Chapter 47. Anorectal Disorders

Anorectal disorders may be due to local disease processes or underlying serious systemic disorders. Most anorectal diseases originate in the anal crypts, glands, internal hemorrhoidal plexus, and external hemorrhoid veins. More serious life-threatening infections tend to lie in the deeper tissues such as the ischiorectal and pelvirectal spaces.

After a detailed history, a digital examination of the rectum should be performed, followed by anoscopy in the left lateral decubitus position. The supine or lithotomy position should be used for debilitated patients.

Skin tags are usually asymptomatic minor projections of the skin at the anal verge, which may be from residual prior hemorrhoids. Most are asymptomatic but inflammation may cause itching or pain.

Engorgement, prolapse, or thrombosis of the internal or external hemorrhoidal vein(s) is termed hemorrhoids.

Diagnosis and Differential

Internal hemorrhoids are not readily palpable and are best visualized through an anoscope. They are found at 2, 5, and 9 o'clock positions when patients are prone. Constipation, pregnancy, ascites, ovarian tumors, radiation fibrosis, and increased portal venous pressure are some of the common causes of hemorrhoids. Rectal and sigmoid colon tumors should be considered in patients older than 40 years.

Clinical Features

Patients report painless, bright red rectal blood on the surface of the stool, toilet tissue or dripping into the toilet bowl after defecation. Thrombosed hemorrhoids are usually painful and may appear as a bluish-purple mass protruding from the rectum. Large hemorrhoids may result in prolapse that may spontaneously reduce or require periodic manual reduction by patients or clinicians. They may become incarcerated and gangrenous, and require surgical intervention. Prolapse may cause mucous discharge and pruritus. If not reduced, severe bleeding, thrombosis, infarction, incarceration, urinary retention, or sepsis may occur.

Emergency Department Care and Disposition

Unless a complication is present, management is usually nonsurgical.

1. Hot sitz baths for at least 15 min, 3 times per day, and after each bowel movement will reduce pain and swelling. After the sitz baths, the anus should be gently but thoroughly dried.

2. Topical steroids and analgesics may provide temporary relief. Bulk laxatives, such as psyllium seed compounds or stool softeners, should be used after the acute phase has subsided. Laxatives causing liquid stool are contraindicated as they may result in cryptitis and sepsis.

3. Surgical treatment is indicated for severe, intractable pain, continued bleeding, incarceration, or strangulation.

4. Acute and recently thrombosed painful hemorrhoids (<48 hours) can be treated with clot excision. After analgesia, with a long acting local anesthetic such as 0.5% bupivacaine with epinephrine, an elliptical skin incision is made over the hemorrhoids and the thrombosed clot is evacuated. (Fig. 47-1). Hemostasis is achieved by packing and pressure dressing. The pressure dressing may be removed after about 6 hours, when the patient takes the first sitz bath. Refer for definitive hemorrhoidectomy.