This document provides information on haemorrhoids (also known as hemorrhoids), including:
- Anatomy of the anal canal and haemorrhoidal tissue
- Epidemiology of symptomatic haemorrhoids, affecting around 4.4% of the global population
- Common causes like straining, pregnancy, obesity, and familial tendency
- Grading of internal haemorrhoids from first to fourth degree based on degree of prolapse
- Treatment options like rubber band ligation, sclerotherapy, excisional or stapled haemorrhoidectomy depending on severity
The submandibular gland can be removed through either a transcervical or transoral approach. Key anatomical structures include the marginal mandibular nerve, lingual nerve, hypoglossal nerve, facial artery and vein, and Wharton's duct. The transoral approach has less risk of marginal mandibular nerve injury but a narrower surgical field. Indications for removal include recurrent enlargement, salivary stones, infection, or suspected neoplasm. Care must be taken to identify and preserve nearby nerves and vessels during dissection and removal of the gland.
This document provides details on anal fistula anatomy and classification. It describes the layers of the anal canal including the dentate line and sphincter muscles. Fistulas most often originate from an infected anal gland or crypt and can take different paths through the anal tissues. They are classified based on their path as intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric. Diagnosis involves examination, sometimes aided by imaging tests like ultrasound or fistulography, to identify the internal and external openings and track of the fistula.
Total laryngectomy involves removal of the entire larynx. It has historically been performed since 1866, with improvements over time such as the two-stage procedure developed by Gluck to reduce mortality rates. Today it is generally reserved for advanced laryngeal cancers with extensive spread. The procedure involves mobilizing neck structures like the strap muscles and thyroid gland, dissecting and removing the larynx, and closing the resulting pharyngeal defect. Complications can include issues with the skin flap, pharyngocutaneous fistula, tracheal stenosis, and endocrine abnormalities.
1) Tracheostomy is a surgical opening into the trachea through the neck that allows for an alternative airway. It has several purposes including bypassing upper airway obstruction and making it easier to clear secretions.
2) The procedure involves making incisions through the skin and trachea rings to insert a tracheostomy tube. It can be done via open or percutaneous dilational tracheostomy techniques.
3) Tracheostomy is indicated when normal breathing is compromised due to conditions like upper airway infections/injuries or an inability to cough effectively. It provides benefits like improved ventilation and protection against aspiration.
This document defines and describes various types of medical drains. It discusses open and closed drainage systems, and provides details on specific drains including chest tubes, Foley catheters, NG tubes, suction tubes, Jackson-Pratt drains, rectal tubes, endotracheal tubes, and central lines. For each type of drain, the document outlines uses, insertion procedure, complications, contraindications, and other relevant information.
This document provides an overview of tonsillectomy, including:
- The anatomy and function of the tonsils
- Indications for tonsillectomy such as recurrent tonsillitis
- Techniques for tonsillectomy including both dissection and non-dissection methods
- The steps involved in a typical dissection tonsillectomy procedure
- Post-operative care including monitoring for hemorrhage and managing pain
The document discusses tracheostomy, including its history, definitions, indications, types, procedures, complications, and care. Some key points:
- Tracheostomy can be traced back to 3600 BC in Egypt and was standardized in technique in the 1920s. Modern percutaneous tracheostomy developed in 1969.
- It involves creating a stoma in the trachea that allows for an opening at the skin surface for breathing.
- Indications include upper airway obstruction, pulmonary ventilation, pulmonary toilet, and for some elective procedures.
- Surgical techniques include open tracheostomy and percutaneous tracheostomy. Complications include bleeding, damage to nearby structures, and long term issues like
This document provides information on haemorrhoids (also known as hemorrhoids), including:
- Anatomy of the anal canal and haemorrhoidal tissue
- Epidemiology of symptomatic haemorrhoids, affecting around 4.4% of the global population
- Common causes like straining, pregnancy, obesity, and familial tendency
- Grading of internal haemorrhoids from first to fourth degree based on degree of prolapse
- Treatment options like rubber band ligation, sclerotherapy, excisional or stapled haemorrhoidectomy depending on severity
The submandibular gland can be removed through either a transcervical or transoral approach. Key anatomical structures include the marginal mandibular nerve, lingual nerve, hypoglossal nerve, facial artery and vein, and Wharton's duct. The transoral approach has less risk of marginal mandibular nerve injury but a narrower surgical field. Indications for removal include recurrent enlargement, salivary stones, infection, or suspected neoplasm. Care must be taken to identify and preserve nearby nerves and vessels during dissection and removal of the gland.
This document provides details on anal fistula anatomy and classification. It describes the layers of the anal canal including the dentate line and sphincter muscles. Fistulas most often originate from an infected anal gland or crypt and can take different paths through the anal tissues. They are classified based on their path as intersphincteric, transsphincteric, suprasphincteric, or extrasphincteric. Diagnosis involves examination, sometimes aided by imaging tests like ultrasound or fistulography, to identify the internal and external openings and track of the fistula.
Total laryngectomy involves removal of the entire larynx. It has historically been performed since 1866, with improvements over time such as the two-stage procedure developed by Gluck to reduce mortality rates. Today it is generally reserved for advanced laryngeal cancers with extensive spread. The procedure involves mobilizing neck structures like the strap muscles and thyroid gland, dissecting and removing the larynx, and closing the resulting pharyngeal defect. Complications can include issues with the skin flap, pharyngocutaneous fistula, tracheal stenosis, and endocrine abnormalities.
1) Tracheostomy is a surgical opening into the trachea through the neck that allows for an alternative airway. It has several purposes including bypassing upper airway obstruction and making it easier to clear secretions.
2) The procedure involves making incisions through the skin and trachea rings to insert a tracheostomy tube. It can be done via open or percutaneous dilational tracheostomy techniques.
3) Tracheostomy is indicated when normal breathing is compromised due to conditions like upper airway infections/injuries or an inability to cough effectively. It provides benefits like improved ventilation and protection against aspiration.
This document defines and describes various types of medical drains. It discusses open and closed drainage systems, and provides details on specific drains including chest tubes, Foley catheters, NG tubes, suction tubes, Jackson-Pratt drains, rectal tubes, endotracheal tubes, and central lines. For each type of drain, the document outlines uses, insertion procedure, complications, contraindications, and other relevant information.
This document provides an overview of tonsillectomy, including:
- The anatomy and function of the tonsils
- Indications for tonsillectomy such as recurrent tonsillitis
- Techniques for tonsillectomy including both dissection and non-dissection methods
- The steps involved in a typical dissection tonsillectomy procedure
- Post-operative care including monitoring for hemorrhage and managing pain
The document discusses tracheostomy, including its history, definitions, indications, types, procedures, complications, and care. Some key points:
- Tracheostomy can be traced back to 3600 BC in Egypt and was standardized in technique in the 1920s. Modern percutaneous tracheostomy developed in 1969.
- It involves creating a stoma in the trachea that allows for an opening at the skin surface for breathing.
- Indications include upper airway obstruction, pulmonary ventilation, pulmonary toilet, and for some elective procedures.
- Surgical techniques include open tracheostomy and percutaneous tracheostomy. Complications include bleeding, damage to nearby structures, and long term issues like
The document discusses tracheostomy, including its history, definitions, indications, types, procedures, complications, and care. Some key points:
- Tracheostomy can be traced back to 3600 BC in Egypt and was standardized in technique in the 1920s. Modern percutaneous tracheostomy developed in 1969.
- It involves creating a stoma in the trachea that allows for insertion of a tracheostomy tube to bypass upper airway obstruction and facilitate pulmonary ventilation and toilet.
- Surgical procedures include open tracheostomy and percutaneous tracheostomy. Complications include bleeding, injury to nearby structures, and long term issues like stenosis.
- Ongoing care involves tube maintenance,
This document discusses several benign neck diseases including branchial cleft cysts, branchial sinuses and fistulas, thyroglossal cysts, cystic hygromas (lymphangiomas), hemangiomas, and sebaceous cysts. It describes the anatomy of the neck and classification of neck diseases. For each condition, it covers pathogenesis, clinical features, investigations including imaging, and treatment options which generally involve medical management for infections and surgical excision for definitive treatment.
Tracheostomy involves creating an opening in the anterior wall of the trachea and placing a tube through the opening to provide an alternative airway. It has several functions including improving ventilation and protecting the airway. Tracheostomy is indicated for conditions that obstruct the upper airway or make suctioning of secretions difficult. It requires general anesthesia and involves separating neck muscles and opening the trachea between rings to insert the tube. Postoperative care focuses on suctioning, humidification, tube positioning and preventing complications like infection, bleeding or tube obstruction.
The document provides information on anal fissures and hemorrhoids. It discusses the anatomy and examination of the anal canal. It describes the symptoms, causes, and treatments of hemorrhoids including conservative treatments like diet changes and surgical options like banding or hemorrhoidectomy. It discusses complications of hemorrhoids like thrombosis, incarceration, and anal stenosis. Differential diagnoses including anal fissures, infections, and inflammatory bowel disease are mentioned. Anal fissures are defined as longitudinal tears in the anal canal caused by hard stools or diarrhea.
1. Tracheostomy is a surgical procedure that creates an opening in the trachea to allow direct access to the breathing tube.
2. It is commonly performed when there is airway obstruction or long-term need for ventilation support.
3. A tracheostomy tube has an outer cannula, inner cannula, and obturator to hold the incision open and allow breathing through the trachea.
Gutteral pouches, By Dr. Rekha Pathak, senior scientist IVRIRekha Pathak
- Empyema of the guttural pouches is a condition where pus collects in the guttural pouches of horses, usually due to infection spreading from the pharynx through the eustachian tube.
- Symptoms include intermittent nasal discharge, difficulty swallowing and breathing, and swelling of lymph nodes.
- Treatment involves early antibiotic therapy if possible, but once pus has formed, surgical drainage of the affected pouch is needed, which can be done through the incising along the atlas bone or through the viborg's triangle approach in the neck.
This document provides information about haemorrhoids (also known as piles), including:
1. Haemorrhoids are varicosities of the veins in the anal canal that are common, affecting around 25% of adults. Risk factors include constipation, pregnancy, liver disease, and heredity.
2. There are four grades of internal haemorrhoids based on the degree of prolapse. Symptoms include rectal bleeding, pain, itching, and swelling. Diagnosis involves examination and sometimes proctoscopy.
3. Treatment options range from conservative measures like diet changes to invasive procedures like rubber band ligation, injection sclerotherapy, and various surgical haemorrhoidectomy
The document discusses tracheostomy, which is a surgical procedure that creates an opening in the windpipe. It has several indications including airway obstruction. A tracheostomy tube consists of an outer cannula, inner cannula, and obturator. Emergency tracheostomies are performed when a person cannot breathe, while nonemergency tracheostomies can be upper, middle, or lower on the trachea. Procedures involve anesthesia, incision, tube insertion, and closing. Complications can be intraoperative like bleeding or late like infection. High risk groups include children, smokers, and the elderly. Postoperative care includes antibiotics and cleaning the tube.
The document discusses disorders of the rectum, including injuries, prolapse, proctitis, polyps, and carcinoma. It provides details on the anatomy of the rectum, symptoms of rectal disease, and examinations used to evaluate the rectum. Rectal injuries require surgery and antibiotics due to risk of infection. Surgery is needed for full-thickness rectal prolapse, which can be performed via abdominal or perineal approaches. Proctitis can be treated medically, while polyps and carcinoma may require endoscopic or surgical removal depending on severity. Staging of rectal carcinoma involves examining the extent of tumor spread locally and to distant sites.
1. Nasopharyngeal angiofibroma is a rare, benign tumor that occurs mostly in adolescent males and arises from the posterior nasal cavity.
2. It is locally invasive and can extend into surrounding areas like the nasal cavity, paranasal sinuses, and cranial cavity, causing symptoms like nasal obstruction, epistaxis, and cranial nerve palsies.
3. Diagnosis involves imaging like CT and MRI to determine the extent of the tumor. Surgical excision is the primary treatment but carries a risk of heavy bleeding, so preoperative embolization of feeding vessels is often used to reduce bleeding during surgery.
This document outlines indications and techniques for radical cystectomy in the treatment of bladder cancer. It indicates radical cystectomy involves removal of the bladder and adjacent organs. Lymphadenectomy is also performed to remove pelvic lymph nodes. The extent of lymphadenectomy is controversial but removal of more than 15 nodes may provide prognostic benefits. Post-cystectomy urinary diversion options include abdominal conduits, orthotopic neobladders using bowel segments, and rectosigmoid diversions. Patient selection factors and oncologic outcomes are discussed.
This document discusses the examination and evaluation of lumps in the neck and on the skin. It provides guidance on how to describe lumps and outlines the broad categories of neck lumps including lymph nodes, salivary glands, thyroid, vascular structures and more. It lists relevant investigations and treatments for different types of lumps. Common benign and malignant skin lesions are discussed. Surgical procedures for removing various lumps are also summarized.
This document discusses various types of thoracic surgeries and incisions used. It describes median sternotomy as the most common incision, used for procedures involving the lungs, heart, and esophagus. It provides details on the positioning, incision, and closure for median sternotomy. It also summarizes other incisions like posterolateral thoracotomy and video-assisted thoracic surgery (VATS), noting their indications, advantages, and complications compared to open thoracotomy.
This document discusses branchial anomalies, which occur due to abnormalities during the development of the branchial arches and pouches in early embryogenesis. It describes the normal development of the branchial apparatus and their derivatives. It then summarizes the different types of branchial anomalies, focusing on first, second, third, and fourth branchial anomalies. For each type, it outlines the embryology, clinical features, investigations, and treatment approach. It concludes by mentioning some other congenital anomalies that can be associated with abnormalities of the branchial arches.
Tracheostomy is a surgical procedure that creates an opening in the trachea to allow direct access to the breathing tube. It is one of the oldest surgical procedures, dating back to the 15th century. Tracheostomies can be temporary or permanent depending on the clinical situation and underlying condition. Potential complications include bleeding, infection, and damage to nearby structures like the thyroid cartilage. Care after tracheostomy involves dressing changes, tube changes or decannulation as appropriate for the patient's recovery.
The document summarizes various types of drainage systems and tubes used in abdominal surgery. It describes closed and open drainage systems, as well as different types of drainage tubes like Jackson-Pratt drains, Penrose drains, and T-tube drains. It also discusses catheters, incisions, sutures, and other related topics in abdominal surgical drainage.
This document provides information on techniques for treating priapism. It discusses:
1) Pre-operative evaluation including distinguishing between ischemic and non-ischemic priapism through history, exam, and blood tests.
2) Treatment for ischemic priapism includes immediate decompression through aspiration and irrigation of blood from the corpus cavernosum along with alpha-adrenergic drugs.
3) For non-ischemic priapism, initial observation is recommended and other options include embolization or androgen ablation if it persists.
4) Surgical techniques for refractory cases include percutaneous distal shunts like Winter and Ebbehoj techniques or open distal shunt
A tracheostomy is an opening (made by an incision) through the neck into the trachea (windpipe). A tracheostomy opens the airway and aids breathing.
A tracheostomy may be done in an emergency, at the patient’s bedside or in an operating room. Anesthesia pain relief medication may be used before the procedure. Depending on the person’s condition, the tracheostomy may be temporary or permanent
1) The rectum is approximately 12 cm in length and extends from the rectosigmoid junction to the anal canal. It has multiple flexures and relations to surrounding structures.
2) Anal fistulas are abnormal communications between the anorectal canal and perianal skin. They are usually due to an infection and classified based on their relationship to the sphincter muscles.
3) Evaluation of anal fistulas involves history, examination with EUA, and sometimes imaging. Management depends on fistula type and involves techniques like fistulotomy, setons, advancement flaps, or newer procedures like LIFT to try and control the fistula while preserving sphincter function.
1) The rectum is approximately 12 cm in length and extends from the rectosigmoid junction to the anal canal. It has multiple flexures and relations to surrounding structures.
2) Anal fistulas are abnormal communications between the anorectal canal and perianal skin. They are usually due to infection and classified based on their relationship to the sphincter muscles.
3) Evaluation of anal fistulas involves history, examination with EUA, and sometimes imaging. Management depends on fistula type and may include fistulotomy, setons, advancement flaps, or newer techniques like LIFT.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
The document discusses tracheostomy, including its history, definitions, indications, types, procedures, complications, and care. Some key points:
- Tracheostomy can be traced back to 3600 BC in Egypt and was standardized in technique in the 1920s. Modern percutaneous tracheostomy developed in 1969.
- It involves creating a stoma in the trachea that allows for insertion of a tracheostomy tube to bypass upper airway obstruction and facilitate pulmonary ventilation and toilet.
- Surgical procedures include open tracheostomy and percutaneous tracheostomy. Complications include bleeding, injury to nearby structures, and long term issues like stenosis.
- Ongoing care involves tube maintenance,
This document discusses several benign neck diseases including branchial cleft cysts, branchial sinuses and fistulas, thyroglossal cysts, cystic hygromas (lymphangiomas), hemangiomas, and sebaceous cysts. It describes the anatomy of the neck and classification of neck diseases. For each condition, it covers pathogenesis, clinical features, investigations including imaging, and treatment options which generally involve medical management for infections and surgical excision for definitive treatment.
Tracheostomy involves creating an opening in the anterior wall of the trachea and placing a tube through the opening to provide an alternative airway. It has several functions including improving ventilation and protecting the airway. Tracheostomy is indicated for conditions that obstruct the upper airway or make suctioning of secretions difficult. It requires general anesthesia and involves separating neck muscles and opening the trachea between rings to insert the tube. Postoperative care focuses on suctioning, humidification, tube positioning and preventing complications like infection, bleeding or tube obstruction.
The document provides information on anal fissures and hemorrhoids. It discusses the anatomy and examination of the anal canal. It describes the symptoms, causes, and treatments of hemorrhoids including conservative treatments like diet changes and surgical options like banding or hemorrhoidectomy. It discusses complications of hemorrhoids like thrombosis, incarceration, and anal stenosis. Differential diagnoses including anal fissures, infections, and inflammatory bowel disease are mentioned. Anal fissures are defined as longitudinal tears in the anal canal caused by hard stools or diarrhea.
1. Tracheostomy is a surgical procedure that creates an opening in the trachea to allow direct access to the breathing tube.
2. It is commonly performed when there is airway obstruction or long-term need for ventilation support.
3. A tracheostomy tube has an outer cannula, inner cannula, and obturator to hold the incision open and allow breathing through the trachea.
Gutteral pouches, By Dr. Rekha Pathak, senior scientist IVRIRekha Pathak
- Empyema of the guttural pouches is a condition where pus collects in the guttural pouches of horses, usually due to infection spreading from the pharynx through the eustachian tube.
- Symptoms include intermittent nasal discharge, difficulty swallowing and breathing, and swelling of lymph nodes.
- Treatment involves early antibiotic therapy if possible, but once pus has formed, surgical drainage of the affected pouch is needed, which can be done through the incising along the atlas bone or through the viborg's triangle approach in the neck.
This document provides information about haemorrhoids (also known as piles), including:
1. Haemorrhoids are varicosities of the veins in the anal canal that are common, affecting around 25% of adults. Risk factors include constipation, pregnancy, liver disease, and heredity.
2. There are four grades of internal haemorrhoids based on the degree of prolapse. Symptoms include rectal bleeding, pain, itching, and swelling. Diagnosis involves examination and sometimes proctoscopy.
3. Treatment options range from conservative measures like diet changes to invasive procedures like rubber band ligation, injection sclerotherapy, and various surgical haemorrhoidectomy
The document discusses tracheostomy, which is a surgical procedure that creates an opening in the windpipe. It has several indications including airway obstruction. A tracheostomy tube consists of an outer cannula, inner cannula, and obturator. Emergency tracheostomies are performed when a person cannot breathe, while nonemergency tracheostomies can be upper, middle, or lower on the trachea. Procedures involve anesthesia, incision, tube insertion, and closing. Complications can be intraoperative like bleeding or late like infection. High risk groups include children, smokers, and the elderly. Postoperative care includes antibiotics and cleaning the tube.
The document discusses disorders of the rectum, including injuries, prolapse, proctitis, polyps, and carcinoma. It provides details on the anatomy of the rectum, symptoms of rectal disease, and examinations used to evaluate the rectum. Rectal injuries require surgery and antibiotics due to risk of infection. Surgery is needed for full-thickness rectal prolapse, which can be performed via abdominal or perineal approaches. Proctitis can be treated medically, while polyps and carcinoma may require endoscopic or surgical removal depending on severity. Staging of rectal carcinoma involves examining the extent of tumor spread locally and to distant sites.
1. Nasopharyngeal angiofibroma is a rare, benign tumor that occurs mostly in adolescent males and arises from the posterior nasal cavity.
2. It is locally invasive and can extend into surrounding areas like the nasal cavity, paranasal sinuses, and cranial cavity, causing symptoms like nasal obstruction, epistaxis, and cranial nerve palsies.
3. Diagnosis involves imaging like CT and MRI to determine the extent of the tumor. Surgical excision is the primary treatment but carries a risk of heavy bleeding, so preoperative embolization of feeding vessels is often used to reduce bleeding during surgery.
This document outlines indications and techniques for radical cystectomy in the treatment of bladder cancer. It indicates radical cystectomy involves removal of the bladder and adjacent organs. Lymphadenectomy is also performed to remove pelvic lymph nodes. The extent of lymphadenectomy is controversial but removal of more than 15 nodes may provide prognostic benefits. Post-cystectomy urinary diversion options include abdominal conduits, orthotopic neobladders using bowel segments, and rectosigmoid diversions. Patient selection factors and oncologic outcomes are discussed.
This document discusses the examination and evaluation of lumps in the neck and on the skin. It provides guidance on how to describe lumps and outlines the broad categories of neck lumps including lymph nodes, salivary glands, thyroid, vascular structures and more. It lists relevant investigations and treatments for different types of lumps. Common benign and malignant skin lesions are discussed. Surgical procedures for removing various lumps are also summarized.
This document discusses various types of thoracic surgeries and incisions used. It describes median sternotomy as the most common incision, used for procedures involving the lungs, heart, and esophagus. It provides details on the positioning, incision, and closure for median sternotomy. It also summarizes other incisions like posterolateral thoracotomy and video-assisted thoracic surgery (VATS), noting their indications, advantages, and complications compared to open thoracotomy.
This document discusses branchial anomalies, which occur due to abnormalities during the development of the branchial arches and pouches in early embryogenesis. It describes the normal development of the branchial apparatus and their derivatives. It then summarizes the different types of branchial anomalies, focusing on first, second, third, and fourth branchial anomalies. For each type, it outlines the embryology, clinical features, investigations, and treatment approach. It concludes by mentioning some other congenital anomalies that can be associated with abnormalities of the branchial arches.
Tracheostomy is a surgical procedure that creates an opening in the trachea to allow direct access to the breathing tube. It is one of the oldest surgical procedures, dating back to the 15th century. Tracheostomies can be temporary or permanent depending on the clinical situation and underlying condition. Potential complications include bleeding, infection, and damage to nearby structures like the thyroid cartilage. Care after tracheostomy involves dressing changes, tube changes or decannulation as appropriate for the patient's recovery.
The document summarizes various types of drainage systems and tubes used in abdominal surgery. It describes closed and open drainage systems, as well as different types of drainage tubes like Jackson-Pratt drains, Penrose drains, and T-tube drains. It also discusses catheters, incisions, sutures, and other related topics in abdominal surgical drainage.
This document provides information on techniques for treating priapism. It discusses:
1) Pre-operative evaluation including distinguishing between ischemic and non-ischemic priapism through history, exam, and blood tests.
2) Treatment for ischemic priapism includes immediate decompression through aspiration and irrigation of blood from the corpus cavernosum along with alpha-adrenergic drugs.
3) For non-ischemic priapism, initial observation is recommended and other options include embolization or androgen ablation if it persists.
4) Surgical techniques for refractory cases include percutaneous distal shunts like Winter and Ebbehoj techniques or open distal shunt
A tracheostomy is an opening (made by an incision) through the neck into the trachea (windpipe). A tracheostomy opens the airway and aids breathing.
A tracheostomy may be done in an emergency, at the patient’s bedside or in an operating room. Anesthesia pain relief medication may be used before the procedure. Depending on the person’s condition, the tracheostomy may be temporary or permanent
1) The rectum is approximately 12 cm in length and extends from the rectosigmoid junction to the anal canal. It has multiple flexures and relations to surrounding structures.
2) Anal fistulas are abnormal communications between the anorectal canal and perianal skin. They are usually due to an infection and classified based on their relationship to the sphincter muscles.
3) Evaluation of anal fistulas involves history, examination with EUA, and sometimes imaging. Management depends on fistula type and involves techniques like fistulotomy, setons, advancement flaps, or newer procedures like LIFT to try and control the fistula while preserving sphincter function.
1) The rectum is approximately 12 cm in length and extends from the rectosigmoid junction to the anal canal. It has multiple flexures and relations to surrounding structures.
2) Anal fistulas are abnormal communications between the anorectal canal and perianal skin. They are usually due to infection and classified based on their relationship to the sphincter muscles.
3) Evaluation of anal fistulas involves history, examination with EUA, and sometimes imaging. Management depends on fistula type and may include fistulotomy, setons, advancement flaps, or newer techniques like LIFT.
This slide is special for master students (MIBS & MIFB) in UUM. Also useful for readers who are interested in the topic of contemporary Islamic banking.
ISO/IEC 27001, ISO/IEC 42001, and GDPR: Best Practices for Implementation and...PECB
Denis is a dynamic and results-driven Chief Information Officer (CIO) with a distinguished career spanning information systems analysis and technical project management. With a proven track record of spearheading the design and delivery of cutting-edge Information Management solutions, he has consistently elevated business operations, streamlined reporting functions, and maximized process efficiency.
Certified as an ISO/IEC 27001: Information Security Management Systems (ISMS) Lead Implementer, Data Protection Officer, and Cyber Risks Analyst, Denis brings a heightened focus on data security, privacy, and cyber resilience to every endeavor.
His expertise extends across a diverse spectrum of reporting, database, and web development applications, underpinned by an exceptional grasp of data storage and virtualization technologies. His proficiency in application testing, database administration, and data cleansing ensures seamless execution of complex projects.
What sets Denis apart is his comprehensive understanding of Business and Systems Analysis technologies, honed through involvement in all phases of the Software Development Lifecycle (SDLC). From meticulous requirements gathering to precise analysis, innovative design, rigorous development, thorough testing, and successful implementation, he has consistently delivered exceptional results.
Throughout his career, he has taken on multifaceted roles, from leading technical project management teams to owning solutions that drive operational excellence. His conscientious and proactive approach is unwavering, whether he is working independently or collaboratively within a team. His ability to connect with colleagues on a personal level underscores his commitment to fostering a harmonious and productive workplace environment.
Date: May 29, 2024
Tags: Information Security, ISO/IEC 27001, ISO/IEC 42001, Artificial Intelligence, GDPR
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How to Setup Warehouse & Location in Odoo 17 InventoryCeline George
In this slide, we'll explore how to set up warehouses and locations in Odoo 17 Inventory. This will help us manage our stock effectively, track inventory levels, and streamline warehouse operations.
The simplified electron and muon model, Oscillating Spacetime: The Foundation...RitikBhardwaj56
Discover the Simplified Electron and Muon Model: A New Wave-Based Approach to Understanding Particles delves into a groundbreaking theory that presents electrons and muons as rotating soliton waves within oscillating spacetime. Geared towards students, researchers, and science buffs, this book breaks down complex ideas into simple explanations. It covers topics such as electron waves, temporal dynamics, and the implications of this model on particle physics. With clear illustrations and easy-to-follow explanations, readers will gain a new outlook on the universe's fundamental nature.
Main Java[All of the Base Concepts}.docxadhitya5119
This is part 1 of my Java Learning Journey. This Contains Custom methods, classes, constructors, packages, multithreading , try- catch block, finally block and more.
A workshop hosted by the South African Journal of Science aimed at postgraduate students and early career researchers with little or no experience in writing and publishing journal articles.
How to Build a Module in Odoo 17 Using the Scaffold MethodCeline George
Odoo provides an option for creating a module by using a single line command. By using this command the user can make a whole structure of a module. It is very easy for a beginner to make a module. There is no need to make each file manually. This slide will show how to create a module using the scaffold method.
2. ● Cushions of submucosal tissue containing
venules, arterioles, and smooth muscle fibers that
are located in the anal canal
● Function as part of the continence mechanism
and aid in complete closure of the anal canal at
rest
● 3 hemorrhoidal cushions:
○ Left lateral (3 o’clock)
○ Right posterior (7 o’clock)
○ Right anterior (11 o’clock)
● Excessive straining, increased abdominal
pressure, and hard stools increase venous
engorgement of the hemorrhoidal plexus and
cause prolapse of the hemorrhoidal tissue
● Bleeding, thrombosis, and symptomatic prolapse
Hemorrhoids
4. Pathophysiology
● Thompson’s vascular cushion theory
○ Normal hemorrhoidal tissue represents discrete masses of
submucosa
○ During straining, the vascular cushions can become engorged and
possibly prevent the escape of fecal material or gas
○ With passage of time, the anatomic structures supporting the
muscular submucosa weaken, allowing hemorrhoidal tissue to slip
or prolapse, leading to hemorrhoidal symptoms
● Matrix metalloproteinases (MMPs)
○ Enzymes present in extracellular space and can degrade collagen,
elastin, and fibronectin
○ MMP-9: overexpressed in hemorrhoid tissue in association with
breakdown of elastic fibers
6. History
● Changes in bowel habits
● Rectal bleeding
○ Nature
○ Color
○ Intensity
● Pain
○ Intensity
○ Frequency
○ Duration
● Protrusion or swelling in the rectal area
7. Clinical Manifestations
TYPE DESCRIPTION AND MANIFESTATIONS
Internal
hemorrhoids
● Located proximal to the dentate line
● Covered by insensate anorectal mucosa
● May prolapse or bleed, but rarely become painful unless they
develop thrombosis and necrosis
● Graded according to the extent of prolapse
External
hemorrhoids
● Located distal to the dentate line
● Covered by anoderm
● A skin tag may remain after healing
● External hemorrhoids and skin tags may cause itching and difficulty
with hygiene if they are large.
Combined
internal and
external
hemorrhoids
● Straddle the dentate line and have characteristics of both internal
and external hemorrhoids
● Hemorrhoidectomy: often required for large, symptomatic,
combined hemorrhoids
8. Internal Hemorrhoids
GRADE DESCRIPTION
I Protrudes through anal
canal, but not beyond
the anal verge
II Protrusion, but with
spontaneous reduction
III Protrusion requiring
manual reduction
IV Protrusion that can’t be
reduced (at risk for
strangulation)
Luchtefeld, M., Hoedema, R.E. (2016). Hemorrhoids. In: Steele, S., Hull, T., Read, T., Saclarides, T.,
Senagore, A., Whitlow, C. (eds) The ASCRS Textbook of Colon and Rectal Surgery. Springer, Cham.
https://doi.org/10.1007/978-3-319-25970-3_12
9. Clinical Manifestations
TYPE DESCRIPTION AND MANIFESTATIONS
Internal
hemorrhoids
● Located proximal to the dentate line
● Covered by insensate anorectal mucosa
● May prolapse or bleed, but rarely become painful unless they
develop thrombosis and necrosis
● Graded according to the extent of prolapse
External
hemorrhoids
● Located distal to the dentate line
● Covered by anoderm
● A skin tag may remain after healing
● External hemorrhoids and skin tags may cause itching and difficulty
with hygiene if they are large.
Combined
internal and
external
hemorrhoids
● Straddle the dentate line and have characteristics of both internal
and external hemorrhoids
● Hemorrhoidectomy: often required for large, symptomatic,
combined hemorrhoids
10. Physical Examination
● Focus on the abdomen, groin and
perianal area
● Supine →prone jack knife or left
lateral position
● Inspection
● Digital rectal exam
○ Masses
○ Pain
○ Sphincter tone
Luchtefeld, M., Hoedema, R.E. (2016). Hemorrhoids. In: Steele, S., Hull, T., Read, T., Saclarides, T.,
Senagore, A., Whitlow, C. (eds) The ASCRS Textbook of Colon and Rectal Surgery. Springer, Cham.
https://doi.org/10.1007/978-3-319-25970-3_12
11. Diagnostics
● Anoscopy, rigid proctosigmoidoscopy, and/or flexible sigmoidoscopy
● American Society for Gastrointestinal Endoscopy and the Society for
Surgery of the Alimentary Tract guidelines: bright red rectal bleeding →
anoscopy and flexible sigmoidoscopy
13. Anoscopy
● Examination of the anal canal and the
distal rectum
● Best way to evaluate the anoderm, dentate
line, internal and external hemorrhoids,
papillae, fissures, anal masses, and distal
rectal mucosa
● Anoscope
○ Obturator
○ Scope
○ Light source
● The examination is initiated only after DRE
has been performed.
● Enema is not warranted
● Prone jackknife or left lateral position
Davis, K., Valente, M.A. (2016). Endoscopy. In: Steele, S., Hull, T., Read, T., Saclarides, T., Senagore, A., Whitlow, C. (eds)
The ASCRS Textbook of Colon and Rectal Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-25970-3_4
14. Rigid Proctoscopy
● Suitable to examine the rectum
● Proctoscope needs to hold air so the rectum
can be distended
● Enema preparation within 2 hours of the
procedure
● Use has declined in recent years due to
flexible endoscopy
● Indications
○ Identification and precise localization
of rectal lesions
○ Evaluation of rectal bleeding
● Contraindications: painful anorectal
conditions
Davis, K., Valente, M.A. (2016). Endoscopy. In: Steele, S., Hull, T., Read, T., Saclarides, T., Senagore, A., Whitlow, C.
(eds) The ASCRS Textbook of Colon and Rectal Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-
25970-3_4
17. Management
Medical Therapy ● First- and second-degree hemorrhoidal bleeding: dietary fiber, stool
softeners, increased fluid intake, avoidance of straining
● Pruritus: improved hygiene
Rubber Band
Ligation
● Persistent bleeding from first-, second-, and selected third-degree
hemorrhoids
● Complications: severe pain if rubber band is placed at or distal to the dentate
line, urinary retention, infection, and bleeding
Infrared
Photocoagulation
● Small first- and second-degree hemorrhoids
● Larger hemorrhoids with a significant amount of prolapse are not effectively
treated with this technique
Sclerotherapy ● First-, second-, and selected third-degree hemorrhoids
● 1-3 ml of sclerosing solution is injected into submucosa of each hemorrhoid
● Few complications
18. Management
Excision of
Thrombosed
External
Hemorrhoids
● Thrombosis can be effectively treated with an elliptical excision under local
anesthesia
● Sitz bath and analgesics
Operative
Hemorrhoidectomy
● Elective resection of symptomatic hemorrhoids
● Based on decreasing blood flow to the hemorrhoidal plexus and excising
redundant anoderm and mucosa
● Closed submucosal hemorrhoidectomy: Parks or Ferguson
hemorrhoidectomy
● Open hemorrhoiddectomy: Milligan and Morgan hemorrhoidectomy
● Whiteheads’s hemorrhoidectomy
● Procedure for prolapse and hemorrhoids/Stapled Hemorrhoidectomy
● Doppler-guided hemorrhoidal artery ligation
19. ● The fistula usually originates in the
infected crypt (internal opening) and
tracks to the external opening, usually
the site of prior drainage.
● Majority of fistulas are cryptoglandular
in origin
● Trauma, Crohn’s disease, malignancy,
radiation, or unusual infections may
also produce fistulas
Fistula-in-ano
21. Diagnosis
● Persistent drainage from the internal and /or external
openings
● Indurated tract is often palpable
● External opening is often easily identifiable
● Goodsall’s rule can be used as a guide in determining
the location of the internal opening
○ Fistulas with an external opening anteriorly connect
to the internal opening by a short, radial tract
○ Fistulas with an external opening posteriorly track
in a curvilinear fashion to the posterior midline
○ Exception: if an anterior external opening is >3cm
from the anal margin, such fistulas usuually track
to the posterior midline
22. Parks Classification of Fistula in Ano
Classification Description
Intersphincteric ● Due to a perianal abscess
● Tracks through the distal internal sphincter and
intersphincteric space to an external opening near the
anal verge
Transsphincteric ● Usually results from an ischiorectal fossa abscess
● Extends through both the internal and external
sphincters
Suprasphincteric ● Usually from a supralevator abscess
● Originates in the intersphincteric plane
● Tracks up and around the entire external sphincter
23. Parks Classification of Fistula in Ano
Extrasphincteric ● May arise from foreign body penetration of the rectum,
penetrating injury to the perineum or carcinoma
● Originates in the rectal wall
● Tracks around both sphincters to exit laterally, usually
in the ischiorectal fossa
Classification Description
24. Diagnostics
● Anoscopy: May be required to identify the internal
opening of the fistula
● MRI: Diagnostic imaging of choice for the diagnosis of
fistula-in-ano
● Most patients can undergo surgery even without an
imaging modality
26. Management
Technique Description
Fistulotomy ● Useful in the Majority
● Probe is inserted through the fistula (both openings); then skin and
sphincteric muscles are divided, thereby opening (unroofing) the tract
● Fistulotomy is closed by secondary intention
Seton Placement ● Thick suture placed through fistula tract to allow slow transection of
sphincter muscle
● Made from large, silk suture that is threaded through the fistula tract
to:
○ Allow direct visualization of the tract
○ Allow drainage and promotes fibrosis
○ Cuts through the fistula
● Advantage: avoids complication of incontinence ( in contrast to
fistulotomy)
27. Preferred Techniques
● Simple fistula-in-ano: fistulotomy or unroofing of the fistolous tract
● Complex or high lying fistula-in-ano: seton placement
● LIFT ( Ligation of Intersphincteric Fistula Tract): new procedure that
ligates the fistula at the intersphincteric plane (Rojanasakul procedure)
29. Question
1. Type of hemorrhoid that is located proximal to the dentate line and covered by insensate
anorectal mucosa
a. Internal hemorrhoid
b. External hemorrhoid
c. Combined internal and external hemorrhoid
d. All of the above
30. Question
2. Excessive straining, increased abdominal pressure, and hard stools increase venous
engorgement of the hemorrhoidal plexus and cause prolapse of the hemorrhoidal tissue
a. True
b. False
31. Question
3. Prolapse through the anal canal and require manual reduction
a. First-degree
b. Second-degree
c. Third-degree
d. Fourth-degree
32. Question
4. Located distal to the dentate line and covered by anoderm
a. Internal hemorrhoid
b. External hemorrhoid
c. Combined internal and external hemorrhoid
d. All of the above
33. Question
5. According to Thompson’s vascular cushion theory, normal hemorrhoidal
tissue represents discrete masses of submucosa.
a. True
b. False
35. Question
7. Usually results from an ischiorectal fossa abscess and extends through both the
internal and external sphincters
a. Intersphincteric
b. Extrasphincteric
c. Transsphincteric
d. Suprasphincteric
36. Question
8. Diagnostic imaging of choice for the diagnosis of fistula-in-ano
a. MRI
b. Anoscopy
c. Both
d. None of the above
37. Question
9. According to Goodsall’s rule, Fistulas with an external opening anteriorly
connect to the internal opening by a short, radial tract
a. True
b. False
38. Question
10. Usually from a supralevator abscess and tracks up and around the entire external
sphincter
a. Intersphincteric
b. Extrasphincteric
c. Transsphincteric
d. Suprasphincteric
Editor's Notes
Cushions of submucosal tissue containing venules, arterioles, and smooth muscle fibers that are located in the anal canal
Function as part of the continence mechanism and aid in complete closure of the anal canal at rest
3 hemorrhoidal cushions:
Left lateral (3 o’clock)
Right posterior (7 o’clock)
Right anterior (11 o’clock)
Excessive straining, increased abdominal pressure, and hard stools increase venous engorgement of the hemorrhoidal plexus and cause prolapse of the hemorrhoidal tissue
Bleeding, thrombosis, and symptomatic prolapse may result.
Thompson’s vascular cushion theory states that normal hemorrhoidal tissue represents discrete masses of submucosa. During straining, the vascular cushions can become engorged and possibly prevent the escape of fecal material or gas. With the passage of time, how- ever, the anatomic structures supporting the muscular submu- cosa weaken, allowing the hemorrhoidal tissue to slip or prolapse, leading to typical hemorrhoidal symptoms. Haas et al. noted that supporting tissues can be shown microscopi- cally to deteriorate by the third decade of life
Studies have investigated why this degradation occurs and what are the changes in the local microvasculature. Matrix metalloproteinases (MMPs) are enzymes present in the extracellular space and can degrade collagen, elastin, and fibronectin. MMP-9 has been found to be overexpressed in hemorrhoid tissue in association with breakdown of elastic fibers. Once the hemorrhoids start to prolapse, the inter- nal sphincter can slow the rate of venous return and increase the hemorrhoid engorgement.
A careful history should be done to guide the clinician to an accurate diagnosis. In addition, it is helpful to know which symptoms bother the patient the most. Part of the history should include the patient’s bowel habits. If a patient has constipation, treatment of the consti- pation will be an important part of the treatment plan. Ulcerative colitis and Crohn’s disease need to be considered in patients that have had significant diarrhea. If there has been a significant change in bowel habits, one also has to consider the many possibilities that can lead to this change.
For patients with rectal bleeding, the nature, color, and intensity of the bleeding should be noted. If also accompa- nied by a change in bowel habits, one needs to be suspicious of a malignancy or inflammatory bowel disease.
If pain is a significant component of the presentation, the intensity, frequency, and duration of the pain should be noted. If the pain is severe and described as a tearing sensa- tion primarily at the time of the bowel movement, an anal fissure should be considered. Pain that is constant and has been present for days at a time should elicit consideration of a thrombosed hemorrhoid or perianal abscess as the underlying diagnosis.
Protrusion or swelling in the rectal area can be many differ- ent things. If the protrusion has been present constantly for weeks, months, or even years, it can be something as simple as a skin tag. However, one needs to also be mindful of diag- noses such as condyloma and neoplasm in this situation.
Internal hemorrhoids
May prolapse or bleed, but rarely become painful unless they develop thrombosis and necrosis (usually related to severe prolapse, incarceration, and/or strangulation)
External hemorrhoids
Located below or distal to the dentate line
Covered by anoderm
Because anoderm is richly innervated, thrombosis of an external hemorrhoid may cause significant pain.
It is for this reason that external hemorrhoids should not be ligated or excised w/o adequate local anesthetic
Enlarges secondary to dilation or thrombosis
Skin tag is a redundant fibrotic skin at the anal verge, often persisting as the residua of a thrombosed external hemorrhoid
External hemorrhoids and skin tags may cause itching and difficulty with hygiene if they are large.
bleeding that occurs with hemorrhoids is typically described as bright red in nature with the frequency ranging from rarely to several times per day. The blood can be seen on the toilet paper and in the toilet water, and sometimes patients even describe the sensation of the blood squirting out of the anus. Typically the frequency and severity will increase over time
First-degree hemorrhoids bulge into the anal canal and may prolapse beyond the dentate line on straining.
Second-degree hemorrhoids prolapse through the anus but reduce spontaneously.
Third-degree hemorrhoids prolapse through the anal canal and require manual reduction.
Fourth-degree hemorrhoids prolapse but cannot be reduced and are at risk for strangulation
Internal hemorrhoids
May prolapse or bleed, but rarely become painful unless they develop thrombosis and necrosis (usually related to severe prolapse, incarceration, and/or strangulation)
External hemorrhoids
Located below or distal to the dentate line
Covered by anoderm
Because anoderm is richly innervated, thrombosis of an external hemorrhoid may cause significant pain.
It is for this reason that external hemorrhoids should not be ligated or excised w/o adequate local anesthetic
Enlarges secondary to dilation or thrombosis
Skin tag is a redundant fibrotic skin at the anal verge, often persisting as the residua of a thrombosed external hemorrhoid
External hemorrhoids and skin tags may cause itching and difficulty with hygiene if they are large.
A general physical examination should be conducted with concentration on the abdomen, groin, and perianal area. Typically the patient will be examined in the supine position first before switching to a prone jackknife or left lateral (Sims) position (Figure 12-4). It is important to be as reas- suring as possible during this examination as it is inherently embarrassing and uncomfortable. It is always helpful to explain the steps of the examination so as to minimize sur- prise and discomfort.
The examination begins by gently spreading the buttocks and inspecting the skin, perineum, and the external anal opening. Anal fissures are usually diagnosed just with these simple measures, but if one is not thinking of this possibility, it is easy to miss a fissure. In addition, many other conditions can be identified: dermatitis, fistulas, abscess, anal cancer, skin tags, and condyloma. A digital rectal exam is then per- formed to assess for masses, pain, and sphincter tone. If there is any component of fecal soiling or incontinence, the sphinc- ter tone should also be investigated by asking the patient to voluntarily squeeze during the digital exam.
Patients with anorectal complaints must undergo Anoscopy, rigid proctosigmoidoscopy, and/or flexible sigmoidoscopy (further work-up depends on physical examination, patient age, and history)
American Society for Gastrointestinal Endoscopy and the Society for Surgery of the Alimentary Tract guidelines: suggest anoscopy and flexible sigmoidoscopy for bright red rectal bleeding
Anoscopy is the examination of the anal canal and the distal rectum. Anoscopy offers the best way to adequately evaluate the anoderm, dentate line, internal and external hemorrhoids, papillae, fissures, anal masses, and distal rectal mucosa.
The anoscope is a relatively simple instrument consisting of an obturator, the scope itself, and a light source. There exist several variations in type, size, and length of anoscopes available. Additionally, commercially available anoscopes include slotted or beveled styles, reusable or disposable, and lighted or unlighted. The particular type of instrument and light source used are based on individual preference, expense, and prior training (Figure 4-3).
Regardless of the choice of instrument used, the examina- tion is initiated only after a DRE has been performed (if a DRE is unable to be performed secondary to pain, spasm, or stenosis, an anoscopic exam should not be attempted). For most instances, cleansing of the anorectum with an enema is not warranted. The anoscope (with obturator in place) is liberally lubricated and gently and gradually advanced until the instru- ment is fully inserted. It is important to align the anoscope along the anterior–posterior axis of the anus. If unsuccessful due to patient intolerance, remove the scope, reapply lubrica- tion and try again. After successful insertion, the obturator is removed and examination of the anorectum undertaken. The obturator should then be reinserted while the scope still in the anus, and the anoscope is gently rotated to examine a new area.
The prone jackknife position offers good visualization and ease of insertion as well does the lateral position, however, an assistant must retract the buttock if the lateral position is uti- lized. During the examination, the patient is asked to strain while the anoscope is withdrawn to visualize any prolapsing anorectal mucosa or hemorrhoidal tissue. During the anoscopic examination, hemorrhoids may be banded or sclerosing agents injected and biopsies of any suspicious lesions may be obtained. Complications are rare, but may include occasional bleeding from hemorrhoids or inadvertently tearing the anoderm.
Rigid proctoscopy is suitable to examine the rectum, and in some patients, the distal sigmoid colon may also be evaluated. Similar to the anoscope, the proctoscope consists of an obtura- tor, the scope itself, and a light source. Illumination is supplied by a built-in light source and a lens is attached to the external orifice of the scope after the obturator is removed. The main difference between an anoscope is that a proctoscope needs to hold air so the rectum can be distended. This is achieved by having a bellows attached to the scope, which allows for insuf- flation of air to gain better visualization and negotiation of the scope proximally through the rectum. A suction device or cot- ton tipped swabs can be used to remove any endoluminal debris or fluid or to enhance visualization (Figure 4-4). Ideally, the patient should receive an enema preparation within 2 h of the procedure in order to clear any stool, which may make pas- sage of the scope and visualization difficult.
Proctoscopes are available in three sizes, all 25 cm in length. Different luminal diameters include 11, 15, and 19 mm (Figure 4-5). The largest scope is suited best for pol- ypectomy or biopsies in which electrocoagulation may be needed. In most patients, the 15 mm×25 cm scope is ideal for a general inspection. There is also a disposable plastic, self-lighted proctoscope which is available for use.
The procedure can be performed in either the prone jackknife or left lateral position as previously described. When properly performed, the patient feels little to no dis- comfort. Pain may occur with stretching of the rectosig- moid mesentery due to over insufflation of air or the scope hitting the rectal wall. An overzealous examiner trying to advance the scope too quickly or too proximal is the main cause of patient discomfort. Unfortunately, the art of using the rigid proctoscope has declined in recent years due to the ubiquity of flexible endoscopy. The proctoscope how- ever, still has important indications, especially in the iden- tification and precise localization of rectal lesions or in the evaluation of rectal bleeding. Contraindications are similar to anoscopy and include painful anorectal condition such as acute fissure, incarcerated hemorrhoids, recent anorec- tal surgery (<1 month), or anal stenosis
Many patients should also undergo at least a rigid proctos- copy. This allows the surgeon to rule out malignancies or inflammatory conditions that could be mimicking hemor- rhoids. This is especially true in older patients with bleeding, weight loss, anemia, or change in bowel habits.
Flexible sigmoidoscopy is a procedure wherein a sigmoidoscope is inserted through the anus, the distal colonic mucosa (up to 60 cm from the anal verge) is examined, and any diagnostic or therapeutic maneuvers performed, as needed
Bowel cleaning — The lower part of the colon must be cleaned to permit the endoscopist to see the inside lining of the colon. You will be given specific instructions, with preparation often including a clear liquid diet, laxatives, and use of an enema shortly before the examination.
Medications — Some medications, such as iron preparations, may need to be stopped one to two weeks before the examination. Iron coats the colon, making it difficult to see the lining. If you take these medications, you should ask your healthcare provider if they need to be stopped before the procedure. People who take a blood thinning medication, such as warfarin (brand name: Jantoven), should consult with their clinician regarding the need to stop taking this medication temporarily.
Nonsurgical
Main goal of this treatment is to minimize straining of stool
Warm sitz bath (40 ℃): most effective topical treatment for relief of symptoms (soaking time of 15 minutes)
Supportive: increasing fluid and fiber in the diet, recommending exercise, and adding supplemental fiber agents
Medical: phlebotonics, topical steroids (hydrocortisone)
Procedures
Rubber band ligation (RBL): elastic bands are applied onto an internal hemorrhoid at least 1 cm above the dentate line to cut-off the blood supply (if placed too close to the dentate line, intense pain result postprocedure)
Sclerotherapy: injection of a sclerosing agent into the hemorrhoid, causing the veins to collapse
Surgical
Excision hemorrhoidectomy: surgical excision of hemorrhoids, usually recommended for thrombosed external hemorrhoids
Indicated for the following:
Failure of conservative management
Grade III-IV internal hemorrhoids with severe symptoms
Concomitant anorectal conditions (eg. anal fissure or fistula)
May be done either closed (Parks-Ferguson) or open (Milligan-Morgan) technique
Whitehead hemorrhoidectomy: circumferential excision with mucosal advancement (may result to anal ectropion or whitehead deformity)
Medical therapy
Bleeding from first- and second-degree hemorrhoids often improves with the addition of dietary fiber, stool softeners, increased fluid intake, and avoidance of straining.
Associated pruritus often may improve with improved hygiene.
Many over-the-counter topical medications are desiccants and are relatively ineffective for treating hemorrhoidal symptoms
Rubber band ligation
Persistent bleeding from first-, second-, and selected third-degree hemorrhoids may be treated by rubber band ligation.
Mucosa located 1 to 2 cm proximal to the dentate line is grasped and pulled into a rubber band applier.
After firing the ligator, the rubber band strangulates the underlying tissue, causing scarring and preventing further bleeding or prolapse (Fig. 29-31).
In general, only one or two quadrants are banded per visit.
Severe pain will occur if the rubber band is placed at or distal to the dentate line where sensory nerves are located.
Other complications of rubber band ligation include urinary retention, infection, and bleeding.
Urinary retention occurs in approximately 1% of patients and is more likely if the ligation has inadvertently included a portion of the internal sphincter.
Necrotizing infection is an uncommon, but life-threatening complication.
Severe pain, fever, and urinary retention are early signs of infection and should prompt immediate evaluation of the patient usually with an exam under anesthesia.
Treatment includes debridement of necrotic tissue, drainage of associated abscesses, and broad-spectrum antibiotics.
Bleeding may occur approximately 7 to 10 days after rubber band ligation, at the time when the ligated pedicle necroses and sloughs. Bleeding is usually self-limited, but persistent hemorrhage may require exam under anesthesia and suture ligation of the pedicle.
Infrared photocoagulation
Infrared photocoagulation is an effective office treatment for small first- and second-degree hemorrhoids.
The instrument is applied to the apex of each hemorrhoid to coagulate the underlying plexus.
All three quadrants may be treated during the same visit.
Larger hemorrhoids and hemorrhoids with a significant amount of prolapse are not effectively treated with this technique
Sclerotherapy
The injection of bleeding internal hemorrhoids with sclerosing agents is another effective office technique for treatment of first-, second-, and some third-degree hemorrhoids.
One to 3 mL of a sclerosing solution (phenol in olive oil, sodium morrhuate, or quinine urea) is injected into the submucosa of each hemorrhoid.
Few complications are associated with sclerotherapy, but infection and fibrosis have been reported
Excision of Thrombosed External Hemorrhoids
Acutely thrombosed external hemorrhoids generally cause intense pain and a palpable perianal mass during the first 24 to 72 hours after thrombosis.
The thrombosis can be effectively treated with an elliptical excision performed in the office under local anesthesia.
Because the clot is usually loculated, simple incision and drainage is rarely effective.
After 72 hours, the clot begins to resorb, and the pain resolves spontaneously. Excision is unnecessary, but sitz baths and analgesics are often helpful.
Operative Hemorrhoidectomy
A number of surgical procedures have been described for elective resection of symptomatic hemorrhoids.
All are based on decreasing blood flow to the hemorrhoidal plexuses and excising redundant anoderm and mucosa
Closed Submucosal Hemorrhoidectomy
The Parks or Ferguson hemorrhoidectomy involves resection of hemorrhoidal tissue and closure of the wounds with absorbable suture.
The procedure may be performed in the prone or lithotomy position under local, regional, or general anesthesia.
The anal canal is examined and an anal speculum inserted.
The hemorrhoid cushions and associated redundant mucosa are identified and excised using an elliptical incision starting just distal to the anal verge and extending proximally to the anorectal ring.
It is crucial to identify the fibers of the internal sphincter and carefully brush these away from the dissection in order to avoid injury to the sphincter.
The apex of the hemorrhoidal plexus is then ligated and the hemorrhoid excised.
The wound is then closed with a running absorbable suture.
All three hemorrhoidal cushions may be removed using this technique; however, care should be taken to avoid resecting a large area of perianal skin in order to avoid postoperative anal stenosis (Fig. 29-32).
Open Hemorrhoidectomy
This technique, often called the
Milligan and Morgan hemorrhoidectomy, follows the same principles of excision described earlier, but the wounds are left open and allowed to heal by secondary intention.
Whitehead’s Hemorrhoidectomy
Whitehead’s hemorrhoidectomy involves circumferential excision of the hemorrhoidal cushions just proximal to the dentate line.
After excision, the rectal mucosa is then advanced and sutured to the dentate line.
While some surgeons still use Whitehead’s hemorrhoidectomy, most have abandoned this approach because of the risk of ectropion (Whitehead’s deformity).
Procedure for Prolapse and Hemorrhoids/Stapled Hemorrhoidectomy
Best suited for patients with second- and third-degree hemorrhoids, this outpatient procedure uses a stapling device similar in appearance and mechanism of action to an end-to-end anastomotic (EEA) stapling device used for rectal surgery
Just as with an EEA stapler, proximal and distal tissue donuts, in this case consisting of mucosa and submucosa, are generated by the PPH stapler though the primary means by which this procedure provides relief for internal hemorrhoids is by pexying the redundant hemorrhoidal tissue, ligating the venules feeding the hemorrhoidal plexus and fixing redundant mucosa proximal to the dentate line.
Complications associated with this procedure include chronic anal pain, bacteremia, rectovaginal fistula, formation of an obstructing rectal stricture and even rectal perforation
Doppler-Guided Hemorrhoidal Artery Ligation
Another recent approach to treating symptomatic hemorrhoids is Doppler-guided hemorrhoidal artery ligation (also called transanal hemorrhoidal dearterialization).
In this procedure, a Doppler probe is used to identify the artery or arteries feeding the hemorrhoidal plexus. These vessels are then ligated.
Early reports have shown promise, but long-term durability remains to be determined
Management depends on patient symptoms
If the pain is intense: excision should be offered
If the pain is subsiding: conservative management may suffice (eg. warm sitz baths, analgesics, and bulk-producing fiber supplements)
Anoscopy and proctoscopy to rule out associated anorectal disease are postponed to a later date when the patient is not in acute pain
Drainage of an anorectal abscess results in cure for about 50% of patients.
The remaining 50% develop a persistent fistula in ano.
The fistula usually originates in the infected crypt (internal opening) and tracks to the external opening, usually the site of prior drainage.
The course of the fistula can often be predicted by the anatomy of the previous abscess.
While the majority of fistulas are cryptoglandular in origin, trauma, Crohn’s disease, malignancy, radiation, or unusual infections (tuberculosis, actinomycosis, and chlamydia) may also produce fistulas. A complex, recurrent, or nonhealing fistula should raise the suspicion of one of these diagnoses