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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
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rectal prolapse, fistulae, obesity with deep anal cleft, urinary incontinence, vaginal discharge, etc). Idiopathic pruritus is not
associated with detectable underlying disease, but most commonly the result of dietary and hygiene habits.
Epidemiology
Very frequent complaint; however, only a minority of individuals will seek medical attention. Male:female ratio = 4:1.
Symptoms
Itching, constant or sporadic, cycles (eg, at nighttime). Look for associated symptoms: moisture, drainage, prolapse,
pain/discomfort (particularly after bowel movements).
Differential Diagnosis
Idiopathic pruritus ani: no detectable underlying pathology.
Secondary pruritus ani: result of underlying primary pathology:
Local diseases: fistula, fissure, incontinence, condylomata and other STDs, prolapse, neoplasm, pinworm infection,
etc.
Dermatoses: psoriasis, lichen sclerosus, allergic/contact dermatitis (often secondary to use of topical medications),
radiation injury, etc.
Systemic diseases: diabetes, lymphoma/leukemia, renal failure, jaundice.
Pathology
Secondary pruritus: depending on underlying pathology.
Idiopathic pruritus: unspecific dermatitis.
Evaluation
REQUIRED MINIMAL STANDARD
History: Onset, pattern of occurrence, associated symptoms, daily habits?
Clinical examination: anal configuration? Local skin pathology visible (Figure 4–5) or not visible? Symmetric vs asymmetric,
secondary pathology (eg, scratch excoriations, skin atrophy from chronic steroid use). Signs of chronicity (lichenification)?
Evidence of skin pathology in other body areas? Sphincter function?
Figure 4–5.
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Perianal dermatitis.
Anoscopy/proctoscopy: Tumor, hemorrhoids, proctitis, etc.
Full colonic evaluation only necessary if indicated as per general screening guidelines.
ADDITIONAL TESTS (OPTIONAL)
Cultures: fungal, viral (herpes), chlamydia, HPV.
Biopsy: Bowen disease, Paget disease, dermatoses, etc.
Stool cultures, O&P, perianal tape test (pinworms).
Classification
Idiopathic pruritus vs secondary pruritus.
Nonoperative Treatment
Indicated for idiopathic pruritus and for symptomatic improvement in secondary pruritus:
Elimination of current topical creams/ointments.
Elimination of soaps, overzealous hygiene, recycled toilet paper, alcohol wipes, deodorants, etc.
Application of barrier ointment (zinc oxide based, etc), consider KMnO
7
sitz baths (2 crystals per bath tub such that
water is minimally stained, not purple).
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Corticosteroids creams: only indicated for very short period (< 1 week).
Weight reduction.
Elimination of foods: caffeine (including chocolate, tea, etc), spices, alcohol, tomatoes, citrus fruits, nuts.
Operative Treatment
INDICATION
Only if needed for elimination of underlying pathology (see respective topics). Never indicated for idiopathic pruritus.
OPERATIVE APPROACH
Depending on the primary pathology (see respective chapters).
Outcome
Dependent on success of treating underlying pathology. Idiopathic pruritus commonly responds to change of daily habits.
Follow-Up
Recheck patient after 4–6 weeks of initiated treatment. Order appropriate tests (eg, cultures/biopsies) if no response. Once
resolved, no follow-up needed.
Cross-Reference
Incontinence (Ch. 1)
Skin rash (Ch. 1)
Clinical examination (Ch. 2)
Anal fissure (565.0) (Ch. 4)
Perianal/-rectal fistula (565.1) (Ch. 4)
Fecal incontinence (787.6) (Ch. 4)
SOLITARY RECTAL ULCER SYNDROME (SRUS, 569.41)
Overview
Solitary rectal ulcer syndrome is a distal rectal pathology resulting from recurrent mechanical stress, most commonly rectal
prolapse, recurrent digital manipulations, or recurrent autoinstrumentations, etc. The name is misleading: SRUS is not
required to be solitary and not even required to include an ulcer; other, hyperplastic/polypoid changes may be present.
Epidemiology
Rare, but prevalence is underestimated. Affects all ages depending on underlying pathology/behavior.
Symptoms
SRUS symptoms: bleeding, mucous discharge, pain, tenesmus, incomplete evacuation, urgency.
Associated symptoms from underlying pathology: eg, recurrent rectal prolapse, incontinence, outlet obstruction (eg,
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paradoxical puborectalis contraction).
Differential Diagnosis
IBD: ulcerative colitis, Crohn colitis.
Radiation proctitis.
STDs: eg, lymphogranuloma venereum, herpes simplex, HIV-associated ulcers, primary syphilis, chancroid, etc.
Endometriosis.
Adenomatous changes.
Pathology
Characteristic myofibrosis of lamina propria with paucicellular stroma (ie, striking absence of inflammatory cells, particularly
neutrophils). In addition, thickened mucosa, distorted crypt architecture.
Evaluation
REQUIRED MINIMAL STANDARD
History: symptoms? Evidence of external prolapse (length)? Underlying bowel function (constipation/diarrhea, need for
manual support)? Change in bowel habits? Incontinence (fecal/urinary)? Sexual practices? Previous surgeries (eg, prolapse,
hysterectomy, etc)? Previous colonic evaluations (flex sigmoidoscopy, colonoscopy, BE)?
Clinical examination: triggerable rectal prolapse? Rectal mass?
Rigid sigmoidoscopy: lead point? Visible mucosal changes (ulcerations, thickening?)
Full/partial colonic evaluation prior to elective surgery.
Defecating proctogram.
ADDITIONAL TESTS (OPTIONAL)
Dynamic MRI.
ERUS: thickening of the mucosa and rectal wall.
Classification
SRUS with identifiable prolapse.
SRUS without identifiable prolapse.
Nonoperative Treatment
SRUS without prolapse and manageable symptoms: counseling, dietary changes, fibers, laxatives, abstain from manual or
instrument manipulation, possible biofeedback training.
Operative Treatment
INDICATION
Any SRUS with identifiable prolapse.
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SRUS without identifiable prolapse, but significant treatment-refractory symptoms.
OPERATIVE APPROACH
Prolapse: abdominal or perineal prolapse repair.
No prolapse: local transanal excision; in severe cases need for low anterior resection with coloanal anastomosis.
Outcome
Natural course of SRUS not completely documented; some changes are reversible upon correction of cause.
Follow-Up
Functional reassessment at regular intervals.
Cross-Reference
Prolapse (Ch. 1)
Defecating proctogram (defecography) (Ch. 2)
Hemorrhoids (455.X) (Ch. 4)
Rectal prolapse (569.1) (Ch. 4)
Rectal prolapse–perineal Delorme repair (Ch. 5)
FOREIGN BODIES (937, 936/938)
Overview
Retained or stuck foreign bodies pose a special challenge for defining when surgical intervention is needed. The rate of
successful intestinal passage and of spontaneous rectal expulsion is unknown; the problem hence likely is more frequent
than reported. Patients only seek medical advice for manifest or pending intestinal obstruction or perforation,
pain/discomfort, or if, despite prolonged efforts, they are unable to retrieve the object from the rectum.
Rectal foreign bodies: autoeroticism with lost control because anus/rectum function as a trap that make retrieval difficult: (1)
sphincter muscle results in high-pressure closure behind inserted object and causes further proximal dislocation of the
object; (2) presacral and puborectalis curvatures result in a change of direction; (3) valves of Houston form additional
obstacles. Complications: obstruction, perforation, sphincter injury.
Oral ingestion of foreign bodies (subentity: hair bezoars): young children, underlying psychopathology (Figure 4–6), or
intentional body packing. Common GI obstacles: gastroesophageal junction, pylorus, ligament of Treitz, terminal ileum,
rectosigmoid, anal canal; in addition, anastomotic sites (recurrent ingestions/explorations), adhesive kinks.
Figure 4–6.
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Ingested foreign objects in a schizophrenic patient.
Complications: obstruction, perforation, abscess formation, internal injury, bleeding, corrosion, rupture of body packs with
acute intoxication/death.
Epidemiology
Oral ingestion: incidence unknown, spontaneous passage rate unknown.
Rectal insertion: incidence unknown, spontaneous expulsion rate unknown.
Symptoms
Oral ingestion of foreign object: passage dependent on form, size possible obstruction, possible perforation, possible
bleeding, possible complete passage.
Intracorporeal rupture of body packs
acute toxicity and cardiopulmonary collapse.
Rectal insertion of foreign object: pain, discomfort, bleeding, abdominal pain (ominous sign).
Differential Diagnosis
Intoxication other routes of administration, other causes of loss of consciousness.
Obstruction
other causes of SBO/LBO.
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Pathology
None.
Evaluation
REQUIRED MINIMAL STANDARD
All Forms of Foreign Bodies
History: often not revealing (altered story, denial, psychosis); social and psychological background?
Clinical examination:
Vital signs: evidence of intoxication?
Abdominal exam: distention, peritoneal signs?
Initial abdominal and pelvic x-rays: free air, obstructive pattern, identification and characterization of objects (primary and
unreported).
Oral Foreign Body Ingestion
Chest-x-ray in two projections: esophageal foreign body, free subdiaphragmatic air, mediastinal air.
Serial abdominal x-rays: change of foreign body position?
Caution with digital rectal exam: potential for sharp objects?
Rectal Foreign Body
Clinical examination: careful anal (and vaginal) evaluation: risk of laceration, risk to examiner. Gentle digital rectal exam:
avoid pushing object more proximally!
ADDITIONAL TESTS (OPTIONAL)
None.
Classification
None.
Nonoperative Treatment
Orally ingested foreign bodies: EGD with attempted endoscopic removal (through protector sheath), or watchful waiting
(serial clinical and radiological exam).
Rectal foreign bodies: attempt at bedside extraction (70–75% successful).
Operative Treatment
INDICATION
Irretrievable foreign body.
Foreign body with complication.
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OPERATIVE APPROACH
Attempt at extraction under anesthesia.
Laparotomy with either bimanual expulsion (milking) or enterotomy and retrieval of foreign body.
Outcome
Nonsurgical retrieval or passage of foreign bodies in 75–80%; need for surgical intervention in 20–25%. Unspecified risk of
recurrent episodes.
Follow-Up
Prevention strategies?
Cross-Reference
Pain, perirectal (Ch. 1)
Conventional x-rays (plain films) (Ch. 2)
Solitary rectal ulcer syndrome (SRUS, 569.41) (Ch. 4)
GAY BOWEL SYNDROME
Overview
Coined in the pre-HIV era, the term "gay bowel syndrome" comprised a rather unselective potpourri of unusual anorectal and
GI symptoms experienced by homosexual males: abdominal pain, cramps, bloating, flatulence, nausea, vomiting, diarrhea,
enteric infections (bacterial, viral, fungal, parasitic), trauma.
With better understanding of the underlying causes, this term is outdated: the derogatory terminology should be abandoned
and more specific entities and terms recognized and used:
Condylomata acuminata, mollusca contagiosa.
Hemorrhoids.
Proctitis (lymphogranuloma venereum, gonorrhea, syphilis, herpes simplex, etc).
Perirectal abscess/fistula.
Anorectal ulcer/fissure.
Acute enteritides (salmonella, shigellosis, Campylobacter, Clostridium difficile, E coli, viral pathogens, Staphylococcus
aureus, etc).
Chronic diarrhea (Cryptosporidium, Microsporidium, Cyclospora, Giardia, Isospora, Entamoeba histolytica,
Mycobacterium avium complex [MAC], CMV, HIV enteropathy).
Benign polyps.
Lymphoma.
Viral hepatitis.
Anorectal trauma and foreign bodies.
Tuberculosis, atypical mycobacteriosis (MAC).
Associated symptoms (urethritis, etc).
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Cross-Reference
Discharge (Ch. 1)
Ulceration (Ch. 1)
HIV-associated anorectal diseases (042) (Ch. 4)
Sexually Transmitted Diseases (STDs, 091, 098, 099) (Ch. 4)
Anal condylomata (078.10) (Ch. 4)
Anal cancer (154.2, 154.3) (Ch. 4)
Infectious enterocolitis (002-009.X) (Ch. 4)
HIV-ASSOCIATED ANORECTAL DISEASES (042)
Overview
Anorectal disorders are frequent in HIV-positive men who have sex with men (MSM) and may represent the original reason
to seek medical attention. Improved treatment options with availability of HAART (highly active antiretroviral therapy) have
dramatically changed the previously universally fatal HIV infection as such, and opportunistic infections and HIV-associated
tumors (lymphoma, Kaposi sarcoma) have decreased since 1994. Yet, despite HAART, the incidence of anorectal problems
has not changed, and anal dysplasia and cancer are on the rise. The original risk constellation (unprotected anorectal
intercourse) appears to be primarily responsible for a majority of the problems.
Most common clinical presentations (frequently multiple synchronous problems) are:
One-third anal condylomata.
One-third HIV-associated ulcers.
One-third other problems: abscess and fistula-in-ano, hemorrhoids, STDs, trauma/foreign body, anal
dysplasia/neoplasia, molluscum contagiosum, tuberculosis (typical, atypical).
HIV-associated ulcer: painful flat and often eccentric lesion at the anal verge, caused by combination of mechanical trauma,
multibacterial and viral infection.
Surgical treatment in HIV-positive patients, which historically (1986) had unacceptably high morbidity/mortality, has become
safer: healing time is prolonged and poor outcomes are still possible, but overall symptom relief and eventual healing rate
approximates that of HIV-negative patients.
Epidemiology
Anorectal disorders develop in 3–35% of HIV population (particularly MSM).
Symptoms
Depending on pathology worsening and increasingly constant perianal and/or deep rectal pain, possible fever, possible
urinary retention, bleeding/discharge, growth:
Condylomata: lumps or bumps, itching, bleeding.
HIV-associated ulcer: pain, purulent discharge, bleeding.
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STDs: perirectal pain (HSV), mucopurulent discharge and urgency/tenesmus (lymphogranuloma venereum), diarrhea,
etc.
Abscess: swelling, pain, inflammatory mass, fevers.
Anal intraepithelial neoplasia (AIN) cancer: range between asymptomatic to pain, mass/lesion.
Hemorrhoids: bleeding, prolapse.
Other HIV-associated symptoms: wasting, fat redistribution syndrome (fat accumulation, lipodystrophy), lymphadenopathy,
seborrheic dermatitis, dementia, etc.
Differential Diagnosis
Pain
Non-HIV related causes: chronic anal fissure, thrombosed external hemorrhoid, abscess, levator ani spasm, anismus.
HIV-related: HIV-associated ulcer, HSV infection, abscess, STDs, trauma.
Ulceration
Chronic anal fissure (unlikely in MSM): higher location (anal canal), tight sphincter tone, tags very common.
Idiopathic HIV-associated ulcer: often also in posterior midline or eccentric/multicentric, low location (anal verge), lax
sphincter tone, tags uncommon, possible mucosal bridging.
Specific infections: HSV, CMV, chancroid, tuberculosis, Cryptococcus, actinomycosis.
Acute trauma (intercourse, foreign bodies).
Neoplastic: anal cancer, lymphoma.
IBD (ulcerative colitis/Crohn disease).
Growth/Lump
Condylomata.
Cancer, lymphoma, Kaposi sarcoma.
Actinomycosis, chancroid, etc.
Pathology
HIV-associated ulcer: epithelial ulceration, unspecific acute and chronic infiltrates.
Other pathologies: dependent on underlying disease.
Evaluation
REQUIRED MINIMAL STANDARD
History: Onset/pattern of symptoms, lumps/bumps, underlying bowel function and habits, preexisting incontinence? HIV test
done? Time since HIV infection? Partner diseases? Opportunistic infections and tumors? Weight loss? Current HAART
medications?
If not already done: HIV test.
Immune status: CD4 count, viral load.
Clinical examination: