Professional Documents
Culture Documents
By
Dr Hemant D Toshikhane MS(AY.) PROF & HOD DEPT OF SHALAYATANTRA KLEU SHRI BMK AYURVEDA MAHAVIDAYALAYA SHAHAPUR, BELGAUM drhemantt@gmail.com
COMMON PROBLEMS
Per rectal bleeding,
Pain,
Constipation,
Common conditions
Haemorrhoids, Fissure in ano, Fistula in ano,
Anal polyp,
Proctitis, Pilonidal sinus, Rectal prolapse, Neoplasia of anal canal and rectum.
Rectal Anatomy
Anal canal - Haemorrhoids, Fissure in ano, Fistula in ano, Incontinence, Stricture and Anal growth
History
Principal symptoms of rectal and anal conditions:
Bleeding Pain Tenesmus Change in bowel habit Change in the stool Discharge pruritis
DIAGNOSTIC APPROACH
History (Prashna) Physical examination (Darshana, Sparshana)
Investigations
Age
History
Hemorrhoids common all ages but are uncommon below the age of 20 years. Perianal haematomata occurs at all ages
History - Bleeding
Can be fresh or altered
Example of altered is melaena Black tarry stool
History
Sex Hemorrhoids-
common in men
Anorectal abscessmore common in men Pilonidal sinus-
History - Bleeding
Diagnosis of anal conditions which present with rectal bleeding
history focusing on the nature of the pain and its relationship to defecation The pattern of pain helps differentiate anal fissure from hemorrhoids and other conditions. (hemorrhoids and rectal cancer are usually not painful)
Anorectal pain that begins gradually and becomes excruciating over a few days with localized are of tenderness is more likely to be
abscess.
made worse by defecation could be due to
piles.
An occasional, severe, cramp-like pain deep in the anal canal, that often occur at night, lasting about half an hour
proctalgia fugax. Proctalgia fugax pain is excruciating and may be accompanied by sweating, pallor and tachycardia. Patients experience urgency to defecate, yet pass no stool.
A knife-like pain when you have your bowels open, and which may last for 1015 minutes afterwards. often described like 'passing glass'. In addition to the pain, some bright red blood on the toilet paper is noticed. Anal fissure.
Anorectal examination
One of the most important examinations in a patient with abdominal disease. Still its the least popular segment of the entire physical examination.
Should not be omitted from your examination, especially in middle-aged and older patient, why?
risks missing an asymptomatic carcinooma
Anorectal examination
Things never to be forgotten
Explain necessity of procedure and reassure the patient Explain the procedure Tell the patient that is usually uncomfortable but not painfull Get informed consent Ensure adequate privacy
Expose the patient from waist to knee and explain the position of examination.
Equipment: plastic glove + lubricating jelly + good light
Anorectal examination
External inspection:
Piles. Skin tags (normal, Crohn's, hemorhoids). Rectal prolapse. Anal fissure. Fistula. Anal warts. Carcinoma. Signs of incontinence, diarrhea. Ask pt. to strain. Rectal prolapse upon straining. Hemorrhoid prolapse. Incontinence. Ask if straining is painful
Learning Objectives
List the uses of DRE in patient care
List and explain the common physical findings of the prostate exam
Skills Checklist
Communication skills
Explaining procedures
Showing sensitivity to patient needs or responding to discomfort Talking the patient though the exam Sharing exam findings with the patient
Skills Checklist
Technical skills Positioning the patient Performing the exam Explaining exam results Arranging appropriate follow up
Anorectal examination
Palpation
Lubricate index finger. Insert finger slowly, assessing external sphincter tone as enter. Male:
palpate prostate [anterior of rectum] Hard nodule (prostate cancer). Tender (prostatitis).
Rotate finger, palpating along left, posterior, right walls. Withdraw finger.
Anorectal examination
Inspect withdrawn fingertip for: Blood, melaena Stool color Pus Mucous. Other examination would be systemically preformed and depends on the case you have e.g swelling such as anorectal abscess or ulcers.
PROCTOSCOPIC EXAMINATION
Internal Hemorrhoids Hypertrophied Anal papillae Congestion
Bleeding points
Foreign body
PROBING
Advisable only after proper inspection and palpation. Should be done following the Goodsalls rule to avoid faulty direction. A malleable copper probe is passed into the fistula, hold it in position & forefinger of the other hand is inserted into the anal canal. Feel the tip of the probe emerging through the internal opening into the anal canal.
ANORECTAL ABSCESS
An anorectal abscess is a collection of pus in the anal or rectal region Causes: Infection of an anal fissure (cleft or slit), sexually transmitted infections, and blocked anal glands are common causes of anorectal abscesses Abscesses may occur in an area that is easily accessible for drainage, or higher in the rectum. Deep rectal abscesses may be caused by intestinal disorders such as Crohn's disease or diverticulitis.
ANORECTAL ABSCESS
High risk groups include diabetics, immunocompromised patients, people who engage in receptive anal sex, and patients with inflammatory bowel disease. The male to female ratio is approx. 2:1 The most common organisms * E.coli (60%) * Staph. aureus (23%)
ANORECTAL ABSCESS
Symptoms and signs :
( the most common symptom) * Swelling (95% of patients) * Discharge (12% of patients) * Fever(18% of patients ) * Constipation (may occur) * Rigors ,sweating and tachycardia Complications: systemic infection, ,recurrence , scarring and anal fistula formation
* Pain
Rectal prolapse
Rectal prolapse is the abnormal movement of the rectal mucosa down to or through the anal opening.
Mucosal prolapse
Rectal prolapse
Mucosal prolapse is more often seen in children below 3 yrs of age following an attack of diarrhoea or whooping cough , and if it occurs in adult is usually associated with haemrrhoids. Complete rectal prolapse is seen more commonly in elderly women who have a habit of excessive straining during defecation.
Rectal prolapse is often associated with other conditions such as: * Pinworms(Enterobiasis) * Cystic fibrosis * Malnutrition and malabsorption (Celiac disease) * Constipation * Prior trauma to the anus or pelvic area
Proctitis
An inflammation of the rectum causing discomfort, bleeding, and occasionally, a discharge of mucus or pus, And the anus may also be involved. Causes:
Proctitis
Symptoms: pain, discomfort rectal bleeding rectal discharge, pus stools, bloody constipation Tenesmus
Proctitis
Treatment: treatment of the underlying cause usually cures the problem. Proctitis caused by infection is treated with antibiotics specific for the causative organism. Corticosteroid or mesalamine suppositories may relieve symptoms in Crohn's disease or ulcerative colitis.
Types of Polyps
Juvenile Polyps
Commonest form of polyps in children Are red pedunculated spheres lesions Can occur throughout large bowel but are most common in the rectum Usually present before 12 years Present with Prolapsing lump or rectal bleeding Have little malignant potential Treated by local endoscopic resection
Adenomatous Polyps
Are pedunculated lesions Mainly occur in the rectum and sigmoid colon Are often asymptomatic but may produce anaemia from chronic occult bleeding May give rise to crampy pain May secrete mucus Have malignant potential Treated by colonoscopic polypectomy
Villous Papillomas
Are flat, sessile lesions within the rectum Secrete copious amount of mucus producing spurious diarrhoea Present with hypokalemia Significant risk of malignant change Treated by transanal excision of complete lesion If lesion is extensive, mucosal proctectomy and coloanal anastomosis should be done
ISCHIORECTAL ABSCESS