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

• See Hemorrhoids

Cryptitis

Background

• Anal crypts are mucosal pockets that lie between the columns of Morgagnia
  • Formed by the puckering action of the sphincter muscles
• Superficial trauma (diarrhea, trauma from hard stool) --> breakdown in mucosal lining
  • Bacteria enter, inflammation extends into lymphoid tissue of the crypts / anal glands
    • Can lead to fissure in ano, fistula in ano, perirectal abscesses

Clinical Features

• Anal pain
• Sphincter spasm
• Itching w/ or w/o bleeding
• Hypertrophied papillae

Diagnosis

• Anoscopy shows inflammation, erythema, and pus

Treatment

1. Bulk laxatives, additional roughage, sitz baths (treats underlying cause)
2. Surgical referral is indicated when:
   1. Infection has progressed and the crypt will not drain adequately on its own
   2. Surgical treatment is excision

Anal Fissures

Background

• Superficial linear tear of anal canal from at/below dentate line to anal verge
  • May be due to passage of hard stool, frequent diarrhea, or abuse
• Most common cause of painful rectal bleeding
• In >90% of cases anal fissures occur in the midline posteriorly
  • Nonhealing fissure or one not located in midline suggests alternative dx

Clinical Findings

• Acute sharp, cutting pain most severe during and immediately after bowel movement
  • Subsides between bowel movements (distinguishes fissure from other anorectal disease)
• Bright red bleeding, small in quantity (usually noticed only on toilet paper)

Diagnosis

• Having pt bear down may make fissure more noticable
• Sentinel pile, located at distal end of fissure, along w/ deep ulcer suggests chronicity
  • Often misdiagnosed as an external hemorrhoid

DDX

1. Crohn disease
   1. Often painless
2. Squamous cell carcinoma of anus
3. Adenocarcinoma of rectum invading the anal canal
4. Syphilitic fissure
5. GC/Chlam

Treatment

1. Hot sitz baths 15 min TID-QID and after each bowel movement
   1. Provides symptomatic relief and relieves anal sphincter spasm
2. High-fiber diet
   1. Prevents stricture formation by providing a bulky stool
3. Local analgesic ointments with hydrocortisone
4. Meticulous anal hygiene is imperative; after defecation anus must be cleaned thoroughly
5. Surgical referral indicated if healing does not occur in a reasonable amount of time

Complications

1. Perianal abscess
2. Intersphincteric abscess

Fistula In Ano

Background

• Inflammatory tract originating from infected anal gland connecting anal canal w/ skin
  • May be intersphincteric, suprasphincteric, transsphincteric, or extrasphincteric
• Goodsall's Rule
  • Draw imaginary line horizontally through the anal canal
    • If external opening is anterior to this line fistula runs directly into the canal
    • If external opening is posterior to this line fistula curves to post midline of canal
• Causes:
  • Perianal/ischiorectal abscess, Crohn, UC, malignancies, STI, fissures, FBs, TB

Clinical Features

• Fistulous tract open: Persistent, painless, blood-stained, mucous, malodorous discharge
• Fistulous tract blocked: Bouts of inflammation that are relieved by spontaneous rupture
• Abscess
  • Throbbing pain that is constant and worse w/ sitting, moving, defecation
  • May be only sign of fistula
• Fistulous opening
  • Adjacent to anal margin suggests superficial connection (e.g. intersphincteric region)
  • Distant from anal margin suggests deeper, more superior abscess

Diagnosis

• Endocavitary US w/ 3% hydrogen peroxide for definitive diagnosis

Management

1. Ill-appearing
   1. Analgesia
   2. IVF
   3. Anbx
   4. Urgent surgical consultation
2. Well-appearing
   1. Abx
      1. Ciprofloxacin 750mg PO BID AND metronidazole 500mg QID x7d
   2. Outpt sx referral
      1. Improperly excised fistulas may result in permanent fecal incontinence

Anorectal Abscesses

Background

• Usually begin via blocked anal gland (leads to infection/abscess formation)
  • Can progress to involve any of the potential spaces:
    • Perianal
      • Most common
      • Located close to anal verge, posterior midline, superficial tender mass
    • Ischiorectal
      • 2nd most common
      • Larger, indurated, well-circumscribed, located laterally on medial aspect of buttocks
    • Intersphincteric, deep postanal, pelvirectal
      • Rectal pain, skin signs may not be present
      • Constitutional symptoms often present

Clinical Features

• Perirectal abscesses often accompanied by fever, leukocytosis
  • May only be paplpated via digital rectal exam
• Tender inguinal adenopathy may be only clue to deeper abscesses

Diagnosis

• CT or US can be useful to define deep abscesses (esp w/ pain out of proportion to exam)

Treatment

• All perirectal abscesses should be drained in the OR
• Isolated perianal abscess is only type of anorectal abscess that should be treated in ED
  • Consider either linear incision w/ packing or cruciate incision w/o packing
  • Frequent sitz baths
  • Abx
    • Only indicated for:
      • Elderly
      • Systemic signs (fever, leukocytosis)
      • Valvular heart disease
      • Cellulitis
      • Immunosuppression
    • Piperacillin-tazobactam 3.37gm IV q6hr OR ampicillin-sulbactam 3gm IV q6hr

Proctitis

Background

• Inflammation of the rectal mucosa
• Causes
  • Radiation tx
  • Autoimmune
  • Vasculitis
  • Ischemia
  • Infectious (STI and enteric organisms)

Types

Condylomata Acuminata

• Also known as anal warts
• Vary from dot-like to large papilliform, cauliflower-like lesions
• Pain, itching, bleeding, anal discharge
• Perianal involvement often a/w vulvovaginal and penile lesions
• Refer to specialist for laser ablation or cryotherapy

Gonorrhea

• Symptoms vary from none to severe rectal pain w/ yellow, bloody discharge
• Unlike nonvenereal cryptitis, infection is not confined to the posterior crypt
• Diagnosis made by Gram stain and culture
• Also consider dissemination to heart, liver, CNS, and joints
• Treatment: CTX 125mg IM + azithromycin 2gm PO single dose

Chlamydia

• Infection d/t direct anorectal infection or via vaginal seeding to perirectal lymphatics
• Symptoms range from asymptomatic to anal pruritus, pain, purulent discharge
• Lymphogranulomatous variety
  • Acutely painful anal ulcerations a/w unilateral lymph node enlargement
  • Fever and flulike symptoms
  • May result in rectal scarring, stricturing, perirectal abscesses, chronic fistulas
• Treatment
  • Non-LGV: Azithromycin 2gm PO x1 or doxycycline 100mg PO BID x7d
  • LGV: Doxycyline 100mg PO BID x21d

Syphilis

• Primary
  • Anal chancres are often painful
    • May be misdiagnosed as simple fissure
      • Symmetric lesion on opposite side of anal margin is distinguishing feature
      • Inguinal adenopathy is often present
• Secondary
  • Condylomata lata (flatter and firmer than condylomata acuminata)
• Treatment
  • Penicillin G 2.4mil IM x1

Herpes

• Itching and soreness in perianal area progressing to severe anorectal pain
  • Accompanied by flulike illness, inguinal adenopathy
• Early lesions are small, discrete vesicles on erythematous base
  • Vesicles then enlarge, coalesce, and rupture, forming exquisitely tender ulcers
• Treatment
  • Acyclovir 400mg PO TID x10d for initial episode; 800mg TID x2d for recurrent episodes

Rectal Prolapse

Background

• Circumferential protrusion of part or all layers of the rectum through the anal canal
• Risk factors
  • Extremes of age
  • Chronic constipation
• 3 types:
  • 1. Prolapse involving the rectal mucosa only
    • Rarely protrudes more than 2 to 3 cm beyond the anal verge
    • Anal edges appear everted
    • Radially directed folds
    • No sulcus between extruded mucosa and anus
    • Frequently associated w/ 3rd and 4th degree hemorrhoids
  • 2. Prolapse involving all layers of the rectum
    • May protrude up to 15cm
    • Anus appears normal
    • Prolapse appears as red, ball-like mass w/ concentric folds
    • Sulcus may be palpated between the extruded bowel and anus
  • 3. Intussusception of upper rectum into and through the lower rectum

Clinical Features

• Irritation to mucosa caused by recurrent prolapse results in mucous d/c and bleeding
• Associated anal sphincter weakness may result in fecal incontinence
• In children, parents often mistakenly believe that the prolapsed mucosa is hemorrhoids

Treatment

1. Children
   1. Reduce via slow steady pressure applied to prolapsed segment
   2. Prevent constipation
   3. Refer for evaluation of underlying conidtion (CF, pelvic floor weakness, diarrhea)
2. Adults
   1. Reduction
      1. Thumbs over luminal surfaces medially and fingers grasp outer walls laterally
         1. Apply continuous pressure first w/ thumbs followed by internal rolling of fingers
         2. After reduction perform digital rectal exam to evaluate for rectal mass/polyp
   2. Difficult reduction
      1. Prolonged prolapse may lead to rectal wall edema
      2. Can place granulated sugar (not synthetic sweeteners) over prolapsed rectum
         1. Wait 15min for edema to subside and re-attempt
   3. Failed reduction
      1. Obtain emergent surgical consultation
   4. Refer all pts for colonoscopy and to a surgeon for consideration of repair

Rectal Foreign Bodies

Background

1. Most are in the rectal ampulla and therefore palpable on digital examination
   1. Make sure that object is not sharp before exam
2. Injuries may consist of hematoma, lacerations (w/ potential perforation)

Diagnosis

1. 1. Abd xray
      1. Demonstrate position, shapes, and number of foreign bodies
      2. Demonstrates possible presence of free air (perforation of rectum or colon)
         1. Perf of rectum below peritoneal reflection shows extraperitoneal air along psoas ####Perf above peritoneal reflection reveals intraperitoneal free air under diaphragm
   2. CT
   3. Useful when foreign body is radiolucent and for detection of free air

Treatment

1. ED removal suitable for non-sharp objects that are in the distal rectum
   1. Procedure:
      1. Anal lubrication
      2. Pt should bear down as object is extracted w/ obstetric forceps
      3. Observe for at least 12hr to ensure that object did not perforate the rectum
2. Large bulbar objects create a vacuum-like effect
   1. Break vacuum by passing foley behind object, inject air and pull foley out (balloon up)
3. Surgical consultation indicated if:
   1. Removal could injure the sphincter
   2. ED attempts fail
   3. Risk of ischemia, perforation, or if excess manipulation required (risk of bacteremia)

Pruritus Ani

Causes

1. Anorectal disease
2. Poor hygiene
3. Local infection
   1. Pinworms, strep
4. Local irritants
5. Dermatologic conditions
6. Systemic illness
7. Psychogenic factors

Associations

1. Fissures
2. Fistulas
3. Hemorrhoids
4. Prolapse

Clinical Features

• Skin appears normal with early, mild cases
• Acute, severe exacerbations a/w reddened, edematous, excoriated, skin

Treatment

1. Treat underlying cause
2. To avoid scratching at night pt can wear gloves at bedtime
3. Sitz baths 15min TID
4. Zinc oxide can provide protective covering for the skin and may enhance healing

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