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

Treatment

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

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, has portal HTN, coagulopathic
      2. Thrombosis is acute (<48 hr)
      3. Extremely painful
      4. See External Hemorrhoid Excision

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