Case discussion SURGERY

Submitted by,

Nallathambi, Aiswarya Bharathi

Roll call 126.

HISTORY

GENERAL DATA
Name J. P. Age & Sex 58, M

Nationality Filipino Religion Christian Catholic

Marital status Married Referral Source Emergency

Department, SPMC.

Reliability Reliable.

Date and time of admission Jan 18, 2016 at 5.00 pm.

Chief Complaint Severe rectal pain, incapacitating.

History of Presenting illness

This is the first admission for the 58 year old male patient
in Southern Philippines Medical Center, who presented with severe rectal
pain. 6 days PTA, patient experienced severe rectal pain and discomfort
around the anus. The pain was described to be 7 on a scale of 10 initially,
before progressing to 10. There was also difficulty in defecation, and the
stool was hard and in small quantity. The patient was unable to move to the
sides, and unable to stretch, abduct or adduct his thighs. There was no
diarrhea, or stomach pain and 2 days PTA the patient was unable to defecate
since it was too painful. The patients skin showed dermatitis around the anal
region. There was no accompanied bleeding. The patient was able to pass
flatus.

Past Medical History

 2005 Diagnosed with Hypertension, the patient was on ACE
inhibitors for 2-3 years, with very poor compliance. Currently the patient is
not taking any medication for hypertension.

2016 5 days PTA the patient had fever, followed by the rectal pain for
which the patient sought admission.

The patient has not undergone any major surgery and does not present with
any significant comorbidities.

Allergy The patient did not have allergy to specific food or medication

Personal and Social History

Occupation The patient is a driver of a rental car, since 17 years old.

He has to sit in the same position for long hours. The patient consumes
Filipino diet and likes to eat red meat mostly with less fiber in the diet.

Tobacco use 10 sticks a day for 20 years. 20 pack years.

Alcohol use No drinking.

Family history

Father He passed away due to stroke, at the age of 65. (+) Hypertension

Mother Alive and well. (+) Hypertension

Daughter 35 y.o., healthy, (-) Hypertension

Review of Systems

General : (-) weight loss or weight gain

HEENT : Using bifocal lens for 10 years, No auditory complaints; No

dysphagia or odynophagia. No neck stiffness.

Gastro-intestinal : (-) Right Lower Quadrant Pain, (-) Hypogastric Pain, (-)
Diarrhea.

Pulmonary : No complaints of dyspnea or cough.

Cardiac : No Palpitations, No Chest pain, No Orthopnea.

Vascular : No Phlebitis, No Varicocities.

Genitourinary: No complaints of dysuria, nocturia, polyuria, hematuria, or
bleeding

Neurological : No complaints of weakness, numbness, or incoordination.

PHYSICAL EXAMINATION
The patient was awake ,conscious , cooperative.

Vital signs :

Temperature : 37.5 C Pulse rate : 72 bpm

Respiratory rate : 22 bpm Blood Pressure : 150/85

mmHg
(supine, left arm)

Skin : The skin was dry , slightly pale, no rashes, no bruises seen except
around the anal region.

HEENT :

Head : The patient had sparse hair (mild alopecia), scalp was normal.
The conjunctiva is pink, the pupils equally round, 3 mm, reactive to light and
accommodation, sclera and conjunctiva normal. Fundoscopic examination
reveals normal vessels without hemorrhage

The ear was clean, no wax obscuring the ear, hearing normal. Nasal
septum in midline, nasal mucosa and turbinates were normal. Lips and oral
mucosa was dry ,dental caries seen. Oral pharynx is normal without
erythema or exudate.

Neck : Neck was supple, trachea in midline, no palpable lymph node ,thyroid
was non palpable.

Thorax : On inspection, the chest movement was symmetrical, no scars or

rashes There are no enlargement or palpable masses on palpation. There
were tympanic sounds to percussion and the breath sounds were normal
(bronchovesicular).

Cardiovascular : Apex beat noted at left 5th intercostal space midclavicular,

no murmurs noted.
Abdomen : On inspection, slightly enlarged, rotund. The liver and spleen are
non palpable. The bowel sounds were not clear to auscultation with weak
peristaltic movements . Percussion was normal with dull and tympanic
sounds.

Musculoskeletal : The movement in the lower extremities were hindered. No

varicosities or edema noted.

Rectal examination : There was slight engorgement seen on the left side of
the anal opening, along with dermatitis like whitish deposition was seen.
DRE was attempted, but severe pain was noted particularly in the
left buttock region.

Impression :

The patient, most likely, has external hemorrhoids. Further lab

investigations are required to support diagnosis.

DEFINITIONS
Hemorrhoids Hemorrhoids are enlarged veins in the
anus or lower rectum. They may result from straining during bowel
movements or from the increased pressure and hard stools which increases
venous engorgement of the hemorrhoidal plexus .

External Hemorrhoids :

They are located distal to the dentate line and covered with anoderm
which is richly innervated. Thrombosis of external hemorrhoids may cause
significant pain.

Internal hemorrhoids :

They are located proximal to dentate line. They are covered by

insensate anorectal mucosa. They may prolapse or bleed but rarely
painful unless they develop thrombosis or necrosis.

EPIDEMIOLOGY
Worldwide, the prevalence of symptomatic hemorrhoids is estimated at
4.4% in the general population. In the United States, up to one third of the 10
million people with hemorrhoids seek medical treatment, resulting in 1.5
million related prescriptions per year. The number of hemorrhoidectomies
performed in US hospitals is declining. Outpatient and office treatment of
hemorrhoids account for some of this decline.

Patients presenting with hemorrhoidal disease are more frequently

white, from higher socioeconomic status, and from rural areas. There is no
known sex predilection, although men are more likely to seek treatment.
However, pregnancy causes physiologic changes that predispose women to
developing symptomatic hemorrhoids. As the gravid uterus expands, it
compresses the inferior vena cava, causing decreased venous return and
distal engorgement.

External hemorrhoids occur more commonly in young and middle-aged

adults than in older adults. The prevalence of hemorrhoids increases with
age, with a peak in persons aged 45-65 years.

RISK FACTORS
In many cases, the cause for hemorrhoids is unknown. The following lifestyle
choices and conditions can increase the risk for developing hemorrhoids:

Alcoholism; Anal intercourse; Chronic diarrhea or constipation; Diet high in

fat and low in fiber (high fiber foods include whole grain foods, fresh fruits,
and vegetables) and Obesity.

Other risk factors include jobs that require sitting or standing for long
periods; Lack of physical activity; Loss of pelvic floor muscle tone due to age,
pregnancy, childbirth, or surgery; Severe heart disease or liver disease.

Low-fiber diets cause small-calibre 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
haemorrhoidal problems, presumably by means of the same mechanism,
which is thought to be decreased venous return. Prolonged sitting on a toilet
(eg, while reading) is believed to cause a relative venous return problem in
the perianal area resulting in enlarged hemorrhoids. Aging causes weakening
of the support structures, which facilitates prolapse.
 Our patient had severe constipation before and during the onset of
pain. The diet was more of red meat and less green and leafy vegetables
therefore less fiber in the diet which may contribute to the development of
hemorrhoids. The major risk factor for the patient is his job which is driving a
rental car which he has been doing for over 4 decades. The long hours of
physical inactivity and sitting in one position along with lack of exercise could
have also contributed to symptomatic hemorrhoids.

PATHOPHYSIOLOGY
Abnormal swelling of the anal cushions causes dilatation and
engorgement of the arteriovenous plexuses. This leads to stretching of the
suspensory muscles and eventual prolapse of rectal tissue through the anal
canal. The engorged anal mucosa is easily traumatized, leading to rectal
bleeding that is typically bright red due to high blood oxygen content within
the arteriovenous anastomoses. Pain results from rapid distention 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.
Deposit of mucus onto the perianal tissue with prolapse or mucus with
microscopic stool contents can deposit mucus onto the perianal tissue. This
mucus with microscopic stool contents can cause a localized dermatitis,
which is called pruritus ani.

DIAGNOSTICS
Hemorrhoid diagnosis usually involves a simple examination of the
anal and rectal area. This is known as Digital Rectal Examination/DRE. During
the examination, the doctor gently puts a lubricated, gloved finger of one
hand into the rectum. He or she may use the other hand to press on the
lower belly or pelvic area. It is done for women as part of a gynecological
examination to check the uterus and ovaries. Other organs, such as the
bladder, can sometimes also be felt during a digital rectal exam.

If internal hemorrhoids are suspected, the physician may use a lighted

device (e.g., proctoscope, anoscope) to examine the rectal area. To rule out
conditions other than hemorrhoids, other diagnostic tests may be performed.
These tests include sigmoidoscopy and colonoscopy, which involve using a
lighted scope to examine the lower gastrointestinal (GI) tract. The rigid
sigmoidoscope is 25 cm long and 2 cm in diameter with an attached light
source. The examination usually reaches 15 cm. This is a good, simple, and
inexpensive tool to fully assess the rectum, obtain biopsies, and remove
small polyps. The flexible sigmoidoscope is 60 cm long and uses fiberoptic or
video technology. The examination usually reaches the middle descending
colon.

Management

A diet rich in high-fiber foods and low in processed foods is essential.

Increasing fluid intake to six to eight eight-ounce glasses a day also is
important. Most hemorrhoid treatments aim to minimize pain and itching.
Warm (but not hot) sitz baths are the most time-honored and suggested
therapy. Sitting in about three inches of warm water for 15 minutes, several
times a day, especially after a bowel movement has a soothing effect. This
helps reduce the swelling in the area and relaxes spasm of the sphincter
muscle.

Management of Internal hemorrhoids include rubber band ligation

where the mucosa located 1-2cm proximal to the dentate line is grasped and
pulled into a rubber band applier. After firing the ligator, the rubber band
strangulates the underlying tissue, causing scarring and preventing further
bleeding or prolapse. In general, only one or two quadrants are banded per
visit. Infrared photocoagulation is an effective treatment for small first and
second degree hemorrhoid. The instrument is applied to the apex of each
hemorrhoid to coagulate the underlying plexus.

Acutely thrombosed external hemorrhoids generally cause intense pain

and a palpable perianal mass during the first 24 72 hours after thrombosis.
The thrombosis can be effectively treated with an elliptical excision
performed under local anesthesia.

Our patient had pain for longer than 24-72 hours so its unlike that the
hemorrhoids acutely thrombosed. Since hes suffering from intense pain,
analgesics can be administered. So we treat hemorrhoids only when the
patient complains of them. The old adage that it is hard to make an
asymptomatic patient better applies here. No matter how bad the
hemorrhoids look to the practitioner, they should not be treated unless they
bother the patient.
 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), whereas operative resection is
reserved for the latter. It should be emphasized that therapy is directed
solely at the symptoms, not at aesthetics.

PROGNOSIS
When performed well, operative hemorrhoidectomy should have a 2-
5% recurrence rate. Nonoperative techniques, such as rubber band ligation,
produce recurrence rates of 30-50% within 5-10 years. However, these
recurrences can usually be addressed with further nonoperative treatments.
Long-term results from procedure for prolapsing hemorrhoids are unavailable
at this time.

In this respect, hemorrhoids are a life-long condition to be controlled,

not cured. Our patient should have a good prognosis since theres no
accompanied bleeding or rectal prolapse.

THANK YOU.