Project: Ghana Emergency Medicine Collaborative
Document Title: Emergency Management of Ano-Rectal Disorders
Author(s): Jo...
Attribution Key
for more information see: http://open.umich.edu/wiki/AttributionPolicy

Use + Share + Adapt
{ Content the ...
3
WikipedianProlific, Wikimedia Commons
Hemorrhoids
• Symptoms – itching, pain, bleeding,
protrusion
• External hemorrhoids – asymptomatic
unless thrombosed
• Int...
Hemorrhoids
• Pathogenesis
– Inadequate dietary fiber
– Prolonged sitting on comode
– Chronic straining
– Prolonged sittin...
Source unknown

6
Source unknown

7
Thrombosed Hemorrhoids
• External – most common
– Acute onset anal pain
– Palpable perianal mass

• Internal – far less co...
Source unknown

9
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11
Gray’s Anatomy, 20th edition, Wikimedia Commons

12
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Hemorrhoids - treatment
• Medical
– Sitz baths
– Increased dietary fiber
– Stool softener
– OTC topical agents / supposito...
Hemorrhoids - treatment
• Surgical
– Sclerotherapy (injection of phenol in oil or hypertonic
salt solution causing thrombo...
Rectal Prolapse (Procedentia)
• Passage (herniation) of a portion or all of
rectal mucosa thru external anal sphincter
• T...
Dr. K.-H. Günther, Klinikum Main Spessart, Lohr am Main, Wikimedia Commons

23
Rectal Prolapse
• Increased intra-abdominal pressure
– Chronic constipation, protracted coughing,
forceful vomiting

•
•
•...
Source unknown

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Leonard Portal Mark, St. Bartholomew’s Hospital Archives & Museum, London, UK, Wellcome Images

30
Anal Fissure (fissure-in-ano)
• Split in squamous epithelium at or just
inside the anal verge (efface anal canal)
• Sharp ...
Armin Kübelbeck, Wikimedia Commons

32
Jonathanlund, Wikimedia Commons

33
Anal Fissure
• Treatment
– Sitz baths
– Topical analgesics
– Surgery for chronic lesions or intractable pain
– Diminish re...
Cryptitis (Papilitis)
• Inflammation of mucosal lining over crypts
(? passage of hard stools)
• Predisposes to inflamation...
Source unknown

36
Source unknown

37
Cryptitis
• Treatment
– Sitz baths
– Warm rectal irrigation
– Bulk laxatives
– Proctofoam HC

38
Ano-rectal Abscess
• Originates from infected anal glands at
dentate line
• Perianal
• Ischiorectal (buttocks)
• Intersphi...
Source unknown

40
Source unknown

41
Source unknown

42
Ano-rectal Abscess
• Symptoms – dull aching, throbbing pain
worse before defecation and persists
between defecations
• Tre...
Anal Fistula
• Uncommon in general population
– Anorectal malignancy
– Leukemia
– Radiation proctitis
– Actinomycosis
– Ly...
45
Marc A Levitt, Alberto Peña. Anorectal malformations. Orphanet Journal of Rare Diseases. 2, 33. 2007, Wikimedia Commons
Source unknown

46
Source unknown

47
Venereal Proctitis
• Characterized by pruritis, discharge, mild –
moderate pain or irritation, tenesmus
• Usual etiologies...
Source unknown

49
Source unknown

50
Source unknown

51
Source unknown

52
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GEMC: Emergency Management of Ano-Rectal Disorders: Resident Training

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This is a lecture by Dr. Joseph Hartmann from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.

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GEMC: Emergency Management of Ano-Rectal Disorders: Resident Training

  1. 1. Project: Ghana Emergency Medicine Collaborative Document Title: Emergency Management of Ano-Rectal Disorders Author(s): Joseph H. Hartmann (University of Michigan), DO 2012 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. These lectures have been modified in the process of making a publicly shareable version. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact open.michigan@umich.edu with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/privacy-and-terms-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers. 1
  2. 2. Attribution Key for more information see: http://open.umich.edu/wiki/AttributionPolicy Use + Share + Adapt { Content the copyright holder, author, or law permits you to use, share and adapt. } Public Domain – Government: Works that are produced by the U.S. Government. (17 USC § 105) Public Domain – Expired: Works that are no longer protected due to an expired copyright term. Public Domain – Self Dedicated: Works that a copyright holder has dedicated to the public domain. Creative Commons – Zero Waiver Creative Commons – Attribution License Creative Commons – Attribution Share Alike License Creative Commons – Attribution Noncommercial License Creative Commons – Attribution Noncommercial Share Alike License GNU – Free Documentation License Make Your Own Assessment { Content Open.Michigan believes can be used, shared, and adapted because it is ineligible for copyright. } Public Domain – Ineligible: Works that are ineligible for copyright protection in the U.S. (17 USC § 102(b)) *laws in your jurisdiction may differ { Content Open.Michigan has used under a Fair Use determination. } Fair Use: Use of works that is determined to be Fair consistent with the U.S. Copyright Act. (17 USC § 107) *laws in your jurisdiction may differ Our determination DOES NOT mean that all uses of this 3rd-party content are Fair Uses and we DO NOT guarantee that your use of the content is Fair. To use this content you should do your own independent analysis to determine whether or not your use will be Fair. 2
  3. 3. 3 WikipedianProlific, Wikimedia Commons
  4. 4. Hemorrhoids • Symptoms – itching, pain, bleeding, protrusion • External hemorrhoids – asymptomatic unless thrombosed • Internal hemorrhoids – – Bleeding – typically bright red on stool – but not mixed in stool – Protrusion – soiling / mucus discharge incarcerated/strangulated 4
  5. 5. Hemorrhoids • Pathogenesis – Inadequate dietary fiber – Prolonged sitting on comode – Chronic straining – Prolonged sitting (occupational) – Medical conditions causing increased venous pressure • Pregnancy, ascites, pelvic tumor 5
  6. 6. Source unknown 6
  7. 7. Source unknown 7
  8. 8. Thrombosed Hemorrhoids • External – most common – Acute onset anal pain – Palpable perianal mass • Internal – far less common – Pain – Pressure – Bleeding 8
  9. 9. Source unknown 9
  10. 10. Source unknown 10
  11. 11. Source unknown 11
  12. 12. Gray’s Anatomy, 20th edition, Wikimedia Commons 12
  13. 13. Source unknown 13
  14. 14. Source unknown 14
  15. 15. Source unknown 15
  16. 16. Source unknown 16
  17. 17. Source unknown 17
  18. 18. Source unknown 18
  19. 19. Source unknown 19
  20. 20. Hemorrhoids - treatment • Medical – Sitz baths – Increased dietary fiber – Stool softener – OTC topical agents / suppositories – Prescription topical agents / suppositories • Anusol / Anusol HC 20
  21. 21. Hemorrhoids - treatment • Surgical – Sclerotherapy (injection of phenol in oil or hypertonic salt solution causing thrombosis of vessels and sclerosis of connective tissue) – Cryotherapy – Rubber band technique – Bipolar diathermy – Direct-current electrotherapy – Infrared photocoagulation – Surgical excision 21
  22. 22. Rectal Prolapse (Procedentia) • Passage (herniation) of a portion or all of rectal mucosa thru external anal sphincter • Type I – false procedentia – Partial / mucosal prolapse less than 2 cm long – Produces radial folds • Type II – true procedentia – Complete / full thickness rectal wall extrusion – Extends 2 – 5 cm – Produces circular / concentric folds 22
  23. 23. Dr. K.-H. Günther, Klinikum Main Spessart, Lohr am Main, Wikimedia Commons 23
  24. 24. Rectal Prolapse • Increased intra-abdominal pressure – Chronic constipation, protracted coughing, forceful vomiting • • • • Diarrheal disease Cystic fibrosis Malnutrition Pelvic floor weakness 24
  25. 25. Source unknown 25
  26. 26. Source unknown 26
  27. 27. Source unknown 27
  28. 28. Source unknown 28
  29. 29. Source unknown 29
  30. 30. Leonard Portal Mark, St. Bartholomew’s Hospital Archives & Museum, London, UK, Wellcome Images 30
  31. 31. Anal Fissure (fissure-in-ano) • Split in squamous epithelium at or just inside the anal verge (efface anal canal) • Sharp cutting anal pain with defecation that is relieved in-between defecations • Sentinel skin tag ( sentinel pile) present • Occurs in midline –posteriorly (90% male and 75% female) • Predominately noted in young adults 31
  32. 32. Armin Kübelbeck, Wikimedia Commons 32
  33. 33. Jonathanlund, Wikimedia Commons 33
  34. 34. Anal Fissure • Treatment – Sitz baths – Topical analgesics – Surgery for chronic lesions or intractable pain – Diminish resting anal sphincter pressure • Nitroglycerin or calcium channel blocking agents 34
  35. 35. Cryptitis (Papilitis) • Inflammation of mucosal lining over crypts (? passage of hard stools) • Predisposes to inflamation of anal glands leading to abscess formation and possible eventual fistula formation • Characterized by – Anal pain exacerbated with defecation – +/- bleeding and/or pruritis – Tender swollen crypts on palpation 35
  36. 36. Source unknown 36
  37. 37. Source unknown 37
  38. 38. Cryptitis • Treatment – Sitz baths – Warm rectal irrigation – Bulk laxatives – Proctofoam HC 38
  39. 39. Ano-rectal Abscess • Originates from infected anal glands at dentate line • Perianal • Ischiorectal (buttocks) • Intersphincteric (fluctuance in lumen) • Supralevator (CT diagnosis) • Horseshoe / deep posterior anal space – bilateral ischiorectal space abscess 39
  40. 40. Source unknown 40
  41. 41. Source unknown 41
  42. 42. Source unknown 42
  43. 43. Ano-rectal Abscess • Symptoms – dull aching, throbbing pain worse before defecation and persists between defecations • Treatment – Incision and drainage – Antibiotics if • • • • Extensive cellulitis Diabetes Valvular heart disease Immunosuppression 43
  44. 44. Anal Fistula • Uncommon in general population – Anorectal malignancy – Leukemia – Radiation proctitis – Actinomycosis – Lymphogranuloma venereum – Inflammatory bowel disease (Crohn’s) 44
  45. 45. 45 Marc A Levitt, Alberto Peña. Anorectal malformations. Orphanet Journal of Rare Diseases. 2, 33. 2007, Wikimedia Commons
  46. 46. Source unknown 46
  47. 47. Source unknown 47
  48. 48. Venereal Proctitis • Characterized by pruritis, discharge, mild – moderate pain or irritation, tenesmus • Usual etiologies – Viral • Herpes simplex type 2 • Human immunodeficiency virus • Papillomavirus (condylomata accuminata) – Bacterial • Neisseria gonorrhea • Chlamydia trachomatis • Treponema pallidum (condylomata lata –secondary syphillis) 48
  49. 49. Source unknown 49
  50. 50. Source unknown 50
  51. 51. Source unknown 51
  52. 52. Source unknown 52
  53. 53. Source unknown 53
  54. 54. Source unknown 54
  55. 55. Source unknown 55
  56. 56. Source unknown 56

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