Anorectal

ALWAYS:

R/O cancer by PEx (Proctosigmoidoscopy).

Hemorrhoids:

· If they bleed: internal (tx w/ rubber band ligation)

· If they hurt: External

Initial management of hemorrhoids:

Dietary	· Increased fluid intake · Increased fiber intake (foods, fiber supplements) · Reduced fat intake · Moderation of alcohol intake
Behavioral	· Limit time sitting on toilet (e.g., 3 minutes) · Limit defecation to once daily · Avoid straining during defection
Topical Agents	· Analgesics (e.g., benzocaine) · Astringents (e.g., witch hazel) · Hydrocortisone

Fissure:

· Females

· Pain w/ defecation + blood coat stool

· Pt avoid defecation –> constipation

· PEx hurt –> you may need to do it w/ Anesthesia –> you will fine Posterior midline fissure.

· Tx: Soften the sphincter + Stool

o Stool softener

o CCB

o Sphinctrotomy

Abscess:

· Fever + Severe pain (pt can’t sit)

· On PEx: Lateral – Red, hot, painful mass w/ pus.

· Tx: I/D + Abx

Complication of Abscess → Fistula:

· A canal b/w Skin (site of I/D) and anal crypt (site of abscess).

· PEx: Lateral opening w/ Discharge

· Tx: fistulotomy

SqCC

· HIV+

· Fungating mass + inguinal LN

· Dx: Bx

· Tx: Nigro chemoradiation –> surgery.

Chron’s:

· When to suspect? pt fail to improve/deteriorates after surgery!

· Tx: SURGERY

· Colo-vesical fistulas may occur in inflammatory processes (e.g., diverticulitis, Chron disease), iatrogenic injury, foreign body, or malignancy.

· Pneumaturia is pathognomonic.

· CT scan of the abdomen and pelvis with contrast is the best imaging modality to start the workup.

· Management begins with NPO and intravenous antibiotic, and ultimately surgical exploration with colonic resection.

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