Anorectal abscess/fistulaAnorectal 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 |
AppendicitisDefinition 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 FissureDefinition 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 ImpactionDefinition 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 DiseasePilonidal 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) |
| | HemorrhoidsDefinition 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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