NURS-3020 Final Study Guide 2024 Guaranteed Success, Exams of Nursing

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NURS-3020 FINAL STUDY GUIDE 2024 GUARANTEED SUCCESS Treatment Options: Acute rectal cancer, suitable for surgery • stage I, low risk (<3 cm; <30% circumference of the bowel; moderately or well differentiated; localized) • local excision or radical excision • stage I, high risk (not fulfilling low-risk criteria) • radical resection • preoperative radiation therapy ± chemotherapy • stage II - III • radical resection • preoperative chemoradiation therapy • postoperative chemotherapy • stage IV • surgical resection • chemoradiation therapy rectal cancer, not suitable for surgery • stage I - IV • chemotherapy • monoclonal antibodies • stenting • alternative chemotherapy regimen colon cancer, suitable for surgery • stage I - III • surgical resection • postoperative chemotherapy • stage IV • surgical resection after preoperative chemotherapy • preoperative chemotherapy • monoclonal antibodies • immediate surgical resection • postoperative chemotherapy colon cancer, not suitable for surgery • stage I - IV • chemotherapy • monoclonal antibodies • stenting • alternative chemotherapy regimen • Diverticulitis o Evaluation o Sigmoid colon most common location. o Classically presents with abdominal pain and fullness localized to left lower quadrant. o Ranges from mild to severe, described as aching or cramping. o Change in bowel habits including constipation, diarrhea, or both are common. o Dysuria is indicative of inflammation adjacent to bladder. o Nausea and vomiting may be present depending on location and severity of inflammation. o Physical findings include lowgrade fever, mild abdominal distention, and leftlower quadrant tenderness. o May be palpable mass. o Average age of presentation is 62. o Differential Diagnosis (broad) ▪ Appendicitis ▪ Perforated colonic carcinoma ▪ Obstruction with strangulation ▪ Colonic ischemia ▪ Crohn disease ▪ Cystitis ▪ There is a lower threshold for surgery for immunocompromised patients due to >risk of morbidity and mortality with medical management (Hinchey III or IV disease). o Three stage procedure, consisting of diversion and washout followed by resection of the diseased bowel at a second operation, and finally colostomy takedown is an option if patient will not tolerate resection. • Ulcerative colitis o Evaluation ▪ Peaks between ages 1530, with smaller peak age 6080. ▪ Diffuse but contiguous mucosal inflammatory disease with abscess formation in the crypts of Lieberkuhn and penetrate the superficial submucosa. ▪ Classically starts in rectum and extends proximally without skip lesions. ▪ Patients report frequent, small volume watery stool mixed with blood, pus, mucus accompanied by tenesmus, rectal urgency, and even fecal incontinence. ▪ Many patients report crampy abdominal pain with variable degrees of fever, vomiting, weight loss, malaise, and dehydration. ▪ In mild disease, physical exam may be normal, but in severe disease the abdomen is tender and distended. ▪ Severe rectal inflammation may result in considerably tenderness and spasticity of the anus during digital rectal examination and the exam fingers covered in blood, mucus, or pus. ▪ Truelove and Witt classification if severity of disease based on stool frequency, hematochezia, pulse, temperature, hemoglobin, and erythrocyte sedimentation rate. o Differential Diagnosis (extremely broad): ▪ Includes all forms of colitis. ▪ The most common differential dx is between mucosal UC and Crohn colitis. ▪ Cancer ▪ Diverticulitis ▪ Infectious colitis ▪ Salmonellosis and other bacillary dysenteries ▪ Shigellosis ▪ Campylobacter jejuni ▪ Hemorrhagic colitis ▪ Legionella infections ▪ Gonococcal proctitis ▪ Herpes simplex virus in homosexual men ▪ Amoebiasis ▪ Histoplasmosis ▪ Tuberculosis ▪ Cytomegalovirus disease ▪ Schistosomiasis ▪ Amyloidosis ▪ Behcet disease ▪ Druginduced colitis ▪ NSAIDS ▪ Collagenous colitis ▪ Ischemic colitis ▪ Functional diarrhea ▪ Diversion colitis o Diagnostic Studies ▪ There is no single diagnostic test. ▪ Neutrophils predominate in acute; lymphocytes in chronic. ▪ Serum antibody tests can differentiate from Crohn’s Disease. ▪ Serum pANCA in 6070% of patients, but are also found in up to 40% of CD. ▪ Anemia, leukocytosis, and elevated sedimentation rate or C reactive protein usually present. ▪ Look for signs of superinfection, ova, parasites, Cdiff. ▪ In acute setting, colonoscopy and barium enema should be avoided due to risk of perforation. Biopsy by proctoscopy should be sufficient. ▪ Abdominal xray may show dilation of colon and can be used to detect free air when perforation is suspected. ▪ CT scan is most common imaging modality in acute episode. Will show thickened rectum and colon with associated inflammatory changes. ▪ In cases where the diagnosis is unclear, a small bowel series or CT enterography may be performed to look for involvement suggestive of CD. o Treatment Options ▪ Medical Therapy ▪ Goal is to stop an acute flare and maintain remission of mucosal inflammation. o Diagnostic Studies ▪ Physical examination alone establishes a dx of hemorrhoids. Further evaluation with laboratory or imaging studies in unnecessary unless there has been significant hemorrhage. ▪ Digital evaluation can r/o mass lesions or malignancy but internal hemorrhoids can not bed assessed adequately using digital rectal examination. ▪ Anascopy is used to properly evaluate internal hemorrhoids. The examiner asks the patient to push or strain while visualizing each of the three common hemorrhoidal piles in the right anterior, right posterior, and left lateral positions within the anal canal. ▪ All patients should undergo evaluation of the more proximal colon with flexible sigmoidoscopy or colonoscopy as indicated. o Treatment Options ▪ External hemorrhoids ▪ Reassurance if the tags are small and minimally symptomatic. ▪ Hydrocortisone if symptomatic. ▪ Simple surgical excision if causing symptoms of irritation, discomfort, and difficulty with anal hygiene. ▪ Internal hemorrhoids ▪ Mild to moderate (grade I-II) are treated with fiber, fluids, and possibly laxatives to improve bowel habits. ▪ Patients with persistent symptoms and normal bowel habits are candidates for surgical approach. ▪ Surgical treatment in office setting: ▪ Rubber band ligation ▪ Small to moderate sized symptomatic internal hemorrhoids (grade I-III). o Sclerotherapy ▪ Involves using anoscopy to inject sclerosing agent into the apex of Grades I-II internal hemorrhoids; rarely results in complications of necrosis, rectal perforation, and sepsis. o Infrared Coagulation ▪ Application of infrared energy directly to the internal hemorrhoid with an infrared coagulation probe using anoscopy. Grades I-II. Complications unusual but include bleeding, necrosis and sepsis. ▪ Surgical treatment of internal hemorrhoids in operating room (Usually reserved for grades III-IV internal hemorrhoids): ▪ Excisional hemorrhoidectomy ▪ Stapled hemorrhoidopexy ▪ Doppler-guided hemorrhoidectomy • Abscess o Evaluation ▪ Patient c/o acute pain, swelling and possible fever. Occasionally c/o leakage of mucus and pus r/t spontaneous drainage of abscess. ▪ Physical exam often reveals erythema, fluctuance, and asymmetry between the right and left perirectal tissues. o Differential Diagnosis ▪ Hidradenitis ▪ Pilonidal disease ▪ Bartholin gland cyst (rare) o Diagnostic Studies ▪ Radiologic studies not necessary as the vast majority are obvious on the basis of history and physical examination alone. ▪ Some patient with symptoms of an abscess and no physical examination findings may benefit from imaging such as CT, MRI and anorectal US. ▪ MRI is imaging of choice for patients with suspicion of abscess but no obvious physical examination findings or OR for examination under anesthesia. o Treatment Options ▪ Anorectal Abscess ▪ Incision and drainage. o Only immunocompromised patient or patient with associated sepsis are treated with antibiotics. o Penrose or mushroom-catheter drain may be necessary for large abscesses. o Anorectal Fistula ▪ Fistulotomy • Fistula- Small Intestine Fistulas o General Considerations: Fistulas are an abnormal connection between two epithelial lined organs and while enterocutanious fistulas (ECF) may form spontaneously as a result of disease, about 80% are complications of surgical procedures (anastomotic dehisence or injury to bowel during dissection). Fistulas are particularly prone to develop when the surgeon encounters extensive adhesions, inflamed intestine, radiation enteritis, a malnourished patient, or emergency procedures. o A. Symptoms and Signs Postoperative fistula formation is heralded by fever, abdominal pain, and distestion. Frequently a wound infection is recognized and drained 7-10 days postoperatively with subsequent discharge of enteric contents through the abdominal incision. Spontaneous fistulas from neoplasms or inflammatory disease usually develop in a more infolent manner. ECF are often associated with fistulization, so that persistent sepsis is a common feature. Intestinal fluid escaping through the fistula may severely excoriate the skin and abdominal wall tissues. Persistent sepsis and difficulty in nourishing the patient contribute to rapid weight loss. B. Laboratory Findings Treatment of Anorectal Fistula Traditionally, anorectal fistulas have been treated by fistulotomy. Fistulotomy is performed one of three ways. The simplest fistulotomy is a single-stage procedure laying open the fistula tract. A two-stage approach is used for fistulas that involve a significant amount of sphincter muscle. The two-stage approach uses a secton of which is a suture or vessel loop drain that is tied to itself after placement in the fistula tract. With the two-stage approach, the first step is a partial fistulotomy and secton placement. After healing from this first step, the second step is a completion fistulotomy. A final method of fistulotomy involves placement of a cutting seton and then gradual division of the fistula tract and involved sphincter muscle by tightening of the cutting seton over time. While fistulotomy may still be utilized for subcutaneous, intersphinteric, and low transphincter fistulas (all have little or no muscle involvement), fistulotomy has fallen into disfavor because division of the sphincter muscle during fistulotomy as well as contour deformities associated with fistulotomy can result in fecal incontinence and leakage. Thus, while fistulotomy is a highly successful way to treat subcutaneous and intersphinteric fistulas that involve minimal to no anal sphincter muscle, transsphincteric fistulas are better treated with a sphincter-sparing approach to avoid the complication of fecal incontinence. Sphincter-sparing treatment approaches for transsphincteric anal fistulas include fibrin glue, anal fistula plug, the ligation of the intersphinteric fistula tract (LIFT) procedure, and the rectal advancement flap. Prior to any of these sphincter-sparing procedures, a vessel loop draining seton is placed into the fistula tract, and the tract is allowed to heal around the seton for 3 months. While this seton placement procedure step can be omitted, studies have shown that the success rate of the subsequent definitive sphincter-sparing procedure is higher after seton placement. For the fibrin glue procedure, the seton is removed, the internal opening suture closed and then fibrin glue in instilled via the external opening to seal the tract. The anal fistula plug procedure is done in a similar fashion just using the plug rather than the glue. No incisions are made with either of these procedures which tend to be very well-tolerated by patients. Unfortunately, the success rate is only 60%-70% for fibrin glue and probably even lower for the anal fistula plug. Thus, a number of patients (30%-40%) will fail glue or plug at which time further treatment by repeating the glue or plug or by opting for the more invasive LIFT procedure or rectal advancement flap. The main complications of glue/plug are recurrence and abscess (rare). The relatively new procedure is called LIFT because it involves ligation of the intersphinteric fistula tract. During this outpatient operation after removal of the seton (if placed previously), an intersphinteric groove incision is made and the fistula tract in the intersphinteric space is identified and circumferentially dissected free. This dissection allows for proximal and distal suture ligation and division of the fistula tract within the intersphinteric space. This procedure is well-tolerated, spares the sphincter muscle, and is successful 80% of the time. Complications include recurrence of a simpler intersphincter fistula and rarely abscess formation. If the previously mentioned sphincter-sparing techniques are unsuccessful in healing an anal fistula, an anorectal advancement flap can be performed. For patients, this is a significantly more involved operation than the above options as it involves much larger incisions, longer operative time, and longer healing time. In the operating room, patients are placed prone for an anterior internal opening or placed in a lithotomy position for a posterior internal opening. A U-shaped flap or mucosa, submucosa, and some underlying sphincter muscle is dissected proximally with the base of the “U” just distal to the internal opening. Once the flap is completely mobilized, the internal opening in the underlying sphincter muscle in the underlying sphincter muscle is closed with one or two figure of eight sutures. The tip of the flap is then excised and the flap is advanced distally to cover the suture closure of the internal opening. The external opening is enlarged and left open for drainage. Patients undergoing anorectal advancement flap are typically observed overnight to control pain and monitor for anorectal bleeding. If the flap remains in place and heals, the internal opening will be closed, the rest of the fistula tract will heal. The success rate for the rectal advancement flap procedure is 85%-95% with the higher success rates associated with preoperative seton drainage. Prognosis: With the exception of Crohn patients who can develop recurring anal abscesses and fistulas, the prognosis with anorectal abscesses and fistulas is excellent. The new sphincter- sparing techniques for anal fistulas do require multiple operations, but that is a small price to pay in order to minimize the occurrence of fecal incontinence which can be over 50% in patients after traditional fistulotomy. o Hernia • Procedures (review the indications, procedure steps, and education) • Flexible sigmoidoscopy: A flexible sigmoidoscopy is an examination of the lower part of the gastrointestinal tract called the colon or large intestine. It is performed by an endoscopist, who is a doctor or other health professional with special training in endoscopic procedures. There are several reasons that flexible sigmoidoscopy may be recommended, with one of the most common reasons being the need to screen for colon cancer in people older than 50 years. Colonoscopy allows the clinician to examine the entire large intestine and is preferred in certain situations. REASONS FOR SIGMOIDOSCOPY The most common reasons for flexible sigmoidoscopy are the following: ●As a screening test to detect colon polyps or colon cancer ●Blood in the stool or rectal bleeding ●Persistent diarrhea ●After radiation treatment to the pelvis when a patient has lower gastrointestinal symptoms ●Evaluation of the colon in conjunction with a barium enema ●For the medical management of colitis (inflammation of the colon) SIGMOIDOSCOPY PREPARATION A healthcare provider will provide specific instructions about how to prepare for the examination. The instructions are designed to maximize your safety during and after the examination, minimize complications, and allow the endoscopist to easily view the colon. It is important to read these instructions ahead of time and follow them carefully. Call your clinician or the endoscopy unit if you have questions. Bowel cleaning — The lower part of the colon must be cleaned to permit the endoscopist to see the inside lining of the colon. You will be given specific instructions, with preparation often including a clear liquid diet, laxatives, and use of an enema shortly before the examination. Medications — Some medications, such as iron preparations, may need to be stopped one to two weeks before the examination. Iron coats the colon, making it difficult to see the lining. If you take these medications, you should ask your healthcare provider if they need to be stopped before the procedure. People who take a blood thinning medication, such as warfarin (Coumadin), should consult with their clinician regarding the need to stop taking this medication temporarily. Most medications for high blood pressure, heart disease, lung disease, and seizure disorders are safe during sigmoidoscopy and can be taken the day of the examination. Medications for diabetes may need to be adjusted before the test; talk to your healthcare provider for advice. WHAT TO EXPECT DURING THE PROCEDURE The procedure — Flexible sigmoidoscopy usually takes between 5 and 15 minutes. It is performed while you lie on your left side with your legs bent like they would be if you were sitting in a chair. The sigmoidoscope, which is approximately the size of one finger, is inserted into the anus and advanced through the rectum, sigmoid colon, and descending colon. The sigmoidoscope has a camera and a light source that permits the endoscopist to see the inside of the colon on a television monitor. The endoscope can be used to take biopsies (small pieces of tissue) and to introduce or withdraw fluid or air. Biopsies do not hurt because the lining of the colon does not sense pain. However, you may feel cramping as air is introduced through the scope and as the scope is passed through segments of the colon. The air is needed to permit the endoscopist to advance the scope and see the lining of the colon. ●Prolapsed internal hemorrhoids that can be manually reduced (Grade III), particularly if more than one column is involved* ●Prolapsed and incarcerated internal hemorrhoids (Grade IV)* ●Symptomatic internal hemorrhoids (eg, pain, thrombosis) refractory to conservative measures ●Symptomatic internal hemorrhoids (eg, pain, thrombosis) refractory to office-based procedures, or unable to tolerate office-based procedures because of pain* ●Combined internal and external hemorrhoids ●Symptomatic internal hemorrhoids in the presence of a concomitant anorectal condition that requires surgery *It is important to note that for some indications, failed prior treatment is not required prior to proceeding with surgical treatment. PREOPERATIVE EVALUATION AND PREPARATION The preoperative assessment includes a detailed history; physical examination, which includes external inspection of the anus and a digital rectal examination; and anoscopy. Medications, particularly those that increase the risk of bleeding (eg, warfarin, aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs [NSAIDs]), should be reviewed and are preferably held in the perioperative period depending on the indications for treatment and risk of cessation. Consultation with the patient's primary care provider or cardiologist may be warranted. Perioperative management of anticoagulation is discussed separately. The patient is instructed to undergo a cleansing enema before the procedure. A full mechanical bowel preparation is not indicated and may be counterproductive. There is a paucity of data regarding the need for antibiotic prophylaxis. One retrospective study reported that there was no benefit to preoperative use of metronidazole compared with no antibiotics. The authors agree that antibiotics are not necessary in most clinical settings, as the risk of infection is low. Patients with underlying immunosuppression or extensive cellulitis may benefit from perioperative antibiotics, such as metronidazole or a second-generation cephalosporin. Immediately prior to performing the procedure, anoscopy should be repeated in the semi- inverted jackknife or left lateral position. The assessment includes an evaluation for the presence of external hemorrhoids, location, volume, redundancy, and grade of internal hemorrhoids. ANESTHESIA Hemorrhoid surgery can be performed using general anesthesia, regional anesthesia (spinal, epidural), perianal block, or straight local anesthesia. The choice is often one of surgeon preference, but patient-related factors also play a role. One of the authors uses intravenous sedation and a perianal block for nearly all hemorrhoid surgeries. Occasionally, a regional (spinal) anesthetic or general anesthetic may be needed for selected patients, such as those with respiratory conditions (ie, cannot lay supine or prone, require airway protection). The patient is first anesthetized (general, regional, intravenous) and positioned for the procedure. An anal block is performed, and a Hill-Ferguson retractor is placed into the anal canal and rectum to facilitate adequate inspection of the individual internal hemorrhoid columns. Positioning — Patient positioning is another primarily surgeon-dependent variable. Although many anesthesia providers may be more comfortable with the lithotomy position, the authors prefer prone jackknife positioning for most cases, as it provides an excellent view and exposure of the perianal region for the surgeon as well as for an assistant or trainee. The prone position can be used for patients who need their airway controlled. The patient is typically intubated on the transport stretcher first, then turned prone onto the operating room table. For these patients, it may be prudent to keep the patient's stretcher in the operating room in the event that the patient needs to be quickly returned to the supine position, though this is rarely necessary. For patients unable to tolerate the prone position because of concerns with airway control, the lithotomy or left-lateral positions are acceptable alternatives. However, visualization and access to the base of the hemorrhoid may be more difficult. In all cases, care should be made to avoid unnecessary pressure on the male genitalia and to pad all bony prominences, particularly the legs when lithotomy position is used. Perianal anesthesia/block — Because of the frequency of postoperative pain, a perianal block is administered to most patients. In a systematic review that assessed analgesia following hemorrhoidectomy, perianal infiltration of local anesthetic provided significant pain relief, whether given alone or as a supplement to other forms of anesthesia. If spinal anesthesia is used, perianal anesthesia is not necessary. In randomized trials, long-acting liposomal bupivacaine (eg, Exparel) was associated with a significantly greater decrease in post-hemorrhoidectomy pain compared with traditional bupivacaine. An anal block is performed by injecting local anesthetic (eg, lidocaine, bupivacaine), typically with epinephrine, into the ischiorectal fat immediately peripheral to the external sphincter. Sodium bicarbonate (1 cc per 30 cc lidocaine) can be added per provider discretion to help minimize local irritation with injection if the patient remains awake. EXTERNAL HEMORRHOIDECTOMY External hemorrhoids generally do not require surgical management. Exceptions may include thrombosed external hemorrhoids or large external hemorrhoids that cause symptoms that cannot be controlled or interfere with hygiene. Thrombosed external hemorrhoids — Patients with a thrombosed external hemorrhoid present with an acutely painful purplish or blue mass in the perianal area. Some surgeons advocate excision of the thrombosed external hemorrhoids to prevent recurrent thrombosis. For those patients who present in persistent pain (typically within 72 hours from the onset), excision of the thrombosed external hemorrhoid provides immediate relief. Conservative management only is recommended when the patient presents with diminishing symptoms (typically later than this 72- hour timeframe). After 48 to 72 hours, the thrombus organizes and contracts, lessening symptoms and obviating the need for surgical management. Occasionally, a thrombosed hemorrhoid will evacuate spontaneously, leaving a small ulcer with residual clot at the anal opening. This will typically resolve on its own over a few weeks, although the patient may be left with a skin tag that rarely causes enough symptoms to warrant its removal. However, in those patients that have a large enough skin tag that causes skin irritation, itching, pain, or inability to keep proper hygiene, excision can be beneficial. Techniques — When indicated, external thrombosed hemorrhoids are best treated with hemorrhoid excision, rather than incision and simple evacuation of the clot, an approach that should generally be avoided. However, if timely evaluation by a surgeon is not available and the provider is not comfortable with excision of the thrombosed hemorrhoid, incision of the hemorrhoid can be performed to remove the clot, which should lessen symptoms. The recurrence rate for a completely excised thrombosed hemorrhoid is 5 to 19 percent. By comparison, simple incision and evacuation of the clot is associated with a 30 percent risk of reaccumulation and thrombosis, which may disseminate to adjacent hemorrhoidal columns. Excision — Excision of external hemorrhoids (thrombosed or symptomatic) can be performed in the operating room, emergency room, or an appropriately equipped office. The skin overlying the hemorrhoid is prepped with povidone iodine solution, and local anesthesia is infiltrated into the skin at the base and overlying the area of excision around the hemorrhoid. A supplemental anal block, in addition to this infiltration can also be performed, and is preferred by the authors. ●Excision of a thrombosed hemorrhoid is performed by making an elliptical incision in the skin overlying the hemorrhoid. The thrombosis and the resultant edematous tissue create a readily identifiable plane for dissection. The incision is carried around the hemorrhoid and dissected with care from the superficial fibers of the anal sphincter, making certain to avoid injury. Patients with extensive thrombosis have a higher risk of injury if the perianal skin and anoderm are aggressively resected. The excision can be performed with a scalpel, scissors, or electrocautery pen, depending on the preference of the surgeon. The skin edges can be left open and allowed to drain or reapproximated with absorbable sutures, also depending upon surgeon preference. A topical antibiotic ointment can be applied to the wound; however, this is not necessary, as infection is rare in this well-vascularized site. ●Excision of a nonthrombosed hemorrhoid is performed in the same manner, simply making an elliptical incision around the skin and hemorrhoidal tissue (in the absence of a clot). eTHoS trial cited above, serious adverse events, such as rectal bleeding, anal stenosis, and urinary retention, occurred in 9 and 7 percent of patients undergoing conventional and stapled hemorrhoid surgery, respectively. Stapled versus hemorrhoidal artery ligation — In a multicenter randomized trial of 393 patients with grade II or III internal hemorrhoids, hemorrhoidal artery ligation resulted in less postoperative pain (visual analogic scale 2.2 versus 2.8 postoperative; 1.3 versus 1.9 at two weeks) and a shorter sick leave (12 versus 15 days) but was more expensive (€2806 versus €2538), took longer to perform (44 versus 30 minutes), left more residual grade III disease (15 versus 5 percent), and required more reoperations (8 versus 4 percent). Otherwise, hemorrhoidal artery ligation and stapled hemorrhoidectomy had comparable complication (24 versus 26 percent) and patient satisfaction rates (>90 percent in both groups). Techniques Conventional — A variety of devices, including surgical scalpels, scissors, or electrosurgical devices (eg, monopolar electrocautery, advance bipolar sealing [Ligasure], ultrasonic desiccation [Harmonic scalpel], laser), can be used to make the incision and excise the hemorrhoidal tissue. The goals of hemorrhoid resection are to remove the redundant tissue, avoid damage to the sphincter, and avoid taking too much anoderm, which might lead to anal stenosis. For conventional hemorrhoidectomy, the junction of the internal and external component of the hemorrhoid is grasped with a small clamp (eg, Allis, Babcock) to retract the hemorrhoid away from the sphincter muscles. Using a scalpel or electrocautery pen, the rectal mucosa is scored in an elliptical or diamond shape around the hemorrhoidal bundle to delineate the plane for excision of the hemorrhoid. The incision is carried deeper starting distally on the external hemorrhoidal tissue and extending proximally across the dentate line to the superiormost extent of the hemorrhoidal column. The hemorrhoid tissue is carefully dissected from the superficial internal and external sphincter muscles toward the main vascular pedicle in the anal canal. Care must be taken not to narrow the anal canal when multiple hemorrhoidal excisions are performed. Only the redundant anoderm associated with the hemorrhoidal tissue should be removed, preserving a minimum of 1 cm of anoderm between columns. The base of the pedicle is suture ligated, and the hemorrhoidal tissue is removed. The mucosal defect is then left open to heal by secondary intention, or closed with a continuous 2-0 or 3-0 absorbable suture (eg, Vicryl). To minimize the chance of narrowing the anal canal, a Hill- Ferguson retractor should be left in place until all suturing is complete. Stapled — Stapled hemorrhoidopexy is an alternative to conventional internal hemorrhoidectomy. This procedure does not effectively treat most external hemorrhoids. The need for a specialized device makes this procedure more expensive. The technique uses a circular stapling device to excise a circumferential column of mucosa and submucosa from the upper anal canal, which reduces the hemorrhoidal tissue back into the anal canal and fixates them into position. The device also interrupts part of the hemorrhoidal blood supply, thereby decreasing vascularity. An anal dilator or obturator is provided with the surgical stapler and provides gentle dilatation of the anal canal. The circular stapling device is introduced into the anus, and the mucosa/submucosa contents are brought into the stapler. Before the stapler is engaged or fired, the posterior wall of the vagina should be assessed to ensure the stapler has not inadvertently engaged it. This can be noted by moving the stapler and seeing that the posterior vaginal wall does not tent or move with it. When the stapler is fired, it creates a circular fixation of all tissues within the nonabsorbable circumferential purse string suture to the rectal wall. In effect, it will draw up and suspend the prolapsed internal hemorrhoid tissue. The staple line should be fully evaluated as this is a potential source for early bleeding and may require a suture ligation. The most critical component of the procedure is the placement of the purse-string suture in the mucosa/submucosa approximately 4 cm from the dentate line. It is important that the purse-string suture be placed far enough proximal to avoid involving the sphincter muscles within the stapling device, and to minimize other complications (eg, changes in continence, stricture, fistula). One role for stapled hemorrhoidopexy devices is to treat patients with bleeding and/or prolapsing grade II to IV internal hemorrhoids who have failed rubber band ligation. Another role may be for patients seeking a less painful alternative to conventional surgery, but the patient must be willing to accept a higher risk of recurrence. Occasional but important complications have been reported, including persistent postdefecation pain, which affects a small percentage of patients. One study suggested that such symptoms may respond rapidly and completely with oral nifedipine. Although an option for patients with grade II to IV internal hemorrhoids, the stapled techniques, as stated above, will not address the external hemorrhoid component if present. Thus, in patients with combined internal and external hemorrhoids, the external hemorrhoids are surgically excised, obviating the benefit of using the stapling device. Hemorrhoidal artery ligation — An alternative to a conventional hemorrhoidectomy or stapled hemorrhoidopexy is Doppler-guided transanal hemorrhoidal artery ligation (HAL), also known as transanal hemorrhoidal dearterialization (THD). HAL uses a specially designed proctoscope housing a Doppler transducer to identify each hemorrhoidal arterial blood supply, which is subsequently ligated. A meta-analysis identified 28 observational studies involving 2904 patients undergoing Doppler- guided hemorrhoidectom. Recurrence rates ranged between 3 and 60 percent (pooled mean 17.5 percent), and the rate of postprocedure hemorrhage was 5 percent. A later randomized trial that included 40 patients with grade II or grade III hemorrhoids found that, although fecal soiling was decreased using both treatments, patients treated with HAL had significantly increased fecal soiling after one year compared with open hemorrhoidectomy. Additional trials with longer-term observation are needed to determine the utility of this approach. In a randomized trial of 337 patients with symptomatic grade II or III internal hemorrhoids, HAL resulted in fewer recurrences than rubber band ligation at 12 months (30 versus 49 percent). However, this difference was almost entirely accounted for by the need for repeat banding, which is a common practice, but was counted as recurrences in this study. Compared with rubber band ligation, HAL was associated with more pain at one and seven days after the procedure, more serious adverse events requiring hospitalization (7 versus 1 percent), and higher cost (£1750 versus £723). Thus, HAL is more effective but more painful and costly compared with a single rubber band ligation. For patients with symptomatic grade II or III internal hemorrhoids, a course of rubber band ligation remains the first-line procedure of choice due to its low morbidity and cost. Patients who fail, refuse, or could not tolerate rubber band ligation should be referred for one of the surgical hemorrhoidectomy procedures. Rubber band ligation of internal hemorrhoids is discussed in detail in another topic. POSTOPERATIVE CARE AND FOLLOW-UP It is fairly common for patients to experience a fair amount of pain over the first few days, along with significant swelling. Postoperative instructions include warm sitz baths, stool softeners, and pain medication including oral narcotics and anti-inflammatory medications. Often, the wounds will open up after three to five days, and patients may note mucus drainage from the area. High fevers (>101° F), significant expanding erythema or necrosis, or unremitting pain are all concerning and warrant physician evaluation. Pain management — Pain following hemorrhoidectomy is nearly universal and may in part be due to spasm of the internal sphincter. Perianal anesthetic infiltration at the time of hemorrhoidectomy is important for reducing postoperative pain. Initial pharmacologic treatment to control postoperative pain consists of oral analgesics, such as nonsteroidal anti-inflammatory drugs and/or acetaminophen. Opioids may be given if pain is not well controlled but carry the potential adverse effects of inducing constipation and possibly worsening the pain. Local care — A sensation of "tightness" after the procedure can usually be alleviated with a warm sitz bath that can be performed as often as needed by the patient. Of note, simple warm water is all that is required, and the addition of other bath or Epsom salts is not necessary. Avoiding constipation — A bulk fiber supplement and/or increased dietary fiber and fluid intake will help reduce postoperative constipation and pain upon defecation. Fecal impaction after a hemorrhoidectomy is associated with postoperative pain and opiate use. Most surgeons recommend stimulant laxatives, stool softeners, and bulk fiber to prevent this problem. Should impaction develop, manual disimpaction with anesthesia may be required. Testicular Torsion o Cushing disease- due to chronic glucocorticoid excess where there is excess ACTH or by adrenocortical tumors that secrete glucocorticoids independently. ▪ Symptoms: Facial plethora, dorsocervical fat pad, supraclavicular fat pad, truncal obesity, easy bruisability, purple striae, acne, hirsutism, impotence of amenorrhea, muscle weakness, and psychosis. ▪ Hypertension, hyperglycemia, and osteopenia or osteoporosis is common. ▪ Laboratory findings: there isn’t one test to be used, but normally there will be a circadian rhythm of ACTH secretion that is paralleled by cortisol secretion. These levels are highest in the morning and decline throughout the day. **It’s important to first establish the diagnosis, then figure out the underlying cause** ▪ Imaging: Thin section CT or MRI to detect virtually all of the adrenal tumors and hyperplasia. ▪ Treatment: Resection is best, but other options may offer temporary control of hypercortisolism. o Adrenal cancer (adrenocortical cancer)- Cancer that is rare and begins in one or both of the small triangular glands (adrenal glands) located on the top of your kidneys. ▪ Symptoms: muscle weakness, weight gain, pink or purple stretch marks on the skin, excess facial hair from hormones on women, enlarged breast tissue and shrinking testicles for me; nausea, vomiting, abdominal bloating, back pain ▪ Diagnosis: blood and urine tests show increased hormones, CT, MRI to see growths on adrenals, after removal of adrenal gland, biopsy. ▪ Treatment: removal of adrenal glands. Mitotane is also required after surgery to delay any reoccurance of the disease after surgery. Radiation and chemo are also used. o Polycystic kidney Testicular torsion is a twisting of the spermatic cord leading to ischemia and infarction – surgical emergency. ➢ Physical Exam: 1. Cremaster Reflex: 2. Prehn’s Sign: ➢ Diagnostics o Ultrasound to confirm while waiting for a surgical consult ➢ Treatment Surgery: detorsion or orchiectomy Urethral Stenosis Urethral stenosis is a narrowing of the urethra derived from congenital or acquired abnormalities. ➢ Acquired abnormalities include 1. Inflammatory: chronic urethral stones, vascular surgery, trauma, enlarged lymph nodes, iliac artery aneurysm, retroperitoneal fibrosis. 2. Cancer 3. Infection: urinary TB, retention secondary to BPH ➢ Signs and Symptoms Acute Obstruction – severe flank pain, possible radiation into groin or testes/ labia. Chronic Obstruction – may be asymptomatic but when a flare occurs signs and symptoms will be that of the Acute Obstruction. ➢ Diagnostics CT Urogram with contrast ✓ revealing delayed function ✓ dilated renal pelvis & ureter down to the site of obstruction. ➢ Differential 1. Epididimytis 2. Testicular Torsion 3. Appendage Trosion ➢ Treatment Depends on the cause a. Resection of Lesion b. Cystoscopy – balloon dilation c. Ureteral Stents BPH Benign Prostatic Hyperplasia: Enlarged Prostate ➢ Exam 1. Prostate exam: palpate for nodular masses and general size 2. most are benign ➢ Diagnostics o Transrectal Ultrasound: if palpable nodules o PSA is controversial but may be obtained for baseline analysis, consider age as it will change the norms and possibily complicate treatment options. ➢ Treatment o Medication management: 1. Alpha Blockers: tamsulosin, alfuzosin, doxazosin, prazosin, terazosin • relax smooth muscle in the bladder neck to relieve symptoms of obstruction 2. finasteride 5mg Daily • hormone manipulation; requires 6 months or more for treatment evaluation 3. Dutasteride 0.5 mg daily • reduces the size of the prostate to improve blood flow 4. Tadalafil 2.5mg to 5mg daily • DO NOT give with alpha-blockers; worsen the hypotensive effect o Surgical Intervention 1. TURP: TransUrethral Resection of the Prostate ▪ Most common, indications unresponsive to medical therapy, renal insufficiency, recurrent UTIs, bladder stones, or gross hematuria Acute pyelonephritis requires hospitalization for intravenous administration of antibiotics and crystalloids until the patient is afebrile; this is followed by a full course of oral antibiotics. methemoglobinemia and hemolytic anemia have been reported, usually with overdoses or underlying renal dysfunction. If a broad-spectrum antibiotic was initially prescribed empirically for urinary tract infection, and urine culture results return establishing efficacy of a narrow-spectrum antibiotic, treatment should be “de- escalated” to the narrow-spectrum antimicrobial. • In cases of interstitial cystitis/painful bladder syndrome patients will often respond to a multi- modal approach that may include urethral/vesicular dilation, biofeedback, cognitive-behavioral therapy, antidepressants, dietary changes, vaginal emollients, and other supportive measures. Vaginal estrogen effectively relieves urinary urgency and frequency as well as recurrent UTIs related to vulvovaginal atrophy of menopause (also known as genitourinary syndrome of menopause). When to Refer • Anatomic abnormalities leading to repeated urinary infections. • Infections associated with nephrolithiasis. • Persistent interstitial cystitis/painful bladder syndrome. Pyelonephritis When to Admit • Severe pain requiring parenteral medication or impairing ambulation or urination (such as severe primary herpes simplex genitalis). • Dysuria associated with urinary retention or obstruction. • Pyelonephritis with ureteral obstruction. Acute Ampicillin, 1 g every 6 hours, pyelonephritis and gentamicin, 1 mg/kg every 8 Intravenous hours $540.00 not 14days including intravenous supplies Ciprofloxacin, 750 mg every 12 hours2 Oral Oral 7–14 $79.00–158.00 days Levofloxacin, 750 mg daily 5days $181.00 Trimethoprim-sulfamethoxazole, Oral160/800 mg every 12 hours3 10–14 $18.00-25.00 days Essentials of diagnosis: Fever, Flank pain, Irritative voiding symptoms, Positive urine culture. Acute pyelonephritis is an infectious inflammatory disease involving the kidney parenchyma and renal pelvis. It develops when pathogens ascend to the kidneys via the ureters. Pyelonephritis can also be caused by seeding of the kidneys from bacteremia. It is possible that some cases of pyelonephritis are associated with seeding of the kidneys from bacteria in the lymphatics. Gram- negative bacteria are the most common causative agents inc