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Pooper Problems: Part I

Mizuho Morrison, DO and Matthieu DeClerck, MD
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Tags GI · Surgery

Anorectal problems are common presentations in the urgent and primary care setting. Here we review some of the most common anorectal disorders, their physical exam findings, treatment, and complications that should be identified and dispositioned appropriately.

 

Pearls:

  • Fissures outside of the 6:00 position require specialist follow up because they are more likely to be representative of a systemic disease such ulcerative colitis, Crohn's, HIV, tuberculosis or malignancy.

  • Patients who are immunocompromised or toxic appearing and present with symptoms of perianal abscess should be evaluated for deep post-anal abscess.

 

HEMORRHOIDS

  • The most common cause of rectal bleeding that we see in the Urgent Care setting.

  • Patients often report blood on the toilet paper or a small amount of blood in the toilet bowl.

  • Hemorrhoids are usually caused by constipation and lack of dietary fiber

    • Conditions that increase straining and pressure on the venous plexus can cause hemorrhoids.

  • TYPES of HEMORRHOIDS

    • External hemorrhoids:

      • Distal to the dentate line at the anal verge.

      • They are painful because they are made of squamous epithelium, which is innervated.

      • Can be visualized on simple inspection of the anus.

    • Internal hemorrhoids:

      • Proximal to the dentate line.

      • Are not painful because they are made of rectal mucosal epithelium which only has a  visceral innervation.

      • Visualization requires an anoscope.

  • MEDICAL MANAGEMENT

    • Sitz baths are the mainstay hemorrhoid management. Instruct patients to sit in a bath of warm water with salt added several times a day.

    • Petroleum based lubricants like Preparation H or Anusol reduce inflammation.

    • Topical lidocaine 1.5% works to anesthetize the area.

    • Add a laxative or stool softener to relieve constipation or immodium to prevent diarrhea.

  • THROMBOSED HEMORRHOIDS

    • External hemorrhoids that become painful and irritated are likely thrombosed.

    • If a patient presents within the first 48 hours after thrombosis it can be excised in the UC setting.

    • If the patient does not wish to have the thrombosis excised or the thrombosis has been present for > 48 hours, treat medically and arrange for follow up with colorectal surgery.

    • Complications of thrombosed hemorrhoids are rare and include uncontrolled bleeding, abscess, fistula formation, infection and ischemic hemorrhoids.

 

ANAL FISSURES

  • Fissures are a tear in the skin below the dentate line that extends distally to the anal verge.

  • The most common presentation will be pain with bowel movements.

  • Fissures occur commonly in postpartum patients at the 12:00 (anterior towards perineum) and the 6:00 (towards the back) position.

  • The 6:00 position is most common in both men and women.

  • TREATMENT:

    • The treatment for anal fissures includes all of the same treatments for hemorrhoids (see above) as well as calcium channel blockers that relax smooth muscle and prevent spasm.

    • Complete resolution could take between 4-6 weeks!

  • CONSIDERATIONS:

    • Fissures located anywhere but the 6:00 position in men and women who are not postpartum require specialist follow up because this could be secondary to a another condition such ulcerative colitis, Crohn's, HIV, tuberculosis or malignancy.

    • Consider sexual abuse in children who present with fissures.

 

CRYPTITIS

  • Inflammation of the pockets between the columns of Morgagni at the dentate lines.

  • Present with anal pain, spasm and sometimes itching or bleeding.

  • Will have some localized tenderness on digital rectal exam.

  • Visualization with the anoscope is required which will demonstrate a small amount of pus or inflammation in the crypts at the dentate line.

  • Treatment includes the same medical therapies for patients with hemorrhoids.

 

ANORECTAL ABSCESS

  • Perianal abscesses begin as infected  crypts that extend downward towards the anal verge, from the dentate line. They appear as a superficial tender mass close to the anal verge which  may or not be fluctuant.

  • Ischiorectal abscesses present as a tender, fluctuant mass on the buttocks itself.

  • The treatment of both perianal abscesses and ischiorectal abscesses is incision and drainage with or without antibiotics depending on the presence of surrounding cellulitis and if the patient is ill appearing.

  • Postanal abscesses extend upward, through the different layers of musculature and connect the ischiorectal fossa bilaterally.

    • Consider deep postanal abscess when the patient is immunocompromised or ill appearing especially if unable to visualize an abscess exam.

    • Refer to an emergency department for advanced imaging and surgical consultation.

 

ANAL FISTULA

  • Fistulas began as abscesses that then tunnel either externally into the buttocks or internally into the rectum.

  • Fistulas present with chronic purulent drainage or malodorous discharge usually in patients who have an underlying condition such as Crohn's disease, ulcerative colitis, cancer or previously had radiation therapy to the perineum.

  • Patients with fistulas who present with significant pain or increased discharge should be treated with a course of antibiotics and surgical referral for definitive management.

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Ice, Ice Baby Full episode audio for MD edition 185:05 min - 87 MB - M4AHippo Urgent Care RAP - November 2017 Written Summary 488 KB - PDF