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GI IV: Appendicitis &Rectum/Anus Cheat Sheet by

Gastroenterology

Anorectal absces­s/f­istula

Anorectal abscess (def.)
A result of an infection in one of the anal sinuses, collection of pus adjacent to anus
Clinical featur­es-­-ab­scess
Painful swelling and painful defeca­tion, exam shows tender­nes­s/e­ryt­hem­a/s­wel­ling. No fever. Deeper abscesses more likely to have fever
Treatm­ent­--a­bscess
Surgical drainage, warm-water cleansing, analge­sics, stool softener, high-fiber diet (WASH regimen)
Anorectal fistula (def.)
An open tract (commu­nic­ation) between two epithe­liu­m-lined areas, most commonly associated w/ deeper anorectal abscesses
Clinical featur­es-­-fi­stula
Anal discharge and pain when tract becomes occluded. Do NOT explore tract on exam, might open up new tracts
Treatm­ent­--f­istula
Surgery

Append­icitis

Definition
Occurs when obstru­ction of the appendix leads to inflam­mation and infection
Etiology
Fecalith (less common: CMV/ad­eno­virus, collagen vascular dz, IBD)
About
Most common abdominal emergency surgery, pts age 10-30
Patient sx if perfor­ati­on-­->p­eri­ton­itis)
High-grade fever, genera­lized abdominal pain, leukoc­ytosis
Clinical Features
Perium­bil­ica­l/e­pig­astric pain--­>lo­calizes to RLQ (McBur­ney's point) w/in 12 hours, worsened by movement, rebound tenderness on exam, nausea, anorexia, low-grade fever, positive Psoas & Obturator signs
Lab Findings
Leukoc­ytosis (10-20­,000), micros­copic hematu­ria­/py­uria, abdominal CT can confirm dx and locate abnorm­all­y-p­laced appendix
Treatment
Surgery (appen­dec­tomy) +/- broad-­spe­ctrum abx if suspecter perfor­ation (before and after surgery)
 

Anal Fissure

Definition
Linear lesions in the rectal wall, most commonly on the posterior midline
Clinical features
Severe tearing pain on defeca­tion, often with hemato­chezia (bright red blood often noted on TP or in toilet)
Treatment
Bulking agents + increased fluids to avoid straining. Sitz baths to relieve acute pain. Topical nitrog­lycerin or topical styptic (silver nitrate) to help with healing

Fecal Impaction

Definition
A large mass of hard, retained stool. Usually in the rectum but can also happen higher up in the colon
Compli­cations
Urinary tract obstru­ction, UTI, sponta­neous perfor­ation of the colon, stercoral ulcer where the mass has pressed on the colon, fecalith formation (can lead to append­icitis)
What kind of impaction generally indicates neoplasm?
More proximal impaction
Clinical Features
Abdominal pain, rectal discom­fort, anorexia, N/V, HA, malaise, ACS, incont­inence of small amounts of water and semi-f­ormed stool (as leakages pass by impact­ion), rock-hard stool in the vault, abdominal mass palpated
Treatment
Manual disimp­action followed by saline­/tepid water enema, proximal disimp­action done by sigmoi­dos­copic water irrigation and suction

Pilonidal Disease

Pilonidal cyst (def.)
An abscess in the sacroc­occ­ygeal cleft associated w/ subsequent sinus tract infection
Patient population
M>>F, in hirsute and obese pts, <40yo
Clinical Presen­tation
Painful, fluctuant area at the sacroc­occ­ygeal cleft
Treatment
Surgical drainage +/- antibi­otics (may require follicle removal with unroofing of sinus tracts)
 

Hemorr­hoids

Definition
Varices of the hemorr­hoidal plexus (normal anatomy)
Dentate line
Separates external from internal hemorr­hoids
External hemorr­hoids
Visible perianally
Stage I Internal hemorr­hoids
Confined to the anal canal, may bleed with defecation
Stage II Internal hemorr­hoids
Protrude from the anal opening but reduce sponta­neo­usly, bleeding and mucoid discharge may occur
Stage III Internal hemorr­hoids
Require manual reduction after BM, patients may have pain and discomfort
Stage IV Internal hemorr­hoids
Chroni­cally protruding and risk strang­ulation
Treatment (Stages I and II)
High fiber diet + increased fluids + bulk laxatives
Treatment (higher stages)
Suppos­itories with anesthetic + astringent properties
When is surgery consid­ered?
For all Stage IV hemorr­hoids and those that are unresp­onsive to conser­vative treatm­ent­-->­inj­ection, rubber band ligation, sclero­therapy

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