NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Treatment involves unroofing the tract, draining any undrained collection, and allow- ing the tract to re-epithelialize . If the tract traverses the anal sphincter, a seton or string should be placed within the tract and allowed to traverse the sphincter without making the patient incontinent.

Case 8.39 Severe Anal Pain with Perianal Mass

A patient presents with severe anal pain, a tender fluctuant perianal mass, and fever.

Q: What is the likely diagnosis and appropriate management? A: The most likely diagnosis is perianal abscess , which results from an infection that occurs in anal crypts and glands that are present at the dentate line. There are four basic types of abscess: perianal, ischioanal, intersphincteric, and supralevator. Treatment of the first two types requires drainage through a perianal incision. An intersphincteric abscess, which causes pain within the anal canal, may require drainage within the anal canal. The supra- levator, a higher, more complex abscess may arise from the perianal area or higher within the abdomen; the decision regarding the site of drainage depends on its location and origin. The primary treatment is drainage, not antibiotics. A patient complains of pain and drainage in his sacrococcygeal area of the lower back. You examine him and find an abscess in that location. Q: What management is appropriate? A: This condition is a pilonidal abscess , which is an infection in a hair-containing sinus in the sacrococcygeal area. Treatment involves draining or unroofing the abscess, removing all hair, and leaving the wound open to heal by secondary intention. Resection of the pilonidal cyst or sinus may be required in the future.

Case 8.40 Need for Colostomy

A 58-year-old is having a stoma created in the operating room the next day. Q: How would you respond? A: Stomas are artificially created openings between the intestinal, respiratory, or urinary tracts and the skin (Fig. 8-47). Stomas may be temporary or permanent. Most temporary stomas SAMPLE Q: What preparation is necessary? A: The patient should meet with the physician and enterostomal therapist to be educated about stomas and their care. The most common complication related to a stoma is leak- age around the appliance (bag) and patient dissatisfaction due to a poor location of the stoma on the abdominal wall. A stoma should be placed where it can be cared for con- veniently and not in a skin fold where leakage could occur. It is best to determine this position preoperatively, with the patient in a sitting position. Other postoperative com- plications include parastomal herniation, bowel obstruction, stenosis, abscess, prolapse, and fistula formation. Your resident asks you to describe the different types of stomas.