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Rectal Prolapse Therapy

The definition of rectal prolapse is the protrusion of the full thickness of the rectal wall through the anus (Figure 86.1). This protrusion differs from mucosal prolapse and internal intussusception. In cases of mucosal prolapse, only the inner mucosal rectal layer protrudes through the anus (Figure 8-6.2). Conversely, in cases of rectoanal internal intussusception, the prolapsed tissue remains confined within the rectal lumen. The preoperative knowledge of this type of prolapse will help direct the appropriate therapeutic option. The etiology of rectal prolapse is unclear. However, factors involved in the development of rectal prolapse may be congenital or acquired. Moreover, there are conditions that can be associated or predispose to the development of rectal prolapse. These problems include intestinal disorders such as constipation and chronic straining, neurologic diseases, especially spinal cord abnormalities and depression, nulliparity, lack of rectal fixation to the sacrum,...

Reduction of Rectal Prolapse

If rectal prolapse is noted on exam, attempt reduction by grasping protruding bowel with a lubricated glove and gently pushing it back in. 6. Inability to reduce rectal prolapse may lead to venous stasis. Edema and ulceration also may occur. Problem Case Diagnosis. The 2-year-old patient, who has a chronic history of constipation, is diagnosed with simple rectal prolapse. It is noted to occur while squatting. After reduction of the prolapse, therapy for the underlying constipation is begun. Teaching Pearl Question. How can a polyp be differentiated from rectal prolapse on examination

Hemorrhoids

Hemorrhoids are dilated veins located beneath the lining of the anal canal. Internal hemorrhoids are located in the upper anal canal. External hemorrhoids are located in the lower anal canal. B. Internal hemorrhoids become symptomatic when constipation causes disruption of the supporting tissues and resultant prolapse of the dilated anal veins. The most common symptom of internal hemorrhoids is painless rectal bleeding, which is usually bright red and ranges from a few drops to a spattering stream at the end of defecation. If internal hemorrhoids remain prolapsed, a dull aching may occur. Blood and mucus stains may appear on underwear, and itching in the perianal region is common. Classification of Internal Hemorrhoids

Coexistence of Pelvic Floor Dysfunction Symptoms

Various surveys have been performed to obtain a better understanding of the coexistence of symptoms of urinary, genital, and fecal dysfunction. Not surprisingly, there is a high incidence of coexistence of incontinence and support defects (Table 1-1.1). It has been reported that in patients seen with fecal incontinence, 24 to 53 also complained of urinary incontinence, and 7 to 22 complained of genital prolapse. Of patients who presented with rectal prolapse, 66 also complained of urinary incontinence and 34 complained of genital prolapse.6-8 In a survey of patients who had undergone surgery for rectal prolapse and fecal incontinence at our institution, with an included control group of clinic patients, the incidence of urinary incontinence was 53 in those who had previous surgery for fecal incontinence and 65 in those who had previous surgery for rectal prolapse. Genital prolapse was found in 18 of patients with fecal incontinence and 34 of patients with rectal prolapse. The control...

Continence Abnormalities

Although vaginal delivery is probably the most common cause of fecal incontinence, there are several other less common causes. Other traumatic etiologies include surgery for perianal fistula (with an incidence up to 34 ), sphincterotomy for fissure, or hemorrhoids.37 Pelvic fractures or direct anal trauma are other traumatic causes. Infiltration of the nerves and or muscles by neoplastic processes can also result in incontinence. Congenital anorectal malformations or the surgery performed to correct them account for a small percentage of fecal incontinence. Patients with a postsurgery for imperforate anus have an incidence of incontinence up to 47 in some series.38 Idiopathic causes in which there is pelvic floor denervation or dysfunctional, yet intact, musculature account for a significant proportion of fecal incontinence, especially in the elderly population. Etiologies include incontinence associated with rectal prolapse, chronic straining at stool, or other neurologic...

Inflammatory Diseases

Presentation of IBD (Crohn disease and ulcerative colitis) is quite variable and depends on the site and severity of inflamed bowel and chronicity of the disease. Most commonly children present with growth failure, diarrhea, abdominal pain, mucous or bloody stools, or weight loss.

Other Specific Therapies

Vomiting before the onset of diarrhea and large, watery, and relatively infrequent stools suggest viral gastroenteritis. Fever, abdominal pain, and frequent, small-volume, and often bloody stools containing mucus and leukocytes are more commonly seen in bacterial enteritis.

Clinical manifestations diagnostics and treatment of E histolytica infection

The incubation time is dependent on the infectious dose and may vary from a few days to months. Usually symptoms appear after 2-4 weeks. Acute amoebic colitis is manifested as abdominal pain, tenderness, watery diarrhoea, and frequent bloody stools. In proctoscopy, ulcerations with a 'punced out' appearance are typically associated with E. histolytica colitis. Severe disease is more commonly seen in association with malnutrition, pregnancy, immunosuppressive therapy, and in children. The enterotoxic activity of E. histolytica appears to be due to several factors, including secretagogues, like neurohormones and prostaglandins, which may originate both from the parasite and the host (see Ravdin 1988).

Laboratory evaluation of acute diarrhea

Stool cultures for bacterial pathogens should be obtained if high fevers, severe or persistent (> 14 d) diarrhea, bloody stools, or leukocytes are present. E. E coli 0157 H7 Cultures. Enterotoxigenic E coli should be suspected if there are bloody stools with minimal fever, or when diarrhea follows hamburger consumption, or when hemolytic uremic syndrome is diagnosed.

Nonparametric Tests On Ordinal Variables

Judging from the commercials, hemorrhoids produce the kind of pain amenable to do-it-yourself solutions. How about a trial of Preparation Help (H) and Preparation P (P), a placebo We mail one tube of either preparation to 20 of our suffering friends so that 10 receive H and 10 receive P, along with a VAS to fill out. The data might look like Table 10-5. Pain Scores for Hemorrhoid Preparations

Treatment of iron deficiency anemia

Causes of resistance to iron therapy include continuing blood loss, ineffective intake and ineffective absorption. Continuing blood loss may be overt (eg, menstruation, hemorrhoids) or occult (e.g., gastrointestinal malignancies, intestinal parasites, nonsteroidal anti-inflammatory drugs).

Irritable Bowel Anismus

The causes of constipation and altered defecation are mul-tifactorial, and the manifestations are varied. Etiologies of constipation or altered defecation can be divided into two categories - slow transit constipation, and pelvic outlet obstruction. Pelvic outlet obstruction includes etiologies such as paradoxical or nonrelaxation of the puborectalis muscle or anismus (nonrelaxation of the anal canal), rectal prolapse or intussusception, and nonemptying rec-toceles. Associated findings may include perineal descent and solitary rectal ulcer syndrome.

Interpretation of Test Results

The clinical presentation of Peutz-Jeghers is variable. The most common presentations of Peutz-Jeghers are small bowel intussusception, colon obstruction, and gastrointestinal bleeding. Severe digestive obstruction may be identified in affected individuals throughout life, but the average age of onset is 29 years.18 Affected individuals also may exhibit intermittent abdominal pain or rectal prolapse. For an individual to be clinically diagnosed with Peutz-Jeghers, one of the following criteria must be met (a) three or more histologically confirmed Peutz-Jeghers polyps, (b) any number of Peutz-Jeghers polyps with a family history of Peutz-Jeghers, (c) characteristic mucocu-taneous pigmentation with a family history of Peutz-Jeghers, or (d) any number of Peutz-Jeghers polyps and characteristic mucocutaneous pigmentation.15

Perineal Rectosigmoidectomy

The Altemeier operation has been successfully used to treat rectal prolapse by many authors. However, controversies exist regarding recurrence rate. As described by William Altemeier,In principle, the operation obliterates the pelvic pouch, plicates the levators, and resects the redundant bowel. However, the rectum is not fixated to the sacrum.1 The University of Minnesota's group reported their experience with the surgical treatment of rectal prolapse over an 18-year period.3 Perineal rectosigmoidectomy was Figure 8-6.1. Full-thickness rectal prolapse. performed in 183 of 372 patients treated for rectal prolapse follow-up ranged from 12 to 165 months. It was noted that perineal rectosigmoidectomy was more frequently performed in patients with higher comorbidity and older age, compared with the abdominal approach. However, despite the higher recurrence rate (16 vs 5 for abdominal operations) in patients who underwent the perineal operation, this procedure was progressively more often...

Anterior Resection with Rectopexy

The addition of rectal fixation to the sacrum may provide better results regarding the decrease in recurrence rate. This operation is safe and presents the lowest recurrence rate. The reported recurrence rate after sigmoid resection with proctopexy varies from 2 to 10 .1 Initial procedures used the circumferential wrap. However, postoperative complications, including constipation and obstruction have led surgeons to modify the technique leaving the anterior rectum free. Others avoid the placement of the mesh altogether, adopting the use of nonabsorbable sutures to fixate the rectum to the presacral fascia.We currently prefer the latter approach to treat surgically fitted individuals with rectal prolapse. The management of recurrent rectal prolapse depends on the previous procedure. An abdominal approach must be avoided if the patient had previous perineal rectosig-moidectomy, especially if sigmoid resection is contemplated, because of the potential ischemia and necrosis of the...

Rectoanal Intussusception Solitary Rectal Ulcer and Sigmoidoceles

Successful defecation requires the smooth coordination of neurologic and muscular events by the pelvic floor and rectum. Deterioration of a single component of this process may lead to symptomatic rectal dysfunction manifested as constipation from the inability to evacuate. Prolonged untreated dysfunction with straining may ultimately lead to occult or overt rectal prolapse with concomitant rectal ulceration or fecal incontinence.1-3 The etiology of rectal dysfunction remains obscure but is believed to be multi-factorial in nature, involving electromyogenic, psychologic, aging, and hormonal mechanisms. In addition, rectal dysfunction is usually one component of a pathophysiologic process that involves the entire pelvic floor. As a result, several clinical manifestations may occur together or separately as part of the spectrum of this disease process and include nonrelaxation of the puborectalis muscle,rectoanal intussusception, rectal prolapse, perineal descent, solitary rectal ulcer...

Solitary Rectal Ulcer Syndrome

In one study of 13 patients followed for 57 months, Marchal et al.10 found that simple resection did not improve symptoms, colostomy resolved the symptoms and healed the ulcer, and rectopexy and modified Delorme's procedures were prone to relapse of symptoms and ulcers. The authors concluded that considering the high failure rate of surgery, operative management should only be performed in patients with total rectal prolapse or intractable symptoms not amenable to behavioral therapy. In another study of 66 patients who underwent surgery for rectal prolapse and followed for 90 months, 22 of 49 patients who underwent rectopexy failed.11 Four of these patients underwent subsequent proctectomy with coloanal anastomosis of which three also failed, signifying the refractory nature of this disease process to surgical intervention. Ultimately, 14 patients required a stoma. Four of nine patients who underwent Delorme's procedure for the initial operation also failed. Four of seven patients who...

History and Physical Examination

The patient is a 38-year-old G4P2 woman, with a 3-year history of increasing bladder dysfunction and a 6-month history of exteriorized vaginal and rectal prolapse. She stated that the exteriorized portion is quite large, and she brought two Polaroid photos of what appeared to be at least a fourth degree cystocele, as well as a rectal prolapse of a large amount of rectal mucosa. She also complains of urge urinary incontinence for 2 years. She voids 7 to 10 times per day wearing 1 to 2 pads per day, reporting 1 to 2 episodes of incontinence per day. She reported four or more episodes of nocturia per night with no enuresis or recurrent urinary tract infections, and voids with a normal flow. Her obstructive defecation symptoms have been present for 3 years with no fecal incontinence. She is sexually active. She had been fit with a vaginal ring pessary by her primary physician, which she wears without significant difficulties.

Hormonal Impact on Colorectal Function

Very few data are available regarding the impact of estrogen deprivation after menopause on colorectal function. Many of the changes in colorectal function, such as increased incidence of hemorrhoids and weakening of the anal sphincter are thought to be age-related, rather than caused by hormonal changes. However, estrogen receptors have been found in the external anal sphincter, and there is some anecdotal evidence that local estrogen therapy may be useful in the treatment of hemorrhoids.8

G St Johns Wort Hypericum perforatum L

This is a perennial herb native to Europe, Western Asia, North Africa, Madeira, and Azores and introduced to North America and Australia. Aerial parts including fresh buds and flowers have been traditionally used for their sedative, anti-inflammatory, anxiolitic, and astringent qualities to treat burns, insomnia, shock, hysteria, gastritis, hemorrhoids, kidney disorders, etc. Chemical compounds identified include phloro-glucinols (hyperforin and adhyperforin), naphthodianthrones (hypericin, pseudohy-pericin, and isohypericin), flavonoids (kaempferol, luteolin, myricetin, quercetin, hyperoside, and quercetin), essential oils (a- and P-pinene, limonene, myrcene, and caryophyllene), as well as proanthocyanidins, phytosterols, coumarins, xanthones, carotenoids, and phenolic acids. The components of this herb inhibit the reuptake of serotonin, dopamine, and norepinephrine. Hyperforin has antibiotic properties inhibiting Staphylococcus aureus. The flavonoids act as free radical scavengers...

Immediate Questions

Is pain associated with the mass Most children are not in pain at the time of rectal prolapse. There may be some discomfort associated with bowel movements. In some cases, abdominal pain may have preceded rectal prolapse often this occurs in cases of diarrhea-related rectal prolapse. C. Is bleeding associated with the mass Traces of blood occur with rectal prolapse. More significant bleeding is seen with polyps.

Is there a prior history of similar episodes Chronic constipation and straining with stools Does patient have cystic

Straining at stools or with urination can predispose to rectal prolapse. Children with chronic constipation or cystic fibrosis are at risk for recurrence of rectal prolapse. Any history of surgery for imperforate anus Prior history of polyps Does patient have spina bifida Patients with pelvic floor weakness (eg, those with myelomeningocele) often have paralysis of the levator ani muscle in addition to increased intra-abdominal pressure. Is patient malnourished It is thought that malnourished children are at higher risk for rectal prolapse because of the decrease in ischiorectal fat that reduces perirectal support.

Bowel Retraining for Constipation

Along with dietary changes and pharmacotherapies, biofeedback is a viable option for the treatment of constipation. Biofeedback refers to therapy in which patients are trained to be more aware of and responsive to their bowels. It has been increasingly used in the management of functional pelvic floor disorders, such as constipation from obstructed defecation, fecal incontinence, and rectal pain. In patients with constipation secondary to obstructed defecation, biofeedback is used to heighten the patient's awareness of the sphincters and levator muscles to retrain these muscles to consciously relax during the act of defecation. One cause of pelvic outlet obstruction occurs as a result of nonrelaxation of the puborectalis muscles. This condition may be related to significant psychosocial stresses that may cause the patient to alter their normal defecatory patterns.

Physical Exam Key Points

Jaundice, scleral icterus, hepatosplenomegaly, ascites, peripheral edema, caput medusa, xanthomas, palmar erythema, telangiectasia, male gynecomastia, peripheral wasting, hemorrhoids or occult blood in stool, clubbing, changes on neurologic exam (includes mental status, pupillary size, aster-ixis, hyperreflexia or hyporeflexia, clonus, Babinski sign).

Diagnostic criteria for constipation 2 or more of the following

A palpable colon with stool in the left lower quadrant may be detected, although the examination is often normal. Gastrointestinal masses should be sought. Perianal inspection may reveal skin excoriation, skin tags, anal fissures, anal fistula, or hemorrhoids. 1. Fissure in ano, hemorrhoids, fistulas, ischiorectal abscess, colonic neoplasms, hypothyroidism, hypercalcemia, diabetes, Hirschsprung's disease, Parkinson's disease, multiple sclerosis, or cerebrovascular disease may cause constipation.

Differential Diagnosis

Structural Anomaly, Intestinal Duplication, or Meckel Diverticulum. Often presents with painless rectal bleeding. Occasionally can be lead point of intussusception. Vascular Lesions. Include angiodysplasia, hemorrhoids, hemangiomas, and arteriovenous malformations. Such lesions are rare causes of bleeding in children.

Overlapping Sphincter Repair

Anorectal Surgery Pictures

Habit history with regard to the stool consistency, the number of bowel movements in a 24-hour period, symptoms of urgency, the ability to defer defecation, staining of the undergarments, and any loss of control of bowel movements is obtained. In women, an obstetric history should be obtained with specific questions regarding episiotomies, tears, and assisted delivery with suction or forceps. A surgical history should be inquired concentrating on surgical procedures for fissures, hemorrhoids, fistulas, and tumors. Any history of pelvic irradiation or success with previous therapies is important.

The Constipation Scoring System

A study of 232 patients with constipation confirmed the accuracy and validity of the applicability of this constipation scoring system.13 As scores increased, a corresponding significant increase in severity of constipation was noted. This patient population included both patients with colonic inertia (diffuse marker delay on colonic transit studies without evidence of paradoxical contraction) and pelvic outlet obstruction syndromes (paradoxical pub-orectalis contraction, rectal prolapse, rectoanal intussusception, rectocele, or sigmoidocele).

Rectoanal Intussusception

Rectoanal intussusception and SRUS have many common features. Dysfunction of the rectum with the development of abnormal defecatory patterns is usually the underlying pathogenesis. Chronic straining may induce intussusception of the rectal mucosa, which in turn may develop into full-thickness rectal prolapse. The occult intussusception may also predispose to a persistent feeling of incomplete evacuation with the chronic urge to strain. Straining may cause excessive tensile forces on the anterior wall of the rectum resulting in ulceration. Rectoanal intussusception, also known as occult rectal prolapse or internal procidentia, is an intussusception of the rectal wall that does not protrude through the anus. It may be asymptomatic or associated with incontinence or constipation. Although it is strongly associated with mucosal prolapse, full-thickness rectal prolapse, and perineal descent, the finding of occult rectal prolapse is not necessarily pathologic. Diagnosis is made by...

Anal Sphincter Repair

Fecal continence relies on normal sensory, motor, and reflex activity of the colon, rectum, and anus. Stool consistency, colonic transit, rectal sensation, neural integrity, and sphincter function all have a role in individual control of stool and gas. The principal component in facilitating continence is the anal sphincter, whereas the hemorrhoidal cushions, sensory epithelium of the anal mucosa, intrinsic anorectal reflexes, and pelvic floor muscles contribute to its function. The anal sphincter complex is composed of the internal anal sphincter (IAS), the external anal sphincter (EAS), and the puborectalis muscle. The pudendal nerve innervates the EAS and puborectalis whereas the innervation of the rectum, pelvic floor muscles, and IAS is a complex system of sympathetic and parasympathetic neurons supplied by the pelvic and sacral nerves. Damage to any muscular or neural component of the sphincter mechanism may result in fecal incontinence and possible need for surgical...

Prolapse Syndromes

Rectal prolapse occurs when the full thickness of the rectal wall protrudes through the anus. It is the most common type of distal digestive tract prolapse. In mucosal prolapse, only the mucosa of the rectal wall protrudes through the anus. In contrast, internal intussusception can be full or partial thickness but the prolapse does not pass beyond the anus. Intussusception is common in normal, healthy volunteers (up to 50 ) and may be normal. It seldom leads to full prolapse.9 The first description of rectal prolapse is said to be in the Ebers papyrus 1500 BC. The first treatment as outlined by Hippocrates involved hanging patients by their heels and shaking them.10 Obviously, this was rarely successful in the long term. The true incidence of rectal prolapse (mucosal or complete) is unknown mostly because of underreporting. It is associated with long-standing constipation, chronic straining, pregnancy, prior surgery, female gender, aging, neurologic disease, mental illness (up to 53...

Colorectal History

Patients with complex disorders of evacuation will often have a confusing list of complaints, which can include both constipation and fecal incontinence. It is important, in the history of the present illness, to determine the patient's baseline bowel function. For patients with constipation, frequency and consistency of bowel movements should be ascertained. The sensation of the need to evacuate with significant straining leads the physician to consider outlet obstruction in the differential diagnosis. Infrequent bowel movements with no sensation of rectal fullness may lead to consideration of colonic inertia as a cause for constipation. It is always important to ask the patient if there is any prolapse of tissue from the anal canal. Often,patients will complain of severe hemorrhoidal prolapse, when in fact, the patient has full-thickness rectal prolapse. It is always important to determine whether there is any associated rectal bleeding. Obviously,occult malignancy must be ruled out...

First steps

Certain actions must be taken quickly in patients with gastrointestinal blood loss, regardless of the location of the hemorrhage. Significant losses from any site in the digestive tract are usually manifested by signs and symptoms of decreased circulating volume, sometimes even before the bloody stools and hematemesis have appeared. Attention should be paid immediately to circulatory compromise, well before any efforts are made to diagnose the specific cause of blood loss. Thus tachycardia, air hunger, or postural changes require instant administration of intravenous fluids and the typing of at least 3 units (1.5 liters) of blood for possible transfusion. These urgent first steps will often avoid complications of stroke and cardiac or renal impairment, particularly in older patients. Endoscopic and radiological studies should not be undertaken until measures to correct losses of volume have been instituted. At this point, it is also wise to call for a surgical consultation since the...

Anorectal Spaces

The perianal space is that area surrounding the anal canal in the immediate area of the anal verge. Laterally it is continuous with the fat of the buttocks. Cephalically, it is continuous with the intersphincteric space and it contains the distal EAS, branches of the inferior rectal vessels, nerves, and lymphatics. The external hemorrhoid plexus lies in the perianal space and communicates with the internal hemorrhoid plexus at the dentate line.

Evacuation Disorders

Among patients with POO, there are several neuro-muscular-associated or etiologic syndromes, including 1) nonrelaxing puborectalis syndrome, 2) rectocele, and 3) descending perineum syndrome. Nonrelaxing puborectalis syndrome occurs when there is failure of relaxation or paradoxical contraction of the puborectalis muscle at the time of defecatory effort. Paradoxical or nonrelaxation of the puborectalis muscle is the cause in 31 to 42 of patients with POO constipation.2,6 As a result of the chronic straining associated with this syndrome, many other associated disorders may develop including rectal prolapse and rectocele.

J Drug Interaction

Drugs administered by the rectal route may have a local effect (as for hemorrhoids) or a systemic effect (as in the prevention of nausea and vomiting). The rectal route is convenient to use in pediatric patients (children) or in patients who are unconscious or vomiting. The amount of drug absorbed in the rectal route is usually less than if the drug were administered orally. The absorption of drugs administered rectally is unpredictable and can vary among patients.

Exudative diarrhea

Exudative diarrhea is characterized by bloody stools, tenesmus, urgency, cramping pain, and nocturnal occurrence. It is most often caused by inflammatory bowel disease, which may be indicated by the presence of anemia, hypoalbuminemia, and an increased sedimentation rate.

Rectopexy

Several techniques, such as the Ripstein procedure and posterior rectopexy with synthetic mesh, have been described to perform the fixation of the rectum to the presacral fascia with the objective of preventing recurrence of the rectal prolapse. However, the use of synthetic material to fix the rectum has been associated with a multitude of complications including infection, fistulization of the prosthesis into the rectum, presacral bleeding, and obstruction.

Anterior Resection

Anterior resection for the treatment of rectal prolapse removes the redundant sigmoid colon, therefore avoiding problems such as constipation, torsion, and kinking when rectopexy is performed. Moreover, this technique can be safely performed laparoscopically. However, one should remember the risk of anastomotic complications. When this operation is performed for the treatment of prolapse, the rectum should be mobilized to the level of the lateral ligaments and the anastomosis should be fashioned at or just below the sacral promontory.

Commentary

Coexistence of advanced genital and rectal prolapse can be quite challenging to evaluate and treat. This is especially true in the younger, reproductive-age woman. As compared with the elderly woman presenting with very evident exteriorized vaginal and rectal prolapse who may be readily treated with a perineal proctosigmoidectomy and vaginal obliterative colpocleisis, the reproductive-age woman frequently presents with a complaint of rectal prolapse that is intermittent. This type of patient may now typically show up to the clinic with Polaroid in hand. The advent of digital photography has facilitated demonstration of the maximum extent of rectal prolapse. Although this patient did not demonstrate paradoxical contraction of the puborectalis muscle during defecogra-phy, she did demonstrate significant levator hypertonicity on vaginal and rectal examination. This likely contributed to her rectal prolapse because of the need to perform intense Valsalva efforts for bowel evacuation....

Segmental Colectomy

Notable exceptions are individuals with rectal prolapse and constipation. It is important to realize that internal intussusception has been found to lead to constipation in some individuals. For those with severe constipation, a transit study should be performed. If this is prolonged, a colectomy with IRA and rectopexy is combined to surgically treat both problems. Some patients with rectal prolapse also will have an element of constipation, but this is not considered severe. This group will benefit from a sigmoid (segmental) colectomy with colorectal anastomosis and rectopexy. Additionally, when performing a rec-topexy for rectal prolapse and the sigmoid kinks over

Anal area

Can be passed into the space between the anal wall and the mucosa of the protruding mass. If so, this may be an intussusception or a rectal polyp. Rectal prolapse will not allow passage of a finger between the protruding mass and the anal wall. If mass is plum colored, it is likely to be a rectal polyp. b. Determine whether prolapse is complete or incomplete. In complete rectal prolapse, the full thickness of the rectum prolapses through anus. In this situation, concentric mucosal rings may be seen. Incomplete prolapse is limited to two layers of mucosa and reveals radial folds. If more than 5 cm of rectum is emerging, it is most likely a complete prolapse.

Anorectum

Anorectal GISTs account for 9 of 64 GISTs, according to a recently published series.27 Unlike GISTs in other locations, a male predominance has been reported.14,52 Clinical presentation includes rectal pain, bleeding, and rectal mass. Anorec-tal GISTs present as eccentric mural masses that invade the rectal wall. The most common finding at CT is a focal well-circumscribed mural mass, which expands the rectal wall and

The clinical problem

Microscopic gastrointestinal bleeding is common in critically ill patients and may be due to nasogastric trauma more often than stress ulceration. This type of bleeding rarely progresses to bleeding that is clinically relevant. Overt bleeding is defined as hematemesis, bloody gastric aspirate, melena, or hematochezia this is less common, occurring in approximately 5 per cent of a heterogeneous group of intensive care unit (ICU) patients. Clinically important bleeding can be defined as overt bleeding and one of the following drop in blood pressure of 20 mmHg within 24 h of bleeding, blood pressure drop of 10 mmHg and heart rate increase of 20

Anal Cancer

Anus Levator Muscle

Cancers of the anal canal are rare, accounting for approximately 1.5 of gastrointestinal tract malignancies. In the United States, there were an estimated 3400 new cases in 2000. In England, there were 245 new cases in men (1.0 100000) and 377 in women (1.5 100000) in 1997. It was originally thought that anal cancer was associated with chronic irritation from haemorrhoids, fissures, fistulae and inflammatory bowel disease. However, this is now known not to be so. The majority of anal cancers in both sexes are due to infection with human papilloma virus, particularly HPV1 6. There is an increased risk of anal cancer in men and women who practice anal receptive intercourse, who have had more than 10 sexual partners, or who have sexually transmitted diseases such as genital warts, gonorrhoea, or Chlamydia trachomatis. Other aetiological risk factors are immunosuppression, human immunodeficiency virus (HIV) infection, and smoking. Women with anal cancer have a higher incidence of vulval,...

Biofeedback Sessions

Training for dyssynergia, incontinence, or pain begins with the systematic shaping of isolated pelvic muscle contractions. Observation of other accessory muscle use such as the gluteal or thighs during the session is discussed with the patient. Excessive pelvic muscle activity with an elevated resting tone more than 2 V may be associated with dyssynergia, voiding dysfunction, and pelvic pain. Jacob-son's progressive muscle relaxation strategy implicates that, after a muscle tenses, it automatically relaxes more deeply when released. This strategy is used to assist with hypertonia, placing emphasis on awareness of decreased muscle activity viewed on the screen as the PFM becomes more relaxed. This repetitive contract-relax sequence of isolated pelvic muscle contractions also facilitates discrimination between muscle tension and muscle relaxation. Some patients, usually women, have greater PFM descent with straining during defecation associated with difficulty in rectal expulsion....

Horse Chestnut

Butcher's broom (Ruscus aculea-tus) is an evergreen bush native to the Mediterranean region. It has been used extensively in herbal medicine to treat varicose veins, hemorrhoids, and edema, although it has not received as much research in this area as horse chestnut. The active ingredients include a group of saponins known as ruscogenins, which have vasoconstrictive and anti-inflammatory effects in vivo (see Tables 8.1 and F.1).

Ayurvedic Medicine

The foremost characteristic of the vata metabolic type is changeability. People of this type are active, energetic, moody, imaginative, and impulsive prone to erratic sleep patterns, intestinal problems, nervous disorders, and premenstrual syndrome. There is a sensitivity to cold and dry and their vulnerable season is autumn. Pitta types are predictable, aggressive, intense, efficient, articulate, moderate in daily habits, short-tempered, and impatient. They tend to perspire more and may be open to poor digestion, ulcers, skin inflammations, hemorrhoids, and heartburn. In summer they are sensitive to the sun and heat. Kapha is relaxed, stable, conservative, with a tendency to laziness and procrastination. They sleep long and move, eat, and digest food slowly. There is an inclination toward overweight, allergies, sinus, and lung congestion and they are highly susceptible to the cold of winter.

Stool Softeners

Inhaled into the lungs (which it may be in elderly or debilitated patients), it may produce inflammatory responses such as lipoid pneumonia. Its continual use, therefore, is contraindicated, although its occasional administration in otherwise well patients is not harmful. It is employed primarily in patients who must avoid straining at stool, including persons with hemorrhoids and other painful anal lesions. Leakage of mineral oil past the anal sphincter may lead to soiling of clothing.

Prader Willi syndrome

The majority of the affected children have mild to moderate degree of mental retardation and some have severe mental retardation or a borderline intelligence. In the initial preobesity phase, affected babies are usually limp, sleepy, unresponsive, and present typically with a narrowed bifrontal diameter, a triangle-shaped mouth, strabismus, and acromicria. Feeding difficulties in the form of absence of swallowing and sucking reflexes are common at this stage. Usually between age 1 and 4 years these children gradually develop hyperphagia caused either by persistent hunger or a decreased perception of satiety. This eventually leads to gross obesity. These subjects also manifest developmental delay and limited sexual function due to hypogenitalism. Precocious puberty or premature sexual maturation may affect some subjects. Abnormal secondary sex characteristics such as micropenis and cryptorchidism in males and amenorrhoea in females are common. Other associated features in Prader-Willi...

Delormes Operation

The Delorme's procedure involves the removal of the rectal mucosa up to the apex of the prolapse, associated with pleating of the muscular layer of the rectum and anastomosis of the mucosa to the anal canal. This operation has mostly been used to treat mucosal prolapse. Therefore, it is difficult to evaluate the true outcome of the Delorme's operation in the treatment of full-thickness rectal prolapse. Moreover, it has been associated with a very high recurrence rate varying from 17 to 37 . In addition, improvement in fecal incontinence has been marginal.1,2 We rarely recommend the Delorme's operation for the treatment of rectal prolapse, except in those few instances in which mucosal prolapse seems to be the main problem.

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