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

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

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

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