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-->
*See [[Hemorrhoids]]


==Cryptitis==
<!--T:2-->
===Background===
[[File:Rectum anatomy en.png|thumb|Anatomy of the anus and rectum.]]
*Anal crypts are mucosal pockets that lie between the columns of Morgagnia
[[File:Human anus-en.png|thumb|Anatomy of the anus.]]
**Formed by the puckering action of the sphincter muscles
[[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).]]
*Superficial trauma (diarrhea, trauma from hard stool) --> breakdown in mucosal lining
[[File:Gray1078.png|thumb|Coronal section of rectum and the anal canal.]]
**Bacteria enter, inflammation extends into lymphoid tissue of the crypts / anal glands
***Can lead to fissure in ano, fistula in ano, perirectal abscesses
===Clinical Features===
*Anal pain
*Sphincter spasm
*Itching w/ or w/o bleeding
*Hypertrophied papillae
===Diagnosis===
*Anoscopy shows inflammation, erythema, and pus
===Treatment===
#Bulk laxatives, additional roughage, sitz baths (treats underlying cause)
#Surgical referral is indicated when:
##Infection has progressed and the crypt will not drain adequately on its own
##Surgical treatment is excision


==Anal Fissures==
===Background===
*Superficial linear tear of anal canal from at/below dentate line to anal verge
**May be due to passage of hard stool, frequent diarrhea, or abuse
*Most common cause of painful rectal bleeding
*In >90% of cases anal fissures occur in the midline posteriorly
**Nonhealing fissure or one not located in midline suggests alternative dx
===Clinical Findings===
*Acute sharp, cutting pain most severe during and immediately after bowel movement
**Subsides between bowel movements (distinguishes fissure from other anorectal disease)
*Bright red bleeding, small in quantity (usually noticed only on toilet paper)
===Diagnosis===
*Having pt bear down may make fissure more noticable
*Sentinel pile, located at distal end of fissure, along w/ deep ulcer suggests chronicity
**Often misdiagnosed as an external hemorrhoid
===Treatment===
#Hot sitz baths 15 min TID-QID and after each bowel movement
##Provides symptomatic relief and relieves anal sphincter spasm
#High-fiber diet
##Prevents stricture formation by providing a bulky stool
#Local analgesic ointments with hydrocortisone
#Meticulous anal hygiene is imperative; after defecation anus must be cleaned thoroughly
#Surgical referral indicated if healing does not occur in a reasonable amount of time


===Complications===
==Clinical Features== <!--T:3-->
#Perianal abscess
#Intersphincteric abscess


==Fistula In Ano==
===Background===
*Inflammatory tract originating from infected anal gland connecting anal canal w/ skin
**May be intersphincteric, suprasphincteric, transsphincteric, or extrasphincteric
*Goodsall's Rule
**Draw imaginary line horizontally through the anal canal
***If external opening is anterior to this line fistula runs directly into the canal
***If external opening is posterior to this line fistula curves to post midline of canal
*Causes:
**Perianal/ischiorectal abscess, Crohn, UC, malignancies, STI, fissures, FBs, TB
===Clinical Features===
*Fistulous tract open: Persistent, painless, blood-stained, mucous, malodorous discharge
*Fistulous tract blocked: Bouts of inflammation that are relieved by spontaneous rupture
*Abscess
**Throbbing pain that is constant and worse w/ sitting, moving, defecation
**May be only sign of fistula
*Fistulous opening
**Adjacent to anal margin suggests superficial connection (e.g. intersphincteric region)
**Distant from anal margin suggests deeper, more superior abscess
===Diagnosis===
*Endocavitary US w/ 3% hydrogen peroxide for definitive diagnosis


==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>


==DDX==
#Crohn disease
##Often painless
#Squamous cell carcinoma of anus
#Adenocarcinoma of rectum invading the anal canal
#Syphilitic fissure
#GC/Chlam


==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>

Latest 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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