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By O. Kirk. University of South Carolina. 2019.

Hemorrhoids Several potential spaces exist around the anal canal that occur proximal to the dentate line are termed internal (Fig purchase premarin 0.625mg. The space between the internal and external anal hemorrhoids purchase premarin 0.625mg with mastercard, whereas those that occur distal to the dentate sphincter is termed the intersphincteric space premarin 0.625 mg sale. Hemorrhoids are part sphincteric space is contiguous with the perianal space which of normal anatomy that contribute to baseline anal conti- surrounds the external portion of the anus circumferentially. In addition, during times of increased intra-abdominal Lateral to the external sphincter muscle on each side is the pressure, such as during coughing or sneezing, the vascular ischiorectal space which is also bound by the levator ani cushions engorge, maintaining continence. These two ischiorectal spaces connect posteriorly though the deep postanal space, which lies between the levator ani and the anococcygeal ligament. Inspection of the anal area examined for masses, induration, stricturing, or the presence is the first portion of the anorectal examination and should be of a rectocele. Baseline anal tone should be noted and the done with the buttocks retracted laterally. Abnormal masses, patient is asked to squeeze their anal sphincter in order to scarring, swelling, erythema, fluctuance, fissures, and hem- evaluate anal squeeze function. Several types of anoscopes next step is the digital rectal examination which should be are available and should be utilized according to operator 67 Concepts in Surgery of the Anus, Rectum, and Pilonidal Region 635 preference. Anoscopic examination assists evaluating the Operating Room Positioning mucosa of the distal rectum and anal canal. For operative anorectal surgery, both high-lithotomy and Proctoscopy, either rigid or flexible, should be utilized to prone-jackknife positioning are used. In the author’s experience, most anorectal procedures can be done well in Ambulatory Management this position. Prone- jackknife positioning has a distinct advantage when dealing with anterior rectal pathology such Many common anorectal conditions such as hemorrhoidal as performing transanal excision of an anterior rectal lesion, rubber band ligation can be managed in the office setting. This position The components for successful treatment in this setting must also be used for the treatment of pilonidal disease as the include a willing patient, an appropriate environment, and upper gluteal crease is not exposed in high-lithotomy the correct instrumentation. Clinical Conditions: Symptoms The need for excellent lighting cannot be understated and and Management Concepts the absence of headlights or procedural lighting can be a sig- nificant barrier to performing anorectal procedures in the Hemorrhoids office setting. If a table for prone posi- Hemorrhoidal disease is the most common anorectal com- tioning is not available or the patient is unable to accommo- plaint for which patients present to physicians, and often the date this position, the Sims’ position may be used with the actual diagnosis is unrelated to hemorrhoids. Hemorrhoids patient on their left side, left leg extended and right leg are a normal part of anorectal anatomy, but they can enlarge flexed. A trained assistant is invaluable for exposing the glu- secondary to chronic straining. When internal hemorrhoids teal crease, supporting the anoscope, passing instruments, enlarge, the overlying mucosa can become thin and friable and comforting the patient. It may range from a small amount on the toilet paper to dripping in the Local Anesthesia for Anorectal Procedures toilet bowl, but it is typically self-limited. Local anesthesia can be used for office procedures alone or Severity of internal hemorrhoids is categorized according to combined with sedation for procedures performed in the oper- degree of prolapse. A common technique involves injection of bupiva- exhibit any prolapse with straining. Buffering the hemorrhoids prolapse with straining, but spontaneously anesthetic solution with 0. Third-degree internal hemorrhoids prolapse but immediately before injection decreases pain. Fourth-degree internal thetic solution is injected into each quadrant of the subcutane- hemorrhoids are not reducible. This is followed by injecting 10 ml evaluated by asking the patient to sit on the commode and of solution just lateral to each side of the anal sphincter. Cromwell Treatment of internal hemorrhoids varies based on the Anorectal Suppurative Diseases degree of prolapse. All patients should be placed on bulk- ing agents and instructed to drink plenty of fluids in order Most anorectal abscesses are thought to originate in the anal to minimize straining and regulate stool consistency. If bleeding persists or prolapse is viduals, risk factors include diabetes, Crohn’s disease, peri- present, additional therapy may be necessary. Intersphincteric abscesses therapy, infrared coagulation, and rubber band ligation, occur between the internal and external sphincter muscles. Rubber band ligation involves Perianal abscesses occur around the anus just under the peri- placement of a strangulating rubber band on the redundant anal skin and are the most common type of anorectal abscess. This procedure removes some of the redun- Ischiorectal abscesses occur in the ischiorectal space. These therapies are most successful with first- or ischiorectal abscess can present as a horseshoe abscess second-degree internal hemorrhoids. These abscesses may Typically, third- and fourth-degree internal hemorrhoids as be a result of anal cryptoglandular infection versus an intra- well as mixed internal and external hemorrhoids also abdominal process. This can be performed as a The most common presentation for an anorectal abscess conventional excisional hemorrhoidectomy or, in selected is severe constant anorectal pain, erythema, warmth, indura- cases, the so-called stapled hemorrhoidectomy or proce- tion, and fluctuance. It is therefore typically performed example, intersphincteric abscesses typically present with in patients with circumferential and more extensive inter- pain and a normal external anal examination. Physical are generally asymptomatic, but when thrombosis occurs, exam is sufficient for diagnosing most anorectal abscesses. Imaging is an important adjunct when a complex disease is Thrombosis is often associated with pregnancy or exer- suspected, there is early recurrence of a previously drained tion, such as lifting or straining. Within the first 72 h of abscess, or an abscess is suspected but the external physical onset, surgical excision may be performed to hasten recov- examination is normal. Thrombosed hemorrhoids usually consist of multiple resonance imaging are the most common imaging modalities small thrombi; therefore, incision and drainage is gener- utilized. After this time Appropriate treatment of anorectal abscesses includes period, the thrombosis usually begins to soften and become incision and drainage. At this stage, it is generally recommended treated in the office, emergency department, or operating that treatment consist of supportive measures including room settings, depending on size, severity, and patient dis- sitz baths, pain control, and avoidance of constipation. Drainage is typically performed by incising the With enlargement of the vascular cushions of the external skin overlying the abscess as close to the external sphincter hemorrhoids, the overlying skin can become redundant as possible. However, there are a few special circumstances leading to the development of external hemorrhoidal tags.

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Tenderness in the left lower quadrant with or without a significant mass would be suggestive of ulcerative colitis cheap premarin 0.625 mg line, diverticulitis order 0.625mg premarin with visa, and irritable bowel syndrome discount premarin 0.625mg online. A mass in the area of the ascending or descending colon or the transverse colon should also be looked for, as these would suggest carcinoma. Among them are thyrotoxicosis, in which case one would be looking for a thyroid tumor and a tremor and tachycardia; carcinoid syndrome, which would cause considerable flushing; Addison’s disease, which would cause hyperpigmentation of the skin; and pellagra, which may cause dermatitis and dementia. Diarrhea that persists after fasting suggests a secretory diarrhea from a polypeptide-secreting tumor, such as villous adenoma, a gastrinoma, or a carcinoid tumor. Serum lactoferrin and calprotectin will distinguish inflammatory bowel disease from irritable bowel syndrome. Giardiasis may be best diagnosed by the 179 finding of Giardia antigen in the stool. If these tests do not provide a diagnosis, the most cost-effective approach at this point is to refer the patient to a gastroenterologist who will undoubtedly perform a colonoscopy as part of the workup. Small bowel aspiration and biopsy will be useful in diagnosing Giardia infection or celiac sprue; angiography will confirm mesenteric ischemia or infarcts. A swallowed string test may pick up Giardia, but when all else fails, a trial of metronidazole will be diagnostic. If a gastroenterologist is not available, the clinician may proceed with a quantitative 24-hour stool analysis for fat. If there is 10 g or more of fat in the stool in a day, then steatorrhea can be diagnosed and one can proceed with the workup of steatorrhea (page 482). If there is less than 7 g of fat per day in the stool, the stool volume after fasting should be done. If it is large and we have ruled out surreptitious laxative abuse, a polypeptide- secreting tumor should be considered. If the volume after a fast is small, the problem is most likely lactose or other food intolerance or an irritable bowel syndrome. The presence of pain on urination should suggest cystitis, urethritis, urethral caruncle, vesicular calculus, urethral stricture, and acute prostatitis. The presence of focal neurologic signs should suggest multiple sclerosis, poliomyelitis, cauda equina tumor, acute spinal cord injury, tabes dorsalis, and diabetic neuropathy. The presence of an enlarged prostate would suggest benign prostatic hypertrophy or an advanced malignancy. Chronic prostatitis would present with a normal-sized or small prostate that is firm. If there is a urethral discharge, a Gram’s stain and culture for gonococcus should be done. If there is a significant amount of residual urine, referral to an urologist for cystoscopy and cystometric testing is done. Diplopia that is unilateral is rare, but it can be encountered in ectopia lentis as associated with Marfan’s disease as well as in congenital double pupil, cataracts, and corneal opacities. Intermittent diplopia would make one think of myasthenia gravis, but remember, Eaton–Lambert syndrome can do the same thing. If there is associated proptosis, one should consider hyperthyroidism or pituitary exophthalmos, especially if it is bilateral. However, when it is associated with chemosis and ecchymosis, one should consider an infectious process. These findings should make one think immediately of cavernous sinus thrombosis, but an arteriovenous aneurysm can produce unilateral chemosis, ecchymosis, and exophthalmos. The findings of associated pyramidal tract or other long tract signs would make one think of a brain stem infarct or a brain stem tumor. Advanced intracranial pressure will put pressure on the sixth nerve and cause diplopia. Multiple sclerosis and basilar artery thrombosis on insufficiency may cause long tract signs along with extraocular muscle palsies. Findings of fever and chills and diplopia should make one think of an orbital abscess, a brain abscess, or a cavernous sinus thrombosis. If there is chemosis or ecchymosis, a cavernous sinus thrombosis is 184 likely, and immediate admission to the hospital and administration of antibiotics after blood culture has been drawn are indicated. True vertigo is characterized by the fact that the person feels he/she or his/her environment is turning. One other form of true vertigo is lateral pulsion, in which the person feels as if he/she is moving to the left or right or may be moving forward or backward. True vertigo is a sign of neurologic or otologic disease, whereas dizziness that is not true vertigo is more likely a sign of cardiovascular disease, drug toxicity, or hypoglycemia. The presence of tinnitus or deafness, especially if the ear examination is negative, is a sign of a more serious otologic or neurologic condition. Disorders such as cholesteatoma, acoustic neuroma, and Ménière’s disease must be considered. On the contrary, vertigo without tinnitus or deafness should prompt consideration of benign positional vertigo and vestibular neuronitis. The finding of abnormalities of other cranial nerves or the long tracts, such as the pyramidal tracts, would suggest multiple sclerosis, an advanced brain stem tumor, acoustic neuroma, or basilar artery insufficiency. A normal neurologic examination with an abnormal ear examination would suggest otitis media, cholesteatoma, or petrositis. If there is hyperventilation during the attack, then hyperventilation syndrome should be considered. If the dizziness is really light-headedness, hypertension may be present, but hypertension may also cause true vertigo. Be sure to take the blood pressures while the patient is lying down and again after rapidly rising to the standing position. Irregularities of the heartbeat, heart murmurs, or cardiac enlargement will suggest cardiac arrhythmia, 186 aortic stenosis and insufficiency, mitral stenosis, prolapse of the mitral valve, and congestive heart failure. Moderate to severe anemia will cause light- headedness and dizziness, but usually not true vertigo.

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Melanoma of the anus premarin 0.625 mg otc, though rare order 0.625 mg premarin with visa, may be seen as bluish- black soft mass which may be confused with Fig discount 0.625 mg premarin with amex. A szvelling or an ulcer may be present in this region and should be examined as has been described in the chapters 3 and 4. An indurated tender swelling with brawny oedema on one side of the anus is usually due to an ischiorectal abscess. In the former a finger can be insinuated between intussusception and the anal margin, but in the latter this is not possible. More pressure will gradually push the finger into the anal canal with rotatory movement. While the finger is within the anal canal and rectum a definite system should be established to get all the informations of rectal examination. When the finger is in the anal canal note the tone of the sphincter, any pain or tenderness and any thickening of the wall of the anal canal. Patients with fissures may have spasm of the sphincters and will complain of excruciating pain during digital examination. Examination may be deferred in these cases as necessary informations cannot be gathered. Informations received in rectal examination can be divided into (a) within the lumen, (b) in the wall and (c) outside the wall. Its freedom from the rectal wall can be easily assessed if the finger is passed between intussusception and the rectal wall. This is evident by the fact that rectal wall can only be felt by bending the examining finger in the rectum. False positive results are sometimes seen after administration of enema or in obstruction of the urinary tract (presumably reflex in origin). This also marks the dividing line between the external and internal haemorrhoidal plexuses. Posteriorly the ring is felt best, then laterally due to presence of sling-like arrangement of the pubo- rectalis component of the levator ani muscle. These landmarks are important in determining the location of different anorectal abscesses or fistula-in-ano. The ascending finger may feel a soft fold of mucous membrane called valve of Houston. It cannot be impressed too strongly that uncomplicated internal piles cannot be felt with the finger. Only chronically inflamed and thrombosed piles can be felt by digital examination. The internal opening of the fistida-in-ano is usually felt as a small dimple in the centre of an indurated area. Most frequently it is situated on the mid-line posteriorly between external and internal sphincters. A diagnosis of ulcer is made by absence of normal smoothness of the rectal mucous membrane. Besides carcinoma, an ulcer may be due to tuberculosis, dysentery, gonorrhoea, soft sore, syphilis etc. History and isolation of the positive organism will establish the nature of the ulcer. A polypus of the rectum is felt as soft round growth about the size of a small grape slipping under the finger. It must be remembered that a soft lesion of the rectal wall, is likely to be felt on the downward stroke of the finger than in its upward course. So, as soon as a soft lesion is felt the finger is pushed up clear of the lesion till it reaches its upper limit. When the lumen of the rectum is constricted a diagnosis of stricture of the rectum is made. Note the position and extent of such constriction and the character of the mucous membrane at the site of the stricture whether ulcerated or thickened. It must be remembered that narrowing of the rectal lumen may be caused by pressure from outside in which case the mucous lining is perfectly smooth. Besides trauma and post-operative stricture, a few inflammatory conditions may give rise to such strictures. An enquiry should be made about previous history of genital sores and inguinal bubo. Carcinoma of the rectum is a condition in which rectal examination is of paramount importance. The remaining 25 percent occur in the upper part of the rectum and are annular in shape. About 90 percent of rectal cancer can be felt by digital examination and it is criminal not to perform rectal examination in patients with any rectal complaint. Try to decide whether the tumour is fixed or mobile, how much is its local spread — whether the neighbouring structures such as bladder and prostate (or uterus and vagina) anteriorly and the sacrum and the coccyx posteriorly are involved. It is useful to remember that the growth preserves its mobility so long as it remains within the fascia propria of the rectum. The structures around the rectum are explored systematically by palpating anteriorly, right lateral, left lateral and posteriorly. The examinations of the prostate, the seminal vesicles and base of the bladder are described under "Examination of a urinary case". To make summary of this examination it may be stated that the normal prostate is firm, rubbery, bilobed, its surface is smooth with a shallow central sulcus and the rectal mucosa can be moved freely over it. The seminal vesicles are palpable just above the upper lateral angles of the gland. The uterus is felt as a tumour whereas the cervix can be felt projecting through the anterior rectal wall which is popularly known as pons asinorum. It is a good practice to feel the cervix first and then follow to the uterus onwards. Bimanual palpation can define the shape and size of the uterus and any ovarian mass in a better way. The index finger when fully inserted reaches about one inch above the floor of pouch of Douglas in the female and about half that distance in the male. The pelvic appendix can be felt on right side and the rectal examination is imperative in pelvic appendicitis as tenderness may not be so obvious per abdomen. In case of female fallopion tubes and ovaries may be palpable and rectal examination is of great help in diagnosing salpingitis, ovarian cysts and tumours.

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The cortex is divided into 3 areas quality 0.625mg premarin, the outer zone (glomerulosa) premarin 0.625 mg on-line, which is the site of aldosterone synthesis; the central zone (fasciculata) discount 0.625mg premarin with mastercard, which is the site of cortisol synthesis; and the inner zone (reticularis), which is the site of androgen biosynthesis. The disorders of hyperfunction of the gland are associated with specific hormones: increased cortisol is seen in Cushing syndrome, increased aldosterone is seen in hyperaldosteronism, and increased adrenal androgens is seen with virilization in women. The most common causes are exogenous, iatrogenic, and those secondary to prolonged use of glucocorticoids. Adrenal neoplasia, such as adenoma or carcinoma, and adrenal nodular hyperplasia account for about 30% of Cushing cases. The clinical findings of Cushing syndrome include deposition of adipose tissue in characteristic sites such as upper fat, moon facies; interscapular buffalo hump; and mesenteric bed, truncal obesity. Other clinical findings include hypertension, muscle weakness, and fatigability related to mobilization of peripheral supportive tissue; osteoporosis caused by increased bone catabolism; cutaneous striae; and easy bruisability. Women may have acne, hirsutism, and oligomenorrhea or amenorrhea resulting from the increased adrenal androgen secretion. Emotional changes range from irritability or emotional lability to severe depression or confusion; even psychosis can occur as well. Glucose intolerance is common in Cushing disease, with 20% of patients having diabetes. Cushing and glucocorticoid use are also associated with hypokalemia and leukocytosis. Other manifestations are delayed wound healing, renal calculi from increased calcium levels, and glaucoma. There is increased susceptibility to infections because neutrophils exhibit diminished function because of high glucocorticoid levels. The diagnostic tests used to establish the syndrome of cortisol excess are the 1-mg overnight dexamethasone suppression test and the 24-hour urine- free cortisol. The 1-mg overnight dexamethasone suppression test is used to rule out the diagnosis of Cushing syndrome or glucocorticoid excess. The problem with this test is that there can be falsely abnormal or positive tests. Any drug that increases the metabolic breakdown of dexamethasone will prevent its ability to suppress cortisol levels. Examples of drugs increasing the metabolism of dexamethasone are phenytoin, carbamazepine, and rifampin. The 1-mg overnight dexamethasone suppression test can be falsely positive in stressful conditions such as starvation, anorexia, bulimia, alcohol withdrawal, or depression. An abnormality on the 1-mg overnight test should be confirmed with a 24-hour urine-free cortisol. The 24-hour urine-free cortisol is more accurate and is the gold standard for confirming or excluding Cushing’s syndrome. Evaluating a Patient with Presumed Cushing Syndrome Hyperaldosteronism Hyperaldosteronism is a syndrome associated with hypersecretion of the major adrenal mineralocorticoid, aldosterone. The normal function of aldosterone is to + reabsorb sodium and excrete potassium and acid (H ). Hyperaldosteronism can be divided into the following: Primary aldosteronism, in which the stimulus for the excessive aldosterone production is within the adrenal gland Secondary aldosteronism, in which the stimulus is extraadrenal The most common cause of primary hyperaldosteronism is a unilateral adrenal adenoma (70%). Primary hyperaldosteronism is characterized by hypertension and low potassium levels. Most of the other symptoms, such as muscle weakness, polyuria, and polydipsia, are from the hypokalemia. Metabolic alkalosis occurs because aldosterone increases hydrogen ion (H+) excretion. Edema is uncommon with primary hyperaldosteronism because of sodium release into the urine. Primary Aldosteronism Secondary Aldosteronism Diastolic hypertension + – Muscle weakness + +/– Polyuria, polydipsia + +/– Edema – +/– Hypokalemia + + Hypernatremia + – Metabolic alkalosis + + Table 2-7. The exception of secondary hyperaldosteronism without edema or hypertension is Bartter syndrome. Bartter syndrome is caused by a defect in the loop of Henle in which it loses NaCl. Etiology includes congenital adrenal hyperplasia, adrenal adenomas (rare), and adrenal carcinomas. Adrenal virilization occurs with or without an associated salt-losing tendency, owing to aldosterone deficiency, which leads to hyponatremia, hyperkalemia, dehydration, and hypotension. When you think about 11 deficiency, think mineralocorticoid excess (hypertension and hypokalemia) with low cortisol production (remember you need C-11 for the final step in converting to cortisol). Patients are female at birth with ambiguous external genitalia (female pseudohermaphroditism), enlarged clitoris, and partial or complete fusion of the labia. Patients may be male at birth with macrogenitosomia; postnatally this is associated with precocious puberty. This is because some infants have inefficient salt conservation as well as immature aldosterone production. During this phase, infants can present with hypotension and hyperkalemia (very similar to 21 hydroxylase deficiency). Later in life (childhood and adulthood), there is better ability to hold onto salt, so the patient develops the typical C-11 deficiency syndrome: hypertension and hypokalemia. C-17 hydroxylase deficiency can occur as well, and is characterized by hypogonadism, hypokalemia, and hypertension resulting from increased production of 11-deoxycorticosterone. The most useful measurements are of serum testosterone, androstenedione, dehydroepiandrosterone, 17-hydroxyprogesterone, urinary 17- ketosteroid, and pregnanetriol. Primary adrenocortical insufficiency is a slow, usually progressive disease due to adrenocorticoid hypofunction. The etiology can be secondary to anatomic destruction of the gland (chronic and acute). Idiopathic atrophy is the most common cause of anatomic destruction, and autoimmune mechanisms are probably responsible. Clinical findings in Addison include weakness, paresthesias, cramping, intolerance to stress, and personality changes such as irritability and restlessness. Chronic disease is characterized by a small heart, weight loss, and sparse axillary hair.