Anorectal disorders: Difference between revisions
 
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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"
**Surgical referral for excision and/or biopsy is warranted
*Inflammatory bowel disease may be associated with skin tag formation


==Hemorrhoids==
==Clinical Features==
===Background===
==Visual Diagnosis==
*Occur when internal/external hemorrhoidal plexuses become engorged, prolapse, thrombosed
<gallery mode="packed">
*Bleeding
File:PMC2653786 ijmsv06p0077g13.png|[[Anal tags]]
**Usually limited (surface of stool, on toilet tissue, at end of defecation)  
File:DSCB4096(anal worms or just toilet paper remainders@).jpg|[[Enterobius]] (pinworms)
***Passage of blood clots requires that colonic lesions are ruled-out
File:M 44 anus 22.jpg|[[External hemorrhoid]]
*Risk Factors
File:Anal fissure 2.jpg|[[Anal fissure]]
**Constipation and straining at stool
File:SOA-Condylomata-acuminata-around-anus.jpg|[[Anal warts]]
**Frequent diarrhea
File:Perianalabscess.jpg|[[Perianal abscess]]
**Older age
File:Hemrrhoids 05.jpg|[[Internal hemorrhoid]] with prolapse
**IBD
File:Pilonidal abscess.jpg|[[Pilonidal cyst]]
File:Full thickness rectal prolapse & mucosal prolapse..jpg|[[Rectal prolapse]]
</gallery>


===Types===
==Differential Diagnosis==
====Internal====
{{Anorectal DDX}}
*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
=====Treatment=====
#Conservative Tx
##Indicated for mild to moderate symptomatic pts w/ grade 1 to grade 3 hemorrhoids
##Stool softeners (psyllium), high-fiber diet, topical analgesics
##Avoid laxatives causing liquid stool (can lead to cryptitis and anal sepsis)
##Sitz bath 15min TID and after each bowel movement (decreases sphincter pressure)
##Outpt surgical referral
##Prolapsed hemorrhoid in pt w/ minimal symptoms can be manually reduced
#Emergent surgical consultation and intervention is indicated for:
##Continued and severe bleeding
##Incarceration and/or strangulation (grade 4 hemorrhoids)
##Intractable pain


====External====
==Evaluation==
*Occur distal to dentate line
===Algorithmic Diagnostic Approach===
*Can be seen at external inspection
*Pain
**More prominent with Valsalva
**Bleeding
*Thrombosed hemorrhoids (bluish-purple discoloration) cause painful defecation
***External [[hemorrhoid]]
**Non-thrombosed hemorrhoids are usually painless
***Prolapsed internal [[hemorrhoid]]
***If pt c/o pain but hemorrhoids are not thrombosed suspect:
***[[Anal Fissure]]
****Perianal/intersphincteric abscesses
****Off midline = cancer, [[HIV]], [[TB]], [[Crohn's]]
****Anal fissures
**No bleeding
*Prolapse
***Swelling
**Requires periodic reduction by the pt
****[[Anorectal abscess]]
=====Treatment=====
*****Perirectal
#Usually self-limiting w/ resolution in 1 week
*****Ischiorectal
#Thrombosed:
*****Intersphincteric
##Consider sitz baths and bulk laxatives if:
*****Supralevator
###Thrombosis has been present >48 hr
****[[Pilonidal cyst]]
###Swelling has started to shrink
****[[Anal fistula]]
###Pain is tolerable
****Hidradenitis suppurativa
##Consider excision if:
***No swelling
###Pt is not immunocompromised, child, pregnant woman, has portal HTN, coagulopathic
****[[Proctalgia fugax]]
###Thrombosis is acute (<48 hr)
*No pain
###Extremely painful
**Bleeding
###See [[External Hemorrhoid Excision]]
***Cancer
***Internal [[hemorrhoid]]
**Swelling
***Itch: [[Condyloma acuminata]]
***No itch: [[Rectal prolapse]]
**Itching
***Discharge: [[Proctitis]]
***No discharge: [[Pruritus Ani]]


==Cryptitis==




==Management==


==Disposition==


==See Also==
*[[Diagnoses by Body Part (Main)]]


==External Links==


==References==


 
==References==
 
<references/>
 
 
 
==Diagnosis==
===Pain and Bleeding===
#external hemorrhoids
##swelling
##looks like skin if not thrombosed
##12,7,9 o'clock
#anal fissure
##no swelling
##off midline = CA, HIV, TB, Crohn's
#prolapsed internal
 
===Pain, No Bleeding===
#swelling
##abscess
###perirectal
###ischiorectal
###intersphincteric
###supralevator
##pilonidal (drain off midline)
##fistula (2/2 chronic abscess; don't probe)
##hidradenitis suppurativa
#no swelling
##proctalgia fugax
###episodic pain (women, pts < 45yo)
##incontinence
###urgency
 
===Bleeding, No Pain===
#CA
#internal hemorrhoids
 
===Painless Swelling===
#itch --> condyloma acuminata (warts 2/2 HPV)
#no itch --> procidentia (rectal prolaps; peds - think CF, malnutrion)
 
===Itching===
#discharge --> proctitis (inflamm changes of rectum within 15cm of dentate line; GC/chlamy, HSV)
#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


[[Category:GI]]
[[Category:GI]]
[[Category:Symptoms]]

Latest revision as of 15:56, 23 April 2025

Background

Anatomy of the anus and rectum.
Anatomy of the anus.
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).
Coronal section of rectum and the anal canal.

Clinical Features

Visual Diagnosis

Differential Diagnosis

Anorectal Disorders

Non-GI Look-a-Likes

Evaluation

Algorithmic Diagnostic Approach


Management

Disposition

See Also

External Links

References

References

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