Anorectal disorders: Difference between revisions
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==Anal Tags==
<languages/>
*Minor projections of skin at anal verge
<translate>
*Sometimes represent residuals of prior hemorrhoids
*Usually asymptomatic
**Inflammation may cause itching and pain
*Skin tags covering anal crypts, fistulas, and fissures are "sentinel tags"
**Surgical referral for excision and/or biopsy is warranted
*Inflammatory bowel disease may be associated with skin tag formation


==Hemorrhoids==
==Background== <!--T:1-->
===Background===
*Occur when internal/external hemorrhoidal plexuses become engorged, prolapse, thrombosed
*Bleeding
**Usually limited (surface of stool, on toilet tissue, at end of defecation)
***Passage of blood clots requires that colonic lesions are ruled-out
*Risk Factors
**Constipation and straining at stool
**Frequent diarrhea
**Older age
**IBD


===Types===
<!--T:2-->
====Internal====
[[File:Rectum anatomy en.png|thumb|Anatomy of the anus and rectum.]]
*Occur proximal to dentate line
[[File:Human anus-en.png|thumb|Anatomy of the anus.]]
*Constant in their location: 2-, 5-, and 9-o'clock positions (when pt viewed prone)
[[File:Gray1080.png|thumb|The interior of the anal cami and lower part of the rectum, showing the anal columns and the anal valves between their lower ends (columns in image numerous than typical).]]
*Not readily palpable; best visualized through anoscope
[[File:Gray1078.png|thumb|Coronal section of rectum and the anal canal.]]
**May be palpable when prolapsed or thrombosed
*Painless bleeding
**Only painful when nonreducible, prolapsed hemorrhoids strangulate OR thrombose
***Can lead to infection/necrosis
*Prolapse
**When prolapse occurs may develop mucous discharge and pruritus ani
***If prolapse cannot be reduced progressive edema and strangulation may result
***Other complications: severe bleeding, thrombosis, infarction, gangrene, sepsis
=====Classification=====
*Grade I: Luminal protrusion above dentate line; no prolapse; painless bleeding
*Grade II: Prolapse with spontaneous reduction; prolapse during straining
*Grade III: Prolapse requires manual reduction; prolapse during straining
*Grade IV: Prolapse—nonreducible; can result in edema and strangulation
=====Treatment=====
#Conservative Tx
##Indicated for mild to moderate symptomatic pts w/ grade 1 to grade 3 hemorrhoids
##Stool softeners (psyllium), high-fiber diet, topical analgesics
##Avoid laxatives causing liquid stool (can lead to cryptitis and anal sepsis)
##Sitz bath 15min TID and after each bowel movement (decreases sphincter pressure)
##Outpt surgical referral
##Prolapsed hemorrhoid in pt w/ minimal symptoms can be manually reduced
#Emergent surgical consultation and intervention is indicated for:
##Continued and severe bleeding
##Incarceration and/or strangulation (grade 4 hemorrhoids)
##Intractable pain


====External====
*Occur distal to dentate line
*Can be seen at external inspection
**More prominent with Valsalva
*Thrombosed hemorrhoids (bluish-purple discoloration) cause painful defecation
**Non-thrombosed hemorrhoids are usually painless
***If pt c/o pain but hemorrhoids are not thrombosed suspect:
****Perianal/intersphincteric abscesses
****Anal fissures
*Prolapse
**Requires periodic reduction by the pt
=====Treatment=====
#Usually self-limiting w/ resolution in 1 week
#Thrombosed:
##Consider sitz baths and bulk laxatives if:
###Thrombosis has been present >48 hr
###Swelling has started to shrink
###Pain is tolerable
##Consider excision if:
###Pt is not immunocompromised, child, pregnant woman, has portal HTN, coagulopathic
###Thrombosis is acute (<48 hr)
###Extremely painful
###See [[External Hemorrhoid Excision]]


==Cryptitis==
==Clinical Features== <!--T:3-->




==Visual Diagnosis== <!--T:4-->


<!--T:5-->
<gallery mode="packed">
File:PMC2653786 ijmsv06p0077g13.png|[[Special:MyLanguage/Anal tags|Anal tags]]
File:DSCB4096(anal worms or just toilet paper remainders@).jpg|[[Special:MyLanguage/Enterobius|Enterobius]] (pinworms)
File:M 44 anus 22.jpg|[[Special:MyLanguage/External hemorrhoid|External hemorrhoid]]
File:Anal fissure 2.jpg|[[Special:MyLanguage/Anal fissure|Anal fissure]]
File:SOA-Condylomata-acuminata-around-anus.jpg|[[Special:MyLanguage/Anal warts|Anal warts]]
File:Perianalabscess.jpg|[[Special:MyLanguage/Perianal abscess|Perianal abscess]]
File:Hemrrhoids 05.jpg|[[Special:MyLanguage/Internal hemorrhoid|Internal hemorrhoid]] with prolapse
File:Pilonidal abscess.jpg|[[Special:MyLanguage/Pilonidal cyst|Pilonidal cyst]]
File:Full thickness rectal prolapse & mucosal prolapse..jpg|[[Special:MyLanguage/Rectal prolapse|Rectal prolapse]]
</gallery>




==Differential Diagnosis== <!--T:6-->


</translate>
{{Anorectal DDX}}
<translate>




==Evaluation== <!--T:7-->




===Algorithmic Diagnostic Approach=== <!--T:8-->


<!--T:9-->
*Pain
**Bleeding
***External [[Special:MyLanguage/hemorrhoid|hemorrhoid]]
***Prolapsed internal [[Special:MyLanguage/hemorrhoid|hemorrhoid]]
***[[Special:MyLanguage/Anal Fissure|Anal Fissure]]
****Off midline = cancer, [[Special:MyLanguage/HIV|HIV]], [[Special:MyLanguage/TB|TB]], [[Special:MyLanguage/Crohn's|Crohn's]]
**No bleeding
***Swelling
****[[Special:MyLanguage/Anorectal abscess|Anorectal abscess]]
*****Perirectal
*****Ischiorectal
*****Intersphincteric
*****Supralevator
****[[Special:MyLanguage/Pilonidal cyst|Pilonidal cyst]]
****[[Special:MyLanguage/Anal fistula|Anal fistula]]
****Hidradenitis suppurativa
***No swelling
****[[Special:MyLanguage/Proctalgia fugax|Proctalgia fugax]]
*No pain
**Bleeding
***Cancer
***Internal [[Special:MyLanguage/hemorrhoid|hemorrhoid]]
**Swelling
***Itch: [[Special:MyLanguage/Condyloma acuminata|Condyloma acuminata]]
***No itch: [[Special:MyLanguage/Rectal prolapse|Rectal prolapse]]
**Itching
***Discharge: [[Special:MyLanguage/Proctitis|Proctitis]]
***No discharge: [[Special:MyLanguage/Pruritus Ani|Pruritus Ani]]


==Diagnosis==
===Pain and Bleeding===
#external hemorrhoids
##swelling
##looks like skin if not thrombosed
##12,7,9 o'clock
#anal fissure
##no swelling
##off midline = CA, HIV, TB, Crohn's
#prolapsed internal


===Pain, No Bleeding===
#swelling
##abscess
###perirectal
###ischiorectal
###intersphincteric
###supralevator
##pilonidal (drain off midline)
##fistula (2/2 chronic abscess; don't probe)
##hidradenitis suppurativa
#no swelling
##proctalgia fugax
###episodic pain (women, pts < 45yo)
##incontinence
###urgency


===Bleeding, No Pain===
#CA
#internal hemorrhoids


===Painless Swelling===
==Management== <!--T:10-->
#itch --> condyloma acuminata (warts 2/2 HPV)
#no itch --> procidentia (rectal prolaps; peds - think CF, malnutrion)


===Itching===
#discharge --> proctitis (inflamm changes of rectum within 15cm of dentate line; GC/chlamy, HSV)
#no discharge --> pruritis ani (pinworms)


==External Hemorroid Excision==
==Disposition== <!--T:11-->
<48 hrs


All pts presenting with anorectal complaints should be considered for HIV testing


==Source==
==See Also== <!--T:12-->
Donaldson; adapted from Coates


<!--T:13-->
*[[Special:MyLanguage/Diagnoses by Body Part (Main)|Diagnoses by Body Part (Main)]]
==External Links== <!--T:14-->
==References== <!--T:15-->
==References== <!--T:16-->
<!--T:17-->
<references/>
<!--T:18-->
[[Category:GI]]
[[Category:GI]]
[[Category:Symptoms]]
</translate>

Revision as of 20:30, 6 January 2026

Other languages:

Background

Anatomy of the anus and rectum.
Anatomy of the anus.
The interior of the anal cami and lower part of the rectum, showing the anal columns and the anal valves between their lower ends (columns in image numerous than typical).
Coronal section of rectum and the anal canal.


Clinical Features

Visual Diagnosis


Differential Diagnosis

Anorectal Disorders

Non-GI Look-a-Likes


Evaluation

Algorithmic Diagnostic Approach



Management

Disposition

See Also


External Links

References

References

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