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

Background

• Occur when internal/external hemorrhoidal plexuses become engorged, prolapse, thrombosed
• Bleeding
  • Usually limited (surface of stool, on toilet tissue, at end of defecation)
    • Passage of blood clots requires that colonic lesions are ruled-out
• Risk Factors
  • Constipation and straining at stool
  • Frequent diarrhea
  • Older age
  • IBD

Types

Internal

• Occur proximal to dentate line
• Constant in their location: 2-, 5-, and 9-o'clock positions (when pt viewed prone)
• Not readily palpable; best visualized through anoscope
  • May be palpable when prolapsed or thrombosed
• Painless bleeding
  • Only painful when nonreducible, prolapsed hemorrhoids strangulate OR thrombose
    • Can lead to infection/necrosis
• Prolapse
  • When prolapse occurs may develop mucous discharge and pruritus ani
    • If prolapse cannot be reduced progressive edema and strangulation may result
    • Other complications: severe bleeding, thrombosis, infarction, gangrene, sepsis

Classification

• Grade I: Luminal protrusion above dentate line; no prolapse; 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

External

• Occur distal to dentate line
• Can be seen at external inspection
  • More prominent with Valsalva
• Thrombosed hemorrhoids (bluish-purple discoloration) cause painful defecation
  • Non-thrombosed hemorrhoids are usually painless
    • If pt c/o pain but hemorrhoids are not thrombosed suspect:
      • Perianal/intersphincteric abscesses
      • Anal fissures
• Prolapse
  • Requires periodic reduction by the pt

Treatment

1. Usually self-limiting w/ resolution in 1 week
2. Thrombosed
   1. Consider sitz baths and bulk laxatives if:
      1. Thrombosis has been present >48 hr
      2. Swelling has started to shrink
      3. Pain is tolerable
   2. Consider excision if:
      1. Pt is not immunocompromised, child, pregnant woman, portal htn, coagulopathic
      2. Thrombosis is acute (<48 hr)
      3. Extremely painful

Procedure With 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

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.

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