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Hello, everyone, thanks a lot for joining, Um, firstly, apologies that it didn't happen on Monday. There was obviously a global outage of Facebook and the likes, which is why we had to reschedule. Thanks a lot for being flexible and coming today. For those of you who, unfortunately aren't able to join us today, we will be posting it on YouTube, and you can watch it play back then. So today we'll be talking about diverticular disease and benign in erectile pathology. But firstly, welcome to this course. It's designed by junior doctors, and it's aimed for junior trainees, not just medical students, not just training doctors but also the wider MDT. Who might want to find out a bit more about the pathology is that they're helping to care for on a daily basis as well. Um, it's not got any nonsense. It's just the core information, which you need for the job and also to pass any exams. You're welcome to post any comments or questions in the Facebook live. I've got it running on my right bear in mind. There's a one minute lag between you asking and me seeing it, and any questions that you want to ask. You can also email it afterwards, and we'll ask some feedback at the end. So the general format of any of these sessions will be a bit of anatomy. A bit of pathology will speak about various disease presentations. Speak about the investigation management, a few complications of management and of the disease process is, and then we will do some cases at the end, too. Consolidate what we've learned so far. It's a bit about myself. My name is Mark. An academic fly to doctor graduated last April during the coated pandemic work currently at University College, London. And my interests are primarily e N t, maybe orthopedics. I'm still considering both. I like research and also like some teaching. So the key learning points for today's session is going to be understanding the spectrum of diverticular disease. It's an umbrella term, and it comprises a few different things, but we're going to split the talk into two parts, so that'd be the first part. The second part will be understanding the core benign in erectile pathologies, which is a very broad topic, but I've chosen to cover the four commonest things that you'll come across when you're on take working as a surgical doctor, but also the things that come up on the exam is the most will be understanding the key concept for investigation and also management, and then apply the skills to some M. C. U Q. Cases. At the end, let's go straight into part one. So diverticular disease. Let's start with a bit of basic anatomy, because I know people will be joining with all sorts of different backgrounds and and prior knowledge. But we'll cover the basics in this slide so the large intestine starts at the ileocecal valve, where the small intestine plums in. Uh, just just this sort of the cecum, uh, the appendix is at the end of that and then goes up. The ascending colon turns 90 degrees to the left, anatomical left at the right hepatic flexure and then turns again. 90 degrees. At the splenic Flexure goes down the descending colon, sigmoid colon and then end of the rectum. You can see they're teeny coli, which are three longitudinal muscle bands on that diagram on the left, you can just see one of them, but they're long to the muscle, and what they do is contract the tube on itself, which is why you get these out pouchings which you call house tra. And that makes it anatomically different to the small bowel which doesn't have these extra and also makes it identifiable on a plain film radiograph. When you can see the pasta in terms of arterial supply, remember, the large intestine is made up of mid gut and hand got so up until two thirds of the way of the transverse colon will be mid gut. And then beyond that will behind gut and the arterial supply mirrors that. So you've got the sm a the superior. Sorry. The the superior mesenteric artery, which supplies all of the ascending colon and two thirds of the transverse colon, the middle colic artery and nasty moses with the left colon artery at that area. And the descending and rectum made up are comprised by the inferior mesenteric artery. Good. So diverticular disease. A few definitions to start diverticul OSIs the diverticular diverticular disease, diverticulitis. They all sound the same, but they're actually very different, and people will use them specifically to mean different things. So we go through a few of those now diverticul OSIs is herniation of the mucosa and submucosa through the muscular is appropriate. And if you look at the top right there, you can remind yourself of the layers of the bowel wall. And the muscle layers aren't a tube. They're actually they're actually in a mesh like that, which leaves these little pockets in between, where if you get kind of a weakness in the in the inner layer, it can poke out of this mesh and form. These little bubbles, which we call a single one, would be a diverticulum, and the general condition is diverticul OSIs. Diverticular disease is umbrella term, which refers to any clinical state caused by symptoms pertaining the diverticular. So whether you have inflammation of the diverticular, whether you have just a diverticular there in the background, it's all encompassed within diverticular disease. If you have complications of diverticulitis, which will go through in a bit like abscess formation or perforation, it's still all comprised within diverticular disease, which is kind of the main umbrella term. It's a bit of epidemiology. 10% of people under the age of 40 have diverticular disease doesn't mean they suffer bouts of diverticulitis, but it means they have at least a few diverticular, a few outpouchings. The incidence goes up with age 50% of people over the age of 50 so it's extremely common. By the time we all die, we will all have at least a few diverticular. It doesn't mean we would have suffered from bouts of diverticulitis. As we explained in the terminology a few minutes ago, the incidence is the same. Men and women. There's no kind of particular one or the other, and it mostly affects the sigmoid colon. Interestingly, it doesn't. It very rarely affects the rectum. And the reason for that is that the layers of muscle. So you know those those teeny that we talked about actually, when it gets to the rectum, forms a continuous sheet around it. So remember before I said they were kind of a criss cross. By the time they reach the rectum, all that muscle forms a continuous sheet, so there's actually kind of nowhere for him to poke out to. So rectal diverticul OSIs is extremely uncommon. Asian ethnicities have a high incidence of right side disease, which can mimic appendicitis. But the typical kind of exam and typical UK presentation will be left iliac fossa pain. So a few risk factors low fiber diet because you're constantly straining because you're constipated, which puts more pressure on the bowel wall and therefore forces that mucosa through that cross matching of muscle. Therefore, making out pouchings more likely to occur. Age. We will discuss that decreased his activity. Obesity, Smoking, alcohol. Not surprising. They're bad for everything, um NSAID and also genetics. So things that affect your connective tissue very logically means that you're kind of cross matching and your mucosa is less structurally sound, and therefore it's more likely for it to pouch out. So let's speak briefly now about the spectrum of diverticular disease because it is a spectrum and it's all encompassing within diverticular disease. So Diverticula OSIs, when we mentioned that earlier is just the presence of diverticular, and that's a symptomatic. It's just out pouchings of the bowel. It's not doing anything. It's just there diverticulitis. The suffix itis, meaning inflammation of is inflammation of the diverticular. That's when you've had diverticula OSIs, and for some reason, one of these out pouchings or many of them, become inflamed. That typically presents with left lower quadrant pain sometimes right, as we've explained, can change in bowel habit. Sometimes constipation, sometimes diarrhea fever because you have an inflammatory response to that lower GI I bleed So fresh red blood coming through the back passage is a very common presentation, which can be by itself or alongside all of those other features. And sometimes an abdominal mass, too, if there's a an abscess or a phlegmon, which we will explain in a short while. So it's uncomplicated. Complicated diverticulitis is if you have peritonitis. If the bowel wall has perforated and there's either AARP fluid or Frank who has just come through the bowel wall and it's in your peritoneum and therefore you get inflammation of the peritoneum peritonitis, and that presents, as I'm sure you probably will know by now with guarding so simply, it's to excruciating to touch the abdomen, um, rigidity, so that the muscles are rigid tight to try and protect it and shock. So you know, hypertension and tachycardia features of sepsis. Complicated diverticulitis can also be when you have diverticulitis with any of the complications which we will talk about later. But those will present, usually with symptoms of fistulas. The fistula is an abnormal connection between two epithelial surfaces. So if you have a connection between your bowel and your bladder, you have pool in your urine. You might have gas coming out your urethra. Uh, you might have a recurrent UTI s. You can also have an abnormal connection between your bowel and your vagina, and you'll get all those things coming out your vagina. Or you can have it from your bowel to your skin and you have skin discharge so it depends where the abnormal connection is. The Hinchey classification is used to speak about the different severity is used to stage about of diverticulitis. So an inflammation of Kim Chee Stage one is just when you have that Diverticulum gets filled with Puss because it's infected and inflamed. And when you have a walled off air of past that's called an abscess so you might have a localized. It's just in one little area pericolonic, because it's next to the bowel because the diverticulum is separate from the bow abscess collection of pus. If that becomes very big because that can swell, swell can swell. It might not pop yet, but it will swell and swell, and it's large. That will be a Hinchey Stage two. And it's in the mesentry by the bit that, you know, connecting the bow to the posterior abdominal wall, which has all the vessels and the fat and things so one and two are uncomplicated. That's kind of an abscess. You can recover antibiotics, and you'll be fine three and four when things start to get a little bit messier. So Hinchey. Stage three is when you have perforation. So one of these inflamed diverticular tops and you get gas coming out into the peritoneum. That's when you might see a runner, the diaphragm or around the bowel wall. That's bad, but not as bad as his Stage four. When you have frank feces because the you know the the rupture is so big in the bowel that feces is coming out and that has a whole you know, there's a whole range of badness. It will. You'll present septic. You'll have extreme guarding. And when you do your emergency operation, um, there's a higher chance of postoperative infections because it's obviously not sterile. So some common complications abscess, which we talked about already, and you get kind of, you know, a collection of pus alongside on on on the of the bowel. You get bleeding so you can have if one of these diverticular and information of it erodes into a small vessel that will just bleed and you'll get large volume PR bleeding. You can have perforation as we've explained sepsis, which we've explained as well, uh, and an obstruction. So if you've had a previous bouts of information and you get scar tissue, which forms where there was severe information, that scar tissue won't expand like the rest of the bowel. And so you can get moments or or, you know, episodes where you go into large bowel obstruction, and so you'll present with absolute constipation and it will back up. You'll get vomiting and you're feeling well, a phlegmon a funny word. It's basically an abscess, which isn't formally walled off, so if you have a large, it is an inflammatory. Massive tissue, which might be a dentist might have passed, but it's not walled off in the same way. Then abscesses. That's what like models. So before we go any further, I'd like to offer you guys a chance for a bit of interactivity. I'd like you to tell me the differentials for left lower quadrant. Abdominal pain. Uh, I won't wait here until all your answers will come back to this. But if you guys for now, right down the yes, I'll write down the link. Oh, e v dot If you can see it, then great. But I'll write it in the chart as well. You can't see it. Great. If you go to that link and start typing in differentials for left lower quadrant abdominal pain, we'll go through to the end. So some investigations Bedside, bloods, radiology. Every time you speak of an investigation, we'll think about an investigation. Think about it in those three things when you're clerking them, what can you do at the bedside there and then blood? What do I need to send off which, you know I can go through an hour or two once I finish writing them up? And what investigations can I get in terms of scans? So the bedside. Everyone's going to get an EKG when they come into a and, um, it's not specific to diverticular disease. If you think you know, they just had a perforation, they might need a laparotomy and a surgery. You're going to want to know what the heart's doing to see if they can handle it. Anyone coming with a fever, you're going to get them a rapid coated swab. And anyone going to theater because of the aerosol generating procedures associated with intubation etcetera, you're gonna need to know the code status. Urine dip, urine, pregnancy test again. Urine pregnancy test. You're going to be putting them through a scanner. Uh, you're going to which will have high dose radiation. So you need to know whether there is a, uh, pregnancy there. In fact, a CT scanners will not accept women of childbearing age through the scanner unless there's a negative pregnancy test and a PR examination. If you don't put your finger in it, you put your foot in it. Bloods. Uh, so you want full blood count using the left? All the normal ones, basically, and you want to know what their electrolytes are doing group and saving clotting more to do with operation. So if you think you might be operating on them or if they're losing a lot of blood, you're going to need to a group and save plus or minus a cross match if you're going to transfuse them there and then radiology. So the easiest one to get would be an erection X ray and an abdominal X ray. The direct chest X ray is important that it's a wreck chest X ray. So that means they've been sitting up or standing up for a minute or so. And the reason you do that is because that allows if there has been any perforation and therefore gas leakage from the about into the abdominal cavity, it allows time for it to rise up because it's less dense than whatever it's sitting in, and therefore you can see it under the diagram. And that top right image there has a little arrow where this so this is normal. The other side is a gastric bubble that is allowed, but on this side, you're not meant to have another on the abdominal X ray. You can also see, uh, this. If anyone knows what this is, type it in the chat. Now I'll give you a few seconds. What I speak about CTAP so ct, abdomen and pelvis, with contrast, is indicated if you suspect diverticulitis and there is another raised inflammatory markets. That's quite low threshold for doing a C T A P if they're in the hospital with it. And that's because you need to know whether there any of these complications. How big is the abscess? Have they got a perforation? Do I need to operate? Those are all answers that you can answer with the CT abdomen. With contrast, don't forget. If you're giving them contrast, you need to know their renal function because if they have renal failure, then you can't get the contrast because you'll get a contrast induced neuropathy. CT angiogram. So gram image of angio, the vessels and CT the method that you're looking at. So you're looking at the vessels with CT, so that is useful if you have a diverticular bleed. So some patients will present the most common cause of fresh, massive G. I hemorrhage in someone you know over 60 will be a diverticular bleed, and I explained why that happened earlier on CT. Angiogram will pick that up. You'll see the bleeding point because you'll see contrast, which you've infused into the vein spurt out at the point where there's the bleeding. You only see that if there's about one meal per minute of bleeding, which is actually quite a lot. Um, so that needs to be. It needs to be kind of posing out to that extent. If you can see it, then you might speak to interventional radiology, and they could maybe embolize it or put a coil in and stop the bleeding at the source. So going back to, um, I got one person saying Coffee bean sign. Um, so the coffee bean sign is for a volvulus. So that's when you have large bowel obstruction. That's when the whole signal twists on itself. I read this looks a bit twisted on itself, but the coffee bean sign basically takes up the whole abdomen where I haven't You haven't haven't seen the whole X ray, but that's only right in the corner. So forget about the coil. Coil is sort of normal in that sense, but what it's actually showing is rigorous sign. And that's a sign just like air under the diaphragm on the top image. It's a sign that there's a rare on both sides of the bowel wall. We all know that air is meant to be on the inside. That's fine but on the outside is bad. If you compare the right image to the left image, do you notice how the right image looks? Kind of three D? And that's because you can see both sides of the bowel wall because there's gas on both sides. You only see a difference when there's a difference and density. So compared on the left image, you have gas, and then you have bowel wall, which is a different density. Therefore, you see a change in color, but then you have bowel wall and, you know, just like vacuum slash fluid in the peritoneum. And that's not got a different density, which is why you don't see a second color change. Compare that to the image on the right. You have gas in the bow, then the wall, then gas on the outside again. So that's why you see, that's why it looks kind of three days because you see both sides of the bowel wall Rigler sign a sign of in the peritoneum and therefore perforation. So the pillars of management. Just like if you ever speak investigations, it's bedside blood and imaging. When you speak about management, it's conservative medical, surgical so conservative management for now, speaking about diverticulitis and complications of that because there's no management of the diverticulosis because, as we mentioned, it's, uh, symptom free. Well done. Someone else got regular sign. Um, so nausea and vomiting Treat that. Give them ondansetron. Give them cyclizine pain treatment with you know the ladder of the ladder of analgesia. Start with paracetamol, then go for a weak opioid. There. Strong opioid basket pan can be quite helpful. Take a higher, higher seen hydrobromide beautiful bromide, which is an anti spasmodic, and when you have kind of colicky pain, that's quite helpful. Lifestyle advice. So if someone comes in with a flare of diverticulitis when you're sending them home because they're better, you can offer them some lifestyle advice. To prevent future flares. Increase the amount of fiber that you remember. We said that constipation is, you know, causes this flares and worsening of diverticular disease to increase amount of fiber. The exercise be better to yourself. Exercise less smoking, less alcohol, etcetera. Is Pegula husk. Sorry, I said that wrong, it is impossible to say is a bulk forming laxative. It's essentially fiber. You put you mix it in a drink, and it is a fiber. If you can't eat enough fiber, have some muscular husk, and that will give you enough fiber to prevent the progression of disease. So no antibiotics. There's anything you wouldn't give antibiotics if they're systemically well, and they have mild pain, not immune suppressed and they don't have significant capabilities. Basically, if they are, well, the pain is not that bad. You think it's probably diverticulitis, but you haven't really confirmed it because the pain is not that bad. You might be seeing them in a GP surgery. Not in any. Then you don't have to give them antibiotics because we are wary of antibiotic resistance. Diverticular bleeds are often managed conservatively. So unless, as I mentioned before, they are hosing, uh, and they need a CT angiogram and, uh, a coil potentially an embolism of the bleed. Then most diverticular bleed settle with conservative management. If you think about it, I mean, what else you going to do? You're either going to toilet or you're gonna wait or you're gonna take out the whole bowel. If the bleeding isn't bad enough to do any of those things, then you manage it conservatively. Keep an eye on them. Make sure the BP is a good level, you know around 120 go from there. So medical antibiotics is the mainstay of treatment for most bouts of diverticulitis. If it's uncomplicated, you can get away with oral antibiotics. In my trust, it's called amoxicillin for five days. Complicated diverticulitis. You give IV antibiotics. Remember the difference between uncomplicated and complicated? We talked about it a few slides ago. Basically, Henchy three or four. Any of the adverse features Sepsis. Do your sepsis. Six. That doesn't change, no matter what pathology you are doing. Uh, early I t input, as always, thromboprophylaxis. So preventing clots. Then you want to give prophylactic, low molecular weight heparin. If they're overweight over 100 kg, you give that twice a day instead of once a day. So my trust, it's enoxaparin 40 mg over 100 kg. You give it twice a day. Same with interferon. If you think they might have surgery, don't give them from prophylaxis. It can wait that you know your consultant is going to be and your patient is going to be angry at you if they can't have the surgery in 12 hours because you've given them little extra heparin versus the tiny risk of them having a P in those 12 hours. If you're not sure, are someone hold it. But if you are sure that they're not going for surgery and they're in hospital, I either Hinchey one or two. It's uncomplicated diverticulitis. You're giving them antibiotics. Then they need to know molecular heparin because they're going to be immobile and they're going to be with an infection and therefore a higher risk of developing, UH, a DVT or a P interventional radiology. We've already mentioned their their role in coiling of large diverticular bleeds, but they can also drain big abscesses. So those big perry colic abscesses the Hinchey twos, which are in the mesentry. If they're more than three centimeters, then you want to cut it out, I said, Comes out. I mean, drain out with a needle on the ultrasound. So surgical, that's we finally at the surgical better if they have previous episode of complicated disease and they've recovered, but they have ongoing symptoms. Either have a fistula or they have a stricture, then they can have an elective surgery. I'll come back to that. Most times when you're thinking about surgery in someone with an acute flare of diverticulitis in in hospital, it's because they're perforated. So they have the diaphragm. They have a regular sign, or most like you found out with a CT abdomen, pelvis, and the radiologist will tell you that there's a perforation. The operation you do for a perforated colon is a heart and procedure, and this is something that you will have have to know what it is so hard and procedure. You do it if there's fecal peritonitis, large perforation or kind of an unsurvivable bit of bowel, if that. If it's a systemic, for example, so what is the heart procedure? There's a little image of it near the top of your screen, but it's when you cut out the sigmoid and then make a stone with the proximal bit and stitch the other bit. So this sigmoidectomy and a proximal end colostomy. But that means in you know, more simple English. You're cutting out a bit that's inflamed and horrible, and now you've got two ends. One of them is making to one of them is not bring the one that make poop out to the surface of the abdomen, and that's an end colostomy, because you've got the end of the bowel, as one Lumen up onto the top lip gloss to me would be if you brought out both sides and cut a little strip in it, and you have the proximal distal bit together. But that's not what you're doing here. Good. So most patients have a single episode of uncomplicated diverticulitis, and they'll just receive medical management. And by that, we discussed just means, um, antibiotics. One third will unfortunately have a recurrence in five years, and they're at higher risk of abscess formation. Uh, and there's often the patients who present at a younger age will have more recurrence. And recurrent disease has a higher mortality because you're more likely to have perforations or strictures or things like that. Only one in for surgery of patients that have a surgery remain symptom free follow up. So if you have come into the hospital and you had an acute flare of diverticulitis, surgeons will often ask the juniors. I asked to book them into a clinic appointment in 6 to 8 weeks, something like that. So it's a non urgent referral to ever treated them in hospital their clinic. And the reason they do that is because usually they want a colonoscopy, and it's and and the reason they want the colonoscopy is to make sure that there are no cancers in the bowel as well. And it's not because diverticulitis causes cancer or that the other way around cancer causes diverticulitis. It's more that if you have diverticulitis, you are usually meeting the two week weight criteria for having philosophy for cancer. You're usually having a change in bowel habit. You're usually over whatever age is 65 you're usually having some some bleeding through that passage. So that's why you get the coloscopy. Let's do some questions about diverticulitis a 56 year old man presents with his first attack of diverticulitis. Which of these complications is least likely to ensue? You've got to kind of many cases and, uh, questions like that, so I'll give you a few seconds to think about it, So the least likely to ensue is malignant transformation for a malignant transformation. To occur, you need chronic inflammation, multiple bouts of information which will eventually change the DNA in the cells and eventually cause, you know, tumor suppressor genes to be mutated, etcetera. In order for you to get a cancer, all those other things, if you're unlucky, can happen with a single bout of diverticulitis. Get a really bad about diverticulitis, and it forms a scar. You get a stricture get really bad bout, and it can form a fistula between you know your bowel and your bladder. You can get an abscess and a phlegmon just with Hinchey born or two. So that's kind of almost part of the attack of diverticulitis. Question, too. Which of the following sites is the development of Diverticula? OSIs? Least likely, and I've talked about this already in very specifically, so I won't give you too long times. This one. The answer is rectum, and that's because the muscle, once it gets to the rectum, forms a continuous sheet, a tube like sheep around it, whereas previously you have those 10 year which strips and you have the cross matching of the muscular is appropriate. Question three, A 75 year old man is admitted with large bowel obstruction and on investigation is found to have significant sigmoid diverticular stricture as the underlying cause what is the most appropriate treatment? This is one of those complications of diverticulitis, which is a stricture and therefore large bowel obstruction. The answer is laparotomy and Hartmann's procedure. So laparotomy means a cut, which often goes from the sternum down to the pubic synthesis and the heart procedure. We already explained what that is. The reason it's not any of the others is because if you have a bowel obstruction, that bowel is a dermatitis is angry and it's not going to do well. If you do any of those other things. If you dilate, it will probably perforate it. Um, if you put a self expanding metallic stent, you're not actually fixing the problem and all that, but also dentist, you'll probably get a recurrence of the obstruction anyway. Loop Ileostomy isn't appropriate because you'll have, um, you know, you're you're cutting in. It's the wrong part of the colon. You know you're bringing out the ileum, which is way proximal and you're not fixing the problem. And the colorectal anastomosis would be If you're putting the two ends back together, the reason you don't do that is again because the bowel is angry and edematous and healing is really impaired. If you're in that state, what you want is the heart procedure. Bring it all out, make sure everything is separate. You can then wait. And six months later you can reverse the heart procedure and then do the anastomosis. So patients who have heart procedure aren't bound to having stones for the rest of their life. During covert. It's been, uh, you know, the surgeons have been struggling to do those reversals, so people are stuck with it for a bit longer than normal. Last question is, what's the most appropriate investigation? Four diverticulitis. And we've kind of gone through that. So we'll go through this very quickly. Great. So they've all come up on my screen above. I hope they have for you as well. Um, Constipation, your enteric pregnancy left topic cyst or shin ovarian Ulcercolitis Impaction Stone cancer rupture poem, arthritis. You see colitis, P i. D. These are all great. Which ones have we not got? Ischemic colitis. That's one that has not been mentioned. That's when you have ischemia, maybe by an embolism. If you have a if you throw up a clot and you, uh, infarct part of your bowel that will present with left. You can also have another differential. Would be epiploic appendagitis um, which I don't know if we mentioned it and we'll go back to the, uh, anatomy quickly. There you go. This top one. Can you see how their mental appendices it's? It's specific to the large bowel, but you have these little kind of fat tags, which come off the large bowel, and those can become inflamed and mimic diverticulitis as well. And in the live specimen, they look like this. You can see this at all these little tags that's called epiploic Appendagitis because it's an appendage. Information of the appendage. Cool. What else have you been mentioned? That's most of it, but and everyone so part, too. But, um, for staying awake for part one part too now, completely separate. Close the chapter of your of your mind, uh, and open up this next one benign in a rectal disease. Absolutely thrilling topic, and we're going to talk about hemorrhoids, fishers, fistulas and abscesses, which is also part of the fistula, will explain that in a bit. So again, some basic and ask me. First, there's a little summary slide so the first thing to mention is about anatomical position and some terminology. So if you're ever describing the anus in your notes to your colleagues, whatever you have to describe things in a clock, that clock is based off the patient being in the lithotomy position, so on in the back, with their legs spread 12 o'clock is up six o'clock down, three o'clock, right, nine o'clock left. But remember, when you're examining patients, they're usually in the left lateral position, which means you have to kind of imagine them on their back and then change it. Change it back because obviously, if you're looking at them in the examination position, you might think 12 o'clock is towards there, right glute. But it's not. It's still as if they're in the lithotomy position, so that's important to mention First. Secondly, we can talk briefly about the anal canal. It's surrounded by two types of sphincter, the internal sphincter in the external sphincter, and they both play a crucial role in the maintenance of fecal incontinence. The internal sphincter surrounds the upper two thirds of the anal canal, and it's formed by the involuntary circular smooth muscle in the bowel wall, so it's involuntary. It's supplied by HIPAA Gastric plexus. The external anal sphincter is a voluntary muscle, so it's skeletal muscle and it surrounds the lower two thirds of the anal canal. So overlaps a little bit with the internal anal sphincter. It blends super early with the pure rectal muscle of the public floor, but we won't go into the public door in detail. But if that rings a bell, then great. The superior aspect of the anal canal above the pectinate line or the Dentate line, which marks the difference between the superior and inferior part of the anal canal. The superior. But it has the same epithelial lining as the rectum, which is the same as basically the whole gut, which is Columbia epithelium. So basically everywhere between, uh, well, the lower part of the esophagus to the to the to the dentist line, the Pectinate line is Columbia Epithelium, inferior to the pectinate line in the canal, is lined by nonkeratinized stratified squamous epithelium. So basically the same as skin is not keratinized, which means it doesn't have as much character in it. And this is quite an interesting area of the body because it is where the endo dumb meets the road. Um, there's no kind of method. Um, intermediate, which normally is yeah, above picnic down is divide from the embryonic hind gut and below is derived from the rectum. Good. There's a little summary table there. If you want to look at the you know because because above and below have a different arterial venous nerve and lymphatics and I've left it there for your, uh, perusal later on. So hemorrhoids straight into our first pathology. Sorry about the picture at the bottom. So what is it? Hemorrhoid is a swollen vein in the lower rectum. This might come as a surprise, but hemorrhoids themselves are normal. They are vascular cushions, and without them, we'd all be incontinent. So you need them. We'll be incontinent to like, kind of liquid and gas. You need internal hemorrhoids in order to maintain continent. So look on this image on the image right hand side. That is just the vascular cushion which, if you imagine, it's normal. The other side, when everything is collapsed, forms like an airtight liquid tight seal, so without them would be incontinent. But hemorroidal disease, which is what the slide maybe should be called is when you have a problem with the hemorrhoids. So they might become engorged too big, and they might start to prolapse out of the body. They might become thrombosed clot in them, and that causes pain. X true external hemorrhoids. I hemorrhoids from the peripheral vessels outside, you know, below the pectinate line are actually extremely rare. So when you hear someone saying external hemorrhoid, ask yourself, Do they mean external hemorrhoid or have they not listen to this talk and read the books, and do they actually mean a prolapsed internal hemorrhoids, which is much more common? So that picture of the bottom is a prolapsed internal hemorrhoid and those vascular cushions which meant I know the diagram above and he has two. In actual fact, we have three at the 37 and 11 o'clock position. Remember that. You know the the clock position that we talked about earlier, and that forms a bit like, you know, the valves in the heart in a liquid and airtight seal. So how does it present? It presents, usually with painless PR bleeding, So painless blood coming from the back passage usually kind of either splattered in the bowl, or patients will say that they still on wiping. Um, I noticed some blood on the tissue paper. It can also cause itching, and I put pain if one goes in brackets because it's slightly rarer. But if they, for example, some of the history of hemorrhoidal disease, comes in with acute pain, that's exquisitely tender to touch and you have a look and you see a hemorrhoid, then you think it's probably the most risk factors. Heavy lifting, prolonged sitting obesity, constipation, pregnancy, anything which increases your intra abdominal pressure and increases. You know constipation because you're forcing it out pregnancy, because you got to be pushing down heavy lifting because you're straining and being fat. Anything that increases your intra abdominal pressure will make you a higher chance of developing hemorroidal disease not having hemorrhoids, because we will have them so diagnosis. Pretty simple. You have a look that can diagnose prolapsed internal hemorrhoids or external hemorrhoids, but can be quite difficult to diagnose fully internal hemorrhoids that haven't yet prolapse because they're not severe enough because typically and powerful imagine touching a soft, squishy vein inside the body. You can't really feel it. There's nothing. There's nothing to feel, so you often need to do proctoscopy, which is a small like a mini colonoscopy. It's kind of like a speculum that you might use in a female examination, but you put it in and it's got a light, and you can see the hemorrhoids, then on the clear surface of the proctoscope. So treatment for hemorrhoids, conservative treatment. A sitz bath that's basically sitting in warm kind of salty water and that soothes itching and helps them kind of retract back in dietary fiber. Remember, we said consultations risk factor and will make them worse. So increasing your dietary fiber will help and hydration for the same reason. Because it opens up your stools. Medical the same sort of, uh, topic you want Stool softener's, um, in order to, you know, decrease the how how firm the stool is and therefore decrease the straining that's needed in order to have a big and your soul is basically a topical, uh, anesthetic and a soothing agent, which you put on the hemorrhoids themselves, which can relieve that you know those itching symptoms or sometimes the low key bleeding symptoms as well. If they're thrombosed, I the blood that's in them has clotted off, and it becomes extremely painful. You can use topical G t n uh, trying to train surgical management of hemorrhoids. You can cut them out, and not surprisingly, and that's the main way of doing it. So this is a surgical procedure, and you'll go in and cut them out and stitch up what you've cut out. You can also do band ligation, which is when you basically put in a plastic band around it and squeeze it really tight. And it either kind of stays there and shrivels up or the band so tight it just falls off. Or sclerotherapy, which you might use for a certain viruses as well, where you inject some sort of chemical, which just like coagulate the blood and basically what it all off a thrombectomy. She is when you have a thrombus, a thrombosed hemorrhoid, and there's a blood clot in there. What you can do is make a small little incision a couple millimeters within the hemorrhoid and then use some tweezers and pull out the clot. And that will often, uh, relieve the symptoms because then you'll get it again. Cool is hemorrhoids In a nutshell. Let's move on to the next most common interactive disease. Benign interact disease, which is, um, anal fissures ache. A fissure in anal. Um, what is it? It's a mucocutaneous by mucosa and skin. Remember that back in line defect of the anal canal? Basically a tear. Very painful, as you can imagine, and so it presents with painful PR bleeding. So why is it painful? Remember below that pectinate line is innovated is basically skin. We said It's nonkeratinized squamous epithelium. It's part of the modem, and therefore the innovation, if you go back to that table, is somatic. You know it's part of the dermatologists, three or four, whatever, and you you feel it. That's why it's painful. If you had a tear higher up in the rectum, you wouldn't feel exquisitely painful in the same way. So it's above the line. You don't feel in the same way you might feel pressure. You might feel pushing. Let's say you have a perforation in your rectum. You don't feel the tear of your rectum. You feel the peritonitis. You feel the pain that's caused by inflammation. Peritoneum, not the tear in the bowel itself. That's why it's painful, so risk factors, mostly idiopathic as you can imagine. The constipation, uh, just a mechanical thing. If you're pushing out a massive who, then it will tear sometimes. Also, Crohn's and tuberculosis systemic problems, which you know, causes information everywhere. TB is surprising, I admit, but it's true. So how do you diagnose it again? PR examination Now often a telltale sign of someone who has an anal fissure will be that they refused to be examined. You know, they might let you have a look, but as soon as you even, like, spread one of their cheeks, you can't even you can't even do that because it's too exquisitely painful. Because imagine, you're just as soon as you do that. You're kind of opening the fissure, and every time they're opening the bowels, they're opening the fissure. That's why it's extremely painful, and actually, it's quite hard to heal. If you've ever cut your finger on, you know, on a joint or something, then it's the same sort of concept conservative management. Oh, sorry I haven't mentioned anyway. So anyway, is an examination under anesthesia. So if these people can't tolerate an examination normally then sometimes in order to diagnose and treat them properly. You give them an anesthetic just a very, very quick one, half an hour or so and it wouldn't be a full intubation. You probably use a laryngeal bass just a quick take a thing, uh, and examine them properly. And sometimes if you see something, you might do some of the surgical things at the same time. Quite interestingly, the fissure's 90% of the time it happened in the posterior midline. I either six o'clock position. I don't know why, but that's true. Management. Conservative stool softeners, fiber hydration. Same as the other things that should make sense to you by now if you're if it's painful, too. Um, you know, if you're passing large pulling, stretching all out, then make sure it's soft and make it easier to happen. Medical topical g t n g e n is a vasodilator and also relaxing. So instead of you know, the muscle being really spasmed and cramped, it will just relax a little bit, uh, diltiazem same mechanism. Botulinum toxin. I, Botox not used for wrinkles but again used to relax the muscle and allow healing surgical. So this is the kind of the meat of it. So lateral sphincterotomy or advancement flaps. I'll explain one at a time. Lateral sphincterotomy ostomy cut in sphincter sphincter, lateral the side cut the sphincter at the side. Um, what that does is it kind of opens that. And it means that you've got kind of a kind of a bigger a bigger wound, so to speak, which instead of it being small and just tearing and healing and tearing and healing, is kind of a bit flatter and more open and allows it to heal almost by secondary intention. Um, as you can imagine, if you're messing around with the sphincter, there is a chance of causing incontinence, or 10% of people who have a lateral sphincterotomy, which is the best treatment for, you know, fissures that haven't responded to conservative medical treatment. 10% of them will develop incontinence. Two status advancement flap. Very complicated plastic surgery sort of thing where they're like flapping some of the skin over and passing out. We don't know much about it, but a flap is when you move a whole chunk of skin, sometimes muscle across somewhere, for example, you might move this part of your skin onto the nose. If you have a cancer to reconstruct, that's what flap is. It's a plastic surgery. I think so. Fistulas on two are kind of final topic. Um, what is the fistula? It's an abnormal connection between two epithelial services. I mentioned that earlier. So for anal fissures that will be between the rectum and the skin to imagine, obviously there's the main opening between the rectum and the skin itchiness. But an abnormal connection between two epithelial surfaces. Epithelium surface, one being the rectum and epithelium surface to being basically the butt cheek the skin elsewhere, Um, and there's different types, so you can have extras enteric supersymmetric transmitter into and sub mucosal sub mucosal is basically doesn't go through or has nothing to do with the muscles into Sphincteric comes out of the rectum, goes through the internal sphincter. But then it doesn't go through the external sphincter and instead passes between the sphincter's interstim enteric. And that's the most common type of history. Then you have transtrochanteric, which goes through the internal and external sphincter quite fairly bad news. Um, then you have super sphincteric. It goes above both sphincters, an extra enteric, which extra it goes all the way above. From the rectum bypasses everything super goes through the internal and then up and around the external. So there's different types. How does it present? It presents as as a hole somewhere that isn't the anus that is discharging. Usually it's usually foul smelling fluid, so it's usually sort of poorly liquid. Um, and it just kind of seeps out. It's obviously distressing because it's, you know, sort of akin to incontinence, you know, smelling and whatever. Um, it's not painful by itself, but you have got an abnormal connection between the rectum and the skin, and you've got bacteria and feces going through that, or at least liquid bits of feces going through that. And so, as you can imagine, that can cause an infection. So you have this tube where bits of diarrhea essentially are going through. It eventually will become infected, and then it will form an abscess. Within that we'll go through. There's a picture of that in the next slide risk factors, the things that you'd expect things that cause you to have more infections in general TV, diabetes, HIV and then Crohn's disease, which is a fistula eating disease. Unlike ulcerative colitis, which is non fistula eating disease. Um, and why is, that is because you see isn't transmural. It only affects the inner layer of the rectum, whereas Crohn's affects the whole way of the rectum. And therefore there's a chance of visitors happen. That's the main, the main cause. If there's someone who presents with recurrent anal fistula, then they are almost always investigated for current. I haven't mentioned everything I want to mention. I think so. So that will go through those little pictures in a second. How do you diagnose it? Surprise, Surprise! It's a P R. Examination. As with all these benign in erectile pathologies, it's best to have a look, uh, and put a finger on it, if you can, if they let you. Um, good source rule is something I will explain very briefly. Now it is in reference to that bottom diagram. So in that bottom diagram, we have the answers in the center. We've got the anterior 12 o'clock position upwards posterior, um, six o'clock position going down, and we've created an imaginary line across the middle from 9 to 6 o'clock. If that makes sense, and good source rule states that if you're in within three centimeters of the anus in around so three centimeters like that, then fistula external fistula openings go in a straight line to the internal fistula openings, whereas if it's posterior, they often do a curve towards the midline and then go in. So going back to this, you see these lines. Obviously, this is a two D image, but going forward to this one, all you can see is the anus, and all you can see is the external opening. But somewhere there's an internal opening. And that's important because if you're in surgery using these things up here, which are called Lockhart memory Probes and you're trying to find without pressing it through and damaging the bowel will further or you know the soft tissue further, you're trying to find the path between the external and the internal, UH, which is which then allows you to do some of the management, which I speak about in a second. So that's why it's important to know this good source rule is because you're trying to guess where it is. So it's anterior. You can have a safe bet that you go from where the external whole is straight towards the center of the Penis, but going backwards. Whereas if it is posterior, then you know that you'll probably have to curl towards the midline and then go up. That's why it's important to know again the you a examination under anesthesia because you're you know, you're putting that probe in a fistula around the bottom, not very comfortable. Uh, an MRI is important as well. If you have sort of a complex type of fistula, and you just basically can't figure out what's going on with the lock our memory probes imagine you have this extra sent Eric or Super Center, which is going in a snake and all sorts of complex stuff. Then an MRI will, because that's the best modality for soft tissue, and MRI will show you what's going on. There's a nice picture of, uh, perennial abscess. So here you had a fistula going this way, this way, this way, going that way. And at some point somewhere in the fistula, there was a blockage and infection. And then there's a big abscess which needs to be drained, so management if you have an abscess by a collection of pass which in this case is walled off by the fistula tract, which, which makes it an abscess, then into an I and D, which is an incision and drainage. And in brackets, you let it heal by secondary intention. So you cut into it, you drain the pus, and then you leave it open. So you put packing and you put gauze put Aquacel, which is a sort of sort of a hemostatic sort of goes like ribbon. You pack that in, and then you put a pressure dressing on top, and that will then allow it to heal by secondary intention. That's the only way you can do it, really. Sometimes if they're deep and you can't leave it open because you have a massive, gaping wound, you can try and do like a needle aspiration. But I've seen a few of those, and they basically always record, often within days until something more definitive is done. But at least it drains the infection. So if their septic, then that needs to be done before the main thing, if their septic again. 76. So what are some things that you do once you found out the fistula tract. You can do fiber and blue, which is the kind of most basic thing which basically, you should forget about immediately because the glue and it really works. So forget about that. A seat on is very commonly used and is the kind of most conservative initial operation. So you might put them under general anesthetic, doing the you A. Use a lot of memory probe and figure out where this tract is. And now you've got that probe from the external through the fistula and into the internal opening, and you want to now thread a a seat on which is essentially literally just a piece of thread. Thread it through, bring it out, and basically I'm not. So what you've done is you've basically just made a loop from the external into the external, into the external, opening through the tracks out of the internal opening out of the anus and you've got a little loop. Sounds ridiculous. I thought it didn't make sense to me for a long time when I was being told about it, but it's actually quite clever. So what? That does and you you don't tight, tight but you kind of, you know, put a little bit of pressure on it. It's kind of a noise patients, because they have a not by there, but, um, but they get over it. And what it does is because of that low, low key tension. It it leaves the track open. Firstly, because you've got a bit of tension, it leaves a track open, which means you're less likely to get an abscess less like to get a collection of infection because it's just freely draining because you're kind of pulling on it. What you do is it opens and then it scars behind, and then you're pulling it more and it scars behind, and eventually it goes like that and you end up. The season ends up falling out because it's being pulled slowly and slowly towards the skin, and behind it is leaving layers of scar tissue. That's brilliant because it will fix the fistula because it would have scarred through. And also you haven't had a massive cut through your sphincter, so you have no impact on on continence. That's how seasons work. They kind of slowly over weeks slash months, pull their way through, go more superficial, more superficial and then leave a scar in trapped behind them. And then you haven't damaged the sphincter because it's, you know, it's been used all the time, and, um, it scars over. So laying open is called a fistulectomy ostomy cut in fistula. And that is when you essentially basically in this image. You would make a cut from the internal through the external and all this, but it would just be removed. So you've now kind of got a larger anus. If it were. If that helps you visualize it, which is obviously useful for the superficial ones. Sometimes maybe the transplant. Eric, because if you if you have most of the external, that's that's fine. But if you've got an interest in America, if you get a super, it's enteric. You can't really do laying open procedure because imagine cutting. Write all this tissue, you've got no strength left, and you're going to become completely incontinent. So Hysterotomy is great if it's superficial but not good. If it's, um, you know, one of these other ones Super Center transplant Eric sort of Contra indicated in Crohn's because it's too much information and that we mentioned high tract. What? I just talked about a second ago. Again, advanced flaps know it's there. No, it's the last line, but it's all very specialist stuff. Cool. A few consolidating, um, questions for us to go through. I'll be looking at the chat in. Answer your question, Emily. Warden can if you want from the beginning. Yes, I think it gets posted to YouTube, and we also go on the mind the Web website so you can watch the beginning, and I'll take that as a compliment. Thank you. So what is the commonest type of fistula in? You know, we have said this out, right? So I hope you will remember. I'll give you a few seconds to kind of work out what each of them are trying to imagine. Each one to transfer enteric going through both the sphincter's super elevator, going way above all of them through the levator muscles complex fibrillator complex version What we just said interstim Terek in between the sphincter's. So it goes through the internal and then comes out and then super generic through the sphincter, but at the top, most common in sphincteric least common supersymmetric. Next question. A 33 old lady is admitted with recurrent discharging fistula, Indiana. She is known to have anal rectal Crohn's Crohn's of that area. On examination, she's found to have a low anal fistula with involvement of a very small amount of the external anal fistula. Sorry, external sphincter. What's the most appropriate course of action? Cool, Happy thoughts of an answer. So the answer is insertion of a loose sit on. If you said Fistulectomy, I'll give you half marks. But remember, it's contraindicated in Crohn's. So laying open the track would have been the right answer here if it weren't for the Chron's disease. But because this person has Crohn's, you have to use a seat on so last question. I think maybe two more questions, uh, four year old boy is brought into the clinic. He gives a history of difficult, painful defecation hint there with bright red rectal bleeding. What's most certain diagnosis. They should all jump out of you, so I'll go through it quickly. Uh huh. 20 last question. The 28 year old male presents with painful bright red rectal bleeding. On examination, he is found to have a posteriorly sighted which remember 90% of them are midline by the six o'clock position. Fissure in a know what's the most appropriate treatment? This is a sort of entry level. Um Fisher question. You should know about it, right? Topical gtm paste, sublingual, GTM paste, right drug. Very wrong location. Anal stretch. That would be bad. Um, they used to do that, but it's extremely painful and didn't really help things. Advancement Flap would be really complex stuff that hasn't responded to all the initial treatments, and Taylor division of the external Anal sphincter would lead to incontinence, and it's not the right answer. Great. So I have a minute a minute ahead of schedule or a minute behind schedule, even. But the take home messages are the spectrum of diversity disease, the difference between fisher hemorrhoids and fistula fissures, painful hemorrhoids, painless fistula. Remember, that's in the context of information that we talked about. The key utilities of abdominal X rays, direct chest X rays, CT a PS and MRI's in this talk, and we've talked about the key management principals and sort of hammered them home. In a few cases. Uh, website has some further learning stuff. Everything in this talk will go into a pdf and uploaded shortly after this. Um, and please, please, please, could you do some feedback? Even if you're watching this on YouTube or whatever, the feedback code should still be live, I think. And you can probably scan that with your phone and answer. It takes literally two minutes, not even takes one minute. And I think it's been posted in the chat as well. Thanks very much for letting me drama on for 60 minutes about some holes, but thank you very much for coming. And I hope it's been an educational experience. Thanks very much.