Welcome to ASG Endo Hangouts for GI Fellows. These webinars feature expert physicians in their field, and I'm very excited for today's presentation. The American Society for Gastrointestinal Endoscopy appreciates your participation in tonight's event, entitled Endoscopic Evaluation and Management of Anorectal Diseases. My name is Marilyn Amador, and I will be the facilitator for this presentation. Before we get started, just a few housekeeping items. We want to make this session interactive, so feel free to ask questions at any time by clicking the Q&A feature on the bottom of your screen. Once you click on that feature, you can type in your question and hit return to submit the message. Please note that this presentation is being recorded and will be posted within two business days on GILeap, ASG's online learning platform. You will have ongoing access to the recording in GILeap as part of your registration. Now it is my pleasure to hand over this presentation to our GI Fellow moderator, Dr. Tariq Saleem from Baylor College of Medicine, Houston, Texas. Hello, everybody, and welcome to our discussion today on the Endoscopic Evaluation and Management of Anorectal Diseases. I will be moderating our discussion today. I would like to start by introducing our panelists. I will start by introducing Dr. Waqar Qureshi, who is a professor of medicine and the director of the Center for Anorectal Disease at Baylor College of Medicine in Houston, Texas. He earned his medical degree from the Royal Free Hospital School of Medicine, London University in the United Kingdom and completed his residency in internal medicine in Rochester, New York, followed by a fellowship at the University of Arkansas Medical School in Little Rock and advanced endoscopy training in Dublin, Ireland. His clinical interests include pancreatic ovulary disease, therapeutic endoscopy, and anorectal disease management for the non-surgeon. He's written a textbook on anorectal disease for the gastroenterologist and a teaching DVD on the subject for the ASGE. Next we have Dr. Steven Landrino, who is an advanced endoscopist and medical director of endoscopy at the University Medical Center in New Orleans. He's been with Louisiana State University since joining in 2011. Prior to that, he completed residency and GI fellowship at the University of South Alabama in Mobile, Alabama. Dr. Neha Mathur is an assistant professor and gastroenterologist at Houston Methodist Gastroenterology Associates at Houston Methodist Hospital. She is board certified in gastroenterology and graduated from University of Texas Medical School in San Antonio. She completed her residency from Rush University in Chicago, Illinois, and came back to Texas to finish her gastroenterology fellowship at University of Texas Health Science Center at San Antonio. She has had experience practicing gastroenterology in a private practice setting and later transitioned to academic. She started the hemorrhoid banding program at Houston Methodist in the gastroenterology department since 2018. Dr. Mathur specializes in general gastroenterology disorders. And next we have Dr. Rahman Sheikh, who's an assistant professor and gastroenterologist in Houston, Texas, and is affiliated with multiple hospitals in the area, including Memorial Hermann Hospital and Baylor St. Luke's Medical Center. He received his medical degree from University of Texas Health Science Center, San Antonio, Joan Teresa Lozano Long School of Medicine. Dr. Sheikh specializes in diagnosing and treating digestive disorders such as stomach pain, ulcers, reflux, constipation, and Crohn's disease. I guess we'll start with Dr. Qureshi, who will begin our discussion, and then we'll move forward from there. Hello. Good evening. It's a real pleasure to be here. I'd like to thank the ASGE for making this possible and for shining a light on this topic that is poorly covered in fellowship programs. I would also like to thank Marilyn Amador, probably the hardest working lady at the ASGE, without which this would not be happening. So let's just go right to it. I have a few slides to just give you some idea of where we're going today. And the learning objectives are how to diagnose common enorectal disorders and office management of hemorrhoids. The most commonly seen enorectal disease by a gastroenterologist include the following. Hemorrhoids, extremely common. Anal fissures, anal pruritus. And we'll be talking about interesting cases with those three diagnoses. Abscesses and fistulae are less commonly managed by gastroenterologists. And the disorders of defecation are problems that can be dealt with by, and in fact, are mostly dealt with by gastroenterologists. So I thought it was very timely, now that more people are interested in office management of disease, that we highlight what gastroenterologists should be able to handle. So most disorders can and should be managed by the gastroenterologists, most enorectal disorders. And I'm hoping that by the end of today, you guys will agree that you should learn some very basic techniques like enoscopy, hemorrhoid banding, and a good digital rectal exam, and be able to manage most of your patients with enorectal disease. So without further ado, let me go on to Dr. Neha Mathur, who is going to talk to us about hemorrhoid, a case of hemorrhoids. Can you all see that? Yes, we can. Okay, great. Thank you. So thank you again, Walker, for inviting me to join on this panel. Thank you, ASGE, for the space to do this. I'll be talking about a case of hemorrhoid banding, and we'll get into it. So there is a patient that I saw, it's a 38-year-old Caucasian male, came to my office with long-standing history of ulcerative pancolitis, actually, but was having and struggling with symptoms of hematochezum. He had been diagnosed in 2008, previously with his inflammatory bowel disease, and was currently well-managed with the Limumab symphony every four weeks. Previously he had failed mesalamine, oral enema, and suppository forms, prednisone, and 6-mercaptopurine. His main chief complaint in the office was prolapse of tissue, seepage of stool, feeling like he needs to defecate, but unable to have a bowel movement due to prolapse of that tissue, and rectal bleeding, but he denied any rectal pain. So some past medical history, pretty straightforward, just the ulcerative colitis, that was his main issue, and with some vitamin D deficiency in the past, no surgical history. He had really no pertinent family history, negative for inflammatory bowel disease or any kind of malignancies in the gastrointestinal disorders. Social history, he was a social alcohol drinker, but denied any tobacco or illicit drug abuse. He had no allergies listed, and the only medications he was taking was Colimumab, vitamin D3, and a multivitamin. So we did get some blood work just to see how he was doing, given his history of inflammatory bowel disease. There was a comprehensive metabolic panel, a complete blood count, CRP and ESR that were all normal. His iron studies did show some mild low ferritin at 11, but outside of that, there was no other inflammatory markers that were positive. He did have a prior fecal calprotectin that I did not show here, a few months prior that was normal. So we opted to go into a colonoscopy to diagnostically see what the symptoms were coming from. So this is just a depiction of his colonoscopy overall, mucosal disease appeared in remission or in quiescent state, including the rectum in the top left. We did do biopsies to ensure that we were truly dealing with something anorectal versus inflammatory bowel disease. And then we get to the rectum here, and certainly he had these large internal hemorrhoids, and you can see the prolapsing tissue, but they were able to be reduced manually. So we did get the biopsies, we took segmental biopsies with random right colon, random left and rectal, and all of it confirmed quiescent disease. So at this point, we felt that his symptoms, his main complaint was not inflammatory bowel disease, but it was rather coming from his internal hemorrhoids that were quite symptomatic. And we discussed hemorrhoid banding with him as a management tool. So hemorrhoids, what are they? They're just collection of arteriovenous sinusoids that are part of your normal anorectal anatomy. Some consider them vascular cushions internally. Very common complaint, like Dr. Koresh, you mentioned 10 million patients complain about this in the United States, but at four and a half percent prevalence, they can be classified as internal, external, or mixed. So your internal hemorrhoids are going to be proximal to or above the dentate line and thus they're going to have visceral innervation, less painful. Your external hemorrhoids are going to be below the dentate line and distal, and you're going to see more somatic innervation, thus the discomfort is more noticeable. Mixed type, we tend to treat them more with external, like external hemorrhoids. So symptoms that can come along with hemorrhoids can include painless rectal bleeding during defecation or with wiping, with toilet paper, there's tissue prolapse that can be felt by patients, anal pruritus, sometimes anal pain, a lump that they're feeling in the anal verge, and of course some leakage, seepage type of complaints with mucus and or stool. They're grades to internal hemorrhoids specifically, and I think that's important and that plays into how we manage them. So grade one, typically the symptoms are painless bleeding and on exam, you'll see a bulge in the anal canal without any prolapse. Grade two, you're going to have the same painless bleeding, but there may be some itching associated with it. You'll see the prolapse of tissue with straining, but they reduce spontaneously. Grade three, we're seeing again painless bleeding, itching, but now we're seeing swelling, straining, excuse me, staining, soilage or seepage of mucus or stool. And then they're going to prolapse beyond the dentate line, but you'll need to reduce them manually. And grade four are, they're painful, they can have some swelling, bleeding associated with it, soilage, and of course on exam, you'll see prolapse of the hemorrhoid tissue that are not reducible despite manual efforts and have chronic changes like inflammatory or ulcerative changes associated with that. And typically a grade one to three, we can manage medically and or less invasively within office procedures. But grade four, you want to point out that this is mainly a surgical approach to these severe or advanced hemorrhoids. Medical treatment options can obviously include just starting with dietary and lifestyle modification. So talking to your patients about, you know, their fiber intake, their water intake, their physical activity, avoiding less sedentary states, going over their medications. You want to incorporate some softening efforts, whether it's fiber or laxatives to ensure a softer movement coming through the anorectal canal. Then there's a warm sits bath that, you know, can help with the edema, the inflammation and even some pruritus complaints that can alleviate those complaints. And then there are, of course, a multitude of topical options over the counter and an analgesic like lidocaine and anti-inflammatories like hydrocortisone cream or suppository. Caveat you want to educate your patient is not to use these anti-inflammatories like hydrocortisone specifically beyond a week because it can cause contact dermatitis and some thinning of the tissue there. So most patients will respond if they're in grade one to two with these simple efforts that you can manage just by talking with them and optimizing these things. However, when you start having more advanced hemorrhoids like our patient here, you do want to talk to them about alternative options. And this is a nice summary from a paper that shows that if you look at the grade A, there's different types of interventions that you can do, non-operative options like sclerotherapy, infrared coagulation, rubber band ligation, and certainly various surgical options. And grade one to three are great candidates for a lot of in-office options, whereas surgery really has its role in grade four or in some cases of grade three. So alternative options to consider in patients who are refractory to medical therapy or persistent complaints and want to have or have high-grade internal hemorrhoids, thrombosed external hemorrhoids that are not responding to topical treatments. And then of course, if they're having complaints like prolapse or leakage symptoms, and sometimes some of these more advanced techniques can definitely help them control that as well. So caveat to all of this is you certainly want to make sure that they've had a good workup and make sure that the symptoms are truly related to their hemorrhoids like we did for our patient. So you want to include a colonoscopy at some point to rule out any other interactal pathology that could be contributing to some of their complaints and refractory nature of their symptoms. So rubber band ligation is what I want to spend more time talking about. It's a quick, effective in-office procedure. And I think all gastroenterologists should really consider adding this in their options and offering this in their office if possible. It works well for grade one to three internal hemorrhoids. It is a painless procedure, unlike surgery. There's no anesthesia involved in that. There's no preparation like a laxative, enema, anything like that ahead of time. You have much less complications associated with this technique, and it is cost effective. So compared to other in-office procedures like sclerotherapy and infrared coagulation, rubber band ligation is more effective and also requires less treatment sessions. Technically, we can look at sometimes on average of two to three sessions. So what is it and how does it work? So we do need a couple of tools in order to do rubber band ligation in the office. We need an anoscope, as Dr. Koresh had talked about. I think this is a great tool to kind of look at the anorectal canal. You don't even have to band somebody, but sometimes just to look, it adds to your digital rectal exam so you can see into the kind of the anorectal region what's going on. So I use that in addition to a band ligator, which is pictured below. And this is just one of the brands that are available. And then we basically position the patient in the left lateral position and insert the anoscope first. And once I know which band or which hemorrhoid chain I'm going after, I try to go for the bulkiest one first to get the best symptomatic relief. You want to then insert your ligator device into the anorectal region. And typically we're aiming for about two to five centimeters above the dentate line. And this particular device that I'm picturing here is really nice because it has a little ridge and it kind of is foolproof and allows you to kind of hit that distance in a more effective and consistent manner. So once you aim it to the right region or right chain of the hemorrhoid that you're aiming for, there's a suction type of device, like a plunger that pulls back and that suctions the chain into your device. There is typically a latex-based rubber band that is loaded at the tip of that device and that is deployed onto that vein once you release the plunger. And it leads to, over time, ischemic and necrosis changes. And it scars that hemorrhoid chain down and leads to fixation of the connective tissue to the rectal wall. And this is just another pictorial of another device that sometimes is available, but you get the gist of it, where the rubber band is placed at the base of that chain and then over time it's creating necrosis and swapping. So this is a view that we can see on flexible sigmoidoscopy or colonoscopy. If you're doing it to follow these patients, we typically don't do that right after the procedure. But if you were, this is what you would see. The band being placed on top left and picture A and picture B over the next two to four days, it's sloughing off and sometimes it leads to ulcer underneath that band and the band will fall off. And then a couple days further down the road, you'll see the scarring starting to happen. As you can see, I don't know if you can see my pointer, but right here, and there's another one in the very bottom of that picture. And then pictorial D is when it's scarred down and you can see how it fixates that rectal connective tissue to the wall. So it's important to know your anatomy as to where you're pointing the bander, and this will help you to know where to band. Not all hemorrhoids are juicy, like we'll see in a minute, but you have an anatomical right posterior, right anterior, and left lateral views, as you can see here. So typically I try to aim for whichever is the bulkiest at the time of their first exam, and you would band that, and I bring them back a couple of weeks later, band the next location or depending on their progress, where the next bulkiest chain might be. So another pictorial to correlate, so this one has the kind of flipped view of the prior view, you have the right posterior at the bottom left, right anterior to the top, and then left lateral kind of in a Y-shaped manner. And that correlates with the large bulky hemorrhoids on the picture to the right. So I tend to place one band at a time to limit complications. If you place one band, it's roughly about 1% complication risk. And if you place more than one band or you choose to place more than one band, if the patient has done well in the past without any major complications, then you may increase that complication risk to 6% to 10%. So it just depends on the patient and their risk factors. Minimum you want to bring them two weeks apart to minimize the scarring and the swelling in that zone. So it's better tolerated for the patient, but you can certainly go longer, like three to four weeks apart as well. Definitely use an anoscope like we talked about, so you know where you're pointed to or your progress. I've banded once before, okay, I didn't get all the tissue, I need to maybe go back in there again for a second banding for more loose tissue that there may be. So after band placement, it's also a very interactive procedure. You want to talk with your patient and see if they're having any discomfort. As I mentioned earlier, this is supposed to be a painless procedure. So if they're having pain, tugging, pulling sensation, you want to readjust the band because most likely either you're too low towards the dentate line, or you got too much tissue, like a mushroom effect onto that band, and you can milk it at the base and loosen up some of the tissue that's been already contracted into that band. And that has usually an immediate relief. If you feel like you're too low, you can just knock off the band with some manual pressure and most of the patients feel immediate relief right away. There's some contraindications or relative contraindications to keep in mind, certainly like we talked about grade four internal hemorrhoids, you want to consider surgery instead of attempting band ligation or other intra-office procedures, mainly because they have a high failure rate or recurrent complaints, about 50% or higher. You want to treat acute thrombosed external hemorrhoids or active anal fissures first before you consider banding them, because it's quite painful and they may not tolerate the procedure. Anticoagulation depends on your comfort zone. I think the surgeons can certainly have a little bit more backup than we do because we are blind to some of these effects. And as you can see, there's a delayed bleeding that usually happens because the band falls off two to four days later, and sometimes the ulcer and the healing process can last up to a week. So it's not the immediate effect of stopping anticoagulation after banding or immediately after banding, it's usually delayed. So you have to keep them off anticoagulation much longer. So if you have patients like on clopidrogel or warfarin specifically, you may want to stop them a week in advance and then keep them off at least one to two weeks after banding. So depending on your patient's indication for anticoagulation, that may not be possible depending on their risk stratification. So surgery may need to be considered in that. Certainly if they're having active perianal disease, perianal fistulas, fissures, Crohn's disease specifically, we should not be performing hemorrhoid banding. If the patient has portal hypertension with cirrhosis, be mindful of rectal varices and be careful that those are not interpreted as hemorrhoids, and you don't want to band those necessarily. Immunodeficiency patients, patients going through chemotherapy or immunocompromised like HIV patients, you want to avoid this type of intervention as it can lead to increased infections and sepsis. Pregnancy as well, band ligation specifically can cause early contraction and pelvic symptoms. So sometimes we consider sclerotherapy if not surgery. Of course, any non-compliant patient who's not going to follow up or follow your recommendations post-procedure may not be the best candidate for something like this. The complications with rubber band ligation include pain, as we mentioned, if it's too tight, delayed hemorrhage, which we already talked about, infections, localized abscesses, you'll have pain, discharge, fever, and the most important thing you want to warn your patient about is pelvic sepsis because this could be fatal and it's an emergency. So if it's a triad of fever, severe pain, urinary retention, they need to go to the emergency department, get on antibiotics, get an exam, get the band removed immediately, and they may need some debridement with surgery. Again, it's rare, but we do warn the patients about that ahead of time, and urinary retention can still happen. Outcomes are pretty good. This is, I think, the best series we can find. The long-term outcomes of rubber band ligation in 805 patients, about 2,114 ligations were done in a median of two ligations per patient. We had a success rate of 71% control of their complaints, and if you took the first-time failure of those patients and rebanded them, you got recruited about 80% of those with retreatment, and that's pretty good, in my opinion. Meta-analysis of 12 trials looked at bleeding resolution in 90% of the patients, and grade three hemorrhoids had about 78% to 84% improvement. Another meta-analysis of 18 trials looked at rubber band ligation compared to sclerotherapy and infrared coagulation, and the rubber band ligation was more effective than the other two, and then compared to surgery, rubber band ligation had more recurrent symptoms but fewer complications and less pain. This is just a scenario of a particular brand, Oregon system, that I tend to use, so it's showcasing that. It's quick. The main thing I want you to get out of here, 30 seconds to a minute. There's no pain. There's no downtime. Again, no preparation compared to conventional surgery, which there's much more recovery time and pain. Our patient did really well. He required three band ligations for grade three internal hemorrhoids. He had immediate improvement within the first band placement. We continued to place the other two for long-term resolution of his symptoms. He felt less obstructed. Prolapse had improved significantly, and his bleeding had resolved completely. And then in summary, I just want to say hemorrhoids are a common complaint, which Dr. Karachi mentioned. You're going to see a lot of this, and you already probably see a lot of this in your clinic. start with medical therapy. If symptoms are refractory to medical therapy, consider rubber band ligation for grade one to three internal hemorrhoids over surgery. Learn how to use these techniques in your clinic. No relative contraindications, so you pick the right fit for the right patient and minimize complications. Rubber band ligation is also quick, inexpensive, and effective for management of internal hemorrhoids. And again, seek opportunities like we're doing right now to learn about more techniques like this and provide it in your own practice. These are my references. And I can take any questions anybody has. Yeah, I do see a question in the chat box and I encourage any other viewers to type questions in the Q&A box if they have any. So the first question is, is there literature to support banding in UC in ulcerative colitis? Yeah, great question. This is why I wanted to highlight this case because typically we shy away from inflammatory bowel disease patient in like a contraindication. So Crohn's is really the main one, the perianal disease. Of course, we wanted to make sure that this was not inflammatory bowel disease. So the data is there and they have done hemorrhoid banding in inflammatory bowel disease patients. And there's obviously surgical data as well, but you want to ensure that they don't have active proctitis or perianal disease, number one. And if so, yes, we do not do band ligation. But when they looked at UC patients, rubber band ligation versus sclerotherapy were the two recommendations for less invasive options. So they have looked at that. I'll go ahead with one question, Dr. Qureshi. So I assume there are some patients who may be averse to anoscopy, unsedated. Will you ever perform band ligation in patients in endoscopy with sedated anoscopy or flexible sigmoidoscopy? Well, I mean, certainly we can do the rubber band ligation like we do for variceal band ligation. You can use that tool. But again, I think you have to reassure the patient because majority of the anus scope is not painful. It's a lot of pressure. I warn them. I use a lot of lubrication and I even use lidocaine in the office. So I'll do a digital rectal exam with lidocaine initially to just kind of let them sit with that ahead of time and then introduce the anus scope and then do the band ligation. And I've hardly had to take patients to endoscopy to have to do that. And I think the key is if somebody is not tolerating that, you might be missing an anal fissure or something else. And that's what you want to really rule out. Why are they so much in pain? And if it's certainly a grade four prolapsed, internal hemorrhoid that's not manually reducible, that may be the other reason. And then band ligation and endoscopy is not really needed at that point. Two more questions here. Does hemorrhoid banding cause any sphincter damage? It should not. Like we said, your goal is five millimeters above the dentate line. So you're above the sphincter and you're really trying to pexy that hemorrhoidal loose prolapse tissue above. So it should not cause, rather surgery is much more higher risk for damaging sphincter, the anal sphincter and having fecal incontinence afterwards. So we prefer hemorrhoid banding to preserve or limit the damage to the sphincter. Next question. Band ligation is not a procedure that gastroenterologists perform at every training program. For trainees interested in learning, do you have any advice on ways to achieve competency during or after training and then incorporating this procedure into their practice? Great question. And so, absolutely. I did not have this available to me in my training either. And I actually sought it out during my time in my first year of practice. It was something that me and a couple of my partners were interested in bringing to our practice. And we reached out to one of the vendors who provides the band kit and the ligators and all that. And they have a training program. So they came to our office. And what we did was we accumulated patients who were interested in hemorrhoid band ligation. And we basically lined them up for a day and made a day for hemorrhoid band ligation. And then we got a little seminar and training session ahead of time. And then the trainer who is an MD came to our, with us in each room. And we discussed their complaints with the patient ahead of time. And they were prepped. And we, as learning providers, did the hemorrhoid band ligation under the supervision of that MD. And so basically you're going room to room, kind of going back to back, and then learning from your techniques. Okay, I need to adjust this. And that's really how you just learn. And sometimes it's just some practice and then doing more and more and kind of developing your own style. So I would encourage you to seek out a couple of vendors and you can meet them at these conferences, national conferences we have, and seek what training program that they provide. And they can come to your institute and even train fellows. We brought it to our own institute to train fellows here. Dr. Landrino wrote a comment. And if you're going to ACG, there will be a hands-on session for fellows for hemorrhoids. That's exactly right. So go to that hands-on session. And then how does rubber band ligation cause urinary retention? So it's usually a contraction, a spasm in the pelvis, and that creates this contraction and you develop. And sometimes if there's inflammation, like we talked about pelvic sepsis, that also does that. And that creates that urinary retention and spastic kind of bladder. So typically you'll know that immediately. And the patients who don't get adjusted in their office are the highest risk for these complications or having multiple band placements in there and in one session are the high risk. Anybody else want to comment on that? Yeah, I'll just add that anybody who presents with urinary retention has pelvic sepsis until proven otherwise. Right. I'll take the lawyers away. You can really avoid that by adjusting it. And so I usually watch my patients for 10 minutes after the band is placed, let them just kind of sit there in the room, come back in 10 minutes. And I ask them, are you having any pain, discomfort, spasms, anything like that? And if they say yes, we don't let them walk out of the office. We go back in and we readjust the band and see what's going on. I just want to add, it's a fantastic talk. A very, very, very thorough, comprehensive. You know, the deployment of the band, the proficiency is fairly quick. I think the proficiency comes with the tactile proficiency. Like the art of adjusting the band takes many bands. And if for some reason you have a patient who has, I have banded with the sigmoidoscopy for patients who've had trauma and who really cannot be awake. And I'm like, I will absolutely respect your wishes and I will do a sedation. I warn them, he may hurt, but you know, I wasn't comfortable doing that until I did a lot in the office. And when I was first trained in fellowship with sigmoidoscopy, nobody taught me to feel. We just band, move on. But really the proficiency comes with feeling how much is too much. How do you adjust it? You know, you can practice by feeling your thumb and the skin. And if you feel a pinching just like that, then that means it's too much. But the proficiency really comes more with adjusting the band and feeling with your fingers and feeling for fingers as well. Great. Excellent. Okay. So that was very comprehensive. Thank you. There's just one other subset that comes to mind is young people with irritable bowel syndrome. They tend to be more sensitive. And I usually give them a chat about how this could hurt, take some Tylenol before getting there. And one of the other things I should mention is that, remember when you use a sigmoidoscope to band, the banding device on the sigmoidoscope costs about $600 and you are getting paid about 200 for that procedure. So somebody's losing money somewhere. And I don't think you should be using a scope to band hemorrhoids. Okay. So in the interest of time then, I'd like to go on and introduce Dr. Steven Landreau to talk to us about anal fissures. Steven. Thank you, Waqar. Thanks for inviting me and thank you to ASGE for producing this. And so my topic is anal fissures, which if you're not careful doing hemorrhoid banding, you may very well cause, probably not, but. All right. Waqar, you can see that? Yes, thank you. Very good. So I'd like to start with the take home and that's that anal fissures are very common. And this is something you're gonna encounter in your practice. As with these other problems, we should be able to manage these in our practice without having to refer them out. And these are conditions that you can make immediate changes in your patient's quality of life. So they will either love or hate you for taking care of these things. We're gonna diagnose fissures clinically based on history in our digital rectal exam. It's fairly straightforward, although there are some caveats and some things to have on the differential that we'll look at. The treatment's gonna be non-surgical. So there's conservative measures and then there's topical ointments. And then only for rare refractory cases would you refer somebody to surgery for anal fissures. And then think about kind of the zebras if you have an atypical fissure, things like IBD, cancer, and certain infections. And we'll talk about a couple of those. So here's the case. We have a 46-year-old man. He was seen in our clinic by one of our advanced practice providers with a five-week history of rectal bleeding, painful defecation. It was sudden onset. He was having pain and bleeding with almost every bowel movement. His medical history is significant for HIV that was controlled, reflux, diabetes, hypertension. And he had had a gastric bypass five years prior to this. 10-year pack year of tobacco, but he had quit over 10 years ago. Social drinker, no family history of colon cancer, polyps, or inflammatory bowel disease. You can see his medications there. So on exam, he was healthy. There were no abnormalities. And then there was no rectal exam performed, or at least not documented, nor was it documented that he refused one, which can happen in patients who have fissures. His labs show a hemoglobin of 11, and his MCV was normal. And the impression and plan was for his GERD and new anemia to schedule an EGD, and then for the rectal bleeding to schedule a colonoscopy. Now, we can probably pick apart a lot of these cases, things we may do differently. That brings me back to my first year of fellowship where I trained in Mobile with Jack DePalma, was my mentor. And there were kind of, I would have been fired, but there were two acceptable reasons for not doing a rectal exam on the patient. That was one, there was no anus, and two, there were no fingers. Now, the no anus thing, you will occasionally come across that in patients who have had an anal cancer, or anal rectal cancer that's been resected. I had a third, and that's patient refusal, but that was not really acceptable to Dr. DePalma either. So every patient, every new consult, every new clinic patient got a rectal exam, and certainly anybody with anal rectal complaints should get a rectal exam. So if we're gonna look at the anatomy, and these pictures are gonna look familiar, the anal sphincter complex is about four centimeters long from the levator complex down to the anal verge. About midway, you have the dentate line, which is the transition from rectal columnar epithelium to the anoderm, which is squamous epithelium. And the anoderm is very richly innervated. And that's part of the reason that hemorrhoid banding, when we do it, it's not painful, is we're banding well above the dentate line. Fissures, however, occur at the dentate line, and typically below, and are exquisitely painful because of that. You have your internal anal sphincter, which is smooth muscle, and that you can get spasm with that, which contributes to the pathogenesis of anal fissures. And then when you have a chronic anal fissure, you can get hypertrophy of tissue distally that we refer to as a sentinel tag or pile, sentinel pile, and then internally as a hypertrophied anal papilla. And so anal fissures are very common. As you heard, they commonly occur in patients who have symptomatic hemorrhoids, and in patients who are having pain with hemorrhoids, you really should consider a fissure because often hemorrhoids can prolapse, they can itch, but unless you have a thrombosed hemorrhoid, if the patient's having pain, there's a good chance that there's a fissure. Most fissures, almost all fissures, will occur in the posterior midline with a minority occurring in the anterior midline. And almost all fissures will be in the midline, and that has to do with the forces of defecation, as well as the vascular supply. So whenever you have trauma from hard stools or multiple loose stools, you can get small tears in the mucosa or in the epithelium. Most of these will heal. However, the blood supply in the posterior midline is really lacking. And so if you get a fissure in that area due to trauma or forces with defecation, the lack of a good blood supply will make that fissure less likely to heal. And you can then get a spasm with your internal anal sphincter, and that can further induce ischemia and lead to the development of chronic fissures. Now, if you have a fissure that's not in the midline, that's unusual. And so those are patients that you need to think about, IBD, specifically Crohn's disease, as well as infections, immunocompromised states, so HIV, STDs, or carcinoma. Those can all present as atypical in similar presentations as a fissure. So the history is pretty straightforward for these. Patients will have acute onset severe pain, may be associated with a bright red rectal bleeding or blood with wiping. The pain occurs with defecation and may last for minutes to hours after a bowel movement. When they come in, you should do a rectal exam. We do these with patients in the left lateral position. And first thing we do is look, so visual inspection, and we're gonna just by spreading the cheeks and looking to see if we see a fissure, to see if we see any excoriations, to see if there's a bulge from a perianal abscess, or if there's a fistulas opening, all important things that you'll see just by looking. Okay, and then we do a digital exam. And the digital exam with a fissure may very well not be tolerated. And that by itself is probably diagnostic of a fissure in the absences of other things I just mentioned. But when you do this exam, you're looking for hemorrhoids, you're looking for abscess, you're looking for fistula, or you're looking for mass lesions also. Now, anoscopy, I don't typically do in patients who have fissures, but it is indicated. And it kind of depends, if they don't tolerate a digital rectal exam, they're not gonna tolerate an anoscopic exam. But if the history is not clear for a fissure and you need to evaluate for these other alternative diagnoses, then anoscopy is helpful. And then finally, in anybody who's had rectal bleeding, we do colonoscopy to rule out neoplasia, IBD, cancer, or anybody who's, it's age appropriate. So now over the age of 45, even in the absence of bleeding for perianal complaints, they obviously need colonoscopy for colon cancer screening. But anybody with rectal bleeding should get a colonoscopy. Now, colonoscopy is not gonna be ordered the next day after you see these patients in clinic because the pain they're having with bowel movements, last thing we're gonna do is give them a bowel preparation and then expect them to tolerate that and then come in to do a colonoscopy. The colonoscopy should be on the list or on the evaluation once their fissure has been treated or is under symptoms or under control. So with regards to treatment, our goal is to improve blood flow so the fissure will heal. And the main mechanism we do that by reducing spasm of the internal anal sphincter. And we've got a couple of options we can do for that. So first is gonna be conservative management. And for that, we're gonna do, as you heard with hemorrhoids, we'll use laxatives, we use bulk agents, 20 to 30 grams of fiber. And then there's some data also for elimination diets for eliminating things such as dairy and wheat and that may help with sphincter pressures. We recommend SIDS baths. So 10 minutes soak in lukewarm water after each bowel movement and then before bedtime can help with symptoms as well. And then our main treatment is gonna be topical agents. And so we have two options. One is calcium channel blockers, which is off-label for using for anal fissures. And then we have nitroglycerin or nitrates, which it does have a labeling for anal fissure treatment. So first I'll talk just a minute about the nitrates. This is what I was using. We did have a training program in our fellowship and y'all alluded to Mitch Guttenplan came down and he would come down annually and lecture to the fellows and teach us about hemorrhoids as well as fissures. And so we started using nitroglycerin and we've used that a lot for fissures, but the big side effect with it is headaches and orthostatic hypotension. And so it's really not well tolerated by patients. It needs to be done BID to three times a day and you need to do it for at least eight to 12 weeks. Now it's hard to get somebody to take a PPI daily for and take that correctly. So how are you going to get somebody to put something in their anus three times a day and do that consistently? Well, fissures hurt so bad that these patients, they want relief from this. And so they'll do exactly what you tell them, at least initially. Now, once the fissures start healing, their pain will improve. And the trick then is though to keep them or educate them that they need to continue to do the treatment so that they can get complete healing of that fissure and not just kind of the surface epithelium because we really need the deeper inflammation to get better to prevent the development of chronicity. So I've switched mainly from using nitrates to using calcium channel blockers. And so what I'll usually do is diltiazem 2% cream. The other option is nifedipine that you can use 0.5% cream. And again, you're doing it twice a day to three times a day. With calcium channel blockers, the side effects are not as severe. You can get a dermatitis with it. And to a lesser extent, you can get headaches, but not nearly what we see with the nitrates. The efficacy of the calcium channel blockers is also probably a little better than nitrates, quite a bit better if you account for side effects. And calcium channel blockers, we can also use more than one course if patients have recurrent fissures. You can have it compounded with topical lidocaine as well for these patients. Now, if they fail conservative and topical agents or don't tolerate because of side effects, next option we have is Botox. And so Botox can be injected on each side of the anal fissure, typically 10 units on each side, and that relaxes the internal anal sphincter and allows the fissure to heal. Botox injections, you can get some injection site reactions as far as side effects, and the effects typically for a couple of months, and it can be repeated if needed. And as far as like efficacy, calcium channel blockers and Botox, all these things in conservative, when you use them sequentially, they work about the same. So you'll get, if you don't get improvement with conservative or topicals, you get an additional improvement with Botox. But if you were to compare them head to head as initial treatment, the efficacy is very similar. Finally, if they do not improve with our non-surgical therapies, the tried and true treatment for these since over the past 50 to 60 years is a lateral internal sphincterotomy. And so the surgeons will incise the internal anal sphincter beneath the fissure, thereby relaxing the internal anal sphincter pressure and allowing the fissure to heal. This comes with a real risk of incontinence in the neighborhood of five to 10%, and it has a two to three month recovery period with having this done. So it takes, there's quite a recovery. So you want to try and avoid that when we can. And in the vast majority of cases we can with going through these other agents. So if we come back to our case, he missed his initial endoscopy appointment. And I first met him when he came into the GI lab eight weeks later, he was still having symptoms of pain and bleeding. And we did his EGD, which showed a RUE and Y gastric bypass, and his colonoscopy showed a fissure. Okay. So here is his, on the upper exam, is his small hiatal hernia. And then his gastrojejunostomy, the candy cane portion, that all looked fine. And then his small bowel looked good. So, but that's not our purpose. So here, this is the pendocelial orifice. PrEP was okay. We were able to clean it up at least enough to find the small adenoma. But then in the rectum, with the scope, and on rectal exam, before inserting the scope, we could feel a defect in his left lateral position, kind of nine o'clock. And then, so with coming back with the scope, you can see this, quote, fissure here. And this is not in the midline. This is in the left lateral position. So this is abnormal or atypical. On a retroflex view, we can see this heaped up abnormal mucosa and the defect. And there's maybe some other hypertrophy anal papilla. And here you can see nicely the dentate line. I'll call attention to that too. Anything above here would be considered internal hemorrhoids. Anything here below would be considered external. External doesn't necessarily mean, as Dr. Mathur alluded to, doesn't necessarily mean outside. And then, so finally, here's the closer up view. And so we have this linear defect. And we thought this was neoplastic versus infectious. And so we took biopsies of it, and that came back as a squamous cell carcinoma. And so we referred him to colorectal surgery, in this case, as well as oncology. He had a PET CT that only showed hypermetabolic activity at the anus. There was no evidence of metastatic disease. And he's currently undergoing chemotherapy as well as radiation therapy. So just to summarize, anal fissures are really common, and you guys are gonna encounter them frequently. We're gonna make the diagnosis based on our history of that pain and rectal bleeding with defecation. And we're gonna confirm the diagnosis with our digital rectal exam as well as evaluating for abscesses or hemorrhoids at that time. Conservative treatment and topical ointments, mainly calcium channel blockers are going to be our first line therapy. And then don't forget about colonoscopy for bleeding regardless of age, and certainly age appropriate if they're over 45. And then in atypical cases, for IBD, carcinoma, and infections. With that, thank everybody for their attention and I'm happy to take a couple of questions. Thank you for the excellent talk. Again, reminding everyone, let's use the Q&A box for questions. I guess I'll get started with one question. So for topical therapy, you mentioned topical calcium channel blocker. Is that something that's readily available in most pharmacies? Or because you mentioned using a compounding pharmacy for lidocaine, but without lidocaine, is the calcium channel blocker available readily at most pharmacies? Yeah, so we use a compound. There's a couple of compounding pharmacies that we use here that I use for the calcium channel blocker for diltiazem. And I use diltiazem more than ephedipine. And then also, we were using compounding also for the nitroglycerin. One of the issues that came up with the nitroglycerin is a company put a commercially available product of nitroglycerin out, and it was actually higher concentration than what we used to have compounded. And so you had more headaches and side effects with it. But they sent cease and desist letters to all the compounding pharmacies about doing nitroglycerin. So that's kind of when I switched to calcium channel blockers. But then I've also much less headaches and things with doing it. And what we'll have the patients do with that, I mentioned, we'll have them put a pea-sized amount kind of on the tip of their finger, and then kind of go one knuckle just inside the anus and have them do that. Tell them three times a day, hoping they do it twice a day, and then again, trying to coach them through doing it for at least eight weeks. I see one other question here. Can you feel an anal fissure on palpation? And if you can, then what exactly are you feeling for? The patient certainly can feel the anal fissure when you palpate it. And you're looking for, if it's a chronic, a deep fissure, sometimes you can actually see the muscle fibers when you see those. But you're feeling for a break in the mucosum, most often what you'll feel when there's a fissure is actually just spasm of the internal anal sphincter. And so when you're doing your rectal exam, you may actually feel a ridge between the external anal sphincter and the internal anal sphincter because of that spasm of the internal anal sphincter. And so that's probably the most common finding when there's a fissure. And often you just feel a roughness in where the fissure should be. But as you correctly pointed out, it is extremely tender. So you don't really need to feel much. The patient tells you they have a fissure. One of the things I'd like to also mention is that one of the reasons we moved away from nitrates is that if you are taking erectile dysfunction drugs, nitroglycerin can cause a dangerous drop in your blood pressure. And so that's something you have to be wary of also. That's great. Very comprehensive. Excellent talk, Stephen. I'll give you a plug. I pulled for more reading. You guys are happy. There's a paper by two of our panelists here that I referenced from two years ago. It is an excellent review, very concise on the management of fissures. Thank you. Okay. So we've been itching to get to the next part. Anal pruritus is quite vexing. It can be quite difficult to treat and really gets under your nails, so to speak. So my colleague, Dr. Rehman Shaikh is going to tell us about anal pruritus, ANI. You took my joke. You took my joke. I was itching to give it. Just have a good time. Thank you for the introduction and thank you guys for the opportunity and I'm impressed by the turnout. So I hope you guys have been taking full advantage because these are really, really good talks. I hope I can live up to the bill. So today I'll be talking about pruritus ANI, which it'll probably bother you just as much as your patients and patients in cases that are very, very challenging. And I have one actually that I'm currently trying to get better for a patient. So I had a 57-year-old male with relapsing-remitting multiple sclerosis who was referred to me for pruritus ANI. He first saw his PCP complaining of itching and PCP first tried conservative treatments, talked about loose-fitting clothing, gentle cleansing, at least that's what gets off in the notes. The symptoms persisted, so she performed an anal swab intended for bacterial culture as well as fungal and viral cultures. And lo and behold, there were multiple typical GI organisms with Klebsiella, Anarchoccus, and Pseudomonas. This can be seen in normal gut flora, but his provider ended up treating with five days of Levaquin, with a Levaquin course and a five-day course of prednisone. He did note mild transient relief, but really it was only a few days of relief. So PCP was like, you know what, let's try topical nystatin. Topical nystatin actually provided better relief, but it was short-lived. At that point, he was referred to me because of pruritic ANI continued. So I performed a colonoscopy, obviously you want to rule out any luminal pathology that might lead to a cold fistula or any other perianal disease. Colonoscopy, and this is a retroflex view, he has some hyperperturbated anal papillae and on external exam skin tags, and he also has some hemorrhoids as you can see. This isn't a fully decompressed view, but obviously we can see hemorrhoids here. You know, I saw this large, he had some large hyperperturbated anal papillae and some skin tags. So I thought, well, we've really tried everything. We've tried ointments, we've tried, you know, lifestyle changes. So I thought, you know, well, let's send to have these resected. I mean, he was messaging me very frequently. It was very bothersome. It actually got to the point where it was affecting his quality of life. He stopped working and I'm like, okay, this is this is pretty severe. So let's be a little more aggressive. So we sent to the surgeons, they resected the skin tags, I purchased venal papillae and they did a hemorrhoidectomy. And it didn't do anything. He still had, he still had hyperperiodic anal and I'm like, okay, all right, we'll really try everything. Last stitches, is there some other, you know, skin condition that I'm missing? You know, I think we should send you for a derm. So I sent a derm for a biopsy and they were thinking, well, you just had this colorectal surgery procedure. Let's have a follow-up. If this is still persists, they gave him a topical lopo and steroid and similarly provide a minute mild relief. He went about his day, but it still bothered him. Following the steroid, he used Budra's butt paste with minimal relief. He comes back to me, doc, it's, I'm losing weight. It's just, it's just affecting my life so much. And so I thought, okay, you know, we're kind of like at that last stitch again, capsaicin. And just yesterday he messaged me saying it's causing severe burning. So that's where I stand with this patient right now. So let's talk about peritoneal anion. So simply put it's itching of the skin around the anus. It's itchy, but affects up to 5% of the general population more commonly affects men four time, four time, more likely to affect men than women. There's two forms. One is secondary. So you'll have an identifiable and treatable cause. The other is primary. When it's idiopathic, we don't know what, why there's some thought that there is some kind of irritant and it causes chronic itching and chronic activation of nerve fibers. I think that's where I am with my patient. I'm going to send it back to Durham for a biopsy. So secondary priority anion, you know, you think about anal rectal pathology, anal fissures, hemorrhoids, excessive skin tags, fecal soilage and incontinence, anal fissure. Polished anus syndrome. Apparently this is a thing. It's the results of aggressive, it's like you're polishing your anus. It's in the name of the syndrome. It's aggressive cleansing and use of soaps and scents and lotions. In general for almost every anorectal condition, you want to minimize any aggressive cleansing. Just water, rinse. Don't use toilet paper aggressively. Don't use lotions, soaps, things like that. Dietary factors may play a role. Coffee, tea, spicy foods, citrus, tomatoes. These things have potentially been associated as potential exacerbators or priority anion. Infections should always be a differential. Fungal infections, bacterial infections, parasitic infections, worms, scabies, anal warts. Skin conditions, psoriasis, seborrheic dermatitis or contact dermatitis, lichen planus or Bowen's disease. An exam can give you some insight, but a biopsy is not unreasonable when you've kind of considered everything and tried everything. Evaluation. Just like a lot of things in our specialty, history is very, very important. The timeline. If it's a chronic thing and they've tried things, yeah, you may be headed towards a more aggressive situation where lifestyle changes may not be enough. Toileting behaviors. People who are constantly in the toilet or who have diarrhea. Hygiene is very important. And this is something that as you guys become more comfortable taking care of anorectal conditions, you'll find that a lot of people are very anal about their anus. And they work, they clean, clean, clean, they scrub, they soap. And when I talk to them like, hey, you have natural oils. You shouldn't be so aggressive. They're like, oh my God, no one told me that. That's so weird. It's dirty. I'm like, no, that's your body. So hygiene is a very important thing. Quality and frequency of stools and incontinence. So you've got a good, very good history. I mean, yeah, you can get a history of contact. So maybe someone had scabies, then obviously you want to triple glove and be very careful. Maybe they had some kind of ingestion that makes you think of worms. Some kind of travel history or some kind of social that makes you think of worms. Dietary history, like we talked about, you know, excessive coffee, tea, very spicy foods, citrus. These are things you can counsel your patients to consider limiting to see if it makes a difference. And then if it's a dietary trigger thing, then you can also say, hey, you know what, maybe when you're eating these foods, be aware and apply butt paste or some kind of calming lotion. Examination of the skin, looking for fissures, fistulates, tears, cracks, or thickening. Again, consider colonoscopy, look for luminal pathology that can cause perianal disease. Anoscopy to evaluate for hemorrhoids. And again, if you've tried everything and you're kind of like, you know, I've tried ointments, I've tried various things, think about a perianal biopsy with dermatology. So treatments. Okay. So fiber supplementation to bulk up stool to limit soilage and incontinence. As I mentioned, you can avoid, you can give a trial of avoiding dietary fibers if that makes a significant difference. Limit aggressive cleansing lotions, use of soap and scents, bidets. You can get a, you can get a handheld wash. You can install at the toilet for $20. It's cheaper than your clinic visit. They can buy a bidet instead of using toilet, toilet paper. These are all things you can recommend, but Amazon's a great place to find cheap stuff and it can help the patients. Use plain water rinses, toilet paper, loose fitting clothing. So tight, tight clothes can irritate, minimize airflow. Soothing agents, such as Balneol actually can be helpful. And this was one of the lotions that the Royal Academy of Surgeons actually recommends is Balneol. And so it can be helpful, but avoid alcohol wipes and witch hazel. Witch hazel is the common treatment for hemorrhoids, which is not unreasonable for hemorrhoids as a short-term thing, but for when you're having pruritin, I would probably avoid the use of witch hazel. If it persists, despite doing all these interventions, you can consider a short, very short course of topical hydrocortisone, no more than two weeks. If you go beyond two weeks, you can thin the skin, the perianal skin, and it can become worse. Your pruritis can get worse. And then after you can transition to a barrier clean, sorry, you can transition to a barrier cream. And you want zinc oxide. Desitin and Boudreaux's butt paste actually have 40% zinc oxide, which is actually more than some prescription options. So that's a very reasonable option to go for is a Desitin or Boudreaux's butt paste. You want to treat anorectal pathology. So skin tags, hemorrhoids, fissures. If there's a concern for an infection, you can try topical antibacterial like Bacitracin or a topical antibacterial like Nystatin. So you want to consider a skin biopsy if there's refractory symptoms, or if there are concerning findings on your perianal exam, if you find, you know, very thick skin. I mean, you guys know what psoriasis, I've had done plenty of hemorrhoid cases where I'm like, hey, this looks like psoriasis, you know, I think you should see a dermatologist. So if you're concerned about anything that you see on exam, refer for a dermatology. You can consider topical capsaicin. Although if there is any kind of denuded skin and this underlying mucosa or the epidermal layers is cut, it may burn significantly if you give a high dose of capsaicin. So you have to be cautious with capsaicin. Now, lastly, if there's minimal improvement, which is what I think I am with my patient, methylene blue injection into the skin can relieve symptoms by destroying nerve endings. This is actually a really good algorithm I saw for prurity ENI, right? So you want to treat any inter-rectal conditions like we discussed. If there's large skin tags with fecal retention soilage, if there's large hemorrhoids, if there's fissures, treat those. Again, the skin tag part, I am very hesitant to send off the bat because it is a surgical incision. Sometimes hygiene is sufficient. Using water rinses, not aggressively thinning may be enough, but sometimes, you know, you know, people have had traumatic trauma, episiotomies, they end up having large skin tags. They've had thrombus hemorrhoids and you really can't do much about the fact they just have large skin tags and they're retaining, they're retaining, they're retaining stool and they're constantly getting irritated. Fiber to bulk up the stool. Interestingly, this is something I saw. This is good for short-term antihistamine. Obviously, you don't want them to be on long-term antihistamine, but short-term or PRN, you can consider antihistamine at night. We talked about if there's, you can trial antibacterial, topical, or antifungal. If you find any concerning changes, obviously, don't, you know, don't hesitate to refer to dermatology. If all this fails, you can consider a high-potency, actually, I would probably do a lower-potency steroid, to be honest, to avoid the thinning of the skin in that area. And then you can consider capsaicin. Again, my limited experience, my patient sent me a scathing message because he's been doing this for years and he was like, I'm so mad, it's burned so much. And I'm like, he was like, but then I called him today and he was like, well, I didn't tell you, but I had a small tear. And I'm like, well, okay. I mean, you know, we'll figure out what's going on. But I felt less bad about that because he didn't let you dive into information. He didn't have me do an exam when I examined him. Lastly, you can consider anal tattooing or anal methylene blue to destroy the nerve endings. I do think I'm probably there with my patient. I'm going to try a balanil and calming lotion, just as a, as like, as a possible, you know, just as something he can do more long-term, if it provides some relief. And I'm going to retrial nystatin, because that's the one thing in his history that he says actually provided, you know, relief. And he was like, you know, like, can we try it one more time? So I said, sure. He's, he'll let me know in a couple of weeks how he's doing. If things persist, I will refer to Durham to biopsy. And if that does not reveal any ideology, then I'll work on arranging methylene blue injection for desensitization. I do think that may be playing a role in him. He does have MS. It is always the question of how you, of pain modulation in some of these patients and how some of this may be hypersensitive nerves in the perianal area. So he's actually very open to this idea and that may be where we're headed. But yeah, that's a pruriti anae. It can be a very tough, a tough thing to treat. Especially this patient's been doing this for years and he's coming in three times now. He's gone to surgery, he's gone to Durham. And so I think we're, you know, these patients, you may think about a biopsy and, and anal tattooing. Great. A very polished presentation, if I might say. Excellent. So Tariq, do we have any questions before we? None yet that I can see, but happy to go ahead and just start with one quick question. As far as injection of methylene blue, any specifics in regards to that? You know, I myself haven't done it. So I, my personal experience is limited. This is actually a learning case for me because this is the next step that I'm going to have to investigate. I'll probably reach out to my decolorectal surgery colleagues, but I don't have a whole lot of experience with it. I don't know if any of the other panelists have much experience with it, but that's been described as a kind of last ditch effort. Okay. So I, excuse me, I was just seeing what else we have here. Are there any questions from the fellows? If there aren't, I'm going to show one last short video about what to do with a thrombosed hemorrhoid, which is something that you will see you need to treat within three or four days of its onset of symptoms. Otherwise there's no point doing it and you treat them conservatively and eventually they get better. So let me just play this for you. This is a lady who is 29 weeks pregnant, I believe. And she came over. I don't know if you can see, is this projecting okay? All right. So this is a thrombosed hemorrhoid, extremely uncomfortable. I really wanted her to wait till the end of the pregnancy and let it just settle down. But here I am taking care of this and she was eternally grateful. So here is the thrombosed hemorrhoid. I'm injecting this with some Lidocaine. And this is really the only part that the patient feels. And after this with a scalpel, you just open this to let the clot out. And I think this was about five days because normally the minute you cut, the blood clot just starts to come out. Here I'm sort of digging a little deeper to get to the clot. There it is. And she instantly got relief. Now you don't want to leave this because it will simply close over and reform. So here I am trying to take one side or de-roof it so that it doesn't close. And there's a gaping hole there so that it will not reform. And the patient was forever grateful. And you should be able to do this in your clinic. It doesn't need packing. It may stain a little. You just warn the patient, but it stops bleeding. And that's taking care of a thrombosed hemorrhoid. If there are no questions. Tariq, any questions? Dr. Qureshi, I just wanted to ask you a comment. Do you typically give them antibiotics after you unroof it or you just let it heal? Yeah, no, we don't. It's so superficial and it's wide open. So no, we don't. No. And it's a very satisfying procedure. You know, it's like cannulating a bile duct and letting the pus out. You feel good. And the patient goes from severe pain, can hardly walk, can't sit, to painless. And they're just amazed that you fix them in five minutes. Okay. So Tariq, any questions? I don't see any more questions. Okay, guys, you've done an incredible job. This has been very useful. And I think the fellows are lucky that they tuned into this and I hope that they will start to do hemorrhoid banding and enorectal care in their own practices. And I think more and more fellowships are beginning to introduce enorectal disease training in their fellowship programs. And it's certainly, there's no reason why you should send a patient to a surgeon for a non-surgical problem. Hemorrhoids, fissures, rectal dysenergia, pruritus, this is all non-surgical. And I'm sure that you have unnecessary hemorrhoidectomies being done just because patients send a hemorrhoid to surgeons without thinking about it. So the GI, it's really in our domain to take care of enorectal disease. I think I'm going to hand over to the ever hardworking Marilyn Amador to take it from here. All right. Thank you. Thank you all again to all our moderators and panelists for tonight's presentation. Before we close out, I just want to let the audience know to make sure to check out our upcoming ASG educational events. Registration is open and many of these programs are open. Complimentary to our training members. Visit the ASG websites to register. The next ASG endo hangout session will take place on Thursday, November 10th at 8 p.m. Central time on practical approach in the management of anticoagulation in the setting of GI bleeding. Registration will open next week. At the conclusion of this webinar, you will receive a short survey and we would appreciate your feedback. Your experience with these learning events is important to ASGE and we want to make sure we are offering interactive sessions that fit your educational needs. As a final reminder, ASG membership for fellows is only $25 per year. If you haven't joined yet, please contact our membership team or go to the website to make sure you sign up. In closing, thank you again to all our panelists and moderator for this excellent presentation and thank you to our audience for making this session interactive. We hope this information has been useful to you. And with that, I will conclude our presentation. Have a good night.

anorectal diseases

gastroenterologists

hemorrhoids

anal fissures

anal pruritus

abscesses

fistulas

disorders of defecation

rubber band ligation

diagnosis

clinical setting