tommyk
04-10-2006, 11:32 AM
HY 2125 GREAT BIG CONCEPT!
You have a 22-year-old woman named Linda Evangelista who seeks help for serious pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. Because of the pain, she has avoided having bowel movements, and when she finally did the stools were hard and even more painful.
When seen, she has no fever or leukocytosis.
Physical examination has to be done under spinal anesthesia, because the patient was so afraid of the pain that she initially refused even inspection of the area. The examination confirms the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents, but without success. There is NO signs of endometriosis or swelling vessels on the anal opening. She does not have any anal intercourse and no signs of infection. She is willing to undergo more aggressive treatment now. What is her disease and treatment (VERY VERY HARD QUESTION)?
1-Excision of neoplasm
2-Correct the fistula
3-Drainage of possible abscess
4- Lateral internal sphincterotomy
5-Hemhorrhoids—give NSAIDS
6-Rubber band ligation
7-Idiopathic-give oxycodone
a) Pick #4. The clinical picture is classic for anal fissure, which is perpetuated by the fact that the anal sphincter is too tight. Forceful dilatation under anesthesia, lateral sphincterotomy, or botulinum toxin injections are acceptable options to break the cycle. The only one of those choices given is the sphincterotomy. Excision used to be done for this condition, before the role of the too tight sphincter was found. Fistulotomy is not the answer. She has a fissure, not a fistula. Incision and drainage is another option that addresses a wrong diagnosis. We do that for perirectal abscess, which produces severe pain with fever and leukocytosis, but without blood streaks, and drains spontaneously after several days if not diagnosed and treated. Again, I said she does not have endometriosis. Rubber band ligation is the answer for internal hemorrhoids. Internal hemorrhoids can bleed, but typically do not hurt. Thrombosed external hemorrhoids can hurt tremendously, but those are not amenable to rubber band ligation. Don’t MASK the issue with just symptoms management!
You have a 22-year-old woman named Linda Evangelista who seeks help for serious pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. Because of the pain, she has avoided having bowel movements, and when she finally did the stools were hard and even more painful.
When seen, she has no fever or leukocytosis.
Physical examination has to be done under spinal anesthesia, because the patient was so afraid of the pain that she initially refused even inspection of the area. The examination confirms the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents, but without success. There is NO signs of endometriosis or swelling vessels on the anal opening. She does not have any anal intercourse and no signs of infection. She is willing to undergo more aggressive treatment now. What is her disease and treatment (VERY VERY HARD QUESTION)?
1-Excision of neoplasm
2-Correct the fistula
3-Drainage of possible abscess
4- Lateral internal sphincterotomy
5-Hemhorrhoids—give NSAIDS
6-Rubber band ligation
7-Idiopathic-give oxycodone
a) Pick #4. The clinical picture is classic for anal fissure, which is perpetuated by the fact that the anal sphincter is too tight. Forceful dilatation under anesthesia, lateral sphincterotomy, or botulinum toxin injections are acceptable options to break the cycle. The only one of those choices given is the sphincterotomy. Excision used to be done for this condition, before the role of the too tight sphincter was found. Fistulotomy is not the answer. She has a fissure, not a fistula. Incision and drainage is another option that addresses a wrong diagnosis. We do that for perirectal abscess, which produces severe pain with fever and leukocytosis, but without blood streaks, and drains spontaneously after several days if not diagnosed and treated. Again, I said she does not have endometriosis. Rubber band ligation is the answer for internal hemorrhoids. Internal hemorrhoids can bleed, but typically do not hurt. Thrombosed external hemorrhoids can hurt tremendously, but those are not amenable to rubber band ligation. Don’t MASK the issue with just symptoms management!