Welcome to this latest edition of the “Banding Bulletin”! Generally, in these mailings, we deal with FAQs but I thought that we’d mix it up a bit this month, and share a couple of the more unusual findings that we’ve run across recently. In med school, an old attending used to tell us that “when you hear hoof-beats, it’s usually horses that you’re hearing”. Well, these “one-offs” remind us that every once in a while, those hoof-beats are coming from zebras! We will also include an update on our CRH Anesthesia business. We’d also like to invite you to visit us in Washington DC!
Patient #1 – “prolapsing hemorrhoids”. This was a woman in her late 60’s, complaining of: prolapsing hemorrhoids that require manual reduction most of the time, drainage, and itching with periodic discomfort. Colonoscopy showed hemorrhoidal changes and a few diverticuli, but was otherwise fairly unremarkable. On digital exam, the patient was non-tender, and there was a bit of irritated-looking tissue prolapsing, approximately 5mm in diameter, which was easily reduced. When reducing the tissue, it was clear that it was on a bit of a stalk, and anoscopy confirmed that this was a long, prolapsing hypertrophic papilla. The internal hemorrhoids were actually fairly small and nondescript. The patient was seen in a GI office, and so was referred to surgery for a papillectomy.
Discussion: This case brings up a few points. Obviously, it demonstrates some of the limitations of the flexible scope in evaluating the anorectum! The colonoscope, in retroflexion, has been shown to miss more than 40% of the issues in the anorectum. Looking at the colonoscopy report, the “hemorrhoidal changes” were actually external in nature (the definition of an “external hemorrhoid” NOT being “hemorrhoid tissue outside of the anal verge” but rather “hemorrhoid tissue covered by squamous epithelium (from the dentate line, out)”. I’m assuming that the papilla was not seen because it was pulled into the anal canal as the scope was withdrawn, and then the presence of the scope itself blocked its view.
Patient #2 – another case of “prolapsing hemorrhoids”. These also had to be reduced quite often, and with some difficulty. They were described as being quite large when prolapsing, and mostly on her right side. The colonoscopy also reported hemorrhoids, but not much else going on. On asking the patient to strain, there was some swelling noted in the right anterior area, but no obvious prolapse. A DRE was performed, and in an attempt to visualize the prolapse, the patient was instructed to push, trying to “poop out” the examining finger. On doing this, there was more prolapse in the RA area, but with continued pushing, eventually, the concentric mucosal folds characteristic of rectal prolapse were demonstrated. A surgery consult was arranged.
Discussion: When it comes to any sort of prolapse, it is important to remember that what happens at home often cannot be replicated in the office. Many of these issues do not even occur every time that the patient defecates, much less when the patient is on the exam table, in the left lateral position, with you yelling at them to PUSH just like you are an OB in Labor and Delivery! Defecography and a bunch of diagnostic maneuvers (such as “pooping the exam finger out”) will sometimes demonstrate the true problem, but certainly not always. Ever since the advent of the smart-phone, I’ve asked the patient to use the “butt selfie” technique if I could not define the phenomenon that the patient was describing in the office, and as an example, I now have seen more cases of rectal prolapse demonstrated
CRH will be at the ACG Eastern Regional conference in full force from June 2nd – 4th in Washington DC, so please come say “hello”, ask any questions you might have, and let us know how we can better serve you.
CRH Anesthesia is excited to announce its latest acquisition! This brings the number of ASC’s that CRH serves up to 120, in 18 states providing 700,000 procedures annually. If you are thinking about realizing some or all of the equity that you’ve built into your current anesthesia service, or if you currently outsource your anesthesia and would like to bring it “in house”, or if you are thinking about building a deep sedation program, please let ME know! We’ll connect you with our CRHAM team and see how we can help!
In the meantime, thanks so much for checking out this edition of the Bulletin, and stay safe!