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Perianal Poop-pourri: Disorders of the Anorectum

Perianal Poop-pourri: Disorders of the Anorectum. Elizabeth Schaefer, M.D. easchaef@stvincent.org St. Vincent Pediatric Gastroenterology 8402 Harcourt Rd. Suite #402 Indianapolis, IN 46260 (317) 338-9450. Objectives. Review clinical presentations of classic perianal disorders

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Perianal Poop-pourri: Disorders of the Anorectum

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  1. Perianal Poop-pourri:Disorders of the Anorectum Elizabeth Schaefer, M.D. easchaef@stvincent.org St. Vincent Pediatric Gastroenterology 8402 Harcourt Rd. Suite #402 Indianapolis, IN 46260 (317) 338-9450

  2. Objectives Review clinical presentations of classic perianal disorders Make the diagnosis Review the management and identify when and who to consult

  3. Is this normal? • Document anal opening not in the center of the perineal pigmented area • API (Anal Position Index): • Normal: halfway between coccyx and introitus or scrotum • Female: anus-fourchette/coccyx-fourchette 0.45+/- 0.08 • Male: anus-scrotum/coccyx-scrotum 0.54 +/- 0.07 • 4% of infants • Refer to surgery if severe constipation associated with API <2SD from the mean • <0.29 in girls, <0.40 in boys

  4. What does this “bucket handle” bridge represent? • Rectum passes through the levator ani • Fistulous tract extends to perineal region • Prognosis favorable for low lesions because they lie within the levator ani complex

  5. Rectal Fissure • Superficial tears of anoderm, inferior to the dentate line • 90% posterior • Due to constipation, although history only elicited in 25% of cases • Presentation: pain, bleeding • Diagnosis: • acute fissures are typically small • chronic fissures assoc w/ skin tag or fibrosis • Remember if fissure is large or there is bruising, consider abuse

  6. Rectal Fissure • Management • Decrease trauma • Stool softeners • Lubricant laxative • Fiber • Reduce anal sphincter tone • Warm sitz baths • Good hygiene • >80% heal • Chronic fissures • >6 weeks • Uncommon in kids • Dilation to reduce anal spasm • Nitric oxide (0.2% glycerol trinitrate) • Botulism toxin • Surgery: • lateral internal sphincterotomy

  7. Perianal Strep Presentation Well demarcated rash 6 mo – 10 yrs old Cellulitis in 90%, pruritis in 80% Pain, pruritis, bleeding Familial spread possible Diagnosis: Group A B-hemolytic streptococcal infections found on perianal cx Treatment: 10 days of oral penicillin EES for PCN allergic patient Clindamycin +/- mupirocin 40-50% recurrence rate

  8. Chronic Pruritis Ani • Enterobius vermicularis • Presentation: anal pruritis • Dead parasites and eggs in the perianal area may also cause abscesses and granulomas

  9. Perianal Fistula • Chronic track of granulation tissue connecting two epithelial lined surfaces • Most fistulas originate below the dentate line • A fistulous abscess becomes a fistula when it ruptures • Surgical drainage • Except in known or suspected Crohn’s disease • Pack the cavity or catheter to drain • Sitz or tub baths, analgesics • Antibiotics

  10. Perianal Fistula • The internal opening in children is on the pectinate line radially opposite the external orifice • Unroof the fistula • Keep area clean with soap and water

  11. Infliximab in Patients with Fistulizing Crohn’s Disease Perianal Fistula Case Study Pretreatment 2 Weeks 10 Weeks 18 weeks Present D, et al. NEJM. 1999; 340:1398-405.

  12. Perirectal Abscess • Majority result from a crypt of Morgagni infection • Classification determined by anatomic location of lesion relative to the levator ani and sphincteric muscles

  13. Perirectal Abscesses • Presentation • Males > Females • 98% report persistent perirectal pain • Abscesses identified in 95% of cases when an external perianal exam in combined with a digital rectal exam • Management • Sitz baths • Antibiotics • Surgical options: • If chronic fistulae beyond 3 months despite medical management • Fistulectomy • Fistulotomy • Seton loop • Consider evaluation for neutropenia, leukemia, HIV, diabetes, IBD

  14. Rectal Prolapse • Mucosal vs full thickness • Males > Females • Etiologies: • Constipation • Diarrhea • Cystic fibrosis • Other: intra-abdominal pressure, polyps, parasites, malnutrition, pelvic floor weakness • Usually self limited • If recurrent and pronounced • Sweat chloride • Screen for parasites

  15. Rectal Prolapse • Treatment: Manual reduction, treat primary inciting factor • If persistent: surgical – injection of sclerosant or hypertonic saline submucosally or submuscularly above dentate line • Prognosis generally good

  16. Hemorrhoids • Small asymptomatic: not uncommon • Symptomatic: • Due to chronic straining • Anal infection spreading to hemorrhoidal veins • Underlying Crohn’s disease • Male = Female • Presentation: Bleeding, pruritis, prolapse, pain • Diagnosis: Clinical history and careful exam

  17. Hemorrhoids • External Hemorrhoids • From ectoderm and arise distal to dentate line • Stratified squamous epithelium • Inferior rectal nerve - painful • Internal Hemorrhoids • Above the dentate line from embryonic endoderm • Simple columnar epithelium • Painless • Classified by the degree of prolapse • Pathogenesis: ? • Low fiber diets • Decreased venous return • Prolonged sitting on toilet • aging

  18. Hemorrhoids: Treatment • Conservative Options • Indication: Grade I & II internal; non-thrombosed external • Sitz baths bid-tid • High-fiber diet • Fluid intake • Stool softeners • Topical/systemic analgesic • Proper anal hygiene • Short term topical steroid (hydrocortisone acetate 2.5% and pramoxine HCL1% cream) • Non-surgical Options • Indication: Recalcitrant hemorrhoids • Rubber band ligation* • Infrared coagulation* • Injection sclerotherapy • Laser therapy • Cryosurgery • Surgical Management • Nonsurgical treatment failure • Grade III & IV internal with severe symptoms • 5-10% eventually require surgery • Hemorrhoidectomy

  19. More is not necessarily better

  20. References • Browning J, Levy M. Cellulitis and Superficial Skin Infections. In: Long SS, Pickering LK, Prober CG, ed. Principles and Practice of Pediatric Infectious Diseases. 3rd ed. Hamilton, Ontario: Churchill Livingstone; 2008. Chapter 72. • Davari HA. The anal position index: a simple method to define the normal position of the anus in neonate. Acta Paediatr. 2006;95:877 • Gourgiotis S, Baratsis S. Rectal prolapse. Int J Colorectal Dis. 2007;22:231-243 • Langer M, Modi BP: Benign Perianal Lesions. In Kleinman RE, Goulet O, et al, eds. Pediatric Gastrointestinal Disease. 5th ed. Hamilton, Ontario: BC Decker Inc; 2008” 368-369. • Pfefferkorn M, Fitzgerald J. Disorders of the Anorectum: fissures, fistulae, prolapse, hemorrhoids, tags. In: Wyllie R, Hyams JS, eds. Pediatric Gastrointestinal and Liver Disease, 3rd ed., 2006; 801-807. • Walker W, et al, eds. Pediatric Gastrointestinal Disease. 4th ed. Hamilton, Ontario: BC Decker, 2004: Chapter 35

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