Anorectal Disorders and Appendicitis

• These notes cover disorders of the anorectal area, hemorrhoids, anorectal abscess, anal fistula, anal fissure, pilonidal disease, appendicitis, and peritonitis

Disorders of the Anorectal Area

• Many disorders in the rectal area result from constipation or failure to empty the rectum when peristalsis occurs
• At the mucocutaneous border of the anal canal, the mucous membrane changes to skin with cutaneous somatic nerve endings

Hemorrhoids

• Hemorrhoids are swollen and inflamed veins around the anus or lower rectum
• May result from straining to move stool
• Incidence: by age 50, about 50% of people have hemorrhoids to some extent
• Anal tag can be a sign
• Causes/Risk Factors: Pregnancy, aging, chronic constipation or diarrhea, anal intercourse, obesity, prolonged sitting, spicy foods, and alcohol
• Symptoms: Itching, anal pain, bright red bleeding with defecation, protrusion through the anus, and painful swelling around the anus
• Diagnosis: Proctoscopy (digital rectal exam), anoscopy
• Non-drug treatment: Good personal hygiene, avoid excessive straining, high-fiber diet, and increase fluid intake
• Sitz bath is a warm compress
• Treatment using suppositories & analgesic ointments such as Faktu and bismuth subgallate
• Bismuth subgallate suppository is applied BID for 5 days for odor
• Hydroxyethylrutoside (varemoid) BID is another form of treatment
• Surgery can shrink and remove hemorrhoids
• Hemorrhoidectomy is used for advanced thrombosed veins
• Lithotomy or prone jackknife positions are used for surgery
• Prevention: Keep stool soft, empty bowels as urge occurs, exercise, and increase fiber intake

Anorectal Abscess

• A pus-filled cavity caused by bacteria invading a mucus-secreting gland in the anus and rectum
• Immunosuppressed individuals are highly susceptible
• Most abscesses result in an anal fistula
• Signs and Symptoms: Inability to sit comfortably, difficulty or pain with passing stool, abscess around anus, peri-rectal swelling, throbbing sharp, or dull pain, and fever
• Diagnosis: Anoscopy and digital examination of the anus and rectum
• Management: Sitz bath, analgesics/antibiotics such as clindamycin and cefalexin, and surgical incision & drainage of abscess using a Penrose drain for drainage and peroxide balls for coagulation

Anal Fistula

• A tiny, tubular, fibrous tract extends from the anal canal to an opening beside the anus
• Develops in the upper part of the anus; glands become infected
• Signs and Symptoms: Pain and swelling, skin irritation, pus or discharge, fever and malaise, and difficulty with bowel movements
• Labs and Diagnosis: Physical exam, imaging studies, fistulography, and anoscopy
• Medical Treatment: Antibiotics such as ciprofloxacin and metronidazole, calcium channel blockers, topical nitrates, onabotulinumtoxinA, and topical anesthetic creams
• Surgical Procedures for Perianal Fistulas: Fistulotomy, Seton drain placement, ligation of the intersphincteric fistula tract, fistulectomy, and filling the fistula with fibrin glue

Anal Fissure

• A longitudinal tear or ulceration occurs in the lining of the anal canal
• Causes: Trauma by passing a large firm stool or childbirth
• Clinical Manifestations: Extremely painful defecation, constipation, and bright red blood on toilet tissue
• Management: Dietary modifications, sitz bath, stool softeners such as Dulcolax and Lactulose, and surgical excision/closure of the fissure

Pilonidal Disease

• Pilonidal Cyst: An abnormal pocket in the skin containing hair and skin debris
• Located near the tailbone at the top of the cleft of the buttocks
• Contains hair that becomes infected, forming an abscess and then a sinus tract
• Constant irritation can cause hair to become embedded and infected
• Management: Surgical incision of abscess, medication antibiotics, stool softeners, health teaching on hygiene, diet, sitz bath, and loose clothing

Appendicitis

• Appendicitis is the inflammation of the appendix or vermiform appendix
• Causes: Fecalith, kinking of the appendix, swelling of the bowel wall, foreign body, and tumor
• Pathophysiology: Obstruction of the appendiceal lumen, buildup of mucous, increased pressure, decreased blood flow, irritation and lesion, inflammation, and appendicitis
• Signs and Symptoms: Appendix walk, increased WBC, RLQ density, localized bowel distention, (+) Pointing sign, (+) Rovsing's sign, (+) Psoas signs, (+) Obturator's sign, (+) Blumberg's sign
• Complications: Ruptured appendix, peritonitis, and portal pylephlebitis
• Diagnostic Exam: Ultrasound and CT scan
• Medical Management: IV fluids, antibiotic therapy (e.g., cefuroxime), and drainage
• Surgical Management: Appendectomy or laparotomy/laparoscopy
• Nursing Management: Assess pain level, relevant lab findings, and vital signs
• Nursing Diagnoses: Acute pain, risk for deficient fluid volume, and risk for infection
• Nursing Management Goals: Relieving pain, preventing fluid volume deficit, reducing anxiety, eliminating infection, maintaining skin integrity, and attaining optimal nutrition
• Nursing Interventions: IV infusion (D5LR), antibiotic therapy, positioning, and oral fluids
• Preoperative Interventions: NPO status, administer IV fluids, monitor pain and bowel sounds, monitor for signs of ruptured appendix, position right-side lying or low-Fowler's, apply ice packs, administer antibiotics, and avoid heat, laxatives, or enemas
• Postoperative: Monitor temperature and incision, NPO until bowel function returns, and advance diet as tolerated

Peritonitis

• Peritonitis is the inflammation of the peritoneum
• Causes: Bacterial, fungal from GIT and internal reproductive organs, medical procedures, ruptured appendix or stomach ulcer, and trauma
• Complications: Sepsis, shock, and intestinal obstruction
• Medical Management: Fluid, colloid, and electrolyte replacement, oxygen therapy, intestinal intubation, analgesics, anti-emetics, antibiotics, Utz and CT-guided peritoneal drainage, surgical excision, resection, and fecal diversion
• Nursing Management: Intensive care is required
• Nursing Assessment: Pain, GI function, and fluid and electrolyte
• Nursing Diagnoses: Acute pain, deficient fluid volume, risk for shock