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Benign Colorectal and Perianal Disease - Coggle Diagram
Benign Colorectal and Perianal Disease
Diverticular DIsease
Definition
Outpouching of a hollow (or fluid filled) structure
True Diverticulum
Includes all layers of the structures
False Diverticulum
Only mucosa
Epidemiology
VEry common colonic pathology in western world
Under the age 45 10%
Over 60 60%
Over 70 70%
Risk Factors
Age
Lack of dietary fibre
Red meat
Lack of exercise
Connective tissue disorder
Fhx
Path theory
High pressure within the colon due to lacak of stool bulk creates outpouchings
Diverticulitis
Definition
Inflammation in diverticular disease
Epidemiology
1 in3 recurrence
10% of people with diverticular disease get diverticulitis
Uncomplicated
Presentation
LIF pain
Elevated inflam markers
CT scan thickened sigmoid colon with adjacent fat stranding
Tx
IV / oral abx
Liquid soft diet
Analgesia
Follow up
Once inflam markers downtrending and pain in improving and bowels moving go home oralbx
Colonoscopy 6 w later to r/o malignancy
Complicated
Definition
Perforated
Hinchey Classification + Mx
Stage 1a
Confined pericolic inflammation or phlegmon
Abx +/- CT guided drainage
Stage 1b
Confied pericolic abcess
Abx +/- CT guided drainage
Stage 2
Distant abcess
Abcess drainage
Stage 3
Purulent Peritonitis
HArtmann's surgery
Stage 4
Faecal Peritonitis
Hartmann's surgery
Hartmann's Surgery
Remove the perforated sigmoid colon
Bring out healthy bowel above as end colostomy
Can re-join it to distal rectum stump at a later date > 6months when pt is well
Recurrent Diverticular Disease
Management
Elective Procedure
Anterior resection - removal of diseased sigmoid and rectum with an anastomosis +/- a diverting loop ileostomy (reversible - lets heal)
Complications
Colo ?? Fistula
Presentation
Bubbles in urine
Recurrent UTIs
Tx
Diverticular Bleeding
Management
Resus
IV fluids
Transfusion if active haemorrhage and hb<10 or hb<7
Stop anticoagulants, tx coagulation issues
PPIS
If unlclear source - is it upper GI - often urea elevated if heaver upper GI bleeding as blood is digested
CT angio
Assive if active lower GI
Bleed versus ogd / sigmoidoscopy
IR Embolisation
Lowe GI bleed
Risk of iaschaemic patch and perforation
Life threatening
Embolise
Remove bleeding segment of colon - can't always be sure of location
Haemorroids
Definition
Prolaspe or loss of elasticity of anal vascular cushions usually at 3,7 and 11 o clock in lithotomy
Causes
Raised intra abdominal pressure
Straining
Pregnancy
Obesity
Epidemiology
Common only require tx if symptomatic
Presentation
Discomfort
Itch - mucous discharge irritates skin
Bleeding
painless
Needs to be further investigated to clarify is it haemorroids or not
Pain (if thrombosed)
Bleeding after passing stool
Rarely anaemia
Management
Dietary measures
Fibre
Laxative
Bulking agents
Stool softening agents
Banding
Do not band below dentate line
Indications
Grade 1,2,3
Injection
Indications
Grade 1
Grade 2
Grade 3
Sclerosing agent
Surgery
Haemorroidectomy
Excise external and interal component
Indications
Grade 3,4
Risks
Sphincter damage
Anal stenosis
Haemorrhoidal artery Ligation
Indications
Grade 2,3
Grades
Garde 1
No prolapse, prominent vessels
Grade 2
Prolapse upon bearing down, spontaneous reduction
Grade 3
Prolapse upon bearing down requiring manual reduction
Grade 4
Prolapse with inability to be manually reduced
Investigations
DRE
Sigmoidoscopy or colonoscopy
Check Hb
Acutely Thrombosed Haemorrhoids
MX
Early
After 24 - solid clot - will not drain and will not relieve pain
First 24hrs - incise and drain - clot will be soft and will evacuate
Pain medication
Anal Fissure
Definition
Split in the skin (anoderm) of the anal canal which extends from the anal verge towards the dentate line (innervated skin)
Presentation
12 o clock and 6 o clock
Pain
PR bleeding
Cannot tolerate rectal exam
Sentinel tag
Mound of skin development in front of fissure
Causes
Exam Answer: Consitaption
Complex and multifactorial
IBD, diarrhoea, unknown aetiology
Investigations
Exam
May not tolerate DRE
EUA
r/o sinister causes
Consider Crohn's, STDs, and SCC
Treatment
Stool softeners and increased fibre
Topical GTN or Ca channel blocker
applied twice daily 6 weeks
Failed topical tx - Exam under anaesthesia and botox injection into internal sphincter - cna be reapeated
May impair continence
Failed botox Lateral internal sphincterotomy with caution
Advancement flap
Perianal Abcess
Never in clinical exam - In written exam ⭐
Epidemiology
16.1 per 100,000
800 people a year in IRE
Males
Peak incidence 20-40
90% of peri-anal / rectal abscesses due to cryptoglandular inx
10% due to alternative pathology (Crohns)
1/3 have fistula at time of drainage or subsequently
Path
Glands located at dentate line and extend into the internal sphincter to the intersphincteric groove
Gland obstruction causes stasis, bacterial growth and abcess formation
3, Most common routes of pus is downwards extension to the anoderm (perianal abcess) or across sphincters to ischiorectal fossa
Definition
Fistulas
Classifications
Anatomically
Parks
Anatomical based on relationship to sphincter
Superficila
Intersphincteric
Transphinteric
Suprasphinteric
Definition
an abnormal connection joining two hollow spaces
Management
Fistulotomy
Divide fistula to open
Can be done in simple low fistulas that have little or no sphincter involvement
Be careful in anterior fistulas in females - previous sphincter damage - always take obs hx - perineal tears, and in recurrent fistulas if previous fistulotomy
Complex fistula
Insert a aseton and drain ongoing inefction
Procedure once sepsis settles
Tx sepsis
Other
Setons (loose or cutting)
Endoanal advancement flap
LIFT procedure
Fistula plug / fibrin glue