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Project: Ghana Emergency Medicine Collaborative
Document Title: Emergency Management of Ano-Rectal Disorders
Author(s): Joseph H. Hartmann (University of Michigan), DO 2012
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Hemorrhoids
• Symptoms – itching, pain, bleeding, protrusion
• External hemorrhoids – asymptomatic unless thrombosed
• Internal hemorrhoids – – Bleeding – typically bright red on stool – but
not mixed in stool– Protrusion – soiling / mucus discharge
incarcerated/strangulated
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Hemorrhoids
• Pathogenesis– Inadequate dietary fiber– Prolonged sitting on comode– Chronic straining– Prolonged sitting (occupational)– Medical conditions causing increased venous
pressure• Pregnancy, ascites, pelvic tumor
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Thrombosed Hemorrhoids
• External – most common– Acute onset anal pain– Palpable perianal mass
• Internal – far less common– Pain– Pressure– Bleeding
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Gray’s Anatomy, 20th edition, Wikimedia Commons12
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Hemorrhoids - treatment
• Medical– Sitz baths– Increased dietary fiber– Stool softener– OTC topical agents / suppositories– Prescription topical agents / suppositories
• Anusol / Anusol HC
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Hemorrhoids - treatment
• Surgical– Sclerotherapy (injection of phenol in oil or hypertonic
salt solution causing thrombosis of vessels and sclerosis of connective tissue)
– Cryotherapy– Rubber band technique
– Bipolar diathermy
– Direct-current electrotherapy
– Infrared photocoagulation– Surgical excision
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Rectal Prolapse (Procedentia)
• Passage (herniation) of a portion or all of rectal mucosa thru external anal sphincter
• Type I – false procedentia– Partial / mucosal prolapse less than 2 cm long– Produces radial folds
• Type II – true procedentia– Complete / full thickness rectal wall extrusion– Extends 2 – 5 cm– Produces circular / concentric folds
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Dr. K.-H. Günther, Klinikum Main Spessart, Lohr am Main, Wikimedia Commons23
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Rectal Prolapse
• Increased intra-abdominal pressure– Chronic constipation, protracted coughing,
forceful vomiting
• Diarrheal disease
• Cystic fibrosis
• Malnutrition• Pelvic floor weakness
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Leonard Portal Mark, St. Bartholomew’s Hospital Archives & Museum, London, UK, Wellcome Images 30
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Anal Fissure (fissure-in-ano)
• Split in squamous epithelium at or just inside the anal verge (efface anal canal)
• Sharp cutting anal pain with defecation that is relieved in-between defecations
• Sentinel skin tag ( sentinel pile) present
• Occurs in midline –posteriorly (90% male and 75% female)
• Predominately noted in young adults
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Armin Kübelbeck, Wikimedia Commons 32
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Anal Fissure
• Treatment– Sitz baths– Topical analgesics– Surgery for chronic lesions or intractable pain– Diminish resting anal sphincter pressure
• Nitroglycerin or calcium channel blocking agents
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Cryptitis (Papilitis)
• Inflammation of mucosal lining over crypts (? passage of hard stools)
• Predisposes to inflamation of anal glands leading to abscess formation and possible eventual fistula formation
• Characterized by– Anal pain exacerbated with defecation– +/- bleeding and/or pruritis– Tender swollen crypts on palpation
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Cryptitis
• Treatment– Sitz baths– Warm rectal irrigation– Bulk laxatives– Proctofoam HC
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Ano-rectal Abscess
• Originates from infected anal glands at dentate line
• Perianal• Ischiorectal (buttocks)
• Intersphincteric (fluctuance in lumen)
• Supralevator (CT diagnosis)• Horseshoe / deep posterior anal space
– bilateral ischiorectal space abscess39
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Ano-rectal Abscess
• Symptoms – dull aching, throbbing pain worse before defecation and persists between defecations
• Treatment– Incision and drainage– Antibiotics if
• Extensive cellulitis• Diabetes• Valvular heart disease• Immunosuppression
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Anal Fistula
• Uncommon in general population– Anorectal malignancy– Leukemia– Radiation proctitis– Actinomycosis– Lymphogranuloma venereum– Inflammatory bowel disease (Crohn’s)
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Marc A Levitt, Alberto Peña. Anorectal malformations. Orphanet Journal of Rare Diseases. 2, 33. 2007, Wikimedia Commons45
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Venereal Proctitis• Characterized by pruritis, discharge, mild –
moderate pain or irritation, tenesmus• Usual etiologies
– Viral• Herpes simplex type 2• Human immunodeficiency virus• Papillomavirus (condylomata accuminata)
– Bacterial• Neisseria gonorrhea• Chlamydia trachomatis• Treponema pallidum (condylomata lata –secondary syphillis)
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