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| ==Anal Tags== | | ==Specific Disorder== |
| *Minor projections of skin at anal verge
| | #[[Anal Tags]] |
| *Sometimes represent residuals of prior hemorrhoids
| | #[[Hemorrhoids]] |
| *Usually asymptomatic
| | #[[Cryptitis]] |
| **Inflammation may cause itching and pain
| | #[[Anal Fissure]] |
| *Skin tags covering anal crypts, fistulas, and fissures are "sentinel tags"
| | #[[Anal Fistula]] |
| **Surgical referral for excision and/or biopsy is warranted
| | #[[Anorectal Abscess]] |
| *Inflammatory bowel disease may be associated with skin tag formation
| | #[[Proctitis]] |
| | #[[Rectal Prolapse]] |
| | #[[Rectal Foreign Body]] |
| | #[[Pruritus Ani]] |
| | #[[Pilonidal Cyst]] |
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| ==Hemorrhoids== | | ==Algorithmic Approach== |
| *See [[Hemorrhoids]]
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| ==Cryptitis==
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| ===Background===
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| *Anal crypts are mucosal pockets that lie between the columns of Morgagnia
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| **Formed by the puckering action of the sphincter muscles
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| *Superficial trauma (diarrhea, trauma from hard stool) --> breakdown in mucosal lining
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| **Bacteria enter, inflammation extends into lymphoid tissue of the crypts / anal glands
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| ***Can lead to fissure in ano, fistula in ano, perirectal abscesses
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| ===Clinical Features===
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| *Anal pain
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| *Sphincter spasm
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| *Itching w/ or w/o bleeding
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| *Hypertrophied papillae
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| ===Diagnosis===
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| *Anoscopy shows inflammation, erythema, and pus
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| ===Treatment===
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| #Bulk laxatives, additional roughage, sitz baths (treats underlying cause)
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| #Surgical referral is indicated when:
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| ##Infection has progressed and the crypt will not drain adequately on its own
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| ##Surgical treatment is excision
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| ==Anal Fissures==
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| ===Background===
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| *Superficial linear tear of anal canal from at/below dentate line to anal verge
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| **May be due to passage of hard stool, frequent diarrhea, or abuse
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| *Most common cause of painful rectal bleeding
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| *In >90% of cases anal fissures occur in the midline posteriorly
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| **Nonhealing fissure or one not located in midline suggests alternative dx
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| ===Clinical Findings===
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| *Acute sharp, cutting pain most severe during and immediately after bowel movement
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| **Subsides between bowel movements (distinguishes fissure from other anorectal disease)
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| *Bright red bleeding, small in quantity (usually noticed only on toilet paper)
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| ===Diagnosis===
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| *Having pt bear down may make fissure more noticable
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| *Sentinel pile, located at distal end of fissure, along w/ deep ulcer suggests chronicity
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| **Often misdiagnosed as an external hemorrhoid
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| ===DDX===
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| #Crohn disease
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| ##Often painless
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| #Squamous cell carcinoma of anus
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| #Adenocarcinoma of rectum invading the anal canal
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| #Syphilitic fissure
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| #GC/Chlam
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| ===Treatment===
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| #Hot sitz baths 15 min TID-QID and after each bowel movement
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| ##Provides symptomatic relief and relieves anal sphincter spasm
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| #High-fiber diet
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| ##Prevents stricture formation by providing a bulky stool
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| #Local analgesic ointments with hydrocortisone
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| #Meticulous anal hygiene is imperative; after defecation anus must be cleaned thoroughly
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| #Surgical referral indicated if healing does not occur in a reasonable amount of time
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| ===Complications===
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| #Perianal abscess
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| #Intersphincteric abscess
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| ==Fistula In Ano==
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| ===Background===
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| *Inflammatory tract originating from infected anal gland connecting anal canal w/ skin
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| **May be intersphincteric, suprasphincteric, transsphincteric, or extrasphincteric
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| *Goodsall's Rule
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| **Draw imaginary line horizontally through the anal canal
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| ***If external opening is anterior to this line fistula runs directly into the canal
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| ***If external opening is posterior to this line fistula curves to post midline of canal
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| *Causes:
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| **Perianal/ischiorectal abscess, Crohn, UC, malignancies, STI, fissures, FBs, TB
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| ===Clinical Features===
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| *Fistulous tract open: Persistent, painless, blood-stained, mucous, malodorous discharge
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| *Fistulous tract blocked: Bouts of inflammation that are relieved by spontaneous rupture
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| *Abscess
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| **Throbbing pain that is constant and worse w/ sitting, moving, defecation
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| **May be only sign of fistula
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| *Fistulous opening
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| **Adjacent to anal margin suggests superficial connection (e.g. intersphincteric region)
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| **Distant from anal margin suggests deeper, more superior abscess
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| ===Diagnosis===
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| *Endocavitary US w/ 3% hydrogen peroxide for definitive diagnosis
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| ===Management===
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| #Ill-appearing
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| ##Analgesia
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| ##IVF
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| ##Anbx
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| ##Urgent surgical consultation
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| #Well-appearing
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| ##Abx
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| ###Ciprofloxacin 750mg PO BID AND metronidazole 500mg QID x7d
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| ##Outpt sx referral
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| ###Improperly excised fistulas may result in permanent fecal incontinence
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| ==Anorectal Abscesses==
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| ===Background===
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| *Usually begin via blocked anal gland (leads to infection/abscess formation)
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| **Can progress to involve any of the potential spaces:
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| ***Perianal
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| ****Most common
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| ****Located close to anal verge, posterior midline, superficial tender mass
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| ***Ischiorectal
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| ****2nd most common
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| ****Larger, indurated, well-circumscribed, located laterally on medial aspect of buttocks
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| ***Intersphincteric, deep postanal, pelvirectal
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| ****Rectal pain, skin signs may not be present
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| ****Constitutional symptoms often present
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| ===Clinical Features===
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| *Perirectal abscesses often accompanied by fever, leukocytosis
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| **May only be paplpated via digital rectal exam
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| *Tender inguinal adenopathy may be only clue to deeper abscesses
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| ==Diagnosis==
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| *CT or US can be useful to define deep abscesses (esp w/ pain out of proportion to exam)
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| ===Treatment===
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| *All perirectal abscesses should be drained in the OR
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| *Isolated perianal abscess is only type of anorectal abscess that should be treated in ED
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| **Consider either linear incision w/ packing or cruciate incision w/o packing
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| **Frequent sitz baths
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| **Abx
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| ***Only indicated for:
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| ****Elderly
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| ****Systemic signs (fever, leukocytosis)
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| ****Valvular heart disease
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| ****Cellulitis
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| ****Immunosuppression
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| ***Piperacillin-tazobactam 3.37gm IV q6hr OR ampicillin-sulbactam 3gm IV q6hr
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| ==Proctitis==
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| ===Background===
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| *Inflammation of the rectal mucosa
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| *Causes
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| **Radiation tx
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| **Autoimmune
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| **Vasculitis
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| **Ischemia
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| **Infectious (STI and enteric organisms)
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| ===Types===
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| ====Condylomata Acuminata====
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| *Also known as anal warts
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| *Vary from dot-like to large papilliform, cauliflower-like lesions
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| *Pain, itching, bleeding, anal discharge
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| *Perianal involvement often a/w vulvovaginal and penile lesions
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| *Refer to specialist for laser ablation or cryotherapy
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| ====Gonorrhea====
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| *Symptoms vary from none to severe rectal pain w/ yellow, bloody discharge
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| *Unlike nonvenereal cryptitis, infection is not confined to the posterior crypt
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| *Diagnosis made by Gram stain and culture
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| *Also consider dissemination to heart, liver, CNS, and joints
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| *Treatment: CTX 125mg IM + azithromycin 2gm PO single dose
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| ====Chlamydia====
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| *Infection d/t direct anorectal infection or via vaginal seeding to perirectal lymphatics
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| *Symptoms range from asymptomatic to anal pruritus, pain, purulent discharge
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| *Lymphogranulomatous variety
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| **Acutely painful anal ulcerations a/w unilateral lymph node enlargement
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| **Fever and flulike symptoms
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| **May result in rectal scarring, stricturing, perirectal abscesses, chronic fistulas
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| *Treatment
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| **Non-LGV: Azithromycin 2gm PO x1 or doxycycline 100mg PO BID x7d
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| **LGV: Doxycyline 100mg PO BID x21d
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| ====Syphilis====
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| *Primary
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| **Anal chancres are often painful
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| ***May be misdiagnosed as simple fissure
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| ****Symmetric lesion on opposite side of anal margin is distinguishing feature
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| ****Inguinal adenopathy is often present
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| *Secondary
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| **Condylomata lata (flatter and firmer than condylomata acuminata)
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| *Treatment
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| **Penicillin G 2.4mil IM x1
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| ====Herpes====
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| *Itching and soreness in perianal area progressing to severe anorectal pain
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| **Accompanied by flulike illness, inguinal adenopathy
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| *Early lesions are small, discrete vesicles on erythematous base
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| **Vesicles then enlarge, coalesce, and rupture, forming exquisitely tender ulcers
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| *Treatment
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| **Acyclovir 400mg PO TID x10d for initial episode; 800mg TID x2d for recurrent episodes
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| ==Rectal Prolapse==
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| ===Background===
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| *Circumferential protrusion of part or all layers of the rectum through the anal canal
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| *Risk factors
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| **Extremes of age
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| **Chronic constipation
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| *3 types:
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| **1. Prolapse involving the rectal mucosa only
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| ***Rarely protrudes more than 2 to 3 cm beyond the anal verge
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| ***Anal edges appear everted
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| ***Radially directed folds
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| ***No sulcus between extruded mucosa and anus
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| ***Frequently associated w/ 3rd and 4th degree hemorrhoids
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| **2. Prolapse involving all layers of the rectum
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| ***May protrude up to 15cm
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| ***Anus appears normal
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| ***Prolapse appears as red, ball-like mass w/ concentric folds
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| ***Sulcus may be palpated between the extruded bowel and anus
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| **3. Intussusception of upper rectum into and through the lower rectum
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| ===Clinical Features===
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| *Irritation to mucosa caused by recurrent prolapse results in mucous d/c and bleeding
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| *Associated anal sphincter weakness may result in fecal incontinence
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| *In children, parents often mistakenly believe that the prolapsed mucosa is hemorrhoids
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| ===Treatment===
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| #Children
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| ##Reduce via slow steady pressure applied to prolapsed segment
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| ##Prevent constipation
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| ##Refer for evaluation of underlying conidtion (CF, pelvic floor weakness, diarrhea)
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| #Adults
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| ##Reduction
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| ###Thumbs over luminal surfaces medially and fingers grasp outer walls laterally
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| ####Apply continuous pressure first w/ thumbs followed by internal rolling of fingers
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| ####After reduction perform digital rectal exam to evaluate for rectal mass/polyp
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| ##Difficult reduction
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| ###Prolonged prolapse may lead to rectal wall edema
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| ###Can place granulated sugar (not synthetic sweeteners) over prolapsed rectum
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| ####Wait 15min for edema to subside and re-attempt
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| ##Failed reduction
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| ###Obtain emergent surgical consultation
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| ##Refer all pts for colonoscopy and to a surgeon for consideration of repair
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| ==Rectal Foreign Bodies==
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| ===Background===
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| #Most are in the rectal ampulla and therefore palpable on digital examination
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| ##Make sure that object is not sharp before exam
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| #Injuries may consist of hematoma, lacerations (w/ potential perforation)
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| ===Diagnosis===
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| ##Abd xray
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| ###Demonstrate position, shapes, and number of foreign bodies
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| ###Demonstrates possible presence of free air (perforation of rectum or colon)
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| ####Perf of rectum below peritoneal reflection shows extraperitoneal air along psoas ####Perf above peritoneal reflection reveals intraperitoneal free air under diaphragm
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| ##CT
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| ##Useful when foreign body is radiolucent and for detection of free air
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| ===Treatment===
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| #ED removal suitable for non-sharp objects that are in the distal rectum
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| ##Procedure:
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| ###Anal lubrication
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| ###Pt should bear down as object is extracted w/ obstetric forceps
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| ###Observe for at least 12hr to ensure that object did not perforate the rectum
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| #Large bulbar objects create a vacuum-like effect
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| ##Break vacuum by passing foley behind object, inject air and pull foley out (balloon up)
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| #Surgical consultation indicated if:
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| ##Removal could injure the sphincter
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| ##ED attempts fail
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| ##Risk of ischemia, perforation, or if excess manipulation required (risk of bacteremia)
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| ==Pruritus Ani==
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| ===Causes===
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| #Anorectal disease
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| #Poor hygiene
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| #Local infection
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| ##Pinworms, strep
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| #Local irritants
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| #Dermatologic conditions
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| #Systemic illness
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| #Psychogenic factors
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| ===Associations===
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| #Fissures
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| #Fistulas
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| #Hemorrhoids
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| #Prolapse
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| ===Clinical Features===
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| *Skin appears normal with early, mild cases
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| *Acute, severe exacerbations a/w reddened, edematous, excoriated, skin
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| ===Treatment===
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| #Treat underlying cause
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| #To avoid scratching at night pt can wear gloves at bedtime
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| #Sitz baths 15min TID
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| #Zinc oxide can provide protective covering for the skin and may enhance healing
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| ==Pilonidal Cyst==
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| #
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| ==Diagnosis==
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| ===Pain and Bleeding=== | | ===Pain and Bleeding=== |
| #external hemorrhoids | | #External hemorrhoid |
| ##swelling | | #Prolapsed internal hemorrhoid |
| ##looks like skin if not thrombosed | | #Anal fissure |
| ##12,7,9 o'clock
| | ##Off midline = cancer, HIV, TB, Crohn's |
| #anal fissure
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| ##no swelling | |
| ##off midline = CA, HIV, TB, Crohn's
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| #prolapsed internal
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| ===Pain, No Bleeding=== | | ===Pain, No Bleeding=== |
| #swelling | | #Swelling |
| ##abscess | | ##Abscess |
| ###perirectal | | ###Perirectal |
| ###ischiorectal | | ###Ischiorectal |
| ###intersphincteric | | ###Intersphincteric |
| ###supralevator | | ###Supralevator |
| ##pilonidal (drain off midline) | | ##Pilonidal (drain off midline) |
| ##fistula (2/2 chronic abscess; don't probe) | | ##Fistula (2/2 chronic abscess; don't probe) |
| ##hidradenitis suppurativa | | ##Hidradenitis suppurativa |
| #no swelling | | #No swelling |
| ##proctalgia fugax | | ##Proctalgia fugax |
| ###episodic pain (women, pts < 45yo) | | ###Cramp of pubococcygeus or levator ani muscles |
| ##incontinence | | ###Episodic pain (women, pts < 45yo) |
| ###urgency | | ###Incontinence |
| | ###Urgency |
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| ===Bleeding, No Pain=== | | ===Bleeding, No Pain=== |
| #CA | | #Cancer |
| #internal hemorrhoids | | #Internal hemorrhoid |
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| ===Painless Swelling=== | | ===Painless Swelling=== |
| #itch --> condyloma acuminata (warts 2/2 HPV) | | #Itch: Condyloma acuminata (warts 2/2 HPV) |
| #no itch --> procidentia (rectal prolaps; peds - think CF, malnutrion) | | #No itch: Rectal prolapse |
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| ===Itching=== | | ===Itching=== |
| #discharge --> proctitis (inflamm changes of rectum within 15cm of dentate line; GC/chlamy, HSV) | | #Discharge: Proctitis |
| #no discharge --> pruritis ani (pinworms) | | #No discharge: Pruritis ani |
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| ==External Hemorroid Excision==
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| <48 hrs
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| All pts presenting with anorectal complaints should be considered for HIV testing
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| ==Source== | | ==Source== |
