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Tarasconi A, Perrone G, Davies J, Coimbra R, Moore E, Azzaroli F, Abongwa H, De Simone B, Gallo G, Rossi G, Abu-Zidan F, Agnoletti V, de'Angelis G, de'Angelis N, Ansaloni L, Baiocchi GL, Carcoforo P, Ceresoli M, Chichom-Mefire A, Di Saverio S, Gaiani F, Giuffrida M, Hecker A, Inaba K, Kelly M, Kirkpatrick A, Kluger Y, Leppäniemi A, Litvin A, Ordoñez C, Pattonieri V, Peitzman A, Pikoulis M, Sakakushev B, Sartelli M, Shelat V, Tan E, Testini M, Velmahos G, Wani I, Weber D, Biffl W, Coccolini F, Catena F. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg 2021; 16:48. [PMID: 34530908 PMCID: PMC8447593 DOI: 10.1186/s13017-021-00384-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 07/16/2021] [Indexed: 02/06/2023] Open
Abstract
Anorectal emergencies comprise a wide variety of diseases that share common symptoms, i.e., anorectal pain or bleeding and might require immediate management. While most of the underlying conditions do not need inpatient management, some of them could be life-threatening and need prompt recognition and treatment. It is well known that an incorrect diagnosis is frequent for anorectal diseases and that a delayed diagnosis is related to an impaired outcome. This paper aims to improve the knowledge and the awareness on this specific topic and to provide a useful tool for every physician dealing with anorectal emergencies.The present guidelines have been developed according to the GRADE methodology. To create these guidelines, a panel of experts was designed and charged by the boards of the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) to perform a systematic review of the available literature and to provide evidence-based statements with immediate practical application. All the statements were presented and discussed during the WSES-AAST-WJES Consensus Conference on Anorectal Emergencies, and for each statement, a consensus among the WSES-AAST panel of experts was reached. We structured our work into seven main topics to cover the entire management of patients with anorectal emergencies and to provide an up-to-date, easy-to-use tool that can help physicians and surgeons during the decision-making process.
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Affiliation(s)
- Antonio Tarasconi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy.
| | - Gennaro Perrone
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Justin Davies
- Cambridge Colorectal Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Raul Coimbra
- Riverside University Health System Medical Center, Loma Linda University School of Medicine, Riverside, CA, USA
| | - Ernest Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Francesco Azzaroli
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Hariscine Abongwa
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Belinda De Simone
- Department of Metabolic, Digestive and Emergency Surgery, Centre Hospitalier Intercommunal de Poissy et Saint Germain en Laye, Poissy, France
| | - Gaetano Gallo
- Department of Medical and Surgical Sciences, University of Catanzaro, Catanzaro, Italy
| | - Giorgio Rossi
- Emergency Surgery Department, Parma University Hospital, Parma, Italy
| | - Fikri Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Vanni Agnoletti
- Anesthesia and Intensive Care Unit, AUSL Romagna, M.Bufalini Hospital, Cesena, Italy
| | - Gianluigi de'Angelis
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Hospital of Parma, Parma, Italy
| | - Nicola de'Angelis
- Minimally Invasive and Robotic Digestive Surgery Unit, Regional General Hospital F. Miulli, Bari, Ital - Université Paris Est, UPEC, Creteil, France
| | - Luca Ansaloni
- Department of Emergency and general Surgery, Pavia University Hospital, Pavia, Italy
| | - Gian Luca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Paolo Carcoforo
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
| | - Marco Ceresoli
- General Surgery, Monza University Hospital, Monza, Italy
| | - Alain Chichom-Mefire
- Faculty of Health Sciences, Department of Surgery, University of Buea, Buea, Cameroon
| | - Salomone Di Saverio
- General surgery 1st unit, Department of General Surgery, University of Insubria, Varese, Italy
| | - Federica Gaiani
- Department of Medicine and Surgery, University of Parma, Parma, Italy
- Gastroenterology and Endoscopy Unit, Hospital of Parma, Parma, Italy
| | - Mario Giuffrida
- Department of Medicine and Surgery, General Surgery Unit, University Hospital of Parma, Parma, Italy
| | - Andreas Hecker
- Department of General & Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Kenji Inaba
- Division of Acute Care Surgery, University of Southern California, Los Angeles, CA, USA
| | - Michael Kelly
- Department of General Surgery, Albury Hospital, Albury, Australia
| | - Andrew Kirkpatrick
- General, Acute Care, Abdominal Wall Reconstruction, and Trauma Surgery, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | - Andrey Litvin
- Department of Surgical Disciplines, Regional Clinical Hospital, Immanuel Kant Baltic Federal University, Kaliningrad, Russia
| | - Carlos Ordoñez
- Department of Surgery, Fundacion Valle del Lili - Universidad del Valle, Cali, Colombia
| | | | - Andrew Peitzman
- University of Pittsburgh School of Medicine, UPMC-Presbyterian, Pittsburgh, PA, USA
| | - Manos Pikoulis
- 3rd Department of Surgery, National & Kapodistrian University of Athens, Athens, Greece
| | - Boris Sakakushev
- General Surgery Department, University Hospital St George, Plovdiv, Bulgaria
| | | | - Vishal Shelat
- Department of Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Edward Tan
- Department of Surgery, Department of Emergency Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Mario Testini
- Academic Unit of General Surgery "V. Bonomo" Department of Biomedical Sciences and Human Oncology, University of Bari, Bari, Italy
| | - George Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Imtiaz Wani
- Government Gousia Hospital, Srinagar, Kashmir, India
| | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, University of Western Australia, Perth, Australia
| | - Walter Biffl
- Department of Trauma and Acute Care Surgery, Scripps Memorial Hospital La Jolla, La Jolla, San Diego, CA, USA
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Pisa, Italy
| | - Fausto Catena
- General, Emergency and Trauma Surgery Dept., Bufalini Hospital, Cesena, Italy
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Abdel-Aal AK, Dawoud N, Moustafa AS, Hamed MF, Saddekni S. Percutaneous Transhepatic Embolization of Bleeding Rectal Varices Using A New Embolic And Sclerotic Mixture Augmented By Amplatzer Vascular Plug 2. J Radiol Case Rep 2016; 10:44-51. [PMID: 27761198 PMCID: PMC5065273 DOI: 10.3941/jrcr.v10i9.2580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We report a case of 59-year-old female with non-alcoholic-steato-hepatitis (NASH) induced cirrhosis, who presented with hematochezia. The patient had a history of bleeding esophageal varices treated with endoscopic variceal ligation (EVL). Colonoscopy showed large rectal varices which were the source of her lower gastrointestinal bleeding (LGIB). Since endoscopic treatment for LGIB are limited, and because the patient had portal vein thrombosis which contraindicated transjugular intrahepatic portosystemic shunt (TIPS), we performed percutaneous transhepatic embolization of her rectal varices using a new mixture of embolic and sclerotic agents, followed by Amplatzer plug 2 (AVP 2). To our knowledge, the use of this new mixture with the AVP 2 in the rectal varices treatment has not been previously published in literature. Our case provides an alternative treatment modality that can be used for rectal varices treatment, when TIPS and endoscopic management fails or is contraindicated.
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Affiliation(s)
- Ahmed Kamel Abdel-Aal
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
- Department of Radiology, Cairo University, Cairo, Egypt
| | - Nabila Dawoud
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
| | - Amr Soliman Moustafa
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
- Department of Radiology, Zagazig University, Zagazig, Egypt
| | - Maysoon F Hamed
- Department of Family medicine, University of Alabama, Tuscaloosa, Alabama, USA
| | - Souheil Saddekni
- Department of Radiology, University of Alabama at Birmingham (UAB), Birmingham, Alabama, USA
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Sato T, Akaike J, Toyota J, Karino Y, Ohmura T. Clinicopathological features and treatment of ectopic varices with portal hypertension. Int J Hepatol 2011; 2011:960720. [PMID: 21994879 PMCID: PMC3170857 DOI: 10.4061/2011/960720] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Accepted: 05/12/2011] [Indexed: 12/12/2022] Open
Abstract
Bleeding from ectopic varices, which is rare in patients with portal hypertension, is generally massive and life-threatening. Forty-three patients were hospitalized in our ward for gastrointestinal bleeding from ectopic varices. The frequency of ectopic varices was 43/1218 (3.5%) among portal hypertensive patients in our ward. The locations of the ectopic varices were rectal in thirty-two, duodenal in three, intestinal in two, vesical in three, stomal in one, and colonic in two patients. Endoscopic or interventional radiologic treatment was performed successfully for ectopic varices. Hemorrhage from ectopic varices should be kept in mind in patients with portal hypertension presenting with lower gastrointestinal bleeding.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan,*Takahiro Sato:
| | - Jun Akaike
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Jouji Toyota
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Yoshiyasu Karino
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
| | - Takumi Ohmura
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo-ku, Sapporo 060-0033, Japan
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Sato T, Yamazaki K, Toyota J, Karino Y, Ohmura T, Akaike J. Diagnosis of rectal varices via color Doppler ultrasonography. Am J Gastroenterol 2007; 102:2253-8. [PMID: 17561969 DOI: 10.1111/j.1572-0241.2007.01340.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES There has been no report on the hemodynamic evaluation of rectal varices by percutaneous color Doppler ultrasonography. Here, we report the usefulness of color Doppler ultrasonography for this purpose. METHODS Color Doppler ultrasonography was performed in 44 patients: 31 patients with portal hypertension, 7 with liver cirrhosis (LC) without portal hypertension, and 6 non-LC patients. We examined color flow images and measured velocity of blood flow in rectal varices using fast-Fourier transform (FFT) analysis. Next, we performed colonoscopy on these 44 patients as follow-up to confirm findings by color Doppler. Endoscopic findings of rectal varices were evaluated according to the grading system outlined in "The General Rules for Recording Endoscopic Findings of Esophageal Varices" prepared by the Japanese Research Committee on Portal Hypertension. RESULTS Rectal varices were shown by Doppler color flow images in 27 of the 31 patients (87.1%) with portal hypertension. Blood flow velocity in those 27 rectal varices ranged from 2.0 to 11.6 cm/s (mean 6.5 +/- 2.4 cm/s). Rectal varices were observed in all 27 of these cases by colonoscopy. On the other hand, rectal varices were not observed by colonoscopy in the 7 LC patients without portal hypertension and the 6 non-LC patients not shown to have rectal variceal blood flow via color Doppler ultrasonography. Sensitivity, specificity, and accuracy were 27/27 (100%), 17/17 (100%), 44/44 (100%), respectively, for detection of rectal varices with color Doppler ultrasonography. Next, we compared velocities of rectal varices obtained by color Doppler ultrasonography with colonoscopic findings. Mean velocity (7.1 +/- 2.3 cm/s) in Cb variceal cases (N = 20) was significantly higher than that (4.9 +/- 1.7 cm/s) in the Cw rectal variceal cases (N = 7) (P < 0.05). Mean velocity (8.5 +/- 2.0 cm/s) in the RC-positive cases (N = 9) was significantly higher than that (5.4 +/- 1.8 cm/s) in RC-negative cases (N = 18) (P < 0.01). Mean velocity (9.8 +/- 1.6 cm/s) in rectal bleeding cases (N = 3) was significantly higher than that (6.1 +/- 2.1 cm/s) in patients without bleeding (N = 24) (P < 0.05). Seven days after endoscopic injection sclerotherapy (EIS) treatment, color Doppler ultrasonography showed an extreme decrease in blood flow in all three rectal varices in comparison with values before EIS. CONCLUSIONS Color Doppler ultrasonography can be considered a very useful noninvasive tool for diagnosis of rectal varices.
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Affiliation(s)
- Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Sapporo, Japan
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Nakanowatari M, Sato T, Yamazaki K, Akaike J, Arakawa T, Kuwata Y, Ohmura T, Karino Y, Toyota J, Suga T. Hemodynamic evaluation of rectal varices by color Doppler ultrasonography: a case report. J Med Ultrason (2001) 2007; 34:65-8. [PMID: 27278183 DOI: 10.1007/s10396-006-0131-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2006] [Accepted: 10/10/2006] [Indexed: 11/30/2022]
Abstract
A 69-year-old man with liver cirrhosis was admitted to our hospital with general fatigue. Colonoscopy revealed risky red color sign-positive enlarged tortuous rectal varices. Endoscopic injection sclerotherapy (EIS) was performed three times weekly using 5% ethanolamine oleate with iopamidol; the total amount of sclerosant was 7 ml. Images of rectal varices and the outflowing vessel from rectal varices were obtained via color Doppler ultrasonography before EIS, and fast Fourier transform analysis showed a continuous flow with a frequency shift of 276.6 Hz. We successfully performed EIS for this patient, having effective varicealography. After EIS, colonoscopy revealed shrinkage of the varices in the rectum, and color Doppler indicated an extreme decrease of blood flow in the rectal varices. In conclusion, color Doppler is a useful noninvasive modality for detecting rectal varices and for evaluating the therapeutic effects of EIS.
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Affiliation(s)
- Masayuki Nakanowatari
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo, Sapporo, Hokkaido, 060-0033, Japan.
| | - Takahiro Sato
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo, Sapporo, Hokkaido, 060-0033, Japan
| | - Katsu Yamazaki
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo, Sapporo, Hokkaido, 060-0033, Japan
| | - Jun Akaike
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo, Sapporo, Hokkaido, 060-0033, Japan
| | - Tomohiro Arakawa
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo, Sapporo, Hokkaido, 060-0033, Japan
| | - Yasuaki Kuwata
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo, Sapporo, Hokkaido, 060-0033, Japan
| | - Takumi Ohmura
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo, Sapporo, Hokkaido, 060-0033, Japan
| | - Yoshiyasu Karino
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo, Sapporo, Hokkaido, 060-0033, Japan
| | - Jouji Toyota
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo, Sapporo, Hokkaido, 060-0033, Japan
| | - Toshihiro Suga
- Department of Gastroenterology, Sapporo Kosei General Hospital, Kita 3 Higashi 8, Chuo, Sapporo, Hokkaido, 060-0033, Japan
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