Anorectal abscess/fistula
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Anorectal abscess (def.) A result of an infection in one of the anal sinuses, collection of pus adjacent to anus
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Clinical features--abscess Painful swelling and painful defecation, exam shows tenderness/erythema/swelling. No fever. Deeper abscesses more likely to have fever
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Treatment--abscess Surgical drainage, warm-water cleansing, analgesics, stool softener, high-fiber diet (WASH regimen)
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Anorectal fistula (def.) An open tract (communication) between two epithelium-lined areas, most commonly associated w/ deeper anorectal abscesses
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Clinical features--fistula Anal discharge and pain when tract becomes occluded. Do NOT explore tract on exam, might open up new tracts
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Treatment--fistula Surgery
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Appendicitis
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Definition Occurs when obstruction of the appendix leads to inflammation and infection
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Etiology Fecalith (less common: CMV/adenovirus, collagen vascular dz, IBD)
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About Most common abdominal emergency surgery, pts age 10-30
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Patient sx if perforation-->peritonitis) High-grade fever, generalized abdominal pain, leukocytosis
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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
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Lab Findings Leukocytosis (10-20,000), microscopic hematuria/pyuria, abdominal CT can confirm dx and locate abnormally-placed appendix
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Treatment Surgery (appendectomy) +/- broad-spectrum abx if suspecter perforation (before and after surgery)
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Anal Fissure
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Definition Linear lesions in the rectal wall, most commonly on the posterior midline
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Clinical features Severe tearing pain on defecation, often with hematochezia (bright red blood often noted on TP or in toilet)
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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
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Fecal Impaction
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Definition A large mass of hard, retained stool. Usually in the rectum but can also happen higher up in the colon
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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)
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What kind of impaction generally indicates neoplasm? More proximal impaction
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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
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Treatment Manual disimpaction followed by saline/tepid water enema, proximal disimpaction done by sigmoidoscopic water irrigation and suction
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Pilonidal Disease
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Pilonidal cyst (def.) An abscess in the sacrococcygeal cleft associated w/ subsequent sinus tract infection
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Patient population M>>F, in hirsute and obese pts, <40yo
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Clinical Presentation Painful, fluctuant area at the sacrococcygeal cleft
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Treatment Surgical drainage +/- antibiotics (may require follicle removal with unroofing of sinus tracts)
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Hemorrhoids
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Definition Varices of the hemorrhoidal plexus (normal anatomy)
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Dentate line Separates external from internal hemorrhoids
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External hemorrhoids Visible perianally
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Stage I Internal hemorrhoids Confined to the anal canal, may bleed with defecation
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Stage II Internal hemorrhoids Protrude from the anal opening but reduce spontaneously, bleeding and mucoid discharge may occur
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Stage III Internal hemorrhoids Require manual reduction after BM, patients may have pain and discomfort
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Stage IV Internal hemorrhoids Chronically protruding and risk strangulation
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Treatment (Stages I and II) High fiber diet + increased fluids + bulk laxatives
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Treatment (higher stages) Suppositories with anesthetic + astringent properties
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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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