Anorectal disorders

Anal Tags

• Minor projections of skin at anal verge
• Sometimes represent residuals of prior hemorrhoids
• Usually asymptomatic
  • Inflammation may cause itching and pain
• Skin tags covering anal crypts, fistulas, and fissures are "sentinel tags"
  • Surgical referral for excision and/or biopsy is warranted
• Inflammatory bowel disease may be associated with skin tag formation

Hemorrhoids

association with constipation and straining at stool, frequent diarrhea, and older age. Consider inflammatory bowel disease in patients with frequent diarrhea and hemorrhoids.

When the internal and external hemorrhoidal plexuses become excessively engorged, prolapsed, or thrombosed, they are referred to as hemorrhoids

Internal hemorrhoids proximal to the dentate line course along the terminal branches of the superior rectal artery and are constant in their location, positions at the 2-, 5-, and 9-o'clock positions when the patient is viewed prone Internal hemorrhoids are not readily palpable and can best be visualized through an anoscope. Their appearance is consistent with the columnar epithelial surface of the surrounding anal canal

External hemorrhoids, which are located distal to the dentate line, form as a result of dilatation of veins at the anal verge and can be seen at external inspectio

Hemorrhoidal bleeding is usually limited, with the blood being found on the surface of the stool, on the toilet tissue, or noted at the end of defecation, dripping into the toilet bowl.

When patients describe the passage of blood clots, colonic lesions should be suspected and investigated. Although the most common cause of rectal bleeding is hemorrhoids, other, more serious causes should be investigated. Clinical signs cannot reliably differentiate colonic lesions from hemorrhoids.

Unthrombosed external hemorrhoids are usually painless. If the patient complains of pain but hemorrhoids are not thrombosed, suspect perianal or intersphincteric abscesses or anal fissures. Thrombosed external hemorrhoids arise distal to the dentate line, are painful, and are often described as a burning perianal lump (Figure 88-5). External thrombosed hemorrhoids usually exhibit a bluish-purple discoloration (Figure 88-7). Hemorrhoids may become more prominent with Valsalva maneuver. Pain can be quite severe at the time of defecation and usually subsides with time. As hemorrhoids increase in size, they may prolapse, requiring periodic reduction by the patient

Uncomplicated internal hemorrhoids are painless due to visceral innervation and lack of sensory innervation, accounting for the chief complaint of painless, bright-red rectal bleeding with defecation. If pain is a complaint but there is no thrombosis, examine for perianal or intersphincteric abscesses and anal fissures. Internal hemorrhoids may be palpable on digital examination when thrombosed or prolapsed.2 Nonreducible, prolapsed internal hemorrhoids may become strangulated and thrombosed, result in rectal bleeding, and usually cause exquisite pain. Incarcerated hemorrhoids are quite painful, may become infected, develop necrosis, and may be associated with urinary retention.2 Internal hemorrhoids are classified by the amount of prolapse into the anal canal

Grade I: luminal protrusion above dentate line Do not extend below dentate line and do not prolapse. Cause painless bleeding. Grade II: prolapse with spontaneous reduction Prolapse during straining. Grade III: prolapse requires manual reduction Prolapse during straining. Grade IV: prolapse—nonreducible Can result in edema and strangulation.

When prolapse occurs, the patient may develop mucous discharge and pruritus ani3 (Figure 88-8). If prolapse cannot be reduced, progressive edema and strangulation may result. Other complications include severe bleeding, thrombosis, infarction, gangrene, sepsis, and hepatic abscess formation. Both strangulation and thrombosis are extremely painful and are accompanied by significant edema that must be treated before surgical intervention. Ulceration of the overlying mucosa may also occur. Incarcerated hemorrhoids are quite painful, may become infected, develop necrosis, and may be associated with urinary retention.2

Most treatment is local and nonsurgical unless a complication such as acute thrombosis or gangrene is present. Conservative therapy is suggested for mild to moderate symptomatic patients with grade 1 to grade 3 hemorrhoids. Manual reduction of an uncomplicated, prolapsed internal hemorrhoid in a patient with minimal symptoms, along with warm sitz baths (decreasing sphincter pressures) for at least 15 minutes three times a day and after each bowel movement are the most effective way to relieve pain. After the bath, the anus must be dried gently but thoroughly to avoid maceration of the perianal skin. Topical analgesics and steroid-containing ointments may provide relief. The patient should not sit on the commode for a prolonged period. Bulk laxatives, such as psyllium seed compounds, or other stool softeners should be used after the acute phase is treated. Avoid the use of laxatives causing liquid stool, because cryptitis and anal sepsis can result. The addition of bran or other forms of roughage to the patient's diet should help to prevent future problems.

As a rule, internal hemorrhoids will bleed, and treatment most often involves conservative observation with the addition of stool softeners and a high-fiber diet. Obtain surgical consultation in the ED for grade 4 incarcerated internal hemorrhoids.

External hemorrhoidal hematoma formation is usually self-limiting, with resolution in 1 week. Therapy for thrombosed external hemorrhoids depends on the severity of symptoms. If the thrombosis has been present >48 hours, the swelling has started to shrink, is not tense, and the pain is tolerable, the patient may be treated with sitz baths and bulk laxatives. Suppositories, which are placed proximal to the anorectal ring, are of no help. If, on the other hand, the thrombosis is acute, has lasted <48 hours, and is extremely painful, significant relief can be provided by clot excision. Excision should not be performed in the ED on immunocompromised patients, children, pregnant women, patients with portal hypertension, and those who are anticoagulated or have a coagulopathy.

ith the patient in side-lying or prone position, applying tape to each buttocks with force directed laterally is sometimes helpful to expose the thrombosed hemorrhoids if an assistant is not available. The area of the overlying skin to be incised is infiltrated with a local anesthetic such as bupivacaine (Marcaine®), 0.5%, with epinephrine (1:200,000) and bicarbonate buffering using a 30-gauge needle.2

While applying gentle traction to the skin adjacent to the thrombosed hemorrhoid, make a linear or elliptical incision distal to the anal verge in the overlying skin to expose the thrombosis. Remove the clot through the incision site. Because multiloculated clots can be present, the technique of unroofing a thrombosed hemorrhoid with an elliptical incision and removing the overlying skin gives far better results than the simple incision and evacuation of a clot

Control bleeding by tucking the corner of a small piece of gauze into the wound and leaving it in place for a few hours. A small pressure dressing may be applied external to the gauze and removed when the patient takes the first sitz bath 6 to 12 hours after the drainage procedure. Narcotics may be prescribed, but they cause constipation and may produce more problems. Complications, such as continued bleeding, recurrence, infection, fistula, and abscess formation, may occur, and follow-up should be provided in 24 to 48 hours. Referral for definitive hemorrhoidectomy is also prudent. Emergent surgical consultation and intervention for internal hemorrhoids is indicated for: continued and severe bleeding, incarceration and/or strangulation (grade 4 hemorrhoids), and intractable pain. In general, for less urgent internal hemorrhoids, surgical referral is recommended. A variety of procedures (sclerosing injections, rubber-band ligation, photocoagulation, cryotherapy, electrocautery, laser treatments, staple repair, or excision) are available

Cryptitis

Diagnosis

Pain and Bleeding

1. external hemorrhoids
   1. swelling
   2. looks like skin if not thrombosed
   3. 12,7,9 o'clock
2. anal fissure
   1. no swelling
   2. off midline = CA, HIV, TB, Crohn's
3. prolapsed internal

Pain, No Bleeding

1. swelling
   1. abscess
      1. perirectal
      2. ischiorectal
      3. intersphincteric
      4. supralevator
   2. pilonidal (drain off midline)
   3. fistula (2/2 chronic abscess; don't probe)
   4. hidradenitis suppurativa
2. no swelling
   1. proctalgia fugax
      1. episodic pain (women, pts < 45yo)
   2. incontinence
      1. urgency

Bleeding, No Pain

1. CA
2. internal hemorrhoids

Painless Swelling

1. itch --> condyloma acuminata (warts 2/2 HPV)
2. no itch --> procidentia (rectal prolaps; peds - think CF, malnutrion)

Itching

1. discharge --> proctitis (inflamm changes of rectum within 15cm of dentate line; GC/chlamy, HSV)
2. no discharge --> pruritis ani (pinworms)

External Hemorroid Excision

<48 hrs

All pts presenting with anorectal complaints should be considered for HIV testing

Source

Donaldson; adapted from Coates