure sores
Post-sacral Over ischial tuberosity Normally have
clear cut antecedant history
54
summary
  • diverse pathology
  • high degree of overlap between 1y and 2y care
  • refer bleeding
  • refer odd-looking lesions
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