Cirugia General - Sesion 5 - Repaso de Via Biliar y Patologia Anorrectal - Andrés Pacherres - 2026-1

Introduction to Clinical Review of Anorectal Pathology

Overview of the Session

• The session aims to review key concepts related to anorectal pathology, focusing on differential diagnoses and clinical pearls for exams.

• Emphasis is placed on understanding diagnostic questions and therapeutic concepts relevant for examinations.

Methodology of the Review

• A clinical case will be presented, followed by multiple-choice options to facilitate learning through differentiation.

• The focus will be on identifying key features that distinguish various anorectal pathologies.

Case Presentation: Internal Hemorrhoids

Patient Details

• A 50-year-old male presents with chronic constipation and anal bleeding for two months, noting bright red blood in the toilet after defecation. He denies pain or fever.

Key Findings

• Anoscopy reveals engorged vascular cushions proximal to the dentate line, indicating internal hemorrhoids as a likely diagnosis.

• Important characteristics include painless bleeding post-defecation and spontaneous reduction of protruding tissue.

Differentiating Internal vs External Hemorrhoids

Classification Insights

• Internal hemorrhoids are located above the dentate line and covered by mucosa; external hemorrhoids are below it and covered by skin, often causing pain.

• Chronic constipation increases pressure leading to engorgement of superior hemorrhoidal plexus, which is crucial for understanding this condition's etiology.

Treatment Approaches

• Initial management includes dietary modifications (increased fluid intake and fiber). For grade I hemorrhoids, photocoagulation is recommended; grades II and III may require elastic band ligation or surgical intervention if severe.

Case Presentation: Anal Fissure

Patient Profile

• A 32-year-old female experiences intense anal pain associated with hard stools over ten weeks, presenting with a longitudinal ulcer at the posterior midline during examination.

Diagnostic Criteria

• Key indicators include severe pain triggered by defecation and minimal bleeding noted on toilet paper; these symptoms suggest an anal fissure rather than other conditions like abscesses or cancer.

Case Presentation: Perianal Abscess

Symptoms Description

• A 45-year-old male reports four days of progressive perianal pain accompanied by chills and fever; physical examination shows fluctuating subcutaneous swelling near the anal margin suggesting an abscess diagnosis.

Management Strategies

• Incision and drainage are essential treatments for perianal abscesses; antibiotics should only be used in specific cases such as immunocompromised patients or those with systemic signs like sepsis or cellulitis.

Case Presentation: Anal Cancer

Clinical Features

• A 60-year-old male with HIV presents with a painful mass at the anal region along with rectal bleeding over six months; examination reveals an indurated ulcer with fixed inguinal lymphadenopathy indicative of possible anal cancer diagnosis.

Risk Factors & Diagnosis

• Important risk factors include HPV infection (types 16/18), smoking history, and sexual behavior; classic findings involve indurated ulcers that are firm (petrified), everted edges, which help differentiate from other conditions like fissures or condylomas.

Case Presentation: Anal Fistula

Characteristics

• A 27-year-old male has chronic anal discharge linked to intermittent perineal pain following previous abscess drainage; multiple external openings indicate a fistulous tract formation rather than an active abscess due to lack of fluctuation or localized collection seen in acute cases.

Treatment Considerations

• Surgical intervention via fistulotomy is necessary while being cautious about potential complications such as fecal incontinence due to sphincter involvement during surgery.

Overview of Cholangiitis Treatment

Treatment Approaches

• Todo tratamiento de colangitis lleva hacia un tratamiento etiológico. Si es que le ponen cuál es el tratamiento de elección, cuistomía, manejo de causa.

• Manejo de causa incluye medidas generales y antibióticos, siendo la litiásis la causa principal que requiere descompresión.

Severity Assessment

• Para clasificar la severidad se utilizan criterios como:

• Leve: sin criterios.

• Moderado: mayor a 75 con leve mucoitosis.

• Severo: hipotensión que no responde a líquidos o vasopresores.

Differentiating Conditions Related to Cholangiitis

Key Distinctions

• La alcohócolitiasis puede generar colecistitis, pero no presenta síntomas típicos como hipotensión o fiebre.

• El colangiocarcinoma se caracteriza por una evolución más prolongada y síntomas indoloros en comparación con condiciones agudas.

Case Study: Chronic Cholecystitis Diagnosis

Patient Presentation

• Femenina de 45 años con dolor abdominal recurrente en hipocondrio derecho tras comidas grasosas; diagnóstico probable es colecistitis crónica debido a episodios limitados y ausencia de fiebre.

Clinical Features

• Dolor sordo constante irradiado a escápula, duración limitada a 3 horas por episodio sugiere oclusión temporal del conducto cístico.

Management Strategies for Cholecystitis

Recommended Actions

• Observación y cambio de dieta son claves; el tratamiento definitivo es colecistectomía laparoscópica electiva si hay episodios recurrentes.

Complications Awareness

• El 10% de los casos crónicos pueden asociarse a coledocolitiasis; estar atento a diagnósticos diferenciados entre cólico biliar y colecistitis crónica es crucial.

Colangitis and Associated Symptoms

Clinical Presentation

• Paciente masculino de 65 años con antecedentes de colangitis esclerosante primaria presenta prurito, coluria y pérdida de peso sin dolor abdominal agudo ni fiebre; diagnóstico sugiere colangiocarcinoma perihilar (tumor Klatskin).

Risk Factors and Symptoms

• Principal factor riesgo para tumor Klatskin es la colangitis esclerosante primaria; síntomas incluyen ictericia sin dolor significativo debido al colapso vesicular.

Types of Cholangiocarcinoma Classification

Tumor Types Overview

• Clasificación según Bismuth-Corlette:

• Tipo I: afecta conducto hepático común distal.

• Tipo II: involucra la confluencia biliar.

• Tipos IIIA/B: afectan conductos hepáticos derecho/izquierdo respectivamente.

• Tipo IV: compromete ambos lados simultáneamente.

Differential Diagnosis in Biliary Pathologies

Key Considerations

• Diferenciar entre quistes biliares congénitos e impactaciones litiásicas en el árbol biliar; los quistes suelen ser asintomáticos hasta etapas avanzadas mientras que las litiasis presentan dolor agudo asociado a cólicos biliares frecuentes.

Acute Cholecystitis Diagnosis Criteria

Diagnostic Indicators

• Paciente femenina presenta signos claros como murphy positivo, engrosamiento parietal vesicular y líquido pericolecístico sugiriendo colecistitis aguda tras un episodio prolongado (>24 horas).

Inflammatory Response

• Signos sistémicos como fiebre y taquicardia indican inflamación significativa; evaluación mediante ecografía esencial para confirmar diagnóstico antes del manejo quirúrgico inmediato si necesario.

Mirizzi Syndrome Identification

Clinical Features

• Gran cálculo impactado en bolsa de Hartmann comprime extrínsecamente el conducto hepático común generando dilatación intrahepática normal distalmente; esto indica un caso típico del síndrome Mirizzi donde se debe considerar cirugía urgente si hay complicaciones presentes.