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| ==Anal Tags== | | ==Background== |
| *Minor projections of skin at anal verge
| | [[File:Rectum anatomy en.png|thumb|Anatomy of the anus and rectum.]] |
| *Sometimes represent residuals of prior hemorrhoids
| | [[File:Human anus-en.png|thumb|Anatomy of the anus.]] |
| *Usually asymptomatic
| | [[File:Gray1080.png|thumb|The interior of the anal cami and lower part of the rectum, showing the anal columns and the anal valves between their lower ends (columns in image numerous than typical).]] |
| **Inflammation may cause itching and pain
| | [[File:Gray1078.png|thumb|Coronal section of rectum and the anal canal.]] |
| *Skin tags covering anal crypts, fistulas, and fissures are "sentinel tags"
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| **Surgical referral for excision and/or biopsy is warranted
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| *Inflammatory bowel disease may be associated with skin tag formation
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| ==Hemorrhoids== | | ==Clinical Features== |
| *See [[Hemorrhoids]]
| | ==Visual Diagnosis== |
| | <gallery mode="packed"> |
| | File:PMC2653786 ijmsv06p0077g13.png|[[Anal tags]] |
| | File:DSCB4096(anal worms or just toilet paper remainders@).jpg|[[Enterobius]] (pinworms) |
| | File:M 44 anus 22.jpg|[[External hemorrhoid]] |
| | File:Anal fissure 2.jpg|[[Anal fissure]] |
| | File:SOA-Condylomata-acuminata-around-anus.jpg|[[Anal warts]] |
| | File:Perianalabscess.jpg|[[Perianal abscess]] |
| | File:Hemrrhoids 05.jpg|[[Internal hemorrhoid]] with prolapse |
| | File:Pilonidal abscess.jpg|[[Pilonidal cyst]] |
| | File:Full thickness rectal prolapse & mucosal prolapse..jpg|[[Rectal prolapse]] |
| | </gallery> |
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| ==Cryptitis== | | ==Differential Diagnosis== |
| ===Background===
| | {{Anorectal DDX}} |
| *Anal crypts are mucosal pockets that lie between the columns of Morgagnia
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| **Formed by the puckering action of the sphincter muscles
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| *Superficial trauma (diarrhea, trauma from hard stool) --> breakdown in mucosal lining
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| **Bacteria enter, inflammation extends into lymphoid tissue of the crypts / anal glands
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| ***Can lead to fissure in ano, fistula in ano, perirectal abscesses
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| ===Clinical Features===
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| *Anal pain
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| *Sphincter spasm
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| *Itching w/ or w/o bleeding
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| *Hypertrophied papillae
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| ===Diagnosis===
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| *Anoscopy shows inflammation, erythema, and pus
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| ===Treatment===
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| #Bulk laxatives, additional roughage, sitz baths (treats underlying cause)
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| #Surgical referral is indicated when:
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| ##Infection has progressed and the crypt will not drain adequately on its own
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| ##Surgical treatment is excision
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| ==Anal Fissures== | | ==Evaluation== |
| ===Background=== | | ===Algorithmic Diagnostic Approach=== |
| *Superficial linear tear of anal canal from at/below dentate line to anal verge | | *Pain |
| **May be due to passage of hard stool, frequent diarrhea, or abuse | | **Bleeding |
| *Most common cause of painful rectal bleeding | | ***External [[hemorrhoid]] |
| *In >90% of cases anal fissures occur in the midline posteriorly | | ***Prolapsed internal [[hemorrhoid]] |
| **Nonhealing fissure or one not located in midline suggests alternative dx | | ***[[Anal Fissure]] |
| ===Clinical Findings===
| | ****Off midline = cancer, [[HIV]], [[TB]], [[Crohn's]] |
| *Acute sharp, cutting pain most severe during and immediately after bowel movement | | **No bleeding |
| **Subsides between bowel movements (distinguishes fissure from other anorectal disease) | | ***Swelling |
| *Bright red bleeding, small in quantity (usually noticed only on toilet paper) | | ****[[Anorectal abscess]] |
| ===Diagnosis===
| | *****Perirectal |
| *Having pt bear down may make fissure more noticable | | *****Ischiorectal |
| *Sentinel pile, located at distal end of fissure, along w/ deep ulcer suggests chronicity | | *****Intersphincteric |
| **Often misdiagnosed as an external hemorrhoid | | *****Supralevator |
| ===Treatment===
| | ****[[Pilonidal cyst]] |
| #Hot sitz baths 15 min TID-QID and after each bowel movement
| | ****[[Anal fistula]] |
| ##Provides symptomatic relief and relieves anal sphincter spasm
| | ****Hidradenitis suppurativa |
| #High-fiber diet
| | ***No swelling |
| ##Prevents stricture formation by providing a bulky stool
| | ****[[Proctalgia fugax]] |
| #Local analgesic ointments with hydrocortisone
| | *No pain |
| #Meticulous anal hygiene is imperative; after defecation anus must be cleaned thoroughly
| | **Bleeding |
| #Surgical referral indicated if healing does not occur in a reasonable amount of time
| | ***Cancer |
| | ***Internal [[hemorrhoid]] |
| | **Swelling |
| | ***Itch: [[Condyloma acuminata]] |
| | ***No itch: [[Rectal prolapse]] |
| | **Itching |
| | ***Discharge: [[Proctitis]] |
| | ***No discharge: [[Pruritus Ani]] |
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| ===Complications===
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| #Perianal abscess
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| #Intersphincteric abscess
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| ==Fistula In Ano==
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| ===Background===
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| *Inflammatory tract originating from infected anal gland connecting anal canal w/ skin
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| **May be intersphincteric, suprasphincteric, transsphincteric, or extrasphincteric
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| *Goodsall's Rule
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| **Draw imaginary line horizontally through the anal canal
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| ***If external opening is anterior to this line fistula runs directly into the canal
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| ***If external opening is posterior to this line fistula curves to post midline of canal
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| *Causes:
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| **Perianal/ischiorectal abscess, Crohn, UC, malignancies, STI, fissures, FBs, TB
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| ===Clinical Features===
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| *Fistulous tract open: Persistent, painless, blood-stained, mucous, malodorous discharge
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| *Fistulous tract blocked: Bouts of inflammation that are relieved by spontaneous rupture
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| *Abscess
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| **Throbbing pain that is constant and worse w/ sitting, moving, defecation
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| **May be only sign of fistula
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| *Fistulous opening
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| **Adjacent to anal margin suggests superficial connection (e.g. intersphincteric region)
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| **Distant from anal margin suggests deeper, more superior abscess
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| ===Diagnosis===
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| *Endocavitary US w/ 3% hydrogen peroxide for definitive diagnosis
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| | ==Management== |
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| | ==Disposition== |
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| | ==See Also== |
| | *[[Diagnoses by Body Part (Main)]] |
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| | ==External Links== |
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| | ==References== |
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| ==DDX== | | ==References== |
| #Crohn disease
| | <references/> |
| ##Often painless
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| #Squamous cell carcinoma of anus
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| #Adenocarcinoma of rectum invading the anal canal
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| #Syphilitic fissure
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| #GC/Chlam
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| ==Diagnosis==
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| ===Pain and Bleeding===
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| #external hemorrhoids
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| ##swelling
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| ##looks like skin if not thrombosed
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| ##12,7,9 o'clock
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| #anal fissure
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| ##no swelling
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| ##off midline = CA, HIV, TB, Crohn's
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| #prolapsed internal
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| ===Pain, No Bleeding===
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| #swelling
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| ##abscess
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| ###perirectal
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| ###ischiorectal
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| ###intersphincteric
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| ###supralevator
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| ##pilonidal (drain off midline)
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| ##fistula (2/2 chronic abscess; don't probe)
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| ##hidradenitis suppurativa
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| #no swelling
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| ##proctalgia fugax
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| ###episodic pain (women, pts < 45yo)
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| ##incontinence
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| ###urgency
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| ===Bleeding, No Pain===
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| #CA
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| #internal hemorrhoids
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| ===Painless Swelling===
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| #itch --> condyloma acuminata (warts 2/2 HPV)
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| #no itch --> procidentia (rectal prolaps; peds - think CF, malnutrion)
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| ===Itching===
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| #discharge --> proctitis (inflamm changes of rectum within 15cm of dentate line; GC/chlamy, HSV)
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| #no discharge --> pruritis ani (pinworms)
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| ==External Hemorroid Excision==
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| <48 hrs
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| All pts presenting with anorectal complaints should be considered for HIV testing
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| ==Source==
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| Donaldson; adapted from Coates
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| [[Category:GI]] | | [[Category:GI]] |
| | [[Category:Symptoms]] |
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