Anorectal Disorders

1. Anorectal Disorders Tintinalli’s Ch 88

2. Anatomy • Rectum is anatomic structure, begins at S3 vertebral body • Descends for about 13-15 cm • Opens into anal canal • Junction is dentate line • Proximal to dentate line, rectal ampulla narrows forming columns of Morgagni • Each collumn connects at dentate line forming anal crypt

3. Anatomy Cont. • Superior (internal) hermorrhoidal veins drain into portal system • Inferior (external) hermorrhoidal veins drain into IVC • PNS (S2-S4) contracts rectal wall and relaxes internal anal sphincter • SNS (L1-L3) maintains continence through rectal wall inhibition and contraction of internal anal sphincter

4. Lateral (Sims) or Knee-chest positioning Anoscope Rectal Exam

5. Anal Tags • Minor projections of skin at the anal verge and are sometimes residuals of prior hemorrhoids • Can cause itching and pain • Surgical referral for excision and biopsy

6. Hemorrhoids • Internal • Proximal to dentate line • Course along terminal branches of superior rectal artery • Constant in location  longitudinally at the right posterolateral, right anterolateral, and left lateral (2, 5, 9 o’clock) • Need anoscope for visualization

8. External Located distal to dentate line Dilatation of veins at the anal verge Seen on external inspection Exquisite sensory innervation Common causes Constipation and straining at stool Frequent diarrhea Older age Pregnancy Chronic liver dz Hemorrhoids

9. Clinical Features • Bleeding • Limited, usually on surface of stool, on toilet paper or at the end of defecation • Unthrombosed, external usually painless • If pain and not thrombosed, consider perianal abscess or anal fissure • Thrombosed bluish-purple, painful

10. Clinical features cont. • Internal • Uncomplicated  painless, bright red rectal bleeding with defecation • Nonreducible, prolapsed internal hemorrhoids may become strangulated and thrombosed • Painful, increased rectal bleeding • Incarcerated hermorrhoids • Very painful, may become necrotic, associated with urinary retention

11. Treatment • Conservative • Warm sitz baths for 15 mins TID and after each BM • Topical analgesics and steroid containing ointments may help • Stools softeners ok, but avoid laxatives • Thrombosed • Acute, <48 hours, requires clot excision • Not in ED if immunocomp, children, pregnant, portal HTN, coagulopathy

12. Excision of External Hem • Elliptical excision of thrombosed external hemorrhoid. • Unroofing of thrombosed external hemorrhoid • Evacuation of clot

13. Small pressure dressing applied after excision • Pt may take first sitz bath 6-12 hours after procedure • F/U in 24-48 hours • Complications • Bleeding, recurrence, infection, fistula, abscess

14. Surgery Required • Continued and severe bleeding • Incarceration and/or strangulation • Intractable pain • Otherwise may have outpatient surgical evaluation

15. Cryptitis • Caused by repeated bouts of diarrhea or trauma associated with large, hard stools • Causes breakdown of mucosal lining of the crypts • Bacteria enter with infection/inflammation extending to lymphoid tissue

16. Initiallyn bead-like spot of pus with no symptoms Anal pain, spasm, and itching with or without bleeding Bulk laxatives, high fiber Sitz baths Surgical referral if unable to drain on own Clinical features and Treatment

17. Anal Fissures • Superficial tear of the anal canal beginning at or below the dentate line and extending distally along the anal canal to the anal verge • MCC painful rectal bleeding • >90% occur in midline posteriorly • Consider other DDX if nonhealing or not midline • Crohns, UC, SCC of anus, adenocarcinoma of rectum, leukemia, lymphoma, STD or tuberculous ulcer

18. Caused by passage of large, hard stools or frequent diarrhea Common in children with constipation

19. Acute sharp, cutting pain Worse during and immediately after BM Pain resolves between BM Bright red bleeding usually only seen on TP Symptomatic relief Sitz baths Add bran to diet Local hydrocortisone cream If chronic, will need surgical follow up Clinical features and treatment

20. Anal Fistula • Abnormal inflammatory tract • Originates from an infected anal gland at the dentate region • May result from abscess • Associated with Crohns, UC, colonic malignancies, leukemia, STD, actinomycosis, anal fissures, foreign bodies or tuberculosis

21. Clinical features • If fistula remains open, persistent, painless, blood-stained, mucous, malodorous discharge • If blocked, bouts of inflammation with spontaneous rupture • Abscess formation throbbing pain that is worse with sitting, moving, and defecation • Fibrous cord may be palpable on exam

22. Treatment • Analgesics • IVF • Abx • Cipro 750mg BID x7d • Flagyl 500mg QID x7d • Urgent surgical consult

23. Begins with involvement of anal crypt and its gland Typically polymicrobial Can involve multiple potential spaces MCC is perianal Abscess

26. Clinical features • Early middle aged males • Initially dull, aching, or throbbing pain that becomes worse immediately before BM, lessened after BM but does persist between BM • Worse with moving or sitting • Easily palpable (perianal) • Not usually assoc with fever, leukocytosis or sepsis • Pain worsens as abscess worsens

27. All perirectal abscesses should be drained in OR Perianal may be drained in ED Abx if any systemic symptoms Unasyn or Zosyn Tetanus Treatment

28. Proctitis • Inflammation of rectal mucosa • Due to prior radiation, autoimmune dz, vasculitis, ischemia, or infectious

29. Clinical Features • Anorectal pain, itching, discharge, bleeding or lower abdominal cramping • Consider features of condylomata acuminata, Gonorrhea, Chlamydia, Syphilis and Herpes

30. Treatment • Stool softeners, sitz baths, careful anal hygiene • Empiric therapy aimed at treating gonorrhea, Chlamydia or syphilis

31. Rectal Prolapse • Circumferential protrusion of part or all layers of the rectum through the anal canal

32. Mucosal prolapse • Partial prolapse • Full thickness prolapse

33. Presence of mass, especially after defecation or strenuous activity Mucous discharge with associated bleeding Fecal incontinence Clinical Features

34. Treatment • Reduction if possible • Can attempt with granulated sugar, not synthetic sweeteners • Reduces edema • Surgical consultation

35. Anorectal Tumors • Carcinoma of anal area is rare • increased incidence with smoking, anal intercourse, HIV, and HPV • Clinical features: pain, itching, bleeding mixed with stool, or asymptomatic

36. Surgical referral Treatment

37. Rectal FB

38. Treatment • Keep your game face on • Surgical consult

39. Many causes: Anorectal disease Dietary factors Local infection Local irritants Dermatologic conditions Systemic illness Psychogenic factors Pruritis Ani

40. Early skin is normal May show cracks, skin reddened, edematous, excoriated and moist Chronic—skin thickened Treat underlying cause Add Fiber to diet Wear gloves at bedtime Sitz baths Zinc oxide ointment Clinical Features and Treatment

41. Occur in midline in upper part of natal cleft Sometimes misdiagnosed as perirectal abscess Tx: I&D, Abx only if cellulitis present, surgical referral if recurrent Pilonidal Cyst

42. Perianal surface contains hair follicles and sweat glands that may become blocked Recurrent sites of significant edema, painful nodules, superficial fistulas, and small superficial abscesses Difficult to tx, small abscess can be drained in ED Usually surgical referral Clindamycin may be helpful Hidradenitis Suppurativa

43. Rectovaginal fistula • Presenting complaint is usually flatulence and or malodorous vaginal discharge or gross stool from vagina • Air or stool in urine • CT scan to confirm • Surgical consultation