We hope that this “Holiday” edition of the Banding Bulleting finds you well! In this edition, we’ll touch on one entity that might trip you up in your evaluation of your patients with anorectal complaints, tidy up a few year-ending items, and look forward to the New Year!
A recent phone call, along with a couple of patients presenting at training sessions over the past few weeks, reminds us to mention an entity that we don’t see very commonly but can be confusing when evaluating patients with anorectal complaints. We always preach that overwhelmingly, when patients are complaining about their hemorrhoids “flaring up”, they are actually referring to their anal fissures. Most fissures are not the hyper-acute, incredibly tender fissures that are typically described when discussing this entity, but rather chronic fissures which had partially healed, then “flared up” after some constipated or diarrheal stools caused them to break back open.
Every now and again, patients complaining of “flare-ups” will actually have fistulas-in-ano (FIA). Without getting into a detailed discussion of the pathophysiology of FIA’s, these tracts generally originate from the previously infected anal crypts (located at the level of the dentate line), to the point where the resultant perianal/perirectal abscesses “pointed” and drained spontaneously, or were surgically drained. Sometimes these tracts are completely obliterated during the healing process, but often they only incompletely heal – these are the fistulae that may remain open and draining, or sometimes sealing over until the next “flare-up” occurs.
Both patients seen in the training sessions over the past 2 weeks presented with similar stories – periodic pain (“flare-ups”), followed by some sort of drainage (blood and clear fluid were described here, but purulent material is sometimes mentioned as well). Visual exam of one patient revealed a 2mm open area approximately 3cm from the anal verge, and palpation of the area revealed subcutaneous induration heading back in the direction of the anal verge (the sub-q fistulous tract). The other patient was not as obvious, as he had a small erythematous spot a bit further from the verge which had the same sub-q induration on palpation. The distal end of this tract had superficially healed over, as he was “in-between his flare-ups”. In both patients, anoscopy wasn’t very helpful in identifying the origin of the fistula, but in both, digital exam could feel a small area of localized inflammation in the appropriate area that was likely the culprit.
Both patients required the same evaluation – endoscopy to rule out Crohn’s or cancer, and then surgical referral for treatment of the fistulae if the colonoscopy was negative. For a more complete discussion of the entity, please contact ME and I’ll be happy to get you more information.
Earlier this month, CRH Anesthesia was able to announce our 31st transaction, purchasing 51% of an anesthesia entity in Florida. With this transaction, CRH Anesthesia now serves 68 ASC’s in 13 states! We continue to expand, and we’d love to speak with you if:
You have a current anesthesia program, and would like to improve its performance as well as to realize some of the equity that you’ve built up over time
You currently outsource your anesthesia service, and would like to bring it “in house”.
You are currently utilizing conscious sedation, and would like to build a deep sedation program.
If you would like to learn more about the options available to you, please contact ME and we’ll get more information your way.
We don’t know about you, but we sure are looking forward to having 2020 in the rear-view mirror! With the introduction of the COVID vaccines, hopefully 2021 will eventually allow us to get back to the “old normal”, as we would not miss the “new normal” one little bit! With this in mind, everyone at CRH would like to send along our Holiday wishes, along with our hope that 2021 is a happy, HEALTHY, and prosperous one for everyone. We look forward to catching up with as many of you as we can in the new year, as we’ve been back on the road, providing trainings, “refreshers”, etc. In the meantime, please let US know if you have any questions, would like any additional information, a “virtual refresher”, an in-person training or “advanced” session, or if there is anything else we can do to help the cause. Your CRH Account Manager is also available to help your front and/or back offices, and to provide marketing, billing/coding and practice building support.
Thanks to each of you for your support in ’20, and here’s looking to a great ’21.