Disorders of the anus and rectum Flashcards
Internal vs. external hemorrhoids
○ Internal: Originate inside the rectum
■ Above the dentate (pectinate) line
○ External: Originate outside the anus
Prolapsed vs. Thrombosed hemorrhoids
● Prolapsed Hemorrhoids: When internal
hemorrhoidal tissue bulges outside the anal
opening
● Thrombosed Hemorrhoids: when a blood clot forms inside a hemorrhoidal
vein, obstructing blood flow and causing a painful swelling of the anal
tissues.
T/F Hemorrhoidal tissue is pathologic
F - it is not pathologic itself
_____ increases anorectal venous pressure, causing abnormal
dilatation and engorgement of the anal cushions
Intra-abdominal pressure
Can improving risk factors for hemorrhoids improve the hemorrhoids themself?
Yes
Etiology/Risk Factors of Hemorrhoids
● Advancing Age
● Prolonged sitting
● Physical inactivity/Obesity
● Chronic Diarrhea
● Chronic Constipation
● Straining or lingering seated while stooling
● Elevated resting anal pressure (increased sphincter tone)
● Things that make you strain (heavy lifting, chronic cough…)
● Portal Hypertension
● Tumors
Pregnancy:
● Present in 25 to 35% of pregnancies
Symptoms of Internal hemorrhoids
● Don’t cause cutaneous pain
○ Not innervated by cutaneous nerves
● They can rupture and bleed
● Perianal itching/irritation
● Pain can be caused by:
○ Sphincter spasm
○ Irritation to sensitive perianal skin
Symptoms of External hemorrhoids
● Bleeding
● Irritation (itching/burning)
● Not usually painful unless there is a thrombus
● Hygiene difficulties
Presentation of hemorrhoids
● Often asymptomatic
● Rectal bleeding
● Discomfort or pain - Usually aching or throbbing
○ Usually associated with thrombosis
● Irritation or itching of perianal skin
● Sensation of a bulge (Prolapsed internal hemorrhoids)
Symptoms - Acute Thrombosis of a hemorrhoid
● More common with external hemorrhoids
● Presents with acute onset of perianal pain with central swelling, usually a bluish perianal nodule present
● Can cause excruciating pain due to distention and inflammation of overlying perianal skin, which is highly innervated
Physical Exam for hemorrhoids
● A general abdominal exam to rule out
other diagnosis
● Visual inspection of rectum
● Digital rectal exam (not always
required for diagnosis)
● Anoscopy (if available)
● Note the size and location of findings (skin tags, thromboses)
● Assess the anal wink reflex
Diagnostic Testing for hemorrhoids
Diagnosis is almost always based on the clinic picture
● Lab tests not usually needed
● Anoscopy and/or flexible sigmoidoscopy are recommended to evaluate bright red rectal bleeding if cause is not easily determined.
● Colonoscopy should be considered if rectal bleeding is present with a negative anorectal exam
Treatment for hemorrhoids
● The best treatment is preventive
● Treat Constipation: Increase Fiber and Water intake
● Weight loss and increased physical activity
● Toilet retraining
● Decrease time on toilet
Treatment for hemorrhoids if symptomatic
● Warm baths 2-3 times daily, +/- epsom salt
● Stool softeners
● Topical analgesics
● Systemic analgesics
● Topical steroid cream
Medications for hemorrhoids
● Lidocaine ointment 5% (RectiCare)
● Witch hazel
● Preparation H
Nonsurgical Procedures for hemorrhoids
● Rubber Band Ligation
● Coagulation
● Electrocautery
● Electrotherapy
● Sclerotherapy
● Cryotherapy
● Laser therapy
● Radiowave ablation
Rubber band ligation
● For Grade 2 and 3 Internal hemorrhoids. Does not treat grade 4
● Effective in 75% of patients short-term
● A band ligature is passed through an anoscope and placed on the rectal mucosa
● Tissue will necrose and sloughs off in 1-2 weeks
● No to little anesthesia required
What is this procedure called?
Rubber band ligation
Management of Thrombosis in hemorrhoids
● Acutely thrombosed external hemorrhoids may be
excised if patient presents within 48-72 hours of
symptoms onset (not that helpful after that)
● Local anesthetic with epinephrine
● Elliptical incision
● Excision of thrombosis in the hemorrhoid
● Pressure dressing for several hours
● Let wound heal by secondary intention
Hemorrhoidectomy
● For severely swollen and prolapsed
hemorrhoids
● Grades 3 and 4
● Operative hemorrhoidectomy is safe in
pregnancy, but avoid if possible
● Refer to GI
● Roughly 5% recurrence rate
Anal Fissures
● PAINFUL linear tear or crack
● Distal anal canal
● Common cause of rectal bleeding in infants
● Can be an indication of abuse in children
Pathophysiology of anal fissures
○ Majority=Trauma. Can be caused by:
■ Constipation and passage of a hard/painful bowel movements
■ Anal Sex
■ Diarrhea
■ Vaginal delivery
○ Others: Low-fiber diet, Prior anal surgery,
Abnormality of anal sphincter, Hypertonicity,
Elevated resting pressure of internal anal
sphincter
Disease Progression for anal fissures
● Pain with bowel movements
● Raw area, becomes stretched
● Injured mucosa is abraded by the stool and wiping
● Internal sphincter begins to spasm
Acute vs. Chronic anal fissures
● Acute if present for less than 6 weeks
○ Superficial
○ Linear tear in mucosa
● Chronic if present for greater than 6 weeks
○ Deeper
○ Hypertrophied anal papillae present proximally
○ Fibers of the internal anal sphincter visible
○ Commonly, Skin tags present distally
Presentation for anal fissures
● Severe pain with bowel movements
○ Minutes to hours
● Usually occurs with every bowel movement
● Patient begins to avoid bowel movements
out of fear/apprehension. Worse with
Constipation and Harder stools
● 70-75% of patients note bright red blood,
especially with wiping
Labs for anal fissures
● Not indicated for an ordinary fissure, if
Anterior midline or posterior midline
● If irregular, not midline, or if
underlying pathology suspected
○ ESR
○ Culture
○ STD testing (including HIV)
○ Biopsy
visual examination for Anal fissures
○ Acute fissures appear as fresh, superficial lacerations, almost like a paper
cut.
○ Chronic fissures have raised edges exposing the white, horizontally
oriented fibers of the internal anal sphincter muscle fibers
Diagnostic imaging for anal fissures
Just visual exam needed ususally
● Digital rectal exam - Avoid
○ WILL BE PAINFUL - May worsen inflammation
● Anoscopy/rigid proctosigmoidoscopy
○ WILL BE PAINFUL
○ Only perform once symptoms have improved
● Chronic fissures are less painful, exam techniques
are better tolerated and can be included
Initial Treatment of Anal fissures
○ Fiber supplementation
○ Stool softeners (like Docusate)
○ Laxatives as needed (like Senna)
○ Mineral oil
● Lidocaine-hydrocortisone rectal for pain
● Sitz baths - Provides good relief, helps heal
Next step?
● Intra-anal nitroglycerin 0.4%
More Invasive Treatments for anal fissures
Botox (Botulinum toxin)
● Acute or chronic fissures
● Injected directly into the internal anal sphincter
● Effect lasts for 3 months
Subcutaneous fissurectomy
● Cuts out the fissure without affecting the sphincters
● Less chance of incontinence than sphincterotomy
Surgical Treatment of anal fissures
● Lateral internal anal sphincterotomy
Lateral internal anal sphincterotomy
SOC for Anal fissures
○ Avoid on those with high risk of incontinence
(like multiparous women or older patients)
○ Surgical procedure of choice
○ General or local anesthesia
○ Only the internal sphincter is cut
○ Continence disturbance rate at 2 years, about
14 percent (flatus incontinence 9 %,
soilage/seepage 6 %, accidental defecation 1
%, solid stool incontinence 0.83 %)
Anorectal Abscess and Fistula
● Arise from infection of the epithelium lining of the anal canal
● Severity and depth of abscesses vary
● Abscess cavity often associated with the development of a fistula
Anal Fistula classifiecations
○ Intersphincteric (70%) - Found between the internal
and external sphincters
○ Transsphincteric (23%) - Extends through the
external sphincter into the ischiorectal fossa
○ Extrasphincteric (5%) - Passes from the rectum to
the skin through the levator ani
○ Suprasphincteric (2%) - Extends from the
intersphincteric plane through the puborectalis,
exiting the skin after traversing the levator ani
Pathophysiology/Etiology of abscesses
● Anaerobes
○ Bacteroides fragilis, Peptostreptococcus, Prevotella, Fusobacterium, Porphyromonas, Clostridium
● Aerobes
○ Staphylococcus aureus, Streptococcus, Escherichia coli, MRSA
● 10% of anorectal abscesses form for reasons other than bacterial infection
○ Crohn’s, HIV, tuberculosis, cancer, STD, IBD, diverticular disease, foreign body, appendicitis
Presentation - Abscess
● Perianal pain, varies with abscess location
● Swelling around the rectum
● Perirectal drainage that is bloody, purulent, or mucoid
● Constipation
● Diarrhea
Presentation - Fistulas
○ Recurrent, malodorous perianal drainage
○ Pruritis
○ Perianal pain (if occluded)
○ Recurrent abscess
○ Pain occurs with sitting, moving,
defecating, and coughing and is throbbing
in nature
○ Patient may feel indent
What will you find on Digital Rectal Exam for an abscess?
A fluctuant, indurated mass
What will you find on Digital Rectal Exam for a fistula?
○ A fibrous tract or cord beneath the skin
○ Pus or blood may be expressible
Labs for abscesses
● Immunocompromised patients are at an increased risk of sepsis
as a results of anorectal abscess
○ CBC with diff
○ ESR
● Cultures - VERY IMPORTANT
○ All I&D patients
Imaging for fistulas and abscesses
● Usually not necessary in the evaluation of simple perianal
abscesses and fistulas
● Clinical suspicion of an intersphincteric or supralevator
abscess may require confirmation
○ CT is readily available in most ERs and is commonly used
○ MRI is the best (if available) for imaging of anorectal
abscesses (91% sensitivity)
Fistulography is used for what cases?
● To evaluate anal fistulas
○ Injection of contrast into the internal
opening, radiographs performed
○ Can be painful when injecting the contrast
material into fistulous
○ Generally reserved for cases in which there
is a concern about a fistulous connection
between the rectum and adjacent organs
such as the bladder
Endosonography (perianal sonography) use for imaging
● Emerging as an excellent way of evaluating
complex cases of perianal abscess and
fistula
● Extent and configuration of the abscess and
fistulas can be clearly visualized
● Becoming a test of choice where available
T/F it is okay to watch and wait anorectal abscesses
F - ○ Urgent incision and drainage with culture collection
○ No “watchful waiting” while administering
antibiotics. It is inadequate
○ Delaying surgical intervention results in chronic
tissue destruction, fibrosis, and stricture formation
and may impair anal continence
Treatment of abscesses
○ Routine antibiotic treatment (in addition to drainage)
○ Bactrim DS or vancomycin
● Acute abscesses recur in roughly 10% of patients
○ Patients should be advised to return to the clinic or ER if symptoms
of an abscess recur
Treatment of anal fistulas
○ Treat intra-abdominal disease
■ Crohn’s
○ Surgical intervention indicated for
symptomatic patients
■ Fistulotomy vs. fistulectomy
■ Marsupialization
■ Anal flaps
○ Alternatively, a draining seton may be used to keep the
fistula tract open, which often prevents recurrent abscess.
