Acquired Anorectal Disorders Flashcards
What is a hemorrhoid?
Hemorrhoidal veins are arteriovenous connections which lie in the submucosal space above the dentate line.
There are three hemorrhoidal venous plexi.
They are located in the left lateral, right anterior, and right posterior positions.
During periods of high venous pressure, these veins can become engorged.
How do patients with hemorrhoids present?
Hemorrhoids are an extremely uncommon finding in healthy young children.
About a third of children with portal hypertension are affected by anorectal varices, but these are often asymptomatic.
Parents may report a “protrusion” from the anus, but it is important to differentiate hemorrhoids from other similarly presenting pathology such as rectal prolapse and rectal polyps.
If hemorrhoids are symptomatic, painless hematochezia is a typical presenting symptom.
Adolescents may develop hemorrhoids which present more classically like those seen in adults, including painful thrombosed external hemorrhoids or prolapsing internal hemorrhoids.
How are hemorrhoids classified?
Hemorrhoids are classified as internal or external, depending on their relation to the dentate line.
Internal hemorrhoids arise from the superior hemorrhoidal plexus above the dentate line, and are insensate, while external hemorrhoids arise from the inferior hemorrhoidal plexus and have associated pain.
Internal hemorrhoids can be further classified by the extent of their prolapse (Table 35.1).
What are the initial treatment options for hemorrhoids?
Hemorrhoid management depends on the etiology. In children with anorectal varices secondary to portal hypertension, treatment of the underlying hepatic pathology is necessary.
In older children, hemorrhoids are likely due to prolonged constipation.
Management of this should focus on increasing dietary fiber and water.
Stool softeners can be used as adjuncts, but overly loose stools can aggravate symptoms.
Behavioral changes such as promotion of healthy toilet habits (reduction of prolonged toilet time and avoidance of reading or using electronic devices while stooling) are encouraged.
Sitz baths may help relieve symptoms.
If medical management fails, what are the other options for hemorrhoid treatment?
Internal Grade II or III hemorrhoids recalcitrant to medical management can be treated with rubber band ligation.
In this procedure, a hemorrhoid banding ligator is used to launch a rubber band around the base of the hemorrhoid and results in hemorrhoidal ischemia and necrosis.
It is important to avoid banding external hemorrhoids.
Their location below the dentate line renders them highly sensitive and banding will cause extreme pain from the ischemia.
Other techniques including injection sclerotherapy and infrared coagulation have been employed, but are less common.
Should medical management and non-operative procedures fail, surgery can be considered.
The majority of hemorrhoidectomies are performed by resecting the hemorrhoidal column free from the internal anal sphincter up to its vascular pedicle, which is then ligated.
Some practitioners recommend avoiding resection of more than two hemorrhoidal columns at once as this may increase the risk of anal stenosis.
Stapled hemorrhoidopexy is another option, which may be less painful as the incision is kept above the dentate line; however, this approach is less popular as it is associated with a higher stricture risk.
Are there any concerns practitioners should keep in mind when working up children with hemorrhoids?
Rectal prolapse is often confused with hemorrhoids and vice versa.
Rectal polyps can also mimic prolapsed internal hemorrhoids.
Other rare diagnoses such as rectal hemangioma, rectal duplication and venous malformation of the anal canal can also occur.
A thorough physical examination is pertinent to ensure an accurate diagnosis.
Are there any long-term complications from hemorrhoid management?
Described complications are limited to the postoperative period.
Rectal stenosis from overly aggressive hemorrhoid resection, pelvic sepsis from infection, and fecal incontinence from sphincter complex injury are among these.
What is an anal fissure?
An anal fissure is a tear in the anoderm, or the squamous epithelial mucosa distal to the dentate line.
Anal fissures can be painful and associated with the passage of bloody stools.
At what age do anal fissures occur?
Anal fissures most commonly occur in children at the time of introduction to solid foods.
The stool consistency subsequently changes from loose and seedy, to formed.
The passage of harder stools leads to the tear, subsequent pain and possible stool retention.
This may result in harder and bulkier stools which worsen the tear and may prevent healing.
What are the symptoms associated with anal fissures?
Anal fissures tend to be painful, resulting in crying during defecation.
Often, they are identified after finding bright red blood in the stool in small volume.
How do I diagnose an anal fissure?
Anal fissures can be diagnosed clinically.
The buttocks and anoderm should be spread apart and the anus inspected.
The vast majority of anal fissures are in the posterior midline.
Are there medical conditions I should be concerned about when identifying an anal fissure?
Anal fissures occurring in older children and those that are not in the midline should raise concern for inflammatory bowel disease.
Anal malignancy is extremely rare in children, but should be considered in non-healing fissures in older children.
Additionally, the presence of concomitant bruising or other trauma should raise concern for the possibility of non-accidental trauma.
What is the medical management for anal fissures?
The vast majority of anal fissures heal without any surgical management.
The mainstay of medical management for anal fissures is relief of constipation and loosening of the stools (Fig. 35.1).
Increasing water consumption and fiber intake are central to this management.
Stool softeners can be helpful, but should be used cautiously since overly loose stools can aggravate the fissure.
Regular sitz baths can also be helpful.
If dietary changes fail, are there any non-surgical procedures that should be trialed prior to more invasive methods?
Numerous methods have been reported to accelerate fissure healing.
Topical anesthetic creams (ex EMLA), topical nitroglycerin ointments, and topical calcium channel blockers have been utilized to assist with fissure healing, however high recurrence rates have been reported.
Are there surgical procedures available for anal fissures?
If the above therapies fail, surgical options may be considered.
It is important to consider alternative diagnoses among these recalcitrant fissures.
Numerous procedures have been reported for the management of anal fissures.
Anal dilation, the injection of botulinum toxin (Botox), and lateral internal sphincterotomy have all been described, but with mixed results.
Botulinum toxin injections have temporary effects, with reduced risk of long-term incontinence, however lateral internal sphincterotomy has been shown to have the lowest long-term rate of recurrence.
Fissurectomy, or the removal of the fissure with primary closure, has been reported with reasonable outcomes when combined with Botox to prevent recurrence.
What are the complications of associated with surgical management anal fissures?
Long-term complications are rare, mainly due to the rarity of surgical management of this disease process.
Anal dilations and Botox injections can lead to temporary fecal incontinence, while lateral internal sphincterotomies can lead to long term incontinence if an aggressive sphincterotomy is performed.
What children get perirectal abscesses?
Abscesses are a very common benign condition in infants.
Roughly 90% occur in males. Abscesses can also develop in older children, especially in those immunocompromised or with inflammatory bowel disease.
How do perirectal abscesses present?
The majority of perirectal abscesses in children occur in males under one year of age.
These children tend to present with an inflamed perianal mass, which may or may not be spontaneously draining.
There are usually no systemic signs of infection.
However, older children and those who are immunocompromised, may present with apparent signs of systemic infection including fever and lethargy along with perirectal pain.
How are perirectal abscesses classified?
Traditionally, perirectal abscesses are grouped in four distinct categories based on location.
Perianal abscesses are located near the anus and tend to be superficial.
These are the most common abscesses presenting in infants. Ischiorectal abscesses occur lateral to the external sphincter complex, but superficial to the pelvic floor.
Intersphincteric abscesses can be found between the internal and external sphincter and are often not visible on the skin.
Lastly, supralevator abscesses extend above the levator ani.
Are there any disease processes associated with perirectal abscesses?
Perirectal abscesses are most commonly benign and not associated with other disease processes, but certain children are at higher risk for recurrent abscesses.
Children with perirectal Crohn’s disease can present with chronic abscesses and fistulae.
It is important to note that these children are managed uniquely and practitioners should always consider this diagnosis in children with recurrent, intractable disease.
Additionally, children with immunocompromised states (e.g. diabetes, treatment with steroids, chemotherapy) have a higher incidence of peri- rectal abscesses.
Do perirectal abscesses need to be aspirated or drained?
Management of perirectal abscesses has changed over the past few years.
Traditionally, drainage of the abscess was common, but recent literature has shown that abscess incision and drainage may be associated with a higher rate of fistula formation.
Therefore, in children who are not systemically ill, treatment with antibiotics, warm compresses/sitz baths, and observation is recommended.
If large, abscess aspiration can also be entertained.
Caution is urged when considering incision and drainage among children with inflammatory bowel disease as these children are also at high risk for fistula formation; however this should not be a contraindication in children who are systemically ill.
If I elect to perform an incision and drainage, should I investigate for concomitant fistula-in-ano?
Attempts to probe for a fistula in an inflamed field may lead to inadvertent “false tracking” or sphincter injury and therefore should be avoided.
Furthermore, many fistulae will heal spontaneously and further intervention may not be necessary.
If I perform an incision and drainage on a perirectal abscess, does the child require antibiotics? Should I pack the wound?
Antibiotics may not be necessary after incision and drainage unless the child has systemic signs of infection, or is immunosuppressed.
However, recent data have demonstrated that empiric antibiotic coverage may reduce the incidence of persistent fistula-in-ano after healing.
Following incision and drainage, many practitioners leave packing in the wound to be removed between 24 and 72 h afterwards.
This can help with hemostasis but is not necessary and can make postoperative care more complicated and uncomfortable.
Children may return with recurrent abscesses due to retained packing.
An alternative option is to make two counter-incisions in the abscess and pass a vessel loop or surgical tie through the incisions to allow drainage, with removal at a later date.
What is the appropriate follow-up for patients treated for peri-rectal abscesses?
Infants with simple perianal abscesses likely do not need surgical follow-up, but should be seen by their pediatricians within a short interval of time.
Children who present with recurrent abscesses, or have other concerning signs or symptoms should undergo a more thorough work-up for underlying causes (e.g. immunosuppressed state or inflammatory bowel disease).
What is fistula-in-ano?
Fistula-in-ano is an abnormal connection from the anal crypt to the peripheral skin.
In children, these often arise from crypts proximal to the dentate line, and travel in a straight line subcutaneously.
They may involve the sphincter complex.
What is Goodsall’s rule?
Goodsall’s rule describes the expected route of a fistula-in-ano from the skin to the anal canal depending on the location of the fistula on the skin.
Anterior fistulae tend to travel in a straight line and have an internal opening in a similar radial location, while posterior fistulae can travel in a curvilinear manner, having an internal opening in the posterior midline (Fig. 35.2).
Longer fistulae, and fistulae associated with inflammatory bowel disease may not conform to this generalization.
How are fistulae categorized?
Fistulae are traditionally described by Park’s classification, which classifies the fistula based on its location with the sphincter muscle complex.
Fistulae involving only a portion of the inferior sphincter complex are termed transphincteric, and are among the most common.
Intersphincteric fistulae travel through the internal sphincter, and then travel to the skin through the intersphincteric space.
Suprasphincteric fistula travel above the sphincter complex, and extrasphincteric fistula travel from higher in the rectum and are usually the result of trauma, however these are much rarer.
Are fistulae benign or associated with other diseases?
As with perirectal abscesses, fistulae in children tend to be a benign, self-healing processes.
Weight loss, recurrence, multiple fistulae, and those that do not follow Goodsall’s rule should raise concern for inflammatory bowel disease or other disease processes.
Which fistulae require intervention?
The vast majority of fistulae in children, especially in infants, will close spontaneously.
Fistulae that fail to close spontaneously should be considered for operative intervention.
Fistulae secondary to inflammatory bowel disease should have an attempt at medical management primarily.
Is there any work-up that should be performed prior to intervention?
Children with straightforward fistulae and no warning signs for other disease processes do not need other work-up prior to undergoing operative intervention.
Children with signs or symptoms concerning for inflammatory bowel disease or immunosuppression should have further work-up.
Magnetic resonance elastography (MRE) of the pelvis can be very useful in helping to define the location and type of fistulae.
What are the options for surgical intervention for fistulae and how do I decide which to use?
There are multiple options available for management of a fistula, depending on the depth of the fistula and its involvement with the sphincter.
Superficial fistulas which do not involve a substantial amount of the sphincter complex can be managed with fistulotomy alone.
This involves identification of the fistula and opening of the fistula along its entire tract.
This procedure should not be performed in patients with Crohn’s disease due to poor healing.
If a substantial portion of the sphincter complex is involved, most surgeons opt for placement of a seton in order to spare the sphincter.
The loose seton helps drainage and granulation and can be removed at a later date if it does not fall out spontaneously.
There are additional procedures available, but these are rarely used in the pedi- atric population, with a few reports in teenagers.
They include endorectal and dermal advancement flaps, fibrin sealant, fistula plugs, and ligation of the intersphincteric fistula (LIFT) procedure.
Fibrin sealants and fistula plugs are traditionally utilized after a seton has been used for a short time period, and after curetting and debriding the fistula.
The LIFT procedure is a more modern procedure for management of transphincteric fistulae and involves dissection of the intersphincteric space and ligation of the fistula tract within this space.
If I place a seton in a fistula, when and how should this be followed?
Most surgeons perform a follow-up exam under anesthesia around 6-12 weeks after the initial procedure to evaluate the fistula tract and consider seton removal.
How do you differentiate Intussusception clinically from rectal prolapse?
In rare circumstances, intussusception presents with prolapse of the intussusceptum through the anus.
Such prolapse can be confused with rectal prolapse.
Careful examination can differentiate between the 2 presentations, as follows:
1) The anal crypts are everted with rectal prolapse and not with intussusception.
2) An examining finger can be passed between the prolapse and the anus in patients with intussusception but not in patients with rectal prolapse.
[Medscape]
Best answer among following for precipitating factor causing rectal prolapse is:
A. Diarrhoea.
B. Constipation.
C. Too early or overzealous toilet training.
D. All of the above.
E. None of the above.
D
A, B and C are precipitating factors for rectal prolapse. Other precipitating factors include rectal polyps and cystic fibrosis. Other causes of rectal prolapse include pelvic floor weakness and malnutrition.
Syed/MCQ
Non-operative management of rectal prolapse includes:
A. Correction of bowel habit.
B. Diet containing more vegetable and cereal fibres.
C. Ensuring defecation is prompt and quick and performed in sitting position.
D. Temporary support by finger and prolonged support by stripping of buttock together.
E. All of the above.
E
All of the above.
Syed/MCQ
Regarding operative treatment of rectal prolapse, which of the following is true?
A. Submucosal sclerotherapy is given in lateral and anterior direction.
B. In the Thiersch procedure, three incisions (3, 7 and 11 o’clock positions) are required.
C. Recurrence rate is 10–20 percent.
D. Injection sclerotherapy should not be repeated.
E. Internal fixation by laparotomy is an option.
E
Sclerotherapy is given in lateral and posterior direction. In Thiersch procedure, generally two small incisions are required, at 12 and 6 o’clock positions. Recurrence rate is 5–10 percent. Injection sclerotherapy is repeated at 4–6 weeks, if needed. Internal fixation by laparotomy, mucosal resection and anastomosis are other options of management.
Syed/MCQ
What number of patients with cystic fibrosis have rectal prolapse?
A. All.
B. Half.
C. One-third.
D. One-fifth.
E. One-eighth.
D
One-fifth.
Syed/MCQ
