MINISTRY OF HEALTHCARE OF UKRAINE

DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY

DEPARTMENT OF SURGERY #1

RECTUM DISEASES:

HEMORHOIDES, PARAPROCTITIS, PROLAPSE

Guidelines for Medical Students

LVIV – 2019 2 Approved at the meeting of the surgical methodological commission of Danylo Halytsky Lviv National Medical University (Meeting report № 56 on May 16, 2019)

Guidelines prepared:

VARYVODA Yevgen Stepanovych – PhD, associate professor of Department of Surgery #1 at Danylo Halytsky Lviv National Medical University

KOLOMIYCEV Vasyl Ivanovych – PhD, associate professor of Department of Surgery #1 at Danylo Halytsky Lviv National Medical University

KHOMYAK Volodymyr Vsevolodovych – PhD, assistant professor of Department of Surgery #1 at Danylo Halytsky Lviv National Medical University

MARINA Volodymyr Nutsuvych - MD, assistant professor of Department of Surgery #1 at Danylo Halytsky Lviv National Medical University

Referees:

ANDRYUSHCHENKO Viktor Petrovych – PhD, professor of Department of at Danylo Halytsky Lviv National Medical University OREL Yuriy Glibovych - PhD, professor of Department of General Surgery at Danylo Halytsky Lviv National Medical University

Responsible for the issue first vice-rector on educational and pedagogical affairs at Danylo Halytsky Lviv National Medical University, corresponding member of National Academy of Medical Sciences of Ukraine, PhD, professor M.R. Gzegotsky

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I. Background are a very common anorectal condition defined as the symptomatic enlargement and distal displacement of the normal anal cushions. They affect millions of people around the world, and represent a major medical and socioeconomic problem. Multiple factors have been claimed to be the etiologies of hemorrhoidal development, including and prolonged straining. Up to one third of the 10 million people in the United States with hemorrhoids seek medical treatment, resulting in 1.5 million related prescriptions per year. The number of hemorrhoidectomies performed in hospitals is declining. A peak of 117 hemorrhoidectomies per 100,000 people was reached in 1974; this rate declined to 37 hemorrhoidectomies per 100,000 people in 1987. Obviously, outpatient and office treatment of hemorrhoids account for some of this decline. Hemorrhoids plague all age groups, although they occur most often in individuals aged 46-65 years. Perianal represents an of the soft tissues surrounding the , with formation of a discrete abscess cavity. The severity and depth of the abscess are quite variable, and the abscess cavity is often associated with formation of a fistulous tract. The peak incidence of anorectal is in the third and fourth decades of life. Men are affected more frequently than women, with a male-to-female predominance of 2:1 to 3:1. Approximately 30% of patients with anorectal abscesses report a previous history of similar abscesses that either resolved spontaneously or required surgical intervention. A higher incidence of abscess formation appears to correspond with the spring and summer seasons. While demographics point to a clear disparity in the occurrence of anal abscesses with respect to age and sex, no obvious pattern exists among various countries or regions of the world. Although suggested, a direct relationship between the formation of anorectal abscesses and bowel habits, frequent , and poor personal hygiene remains unproved. occurs when a mucosal or full-thickness layer of rectal tissue protrudes through the anal orifice. Problems with , constipation, and rectal ulceration are common. Rectal prolapse is uncommon; but true incidence is unknown. Peaks in occurrence are noted in the fourth and seventh decades of life. The annual incidence of rectal prolapse worldwide was found to be 2.5 per 100,000 population. Although all ages can be affected, peak incidences are observed in the fourth and seventh decades of life. Mucosal prolapse is more common than complete prolapse. In the adult population, the male-to-female ratio is 1:6. Although in adults women comprise 80-90% of cases. 4

II. Learning Objectives 1. To study the etiological factors of diseases, classification, clinical presentation, diagnostic methods and procedures, treatment and complications (α = I). 2. To know the causes of the disease, risk factors, typical clinical course and complications, laboratory and imaging studies of examination and modern aproaches in conservative and surgical treatment (α = II). 3. To collect and analyze the complaints and history of the disease, to perform physical examination, to determine the order of examination methods and to perform their interpretation, to assess clinical diagnosis, to choose appropriate treatment, to confirm the indications and method of surgical intervention(α = III). 4. To resolve difficult clinical cases in patients with non-typical course or complications of rectal diseases (α = ІV).

III. Purpose of personality development Development of professional skills of the future specialist, study of ethical and deontological aspects of physicians job, regarding communication with patients and colleagues, development of a sense of responsibility for independent decision making. To know modern methods of treatment of patients with rectal diseases and its complications.

IV. Interdisciplinary integration Subject To know To be able

Previous subjects

1. Anatomy and Anatomical structure, Determine the topographic Physiology blood supply, innervation location of different part of and function of the rectum the rectum and perineum

2. Pathomorphology Lifestyle and heredity as Describe macroscopic and Pathophysiology main causes of the changes of hemorrhoids and diseases, etiological fissures; identify factors of diseases morphological forms of rectal diseases 5

3. Propedeutics of Physical examination of Determine the patients internal diseases the rectum and perineum complaints, medical history of the disease, perform general inspection and digital rectal examination

4. Pharmacology Groups and Prescribe conservative representatives of treatment of patient with methylcellulose, rectal diseases , antidiarrheal agents, stool softeners. 5. Radiology Efficiency of radiological Indications and descrition of investigation in patients x-ray, fistulography, with rectal diseases computed tomography examination

Future subjects

Anesthesiology and Clinical signs urgent Determine the symptoms of Critical Care conditions that occur in urgent conditions, differential Medicine patients with diagnosis and treatment complications of rectal diseases, methods of diagnosis and pharmacotherapy

Intradisciplinary integration

1. Rectal cancer Clinical picture of rectal Check imaging studies cancer abnormality

2. GIT bleeding Clinical presentation of Assessment of bleeding GIT bleeding severity

3. Inflammatory Clinical picture of Check endoscopic findings bowel diseases ulcerative and Crohn's disease

V. Content of the topic and its structuring

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HEMORRHOIDS

Etiology Hemorrhoidal complaints are usually not associated with other medical conditions or diseases. However, patients with the following diseases and conditions have an increased risk of hemorrhoidal complaints:  Inflammatory bowel disease and hemorrhoidal problems occur frequently. Unusual hemorrhoidal presentations and findings should alert the clinician to the potential of inflammatory bowel disease.  and Crohn disease are associated with hemorrhoids.  Pregnancy is associated with many anorectal problems. Anatomy&Pathophysiology Hemorrhoidal tissues are part of the normal anatomy of the distal rectum and anal canal. The disease state of “hemorrhoids” exists when the internal complex becomes chronically engorged or the tissue prolapses into the anal canal as the result of laxity of the surrounding connective tissue and dilatation of the . Hemorrhoids are not varicosities; they are clusters of vascular tissue, smooth muscle, and connective tissue lined by the normal of the anal canal. Hemorrhoids are present in utero and persist through normal adult life. Hemorrhoids are categorized into internal and external hemorrhoids. These categories are anatomically separated by the dentate (pectinate) line. External hemorrhoids are hemorrhoids covered by squamous epithelium, whereas internal hemorrhoids are lined with columnar epithelium. Internal hemorrhoids have 3 main cushions, which are situated in the left lateral, right posterior, and right anterior areas of the anal canal. Minor tufts can be found between the major cushions. Most authors agree that low-fiber diets cause small-caliber stools, which result in straining during defecation. This increased pressure causes engorgement of the hemorrhoids, possibly by interfering with venous return. Pregnancy and abnormally high tension of the internal sphincter muscle can also cause hemorrhoidal problems, presumably by means of the same mechanism. Decreased venous return is thought to be the mechanism of action. Prolonged sitting on a toilet (eg, while reading) is believed to cause a relative venous return problem in the perianal area (a tourniquet effect), resulting in enlarged hemorrhoids. Aging causes weakening of the support structures, which facilitates prolapse. Weakening of support structures can occur as early as the third decade of life. Straining and constipation have long been thought of as culprits in the formation of hemorrhoids. This may or may not be true. Patients who report hemorrhoids have a canal resting tone that is higher than normal. Of interest, the resting tone is lower after 7 hemorrhoidectomy than it is before the procedure. This change in resting tone is the mechanism of action of Lord dilatation, a surgical procedure for anorectal complaints that is most commonly performed in the United Kingdom. Pregnancy clearly predisposes women to symptoms from hemorrhoids, although the etiology is unknown. are common in patients with portal . Varices occur in the midrectum, at connections between the portal system and the middle and . Varices occur more frequently in patients who are noncirrhotic, and they rarely bleed. Treatment is usually directed at the underlying . Emergent control of bleeding can be obtained with suture ligation. Portosystemic shunts and transjugular intrahepatic portosystemic shunts (TIPS) have been used to control hypertension and thus, the bleeding. Presentation Most laypersons and many practitioners attribute all perianal symptoms to hemorrhoids. The astute clinician can often listen to a patient's description of symptoms and ascertain the source of the problem or condition before confirmatory examination. Nonhemorrhoidal causes of symptoms (eg, fissure,abscess, , , condylomata, and viral or bacterial skin infection) need to be excluded. Hemorrhoidal symptoms are divided into internal and external sources. Internal hemorrhoids cannot cause cutaneous pain, because they are above the dentate line and are not innervated by cutaneous nerves. However, they can bleed, prolapse, and, as a result of the deposition of an irritant onto the sensitive perianal skin, cause perianal itching and irritation. Internal hemorrhoids can produce perianal pain by prolapsing and causing of the sphincter complex around the hemorrhoids. This spasm results in discomfort while the prolapsed hemorrhoids are exposed. This muscle discomfort is relieved with reduction. Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. Again, the pain is related to the sphincter complex spasm. Strangulation with necrosis may cause more deep discomfort. When these catastrophic events occur, the sphincter spasm often causes concomitant external . External thrombosis causes acute cutaneous pain. This consternation of symptoms is referred to as acute hemorrhoidal crisis. It usually requires emergent treatment. Internal hemorrhoids most commonly cause painless bleeding with bowel movements. The covering epithelium is damaged by the hard bowel movement, and the underlying veins bleed. With spasm of the sphincter complex elevating pressure, the internal hemorrhoidal veins can spurt. Internal hemorrhoids can deposit mucus onto the perianal tissue with prolapse. This mucus with microscopic stool contents can cause a localized dermatitis, which is called 8 pruritus ani. Generally, hemorrhoids are merely the vehicle by which the offending elements reach the perianal tissue. Hemorrhoids are not the primary offenders. External hemorrhoids cause symptoms in 2 ways. First, acute thrombosis of the underlying external hemorrhoidal can occur. Acute thrombosis is usually related to a specific event, such as physical exertion, straining with constipation, a bout of diarrhea, or a change in diet. These are acute, painful events. Pain results from rapid distension of innervated skin by the clot and surrounding edema. The pain lasts 7-14 days and resolves with resolution of the thrombosis. With this resolution, the stretched anoderm persists as excess skin or skin tags. External thromboses occasionally erode the overlying skin and cause bleeding. Recurrence occurs approximately 40-50% of the time, at the same site (because the underlying damaged vein remains there). Simply removing the blood clot and leaving the weakened vein in place, rather than excising the offending vein with the clot, will predispose the patient to recurrence. External hemorrhoids can also cause hygiene difficulties, with the excess, redundant skin left after an acute thrombosis (skin tags) being accountable for these problems. External hemorrhoidal veins found under the perianal skin obviously cannot cause hygiene problems; however, excess skin in the perianal area can mechanically interfere with cleansing. Diagnosis Laboratory Studies  Hematocrit testing is suggested if excessive bleeding with concomitant anemia is suspected.  Coagulation studies are indicated if the history and physical examination suggest coagulopathy. Imaging Studies  Barium enema study or virtual colonoscopy is suggested if proximal colonic and intestinal diseases must be excluded and if endoscopy is not helpful. Diagnostic Procedures  Examination begins with inspection and examination of the entire perianal area. Warn the patient before any probing or poking. Because patient apprehension is great prior to any anal examination, go to great lengths to reassure the patient. Gentle spreading of the buttocks allows easy visualization of most of the anoderm; this includes the distal anal canal. Anal fissures and perianal dermatitis (pruritus ani) are easily visible without internal probing. Note the location and size of skin tags and the presence of thromboses. Normal corrugation of the anoderm and a normal anal wink with stimulation confirms intact sensation. Digital examination of the anal canal can identify any indurated or ulcerated areas. Be sure to palpate the prostate in all men. Because internal hemorrhoids are soft vascular structures, they are usually not palpable. 9

is mandatory for viewing internal hemorrhoids. The anoscope should be a side-viewing one. When angled well by the examiner, the side-viewing anoscope allows the soft hemorrhoidal tufts to fill the beveled end of the scope and to be appropriately evaluated. Prolapse can be observed when the patient performs a Valsalva maneuver. Flexible sigmoidoscopy is performed to exclude proximal disease. Having a patient strain while sitting on a toilet may reproduce prolapse most accurately. Examining patients while they sit on a toilet can be very helpful in indeterminate cases. Colonoscopy, virtual colonoscopy, and barium enema are reserved for cases of bleeding without an identified anal source. These symptoms are not attributable to hemorrhoids and are considered to be non – outlet-type bleeding. Histologic Findings Routine histologic examination of hemorrhoidal tissue is usually unrewarding, especially if it is grossly examined by an experienced anorectal surgeon. Any suspicious tissue must be sent for microscopic evaluation. External hemorrhoids are classified by underlying pathology and symptoms, which include thrombosed veins, bleeding from eroded blood clots, and skin tags causing hygiene problems. Staging Internal hemorrhoids are grouped into 4 stages, as follows:  Stage I - Internal hemorrhoids that bleed  Stage II – Internal hemorrhoids that cause bleeding and prolapse with straining but return to their resting point by themselves  Stage III - Internal hemorrhoids that bleed and prolapse with straining and require manual effort for replacement into the anal canal  Stage IV - Internal hemorrhoids that do not return into the anal canal and are therefore constantly outside Medical Therapy Treatment is divided by the cause of symptoms, into internal and external treatments. Internal hemorrhoids do not have cutaneous innervation and can therefore be destroyed without anesthetic. They are classified by symptoms and are grouped into 4 stages, as described in the Staging section. Because it is believed that straining and a low-fiber diet cause hemorrhoidal disease, conservative treatment includes increasing fiber and liquid intake and retraining in toilet habit. Decreasing straining and constipation shrinks internal hemorrhoids and decreases their symptoms; therefore, first-line treatment of all first- and second-degree (and many third- and fourth-degree) internal hemorrhoids should include measures to decrease straining and constipation. Psyllium seed significantly decreases bleeding and pain compared with placebo. The average American diet consists of 8-15 grams of fiber per day. A high-fiber diet includes more than 25 grams of fiber per day. Psyllium seed (Metamucil) and methylcellulose 10 (Citrucel) are the most commonly used supplements. Many hemorrhoidal symptoms resolve only when they are treated with dietary alterations, including increased fiber and the addition of fiber supplements. Antidiarrheal agents are sometimes required in patients with symptoms and loose stools. Toilet retraining involves reminding patients that the lavatory is not the library. Patients should sit on the toilet only long enough to evacuate the lower intestines. Persistent straining or prolonged sitting can lead to engorged hemorrhoids. Stool softeners play a limited role in the treatment of routine hemorrhoidal symptoms. Oral fiber intake and fiber supplements almost always cure constipation and straining. Remember that hemorrhoidal symptoms are due to prolapse, thrombosis, and vascular bleeding; therefore, creams and salves have a small role in treating hemorrhoidal complaints. Suppositories, except for providing lubrication, also have a small role in the treatment of hemorrhoidal symptoms. Topical hydrocortisone can sometimes ease internal hemorrhoidal bleeding. The author rarely recommends typical medications (eg, suppository, cream, enema, foam) in the treatment of hemorrhoids. Submucosal veins do not get smaller with anti-inflammatory medications. Bathing in tubs with warm water universally eases painful perianal conditions. Relaxation of the sphincter mechanism and spasm is probably the etiology. Ice can relieve the pain of acute thrombosis. The author does not suggest mechanisms such as the for symptom relief. The rigid structure of these portable bathing apparatuses can act in a similar fashion as a toilet seat, causing venous congestion in the perianal area and potentially exacerbating the problem. However, sitz baths do have a role in the treatment of older or immobile patients who cannot routinely get in and out of a bathtub. Many patients see improvement or complete resolution of their symptoms with the above conservative measures. Aggressive therapy is reserved for patients who have persistent symptoms after 1 month of conservative therapy. Treatment is directed solely at symptoms and not at the appearance of the hemorrhoids. Many patients have been referred for surgery because they have severely swollen prolapsed hemorrhoids or very large external skin tags. When questioned, the patients are asymptomatic. A wise professor once said, "You can't make an asymptomatic patient feel better." Treat hemorrhoids only if they cause problems for the patient. Similarly, patients often ask when they should have surgery. Remind them that their hemorrhoids do not bother anyone else, and they should opt for aggressive treatment only when symptoms become bothersome. Treatment of the underlying disease often relieves anal symptoms. Patients with ulcerative colitis can tolerate aggressive surgery if needed. Avoid aggressive treatment in patients with Crohn disease, especially if the rectal mucosa is acutely inflamed. Drain abscesses as soon as possible, despite active disease elsewhere. 11 Pregnancy is associated with many anorectal complaints. Treatment is directed at symptoms. Nonoperative treatment or office thrombectomy usually relieves complaints. Operative hemorrhoidectomy is safe in pregnant women. HIV and anal disease often occur together. Again, conservative therapy is suggested, especially if immunosuppression is evident. Poor healing occurs with low CD4 counts, especially those of less than 200 cells/mm3. Numerous methods to destroy internal hemorrhoids are available; they include rubber band ligation, sclerotherapy injection, infrared photocoagulation, laser ablation, carbon dioxide freezing, Lord dilatation, stapled hemorrhoidectomy, and surgical resection. All of these methods (except stapled hemorrhoidectomy and surgical resection) are considered nonoperative treatments and should be the first-line treatment of all first- and second-degree internal hemorrhoids that do not respond to conservative therapy. With experience, many third-degree and some fourth-degree internal hemorrhoids can be treated nonoperatively. All nonoperative treatments have approximately similar efficiency when administered by an experienced clinician. Rubber band ligation is most common in the United States, because it is the most commonly taught method in training programs. Blaisdell and Barron described and refined ligation therapy. Lord dilatation is seldom used in the United States, and many colorectal surgeons condemn its use, because it is essentially an uncontrolled disruption of the sphincter mechanism. Sclerotherapy can provide adequate treatment of early internal hemorrhoids. Cryotherapy and sclerotherapy are infrequently used today. Most experienced surgeons use 1 or 2 techniques exclusively. Surgical Therapy Operative resection is reserved for patients with third- and fourth-degree hemorrhoids, patients who fail nonoperative therapy, and patients who also have significant symptoms from external hemorrhoids or skin tags. Laser hemorrhoidectomy, as opposed to conventional scalpel and electrocautery techniques, is associated with many myths. Hemorrhoidectomy factories have touted painless or decreased pain and shortened healing times as advantages to performing hemorrhoidectomies by laser. No documented studies support these claims. In fact, one prospective study found no difference between scalpel and laser hemorrhoidectomy. External hemorrhoids generally elicit symptoms due to acute thromboses, recurrent thromboses, or hygiene problems. Manage acute thromboses and recurrent thromboses in a similar fashion. Identify the offending vascular cluster. In the office or clinical setting, inject local anesthetic, and then perform excision of the overlying skin and underlying veins. Enucleation of the thrombosis alone can result in recurrence of the at the same spot; excision of the underlying vein completely prevents this event. Electrocoagulation or topical astringent (Monsel's solution) provides hemostasis. Suturing the wound closed is not necessary and may cause more pain. Remember, acute 12 thromboses spontaneously resolve in 10-14 days; therefore, a patient who presents late and has diminishing pain is best left alone. Recurrence occurs up to 50% of the time when thromboses are left alone. Stapled hemorrhoid surgery, or procedure for prolapsing hemorrhoids (PPH), has become prominent. It was first described in 1997-1998. During PPH, a specially designed circular stapler with smaller staples is used. The technique involves placing a suture in the mucosal and submucosal layers circumferentially, approximately 3-4 cm above the dentate line. The stapler is placed and slowly closed around the purse string. Care is taken to draw excess internal hemorrhoidal tissue into the stapler. The stapler is fired, resecting the excess tissue and placing a circular staple line above the dentate line. This results in resection of excessive internal hemorrhoidal tissue, pexy of the internal hemorrhoidal tissue left behind, and interruption of the blood supply from above. PPH can be done as an outpatient procedure, using local with intravenous (IV) sedation. PPH is mainly used to treat internal hemorrhoids that are not amenable to conservative and nonoperative therapies. Narcotic use and recovery is significantly decreased compared with conventional operative hemorrhoid surgery. PPH does not directly affect the external tissue. Reports have described shrinking of external hemorrhoidal tissue after PPH, probably from decreased blood flow. Good results from PPH combined with judicial excision of occasional skin tags also have been reported. In patients receiving PPH, pain seems to be less severe and of shorter duration than it is in patients who undergo conventional surgery. The use of PPH is suggested in patients with large internal hemorrhoids and minimal external component. This procedure can be done in an outpatient setting with local anesthesia, similar to the protocol used for conventional hemorrhoid surgery. The author has incorporated PPH into practice more frequently, with excellent results. Operative resection is reserved for patients with hygiene trouble caused by large skin tags, a history of multiple external thromboses, or internal hemorrhoid trouble. Perform the operation in the outpatient setting. Proper anesthetic care (especially if local anesthesia with supplementary IV sedation), attention to perioperative fluid restriction, and careful postoperative instructions can ease the patient's recovery. Patients with ulcerative colitis can tolerate aggressive surgery if it is needed. Treat underlying acute disease before any elective anorectal surgery. Avoid aggressive treatment in patients with Crohn disease, especially if the rectal mucosa is acutely inflamed. Drain abscesses as soon as possible, despite active disease elsewhere. If necessary, operative hemorrhoidectomy is safe in pregnant women. Acute hemorrhoidal crisis is a rare event that usually requires emergency treatment. The mechanism of action is large internal hemorrhoid prolapse. The sphincter mechanism 13 squeezes, incarcerating the internal hemorrhoids and strangulating them. The resulting spasm causes edema and occasionally thrombosis of the external hemorrhoids. The resulting pain and swelling are dramatic and very painful. Emergent operative resection is safe and, with conservation of the anoderm, provides good relief. Rapid pain relief with office excision of thromboses and ligation of internal hemorrhoids has been reported. Preoperative Details Hemorrhoid surgery can usually be performed using local anesthesia with IV sedation. Regional or general anesthetic techniques also are used. Routine preoperative workup for these techniques is required. Simple distal rectal evacuation is required for a clean operative field. Distal rectal evacuation is best achieved by small-volume saline enemas. Postoperative Details Attention to regular and soft bowel movements is important. Bulk agents (eg, psyllium seed) and oral fluids are important. Bathing in tubs for comfort and hygiene is part of the routine. Judicious narcotic administration relieves pain. Complications Well-trained surgeons should experience complications in fewer than 5% of cases. Complications include , bleeding, infection, recurrence, nonhealing wounds, and fistula formation. Urinary retention is directly related to the anesthetic technique used and to the perioperative fluids administered. Limiting fluids and the routine use of local anesthesia can reduce urinary retention to less than 5%. Outcome and Prognosis Accurately classifying a patient's symptoms and the relation of the symptoms to internal and external hemorrhoids is important. Internal hemorrhoid symptoms often respond to increased fiber and liquid intake and to avoidance of straining and prolonged toilet sitting. Nonoperative therapy works well for symptoms that persist despite the use of conservative therapy. PPH is an excellent alternative for treating internal hemorrhoids that have not been amenable to conservative or nonoperative approaches. Short- and medium-term results are excellent. Patients with minimal external tags and large internal hemorrhoids are easily treated with PPH and skin tag excision. Operative resection is sometimes required to control the symptoms of internal hemorrhoids. External hemorrhoid symptoms are generally divided into problems with acute thrombosis and hygiene/skin tag complaints. The former respond well to office excision (not enucleation), while operative resection is reserved for the latter. Remember that therapy is directed solely at the symptoms, not at aesthetics. When performed well, operative hemorrhoidectomy should have a 2-5% recurrence rate. Nonoperative techniques, such as rubber band ligation, produce recurrence rates of 30- 14 50% within 5-10 years. However, these recurrences can usually be addressed with further nonoperative treatments. Long-term results from PPH are unavailable at this time.

PERIANAL ABSCESS

Etiology Perirectal abscesses and represent anorectal disorders arising predominately from the obstruction of anal crypts. Infection of the now static glandular secretions results in suppuration and abscess formation within the . Typically, the abscess forms initially in the intersphincteric space and then spreads along adjacent potential spaces. Classification of Abscesses are classified based on their anatomic location. The most commonly described locations are perianal, ischiorectal, intersphincteric, and supralevator. Perianal abscesses represent the most common type of anorectal abscesses, accounting for approximately 60% of reported cases. These superficial collections of purulent material are located beneath the skin of the anal canal and do not transverse the external sphincter. The next most common types of abscesses, in descending order of frequency, are ischiorectal, intersphincteric, and supralevator. An ischiorectal abscess forms when suppuration transverses the external sphincter into the ischiorectal space. Intersphincteric abscesses result from suppuration contained between the internal and external anal sphincters. A supralevator abscess results either from primary disease in the pelvis (eg, , diverticular disease, gynecologic sepsis) or from suppuration extending cranially from an origin in the intersphincteric space, through the longitudinal muscle of the rectum and reaching above the levators. Horseshoe abscesses, while rare, result from circumferential infiltration of within the intersphincteric planes. Pathophysiology An anorectal abscess originates from an infection arising in the cryptoglandular epithelium lining the anal canal. The is believed to serve normally as a barrier to infection passing from the gut lumen to the deep perirectal tissues. This barrier can be breached through the crypts of Morgagni, which can penetrate through the internal sphincter into the intersphincteric space. Once infection gains access to the intersphincteric space, it has easy access to the adjacent perirectal spaces. Extension of the infection can involve the intersphincteric space, ischiorectal space, or even the supralevator space. In some instances, the abscess remains contained within the intersphincteric space. The variety of anatomic sequelae of the primary infection is translated into variable clinical presentations. 15 As mentioned above, perirectal abscesses and fistulas represent anorectal disorders that arise predominately from the obstruction of anal crypts. Normal anatomy demonstrates anywhere from 4-10 anal glands drained by respective crypts at the level of the dentate line. Anal glands normally function to lubricate the anal canal. Obstruction of anal crypts results in stasis of glandular secretions and, when subsequently infected, suppuration and abscess formation within the anal gland results. The abscess typically forms in the intersphincteric space and can spread along various potential spaces. Common organisms implicated in abscess formation include Escherichia coli, Enterococcus species, and Bacteroides species; however, no specific bacterium has been identified as a unique cause of abscesses. Less common causes of anorectal abscess that must be considered in the differential diagnosis include tuberculosis, squamous cell carcinoma, adenocarcinoma, actinomycosis, lymphogranuloma venereum, Crohn's disease, trauma, leukemia, and lymphoma. These may result in the development of atypical fistula-in-ano or complicated fistulas that fail to respond to conventional surgical treatment. Presentation The classic locations of anorectal abscesses listed in order of decreasing frequency are as follows: perianal 60%, ischiorectal 20%, intersphincteric 5%, supralevator 4%, and submucosal 1%. Clinical presentation correlates with the anatomic location of the abscess. Patients with a perianal abscess typically complain of dull perianal discomfort and pruritus. Their perianal pain often is exacerbated by movement and increased perineal pressure from sitting or defecation. Physical examination demonstrates a small, erythematous, well-defined, fluctuant, subcutaneous mass near the anal orifice. Patients with an ischiorectal abscess often present with systemic fevers, chills, and severe perirectal pain and fullness consistent with the more advanced nature of this process. External signs are minimal and may include erythema, induration, or fluctuancy. On digital rectal examination (DRE), a fluctuant, indurated mass may be encountered. Optimal physical assessment of an ischiorectal abscess may require anesthesia to alleviate patient discomfort that would otherwise limit the extent of the examination. Patients with an intersphincteric abscess present with and exhibit localized tenderness on DRE. Physical examination may fail to identify an intersphincteric abscess. Although rare, supralevator abscesses present a similar diagnostic challenge. As a result, clinical suspicion of an intersphincteric or supralevator abscess may require confirmation through computed tomography (CT) scanning, magnetic resonance imaging (MRI), or anal ultrasonography. Use of the last modality is limited to confirming the presence of an intersphincteric abscess. Diagnosis Laboratory Studies 16

 No specific laboratory studies are indicated in the evaluation of a patient with a perianal or anorectal abscess.  Certain patients, such as individuals with diabetes and patients who are immunocompromised, are at high risk for developing bacteremia and possibly sepsis, as a result of an anorectal abscess. In such cases, complete laboratory evaluation is important. Laboratory evaluation of the septic patient is not the focus of this article. Imaging Studies  Imaging studies rarely are necessary in the evaluation of patients with an anorectal abscess; however, clinical suspicion of an intersphincteric or supralevator abscess may require confirmation by CT scanning, MRI, or anal ultrasonography. Use of the last modality is limited to confirming the presence of an intersphincteric abscess. The ultrasound can also be used intraoperatively to help identify a difficult abscess/fistula. Diagnostic Procedures  Digital examination under anesthesia can be helpful in certain cases, because patient discomfort can significantly limit physical assessment. For example, optimal evaluation for an ischiorectal abscess is performed in this manner. A fistula tract can be injected with peroxide solution at the time of examination under anesthesia in order to facilitate the visualization of the internal opening of the fistula.  Evidence suggests that the use of endoscopic visualization (transrectal and transanal) is an excellent way to evaluate complex cases of perianal abscess and fistula. With the endoscopic technique, the extent and configuration of the abscess and fistulas can be clearly visualized. The endoscopic visualization has been reported to be as effective as fistulography. In experienced hands, endoscopic evaluation is the preferred diagnostic procedure in patients with perirectal pathology because of the low risk of bacterial dissemination and the low incidence of patient discomfort. Utilizing endoscopic evaluation after nonsurgical treatment is also effective for the documentation of the patient's response to therapy. Medical Therapy In most patients with anorectal abscess, adjuvant medical therapy with antibiotics generally is not necessary. However, the presence of a systemic inflammatory response, diabetes, or immunosuppression justifies the concomitant use of antibiotics. Surgical Therapy Treatment of anorectal abscesses involves early surgical drainage of the purulent collection. Primary therapy alone is ineffective in resolving the underlying infection and simply postpones surgical intervention. Any delay in surgical drainage of anorectal abscesses prolongs infection, augments tissue damage, and may impair sphincter continence function, as well as promote stricture and/or fistula formation. The ability to drain an anorectal abscess depends on patient comfort and on the location and accessibility of the abscess. 17 Drainage of perianal or superficial abscesses usually can be accomplished in the office or emergency department, using local anesthetics. A small incision is made over the area of fluctuancy in close proximity to the anal verge. Pus is collected and sent for culture. Hemostasis is achieved with manual pressure, and the wound is packed with iodophor gauze. The gauze is removed after 24 hours, and the patient is instructed to take sitz baths 3 times a day and after bowel movements. Postoperative analgesics and stool softeners are prescribed to relieve pain and prevent constipation. The patient typically will follow up with physician in 2-3 weeks for wound evaluation and inspection for possible fistula formation. A potential of anorectal abscess drainage is the formation of fistulous tracts. The type of organism cultured from an anorectal abscess is an important predictor of fistula formation following surgical incision and drainage. Underlying anal fistulas are present in 40% of abscess cultures that are positive for intestinal bacteria; however, cultures growing Staphylococcus species are associated with perianal skin and typically indicate that there is no subsequent risk that anal fistulas will develop. Treatment of ischiorectal, intersphincteric, and supralevator abscesses is performed best under general or regional anesthesia. In the case of ischiorectal abscess, a cruciate incision is made at the site of maximal swelling. Pus is drained and cultured. The ischiorectal fossa is probed with a finger or hemostat to disrupt loculations and facilitate drainage. Placement of a drain only is indicated for the management of complex or bilateral abscesses. To drain an ischiosphincteric abscess, a transverse incision is made in the anal canal below the dentate line posteriorly. The intersphincteric space is identified, and the plane between the internal and external sphincters is exposed. The abscess is opened to allow drainage, and a small mushroom catheter is sutured in situ to assist drainage and prevent premature wound closure. Location and etiology determine the drainage technique to be used for supralevator abscesses. Failure to manage supralevator abscesses with consideration of the primary etiology may result in iatrogenic fistula formation. Evaluation with MRI or CT scanning can exclude intra-abdominal or pelvic pathology as possible sources. If the supralevator abscess evolved from the extension of an ischiorectal abscess, external drainage through the ischiorectal fossa would be indicated. If the abscess resulted from an upward extension of an intersphincteric abscess, appropriate drainage would be created through the rectal mucosa. In cases of posterior supralevator abscess collections, a transverse incision is made in the posterior anal canal below the dentate line. The extends from the intersphincteric plane through the puborectalis sling and into the posterior anal space. A mushroom catheter then is sutured in place to ensure adequate drainage. 18 Anterior supralevator abscesses are superficial and are more common in women than in men. Surgical drainage may be approached using an anteriorly directed transanal incision or by a transvaginal approach entering the posterior cul-de-sac. A mushroom catheter is placed to ensure adequate drainage of the abscess collection. Patients with systemic signs of toxicity are admitted to the hospital and treated with intravenous antibiotics. If the patient does not improve clinically over the next 24-48 hours, reevaluation of the supralevator abscess by CT scan or reoperation may be indicated. In the face of recurrent, severe supralevator abscesses, some patients may require a diverting colostomy for optimal management. Complications Anorectal fistulas Anorectal fistulas occur in 30-60% of patients with anorectal abscesses. The intersphincteric glands lie between the internal and external anal sphincters and are associated most commonly with abscess formation. Major fecal incontinence Outcome and Prognosis Approximately two thirds of patients with rectal abscesses who are treated by incision and drainage or by spontaneous drainage will develop a chronic .

FISTULAS The anal fistula is a common surgical ailment that has been reported since the time of . Anorectal fistulas arise through obstruction of anal crypts and/or glands and are identified by purulent drainage from the anal canal or from the surrounding perianal skin. Other etiologies of anorectal fistulas are multifactorial and include diverticular disease, IBD, malignancy, and complicated infections, such as tuberculosis and/or actinomycosis. The Parks classification system defining the 4 major types of anorectal fistulas in order of decreasing frequency is as follows: intersphincteric (70%), transsphincteric (23%), extrasphincteric (5%), and suprasphincteric (2%). An intersphincteric fistula is found between internal and external sphincters. A transsphincteric fistula extends through the external sphincter into the ischiorectal fossa. An extrasphincteric fistula passes from the rectum to the skin through the . Lastly, the suprasphincteric fistula extends from the intersphincteric plane through the puborectalis muscle, exiting the skin after traversing the levator ani. The Goodsall rule states that an external opening of a fistulous tract that is anterior to a transverse line drawn across the anal verge is associated with a straight radial tract of the fistula into the anal canal/rectum. Conversely, an external opening that is posterior to the transverse line demonstrates a curved fistulous tract to the posterior midline rectal lumen. 19 Different treatment modalities have been evaluated in 443 reported trials. Examples of various research studies include the following:  Treatment with fistulotomy versus the use of fistulectomy  Seton treatment  Marsupialization  Glue therapy  Anal flaps  Radiosurgical approaches  Fistulotomy/fistulectomy at time of abscess incision  Intraoperative anal retractors Two reported meta-analyses evaluated the use of incision and drainage alone vs the employment of incision + fistulotomy. Evidence suggests that following fistulotomy, marsupialization reduces bleeding and permits faster healing. Results from small trials indicate that healing rates after flap repair may be no worse than those following fistulotomy, although this has not yet been proven. Failure rates may increase in cases in which flap repair has been combined with fibrin glue treatment of fistulas. Radiofrequency fistulotomy results in less pain on the patient's first postoperative day and may permit faster healing. However, a great deal is not yet understood about the surgical treatment of anal fistulas. Preoperative Details Because of the acute nature of anorectal abscesses, preoperative bowel preparation is not possible and typically is unnecessary. Intraoperative Details Decisive management of anal fistulas relies on therapeutic interventions. Healing rarely is spontaneous, and failure to achieve adequate treatment often results in recurrent abscess, persistent drainage, and even malignancy. The main paradigms to follow in the management of anorectal fistulas include the following:  Determine the anatomy of the fistula  Provide adequate drainage  Eradicate the fistula tract  Prevent recurrence  Preserve sphincter function - Preservation of sphincter function relies on maintaining the integrity of the anorectal ring. Once the external opening of the anorectal fistula has been identified and the surrounding tissue has been palpated, probing of the fistula tract is warranted. Aggressive probing of the fistula is discouraged to prevent formation of false channels. Using a blunt probe (eg, a small lachrymal probe), the internal origin of a primary fistula can be identified in the majority of cases. 20 When searching for a fistula tract's opening in the anal canal, the Goodsall rule is an excellent guideline. This rule states that an external opening anterior to a transverse line drawn across the anal verge is associated with a straight radial tract into the canal. An external opening posterior to the transverse line follows a curved fistulous tract to the posterior midline rectal lumen. Horseshoe fistulas occasionally are associated with anterior and posterior openings in the anal canal. Treatment options for the management of fistulas are aimed at providing definitive therapy while minimizing the morbidity of the procedure. For example, 2 widely accepted treatment interventions include fistulectomy and fistulotomy. Studies have demonstrated that removal of the entire fistula tract along with the surrounding scar tissue (ie, fistulectomy) unnecessarily results in a larger wound, prolonged healing time, and higher risks of incontinence. As a result, the more conservative approach of unroofing the tract without excising all surrounding tissue (fistulotomy) usually is preferred and decreases the risk of incontinence and fistula recurrence; fistulotomy also shortens wound healing time. A fistulotomy is performed as a primary procedure for superficial fistulas that require minimal dissection of the fistula from the surrounding sphincter musculature. In contrast, simple fistulotomy for repair of high-level fistulas is contraindicated as the primary treatment. The use of loose setons is warranted in high-level fistulas (ie, transsphincteric and suprasphincteric) to reduce the risk of incontinence or in cases in which poor wound healing is anticipated. Setons may also be used as temporary initial intervention in the management of a fistula. A seton is a nonabsorbable nylon or silk suture that is guided through the fistula tract and tied exteriorly, in this way compressing and maintaining suture placement in the tract. Other material frequently used for seton placement include soft vessel loop. The seton suture must be left in place for a prolonged period of time (weeks to months). The ischemic compression by the seton and the local inflammatory reaction of adjacent tissues initiates fibrosis. Once fibrosis of the surrounding tissue develops, it helps to maintain the integrity of the sphincter musculature during subsequent fistulotomy. Setons often are used in patients with fistulas secondary to inflammatory bowel disease (IBD). In addition, the seton allows epithelialization of the fistulous tract, thereby preventing secondary closure and facilitating the drainage of abscesses. Another commonly used type of seton is the cutting seton, which can be used to gradually transect the anal sphincter musculature underlying the fistula by externally tightening the suture to induce pressure necrosis. Typically, retightening the seton over a period of several days is necessary (this can be performed in the outpatient setting). The cutting seton may eliminate the need for subsequent fistulotomy. While the cutting seton 21 is used as an effective therapeutic option for high-level fistulas, it is contraindicated in patients with IBD. Other treatment modalities include resection with coverage using advancement tissue flaps (used for more complex cases) and bioprosthetic fistula plug (porcine). The plug technique is indicated in selected cases with long fistulous tracts. The success rate is variable (50-70%). Postoperative Details Postoperatively, administer analgesics for pain, stool bulking agents, and stool softeners to prevent constipation. Follow-up evaluation of an incised anorectal abscess is important not only for determining whether healing is adequate, but also for assessing the potential development of anorectal fistulas. Antibiotics are used as adjuncts to surgical therapy for patients with a comorbidity, such as diabetes, valvular heart disease, or immunodeficiency. Outcome and Prognosis The recurrence rate of anorectal fistulas after fistulotomy, fistulectomy, or the use of a seton is about 1.5%. The success rate of primary surgical treatment with fistulotomy appears to be fairly good. The overall incidence of major fecal incontinence after the surgical management of complex suprasphincteric fistulas is estimated to be approximately 7%.

RECTAL PROLAPSE.

Three different clinical entities are often combined under the umbrella term rectal prolapse:  Full-thickness rectal prolapse  Mucosal prolapse  Internal prolapse (internal intussusception)

Treatment of these 3 entities differs. Full-thickness rectal prolapse is defined as protrusion of the full thickness of the rectal wall through the anus; it is the most commonly recognized type. Mucosal prolapse, in contrast, is defined as protrusion of only the rectal mucosa from the anus. Internal intussusception may be a full-thickness or a partial rectal wall disorder, but the prolapsed tissue does not pass beyond the anal canal and does not pass out of the anus. FULL-THICKNESS RECTAL PROLAPSE.

Etiology 22 The precise cause of rectal prolapse is not defined; there are a few associated abnormalities that contribute to disease. A half of cases are caused by chronic straining with defecation and constipation. Other predisposing conditions include the following:  Pregnancy  Previous surgery  Diarrhea  Benign prostatic hypertrophy  Chronic obstructive pulmonary disease (COPD)  Cystic fibrosis  Pertussis (ie, whooping cough)  Pelvic floor dysfunction  Parasitic infections – Amebiasis, schistosomiasis  Neurologic disorders - Previous lower back or pelvic trauma/lumbar disk disease, cauda equina syndrome, spinal tumors, multiple sclerosis  Disordered defecation (eg, stool withholding) Pathophysiology The pathophysiology of rectal prolapse is not completely understood or agreed upon. The first thought postulates that rectal prolapse is a sliding through a defect in the pelvic fascia. The second one holds that rectal prolapse is a circumferential internal intussusception of the rectum beginning 6-8 cm proximal to the anal verge. With straining, this progresses to full-thickness rectal prolapse. The pathophysiology and etiology of mucosal prolapse most likely differ from those of full-thickness rectal prolapse and internal intussusception. Often, prolapse begins with an internal prolapse of the anterior rectal wall and progresses to full prolapse. History Patients with rectal prolapse report a mass protruding through the anus. Initially, the mass protrudes from the anus after a bowel movement and retracts soon. As the disease progresses, the mass protrudes more often, in timeof straining, sneezing or coughing. Finally, the rectum prolapses with daily activities, and no longer spontaneously retracts. Rarely, the rectum becomes incarcerated. Pain is variable. From 10 to 25% of patients also have uterine or bladder prolapse,. Constipation occurs in up to 65% of cases. Rectal bleeding also may develope. Patients often report fecal incontinence (28-88%), which occurs for 2 reasons. First, the anus is dilated and stretched by the protruding rectum, disrupting the function of the anal sphincter. Second, the mucosa of the rectum is in contact with the environment and 23 constantly secretes mucus, thus making the patient appear to be chronically wet and incontinent. Physical Examination  Physical signs of rectal prolapse include the following:  Protruding rectal mucosa  Thick concentric mucosal ring  Sulcus noted between anal canal and rectum  Solitary rectal ulcer (10-25%)  Decreased anal sphincter tone To assess the prolapsed the patient is asked to sit on a toilet and strain, after which the rectum should prolapse. If it does not prolapse with just straining, the administration of a phosphate enema usually produces the prolapse. The protruding mass should show concentric rings of mucosa. Mucosal prolapse typically exhibits radial folds instead of concentric rings. Differential diagnosis should involve following conditions:  Hemorrhoids  Intussusception   Rectal polyps should also be considered. Rectal prolapse is usually only a symptom, and evaluation should focus on discovery of an underlying disorder. Diagnosis Laboratory Tests The only pertinent laboratory studies for a patient with rectal prolapse are those studies that are dictated by the patient’s age and comorbidities. There are no specific tests that aid in the evaluation of rectal prolapse itself. Barium Enema and Colonoscopy It is important to evaluate the entire colon in order to exclude any other colonic lesions that should be simultaneously addressed. The presence of such lesions may affect the choice of the procedure to be performed. Evaluation of the colon may be accomplished by means of colonoscopy or barium enema. Barium enema is a better indicator of the redundancy of the colon. Video Defecography Video defecography is used to help document internal prolapse or to distinguish rectal prolapse from mucosal prolapse if it is not clinically obvious. Defecography may reveal intussusception of proximal colon or pelvic outlet obstruction. 24 Radiopaque material (usually barium paste) is instilled into the rectum, and the patient is asked to defecate on a radiolucent toilet. Spot films and videotapes are made and can be used to determine if the rectum intussuscepts on defecation. Rigid Proctosigmoidoscopy Rigid proctosigmoidoscopy should be performed to assess the rectum for additional lesions, especially solitary rectal ulcers. These ulcers are present in about 10-25% of patients with either internal or full-thickness prolapse. If ulceration is present, the area appears as a single ulcer or as multiple ulcers on the anterior rectal wall. The edges are often heaped up, and the area may be bleeding. Biopsy should be performed to confirm the diagnosis and to exclude other pathology. Solitary rectal ulcers can usually be identified by an experienced pathologist. Other Tests Anal-rectal manometry is sometimes used to evaluate the anal sphincter muscles. In almost all patients, the results show a decrease in resting pressure in the internal sphincter and an absence of the anorectal inhibitory reflex. Management No medical treatment is available for rectal prolapsed. Although, internal prolapse should always be first treated medically with bulking agents, stool softeners, and suppositories or enemas. Contributing factors, such as constipation and diarrhea, should be addressed and eliminated if possible. If the prolapse cannot be reduced and the viability of the bowel is in question, emergency resection is required. Rupture of the rectum also constitutes a surgical emergency. Surgical Treatment Surgical treatments can be divided into 2 categories on the basis of the approach used to repair the rectal prolapse: abdominal procedures and perineal procedures. An abdominal procedure or a perineal procedure may be preferred by the patient’s age and comorbidities. The choice of procedure is also dictated by the presence or absence of constipation. Generally, the abdominal procedures have a lower recurrence rate but a higher morbidity. Abdominal Surgical Procedures Abdominal repairs are typically performed in younger patients, whose life expectancy is longer. For these patients, procedures with lower recurrence rates but higher morbidities are most appropriate. Laparoscopic surgical rectopexy procedures have been developed that have outcomes as good as those of open abdominal procedures but are associated with shorter hospital stays and greater patient comfort. Anterior resection Patients with rectal prolapse and constipation often have a redundant colon. 25 In an anterior resection for rectal prolapse, the rectum is mobilized to the level of the lateral ligaments, and the redundant colon (sigmoid) is resected. The left colon is then anastomosed to the top of the rectum. Marlex rectopexy This procedure - Marlex (Ripstein) rectopexy involves mobilization of the rectum down to the coccyx and lateral ligaments. A nonabsorbable material, such as Marlex mesh, is fixed to the presacral fascia. The rectum is then placed on tension, and the material is partially wrapped around the rectum to keep it in position. The anterior wall of the rectum is not covered with the mesh. Suture rectopexy A suture rectopexy is similar to a Marlex rectopexy, except that the rectum is fixed to the presacral fascia with sutures. Resection rectopexy A resection with rectopexy (Frykman-Goldberg procedure) is a combination of an anterior resection and a Marlex rectopexy; it is a good option for patients with a significant component of constipation. Perineal Surgical Procedures Perineal procedures have higher recurrence rates but lower morbidities and are often performed in elderly persons or in patients for whom general anesthesia is contraindicated. Anal encirclement With anal encirclement (Thiersch wire), a nonabsorbable band is placed subcutaneously around the anus. The purpose of this procedure is to keep the rectum from prolapsing by restricting the size of the anal lumen. Anal encirclement is effective in mechanically preventing the rectum from prolapsing, but it does not treat the underlying disorder. And there are some procedures, like Delorme mucosal sleeve resection, Altemeier perineal rectosigmoidectomy and even Hemorrhoidectomy, which can be used in treatment of rectal prolapsed as well.

VI. Plan and structure of class Main stages of the Learning Methods of Time class, their objective in # teaching Guidelines distributi function and the levels of and control on meaning mastering

Preliminary stage

1. Arrangements 1. Relevance 5 min. 26

2. Determining the 2. Educ. objectives 5 min relevance,

educational objectives and motivation

3. Control of the 45 min. intput level of

knowledge, skills and abilities:

1. Etiology and І Survey Questions pathogenesis

Survey, Questions, II level 2. Clinical signs ІІ tests MCQs

Clinical Typical clinical 3. Diagnosis ІІ cases, cases, II level MCQs MCQ

Clinical Typical clinical cases, cases, II level 4. Treatment ІІ MCQs MCQ

Main stage

4. Formation of ІІІ 95 min. students

professional skills: Practical Patients with rectal 1. Master the skills training diseases of the physical examination 2. Perform Practical Patients with rectal physical training diseases, patients examination of cards the patient with

rectal diseases 27

3. Plan the patients Practical Clinical cases, III laboratory and training level MCQs imaging studies

4. Differential Practical Diagnostic diagnosis training algorithms,atypical clinical cases

5. Treatment Practical Typical and schemes training atypical clinical cases

Final stage

5. Correction of the ІІІ Personal Clinical cases and 30 min. professional skills skills III level MCQs

and abilities control,

analysis

and

evaluation

of the

results of

clinical

work,

clinical cases, level III MCQs

6. Summarizing class Results of patients examination,

MCQs and clinical cases solutions

Homework (basic 7. Oriented card for and additional independent work literature) with literature

28

VII. Materials for classes

Questions (α =І, α =ІІ)

1. Etiology and pathogenesis of rectal diseases. 2. Classification of rectal diseases. 3. Clinical signs of rectal diseases. 4. Laboratory diagnosis of rectal diseases. 5. Features of the clinical course of rectal diseases in elderly people. 6. Main differences between hemorrhoids and rectal prolapse. 7. Differential diagnosis of rectal diseases. 8. Treatment of rectal diseases. 9. Complications of rectal diseases.

TESTS 1. Perirectal abscess fistulous disease is most oftenly: A. Associated with a specific systemic disease B. Associated with specific infection disease C. Cryptoglandular in origin D. Associated with hemorrhoids E. Etiology is not known

2. According to their location perirectal abscesses are classified to (one answer is not correct): A. Superficial B. Supralevator C. Ischiorectal D. Intersphincteric E. Perianal

3. The typical complications of perirectal abcess are all, except: A. Internal fistula B. Hemorrhoids C. Sphincter injury D. Perineal sepsis E. Chronic fistula

4. What imaging study is necessary to make diagnosis uncomplicated perirectal abscess 29 fistula disease? A. Sinogram B. Transrectal US C. CT D. No imagine study E. MRI

5. The most effective treatment, which is successful in healing 90% of anal fisures, includes: 1. Stul softeners; 2. Lexatives; 3. Antibiotics; 4. NSAIDs; 5. Sitz bath. A. 1, 2, 3 B. 1, 2, 4 C. 2, 3, 4 D. 3, 4, 5 E. 1, 2, 5.

6. Uncomplicated interanal hemorrhoids typicaly are acossiated with: A. Anorectal pain B. Pain after defecation C. Thrombosis D. Perirectal abscesses E. Bright-red bleeding per rectum

7. Interanal and external hemorrhoids can develop all complications except: A. Incarceration B. Necrosis C. Perianal condylomas D. Thrombosis E. Bleeding

8. Protoscopy reveals nonbleeding grade I hemorrhoids. Indications for surgical treatment are all except: A. III-IV grade hemorrhoids B. Severe bleeding C. Thrombosis D. I-II grade hemorrhoids E. Necrosis

9. Why during hemorrhoidal bleeding the blood is bright-red? A. Hemorrhoidal vein have lots of shunts with rectal 30 B. Hemorrhoids never bleed C. Hemorrhoids develops from arteries D. Bleeding is associsted with coagulopathy E. Most oftenly upper parts of colon are bleeding, which are richy vascularized

10. A 44-year-old man has recurrent hemorrhoids. What treatment modality is not indicated in case of recurency? A. Conventional surgery B. Minimaly invasive treatment C. Increasing D. decreasing constipating foods, E. decreasing time spent on the toilet