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

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