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536 SECTION 9: Gastrointestinal Disorders of bowel remains inside the hernia sac even after reduction, so that the retained bowel remains incarcerated.22,24 In cases of reduction en masse, the patient will continue to exhibit signs and symptoms of incarceration despite apparent clinical reduction. Imaging can assist in the detection of this distinctly uncommon but serious diagnosis. If there is any concern for strangulation, do not attempt hernia reduction. The reintroduction of ischemic, necrotic bowel back into the peri toneal cavity can result in subsequent perforation and sepsis. 25 Bedside US using a linear high-frequency probe with color or power Doppler of the hernia sac can be useful in borderline cases to establish the presence or absence of arterial blood flow. Acknowledgments: The author gratefully acknowledges the contributions of Frank W . Lavoie and Mary Harkins Becker, the coauthors of the chapter on hernias in adults and children in the previous edition. (Hernia in children is now discussed in Chapter 133.) REFERENCES The complete reference list is available online at www.TintinalliEM.com. Anorectal Disorders Jeremy G. Berberian Brian E. Burgess INTRODUCTION Anorectal disorders range from simple to complex and can manifest signs and symptoms of underlying serious local or systemic disorders that may be life threatening. Precise causes may be difficult to deter mine; thus, a focused history and careful examination can narrow the differential diagnosis and aid timely and appropriate management. ANATOMY The rectum begins at the S3 vertebral body and descends for about 13 to 15 cm becoming the anus, which is comprised of the anal canal, anal verge, and anal margin. The rectum narrows and traverses through the muscular pelvic floor, at the level of the levator ani and coccygeal muscles, and becomes the anal canal, 4 cm in length, surrounded by the anal sphincter muscle. The dentate line marks the junction of these two structures as the anal canal continues more distally joining the perianal skin at the anal verge (Figure 85-1). The anal canal mucosa consists of stratified squamous epithelium and contains no hair follicles or sweat glands. At the anal verge, the anoderm thickens and includes hair follicles and other cutaneous appendages. Proximal to the dentate line, the rectal ampulla narrows to conform to the opening of the anal canal. In doing so, its mucosa takes on a pleated appearance, forming 8 to 14 convoluted longitudinal folds: the columns of Morgagni. Each adjacent column is connected at the dentate line by a flap of mucosa that forms a small anal crypt, normally 1 to 3 mm deep. Anal sepsis, cryptitis, perianal abscesses, and fistulas result from inflammation, obstruction, and infection of the crypts and glands. Just proximal to the dentate line, the mucosa transitions from rectal columnar to cuboidal to squamous epithelium. The submucosa, which normally contains the bulk of the bowel’s blood vessels and autonomic nerves, thickens considerably proximal to the dentate line. The superior hemorrhoidal artery, from the internal mesenteric artery, supplies the proximal two thirds of the rectum, whereas the middle CHAPTER hemorrhoidal artery, from the internal iliac artery, supplies the distal one third of the rectum. The inferior hemorrhoidal artery supplies the anus, but also supplies the rectum by a submucosal network. The venous and lymphatic system mirrors the arterial supply.

al two thirds of the rectum, whereas the middle CHAPTER hemorrhoidal artery, from the internal iliac artery, supplies the distal one third of the rectum. The inferior hemorrhoidal artery supplies the anus, but also supplies the rectum by a submucosal network. The venous and lymphatic system mirrors the arterial supply. The superior rectal vein drains into the portal system, whereas the middle rectal vein drains into the inferior vena cava. The inner circular muscle layer of the rectum thickens considerably as it terminates distally in the anorectum to form the involuntary internal sphincter muscles. The more attenuated longitudinal muscles of the rectum extend caudally, blending with fibers of voluntary skeletal muscles from the levator ani and external sphincter groups, to form the intersphincteric space (Figure 85-1). The external sphincters are voluntary skeletal muscles and are actually a caudal extension of the puborectalis muscle, which interacts with the levator ani muscle, forming the pelvic floor. The puborectalis, the proximal external sphincters, and the internal sphincters form the ring of muscles that one palpates when performing a digital examination of the anorectum. Lateral to the external sphincters is the ischiorectal space, and supe rior to the levator ani is the supralevator (pelvirectal) space, where deep, life-threatening infections can occur. Inferior mesenteric and para-aortic nodes drain the proximal two thirds of the rectum, whereas the lower one third of the rectum and proximal anal canal are drained by both the inferior mesenteric nodes and the internal iliac nodes. The inguinal nodes usually drain lymphatics distal to the dentate line. Proximal to the dentate line, the anus is supplied by the sympathetic and parasympathetic nerves, yet is devoid of somatic pain fibers, unlike distal to the dentate line, where somatic fibers are present. Parasympa thetic nervous stimulation (S2 to S4) contracts the rectal wall and relaxes the internal anal sphincter, whereas sympathetic stimulation (L1 to L3) maintains continence through rectal wall inhibition and contraction of the internal anal sphincter. PHYSICAL EXAMINATION A definitive diagnosis cannot be made without a careful examination of the anus and rectum. Patient education before and during the examination will be helpful in obtaining maximal cooperation. The lateral or Sims position is the most common position for routine digital rectal examination and anoscopy. This position is preferred for the elderly or pregnant women. Elevating the upper buttock provides better exposure of the perianal area. In debilitated patients, one may have to perform the examination with the patient in a supine, lithotomy position. A digital examination of the entire inner wall with a lubricated index finger should always be performed before doing any endoscopic pro cedure. In men, palpate the prostate to determine its size, texture, and tenderness or if masses are present. In women, palpate the posterior vaginal wall for a mass, rectocele, or rectovaginal fistula. Note anal tone and sensation. After performing a digital rectal examination, one can determine that the patient will tolerate passage of an anoscope. No bowel preparation is required for anoscopy, suction should be available, and cultures can be obtained. Introduce a well-lubricated, lighted anoscope with the obturator in place. Next, remove the obturator, and gently rotate the anoscope as needed to view the anorectum circumferentially while withdrawing the anoscope (Figure 85-2). The anal mucosa, fissures, external and internal hemorrhoids, condyloma, dentate line, and distal rectal mucosa can be evaluated with the use of an anoscope. More proximal sources of rectal bleeding may be distinguished utilizing the anoscope.

he anorectum circumferentially while withdrawing the anoscope (Figure 85-2). The anal mucosa, fissures, external and internal hemorrhoids, condyloma, dentate line, and distal rectal mucosa can be evaluated with the use of an anoscope. More proximal sources of rectal bleeding may be distinguished utilizing the anoscope. After visual inspection, ask the patient to bear down to detect any rectal mucosal prolapse. ANAL TAGS Skin tags are minor projections of skin at the anal verge and are some times residuals of prior hemorrhoids (Figure 85-3).  CLINICAL FEATURES Skin tags are usually asymptomatic, but inflammation may cause itch ing and pain. Skin tags covering anal crypts, fistulas, and fissures are Tintinalli_Sec09_p0473-0562.indd 536 8/2/19 6:50 PM

inor projections of skin at the anal verge and are some times residuals of prior hemorrhoids (Figure 85-3).  CLINICAL FEATURES Skin tags are usually asymptomatic, but inflammation may cause itch ing and pain. Skin tags covering anal crypts, fistulas, and fissures are Tintinalli_Sec09_p0473-0562.indd 536 8/2/19 6:50 PM CHAPTER 85: Anorectal Disorders 537 Bowel wallExternal Sphincters Lumen Valves of Houston Internal hemorrhoidal plexus Columns of Morgagni Dentate line Longitudinal muscle fibers (intersphincteric plane) External hemorrhoidal veins Anal papilla Anal glands Subcutaneous Superficial Deep Anal crypt Puborectalis Pelvirectal space Submucosa Serosa/peritoneum Circular muscles Longitudinal muscles FIGURE 85-1. Coronal section, anorectum. called “sentinel tags. ” Surgical referral for excision and/or biopsy is warranted because inflammatory bowel disease may be associated with sentinel tags. HEMORRHOIDS  ANATOMY Hemorrhoids are vascular cushions that become enlarged and distally displaced within the anal canal. Current theory suggests that there is anal canal sliding and that hemorrhoidal formation occurs when the supporting tissues of these cushions deteriorate. 1 Consequently, the downward displacement of these cushions causes the internal and external hemorrhoidal plexuses to become excessively engorged, referred to as hemorrhoids—one of the most common problems afflicting human beings (Figure 85-4). Hemorrhoids may become inflamed, thrombosed, prolapsed, ulcer ated, or ischemic. Internal hemorrhoids originate proximal to the dentate line, from terminal branches of the superior rectal artery. They are constant in their location, coursing longitudinally at the right posterolateral, right anterolateral, and left lateral positions; 2-, 5-, and 9-o’ clock positions, when the patient is viewed prone (Figure 85-5A). Commonly, they are single and are located at the 5-o’ clock posi tion. Internal hemorrhoids are not readily palpable and can best be visualized through an anoscope. Their appearance is consistent with the columnar epithelial surface of the surrounding anal canal (Figure 85-5B). External hemorrhoids, distal to the dentate line , are located anywhere along the anoderm, form as a result of dilatation of veins at the anal verge, and can be seen at external inspection . Their appearance is consistent with the stratified squamous epithelium of the surrounding anoderm, which has exquisite sensory innervation.  CLINICAL FEATURES Enlarged hemorrhoids are associated with constipation and prolonged straining at stool, frequent diarrhea, and older age. Increased abdominal pressure may cause obstruction of venous return and engorgement of the hemorrhoidal plexus. Consider inflammatory bowel disease in patients with frequent diarrhea and hemorrhoids. Hemorrhoidal veins can have high resting pressures and are devoid of valves, and as patients age, the supportive connective tissue surrounding the vasculature diminishes. Hemorrhoids can develop during pregnancy and may be the result of sustained increased pressure on the venous drainage of the rectum. Increased portal pressure, from chronic liver disease, may produce marked dilatation and varix formation, distinct from true hemorrhoids, resulting in bleeding that can be extremely difficult to control. Tumors of the rectum and sigmoid colon, often associated with constipation, tenesmus, and incomplete evacuation, may cause hemorrhoids. Although the most common cause of bright red rectal bleeding is hemorrhoids, tumors must be ruled out as a cause of rectal bleeding in patients >40 years of age. Ascites, ovarian tumors, distended bladders, and excessive fibrosis from radiation therapy may contribute to the formation of external hemorrhoids.

morrhoids. Although the most common cause of bright red rectal bleeding is hemorrhoids, tumors must be ruled out as a cause of rectal bleeding in patients >40 years of age. Ascites, ovarian tumors, distended bladders, and excessive fibrosis from radiation therapy may contribute to the formation of external hemorrhoids. Hemorrhoidal bleeding is usually limited, with the bright red blood on the surface of the stool, on the toilet tissue, or noted at the end of defecation, dripping into the toilet bowl. When patients describe the passage of blood clots, one should suspect colonic lesions. Chronic slow blood loss detected on fecal occult blood testing resulting in anemia requires further investigation. Hemorrhoids themselves generally do not cause pain unless they are thrombosed or are strangulated fourth-degree internal hemorrhoids. If the patient complains of pain, but on examination the hemorrhoids are not thrombosed, suspect perianal or intersphincteric abscesses or anal fissures. Thrombosed external hemorrhoids are pain ful and are often described as a burning perianal lump, and they usually exhibit a bluish-purple discoloration ( Figure 85-6). Hemorrhoids may become more prominent with a Valsalva maneuver. As hemorrhoids increase in size, they may prolapse, requiring periodic reduction by the patient. Pain can be quite severe at the time of defecation and usually subsides with time. Uncomplicated internal hemorrhoids are painless due to visceral innervation and lack of sensory innervation. Anoscopy reveals bulging, purple-colored veins at the distal rectum or anal canal ( Figure 85-7). Often a chief complaint is painless, bright red rectal bleeding with defecation. Internal hemorrhoids may be palpable on digital examina tion when thrombosed or prolapsed. 2 Nonreducible, prolapsed, internal hemorrhoids may become thrombosed and strangulated. They appear dark red, exhibit rectal bleeding, and cause exquisite pain and possibly urine retention. Ulceration, necrosis, gangrene, sepsis, and hepatic abscess formation may ensue. Internal hemorrhoids are classified by the amount of prolapse into the anal canal.  TREATMENT Conservative therapy with warm baths is often successful for mild to moderate symptomatic grade I (luminal protrusion above dentate line) and II (prolapse with spontaneous reduction) internal hemorrhoids. Manual reduction of grade III (prolapse needing manual reduction) internal hemorrhoids and warm baths (which decrease sphincter pressures) for at least 15 minutes three times a day and after each bowel movement are the most effective ways to relieve symptoms. After the Tintinalli_Sec09_p0473-0562.indd 537 8/2/19 6:50 PM

anual reduction of grade III (prolapse needing manual reduction) internal hemorrhoids and warm baths (which decrease sphincter pressures) for at least 15 minutes three times a day and after each bowel movement are the most effective ways to relieve symptoms. After the Tintinalli_Sec09_p0473-0562.indd 537 8/2/19 6:50 PM 538 SECTION 9: Gastrointestinal Disorders 1. B 3. 2. FIGURE 85-2. A. Anoscope. B. Anoscope insertion technique (1, 2, and 3). [Reproduced with permission from Reichman EF: Emergency Medicine Procedures, 2nd ed. McGraw-Hill, Inc., 2013. Figure 70-5A-C.] FIGURE 85-3. Anal skin tag. bath, the anus must be dried gently but thoroughly to avoid maceration of the perianal skin. Topical analgesics and steroid-containing ointments may provide relief. The patient should not sit on the commode for a prolonged period. Bulk laxatives and stool softeners should be used after the acute phase is treated. Avoid the use of laxatives causing liquid stool, because cryptitis and anal sepsis can result. A high-fiber, low-fat diet, with increased water consumption, regular exercise, and avoidance of constipating medications, should help prevent future problems. Recommend surgical referral for symptomatic hemorrhoids, because a variety of procedures (sclerosing injections, rubberband ligation, photocoagulation, cryotherapy, electrocautery, laser treatments, radiofrequency ablation, staple repair, or excision) can provide definitive treatment. A rare complication of hemorrhoidal banding is pelvic sepsis. 2 Obtain Tintinalli_Sec09_p0473-0562.indd 538 8/2/19 6:50 PM

(sclerosing injections, rubberband ligation, photocoagulation, cryotherapy, electrocautery, laser treatments, radiofrequency ablation, staple repair, or excision) can provide definitive treatment. A rare complication of hemorrhoidal banding is pelvic sepsis. 2 Obtain Tintinalli_Sec09_p0473-0562.indd 538 8/2/19 6:50 PM CHAPTER 85: Anorectal Disorders 539 Thrombosed internal hemorrhoid Internal hemorrhoid External hemorrhoids Anal verge Thrombosed external hemorrhoid FIGURE 85-4. Coronal section of anorectum. Anterior Internal hemorrhoids Posterior Left Right FIGURE 85-5. A. Internal hemorrhoids at 2, 5, and 9 o’clock. B. Protrusion of internal hemorrhoids. FIGURE 85-6. Nonthrombosed ( A) and thrombosed ( B) external hemorrhoids. [Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 2nd ed. © 2002, McGraw-Hill, Inc., New York.] Engorge fine vessels of hemorrhoid plexus Internal anal verge Flexible endoscope in retroflexed position Excoriated bleeding internal hemorrhoidal tissue FIGURE 85-7. Grade I internal hemorrhoids. [Photo contributor: Philip E. Stack, MD.] surgical evaluation in the ED for continued and severe bleeding, pain, incarceration, and/or strangulation (grade IV internal hemorrhoids, nonreducible prolapse). Early external hemorrhoidal thrombosis is usually self-limiting, with resolution in 1 week. Therapy for thrombosed external hemorrhoids depends on the severity of symptoms. If the thrombosis has been present for more than 48 hours, the swelling has started to shrink, the hemorrhoid is not tense, and the pain is tolerable, the patient may be treated with warm baths and bulk laxatives. Suppositories, which are placed proximal to the anorectal ring, are of no help. If, on the other hand, the thrombosis is acute, has lasted less than 48 hours, and is extremely painful, significant relief can be provided by clot excision. Excision of thrombosed external hemorrhoids should not be performed in the ED on immunocompromised patients, children, pregnant women, patients with portal hypertension, and those who are anticoagulated or have a coagulopathy. Obtain optimal exposure by placing the patient in the side-lying or prone position. The area of the overlying skin to be incised is infiltrated using a 30-gauge needle with a local anesthetic such as bupivacaine 0.5%, with epinephrine (1:200,000), and bicarbonate buffering. An elliptical incision distal to Tintinalli_Sec09_p0473-0562.indd 539 8/2/19 6:50 PM

patient in the side-lying or prone position. The area of the overlying skin to be incised is infiltrated using a 30-gauge needle with a local anesthetic such as bupivacaine 0.5%, with epinephrine (1:200,000), and bicarbonate buffering. An elliptical incision distal to Tintinalli_Sec09_p0473-0562.indd 539 8/2/19 6:50 PM 540 SECTION 9: Gastrointestinal Disorders the anal verge in the overlying skin will expose the thrombosis. Remove the clot through the incision site. Because multiloculated clots can be present, the technique of unroofing a thrombosed hemorrhoid with an elliptical incision and removing the overlying skin gives far better results than the simple incision and evacuation of a clot (Figure 85-8, A–D). Control the bleeding by tucking the corner of a small piece of gauze into the wound and leaving it in place for a few hours. A small pres sure dressing may be applied external to the gauze and removed when the patient takes the first warm bath in 6 to 12 hours. Opioids should be prescribed only at the lowest dose and shortest time necessary for acute pain control, as opioids cause constipation. Complications, such as continued bleeding, recurrence, infection, fistula, and abscess formation, may occur; thus, follow-up in 24 to 48 hours is recommended. Referral for definitive hemorrhoidectomy is prudent. Recently, small studies suggest that patients with acutely thrombosed internal or external hemorrhoids can be treated with topical nifedipine and 1.5% lidocaine ointment or isosorbide dinitrate ointment with surgical follow-up. 2,3 ANAL FISSURES  ANATOMY An anal fissure is the result of a superficial linear tear of the anal canal below the dentate line and extending distally to the anal verge (Figure 85-9). Acute fissures are present for less than 6 weeks; fissures are chronic if they persist longer. The mucosa of the anal canal has a rich supply of somatic sensory nerve fibers. Chronic anal fissures are pale in color with edema of the surrounding tissues. Fissures persist because of the severe, chronic, internal sphincter spasm that may occur along with development of a secondary infection at its base. The fissure edges become fibrotic and raised, possibly exposing sphincter fibers, hypertrophic papillae proximally, and the characteristic sentinel tag distally. The latter is frequently misdiagnosed as an external hemorrhoid when, in actuality, it is the result of edema and fibrosis secondary to the ulcerating fissure. The fissure may become inflamed and form a perianal or intersphincteric abscess that may drain into the anal canal or in the posterior midline externally.  CLINICAL FEATURES Anal fissures are usually single and occur in the midline posteriorly in 80% to 90% of cases. 4 The posterior location of anal fissures may be because of the posterior angulation of the rectum on the anus where the posterior midline of the anorectal canal becomes the “lesser curva ture” for the passage of stool. Anterior anal fissures are associated with younger age (33 years vs. 41 years for posterior fissures), female sex, obstetric trauma, and occult external anal sphincter injury. 5 A chronic nonhealing fissure, lasting more than 6 weeks, or one not located in the midline should arouse suspicion that another, potentially serious cause may be involved. Such diagnostic possibilities include Crohn’s disease, chronic ulcerative colitis, squamous cell carcinoma of the anus, adeno carcinoma of the rectum invading the anal canal, localized anal cancers such as Bowen’s disease and extramammary Paget’s disease, leukemia, lymphoma, syphilitic fissures, chlamydia, gonorrhea, human immuno deficiency virus, and a tuberculous ulcer.

chronic ulcerative colitis, squamous cell carcinoma of the anus, adeno carcinoma of the rectum invading the anal canal, localized anal cancers such as Bowen’s disease and extramammary Paget’s disease, leukemia, lymphoma, syphilitic fissures, chlamydia, gonorrhea, human immuno deficiency virus, and a tuberculous ulcer. Consideration of these diagnoses requires referral for diagnostic biopsy of the ulcer edge, culture of the anal canal, and a systemic evaluation. Fissures due to Crohn’s disease are multiple, off midline, and asymptomatic more commonly than in the general population. 6 Most often, the traditional midline anal fissure is caused by the trauma produced by the passage of a particularly hard and large fecal mass, but it also may be seen after frequent acute epi sodes of diarrhea. Children with constipation will commonly complain of painful defecation only to find an anal fissure upon closer inspection (Figure 85-9A). Child abuse should be considered as a possible cause (Figure 85-9B). Anal fissures are characterized by tearing pain with defecation and rectal bleeding. The pain may persist as a dull ache and burn ing sensation for a few hours after each bowel movement. Invariably it subsides between movements, which is a feature that distinguishes fissures from other forms of painful anorectal disease. The bleeding FIGURE 85-8. Excision of the thrombosed external hemorrhoid. A. The dotted line represents the incision lines to remove the skin and underlying thrombosis. B. Injection of local anesthetic solution. C. The skin incision has already been performed. The skin and underlying thrombosis are dissected free with scissors. D. The ellipse of skin and the underlying thrombosis have been removed. The fibers of the underlying external anal sphincter muscle are visible. [Reproduced with permission from Reichman EF: Emergency Medicine Procedures, 2nd ed. McGraw-Hill, Inc., 2013. Figure 68-4 A-D.] Tintinalli_Sec09_p0473-0562.indd 540 8/2/19 6:50 PM

he ellipse of skin and the underlying thrombosis have been removed. The fibers of the underlying external anal sphincter muscle are visible. [Reproduced with permission from Reichman EF: Emergency Medicine Procedures, 2nd ed. McGraw-Hill, Inc., 2013. Figure 68-4 A-D.] Tintinalli_Sec09_p0473-0562.indd 540 8/2/19 6:50 PM CHAPTER 85: Anorectal Disorders 541 FIGURE 85-9. Anal mucosal fissures. A. Constipation. B. Sexual assault. [A: Photo contributor: Paul J. Kovalcik, MD. Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 4th ed. © 2016, McGraw-Hill, Inc., New York. Figure 9-32; B: Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 4th ed. © 2016, McGraw-Hill, Inc., New York.] is bright red and small in quantity, usually being noticed only on the toilet paper. In infants, the presence of small amounts of bright red blood on the stool or toilet paper is usually the presenting complaint from an anal fissure. Sphincter spasm and pain may be severe enough to make the patient retain stool and avoid defecation. The diagnosis of an anal fissure is usually suggested by the history, but the anal area must be examined in all cases. Fissures may often become more noticeable if the patient bears down as if having a bowel movement. With the patient relaxed, gentle separation of the buttocks will often expose the fissure. The mere retraction of the buttocks and the anal skin may cause considerable spasm and discomfort and may not permit digital examination. Topical 2% lidocaine jelly may provide some relief for examination, but severe pain may require sedation. If the fissure can be visualized, and is present in the posterior midline, rectal examination can be deferred until the patient is having less spasm and pain.  TREATMENT Healing is by the development of granulation tissue and the reepi thelialization of the ulcerated area. Most uncomplicated acute fissures will heal in a few weeks, but relapse can be as high as 50%. If healing does not occur within 6 weeks or relapses are frequent, surgical referral is recommended. Treatment is aimed at providing symptomatic relief, extinguishing the anal sphincter spasm, and preventing stricture formation. Warm baths for at least 15 minutes three to four times a day and after each bowel movement along with stool softeners may suffice. The addition of fiber to the diet will serve to prevent stricture formation by providing a bulky stool. Warm baths and increased fiber will result in healing in about half of all anal fissures. 6 Topical lidocaine ointments and 1% hydrocortisone creams may provide symptomatic relief. Medical therapies for anal fissure are generally no more effective than placebo, and for chronic fissures, all medical therapies are less effective than surgery. 7,8 ANAL STENOSIS Anal stenosis occurs when the pliable tissue is replaced by scarred fibrotic tissue. Congenital and primary causes may occur, yet second ary causes are more common. Stenosis most commonly occurs after surgical hemorrhoidectomy.4 Other causes include radiation, fistulec tomy, trauma, inflammatory bowel disease, chronic laxative use, sexually transmitted diseases, and chronic diarrhea.  CLINICAL FEATURES Typical complaints include constipation, bleeding, pain with stool evacuation, and narrow-caliber stools. As stenosis progresses, performing a digital exam with the little finger is met with severe resistance. Inconti nence secondary to overflow constipation may occur. Careful specialist examination, often with sedation, may be necessary.  TREATMENT Treatment involves stool softeners, fiber supplementation, and daily gradual anal dilatation after initial dilatation in the operating room.

inger is met with severe resistance. Inconti nence secondary to overflow constipation may occur. Careful specialist examination, often with sedation, may be necessary.  TREATMENT Treatment involves stool softeners, fiber supplementation, and daily gradual anal dilatation after initial dilatation in the operating room. Stricturotomy and stricturoplasty are used when conservative manage ment has failed. CRYPTITIS Anal crypts are superficial mucosal pockets that lie between the columns of Morgagni. Formed by the puckering action of the sphincter muscles, crypts normally flatten out during the passage of a stool. Sphincter spasm and superficial trauma caused by repeated bouts of diarrhea or chronic constipation may cause breakdown in the mucosal lining of the crypts, leading to cryptitis. Infecting organisms enter crypt pockets, and inflammation extends into the lymphoid tissue of both the crypts and anal glands. Cryptitis could well be the common denominator for the development of fissurein-ano, fistula-in-ano, and perirectal abscesses (Figure 85-10, A and B). Visualized by anoscopy, the anal papillae appear as slight projections of pink epithelium that produce the serrated appearance of the dentate line. Initially, the locally inflamed crypts are asymptomatic, producing a bead-like spot of pus. Inflammation of the crypts extends to the adjacent papillae. Hypertrophied anal papillae may be palpated as small, hard nodules and are associated with cryptitis.  CLINICAL FEATURES Anal pain, spasm, and itching with or without bleeding are the cardinal signs and symptoms of cryptitis. Rarely, papillae may hypertrophy and Tintinalli_Sec09_p0473-0562.indd 541 8/2/19 6:50 PM

lae. Hypertrophied anal papillae may be palpated as small, hard nodules and are associated with cryptitis.  CLINICAL FEATURES Anal pain, spasm, and itching with or without bleeding are the cardinal signs and symptoms of cryptitis. Rarely, papillae may hypertrophy and Tintinalli_Sec09_p0473-0562.indd 541 8/2/19 6:50 PM 542 SECTION 9: Gastrointestinal Disorders present as a prolapsing polypoid tumor. The crypts most commonly involved are in the posterior half of the anal ring and, in most cases, in the posterior midline, the same location where anal fissures occur. The definitive diagnosis of cryptitis is made by visualization of the ery thema, inflammation, and pus during anoscopic examination.  TREATMENT Treatment when the patient is symptomatic includes bulk laxatives and additional roughage added to the diet to produce formed, soft stools. Warm baths enhance healing by keeping the anus clean and the crypts empty. Refer to a surgeon for drainage when the infection has progressed and there is a deep, redundant crypt that will not drain adequately on its own. Cryptitis may be associated with underlying infections from parasites, inflammatory disorders, and localized trauma. FISTULA-IN-ANO Fistula-in-ano may result after drainage of an anorectal abscess. Fis tulas may also be associated with ulcerative colitis, Crohn’s disease, colonic malignancies, radiation, leukemia, sexually transmitted disease, actinomycosis, anal fissures, foreign bodies, or tuberculosis. Fistula-inano originates from an infected crypt and tracks to the skin. Fistulas are characterized according to the relationship to the anal sphincter: submucosal, intersphincteric, suprasphincteric, transsphincteric, or extrasphincteric (Figure 85-10). Goodsall’s rule is used to help deter mine the location of the internal opening. Although anterior-opening fistulas tend to follow a simple, direct course to the anal canal, posterioropening fistulas may follow a devious, curving path, including some that are horseshoe-shaped, opening in the posterior midline.  CLINICAL FEATURES Open fistulous tracts may produce painless, blood-stained mucus, peri anal itching, and malodorous discharge. If the tract becomes blocked, inflammation may be followed by spontaneous rupture or abscess formation. Abscess formation is associated with throbbing pain that is constant and worsened by sitting, moving, and defecation. Induration or a fibrous cord (more chronic fistula) may be palpated. A fistulous opening adjacent to the anal margin suggests a more superficial connection from the intersphincteric region. An opening more proximal to the anal margin suggests a deeper, more superior abscess. In one study, endoscopic US was more accurate than CT scan (82% vs. 24%) in the evaluation of perirectal fistulas, although endoscopy was comparable to MRI (91% vs. 87%).  TREATMENT IV fluids, analgesics, antibiotics (ciprofloxacin and metronidazole), antipyretics, and surgical consultation are appropriate. Definitive treatment Inflammation of anal crypts (origin) Acute abscess formation in intersphincteric plane (acute phase) Formulation of fistula-in-ano (chronic phase) Upward extension of acute inflammation results in supralevator abscess; lateral in ischiorectal abscess; and downward in perianal abscess Chronic inflammation results in communication of abscess sites with surface, causing fistulas Puborectalis muscle Supralevator abscess Intersphincteric abscess (origin) Perianal abscess Ischiorectal abscess Extrasphincteric fistula Transphincteric fistula Intersphincteric fistula FIGURE 85-10. A and B. Illustration of the mechanism for anorectal abscess and fistula formation. Tintinalli_Sec09_p0473-0562.indd 542 8/2/19 6:50 PM

cle Supralevator abscess Intersphincteric abscess (origin) Perianal abscess Ischiorectal abscess Extrasphincteric fistula Transphincteric fistula Intersphincteric fistula FIGURE 85-10. A and B. Illustration of the mechanism for anorectal abscess and fistula formation. Tintinalli_Sec09_p0473-0562.indd 542 8/2/19 6:50 PM CHAPTER 85: Anorectal Disorders 543 may involve placement of a drain through the fistula, fibrin glue (fibrinogen, thrombin, and calcium), fistulotomy, fistulectomy, or more complex procedures. Improperly excised fistulas may result in perma nent fecal incontinence. Monoclonal antibody use may be considered in patients with Crohn’s disease. ANORECTAL ABSCESSES Anorectal abscesses, more common in middle-aged males, begin with involvement of an anal crypt and its gland. Abscesses are typically polymicrobial with both aerobic and anaerobic bacteria. Infection with Staphylococcus aureus, Streptococcus and Enterococcus species, Escherichia coli, Proteus, and Bacteroides can progress to involve any of the potential spaces that are normally filled with fatty areolar tissue with little inherent resistance to the progression of infection. These spaces include the perianal, submucosal, intersphincteric, ischiorectal, postanal (connecting the ischiorectal space on each side posteriorly), and supralevator (pelvirectal) (Figure 85-11, A–C). A variety of diseases and other conditions are less commonly asso ciated with the development of abscesses, including Crohn’s disease, carcinoma of the anorectum and adjacent organs, trauma, ulcerative colitis, radiation fibrosis, Hodgkin’s disease, tuberculosis, gonococcal proctitis, Chlamydia, Actinomyces, herpes, lymphogranuloma venereum, and immunocompromised states. The most common anorectal abscess location is perianal, and the least common is supralevator (pelvirectal) (Figure 85-11, C–E).  CLINICAL FEATURES Located close to the anal verge, often posterior midline, the perianal abscess is a superficial tender mass that may or may not be fluctuant (Figure 85-11D). Ischiorectal abscesses, which are the second most common, traverse the external anal sphincter; tend to be larger, indurated, and well circumscribed; and are located more laterally on the medial aspect of the buttocks (Figure 85-11C). The patient may exhibit edema, fever, and anorexia. The deeper postanal abscess may not manifest cutaneous signs, but rectal pain and tenderness are invariably present (Figure 85-12). Isolated perianal abscesses are generally the only type of anorectal abscess that can be adequately treated in the ED. Surgical referral after drainage is suggested because fistula formation is not uncommon. Clinical evaluation of a perianal abscess is usually sufficient, but CT or MRI is recommended if pain is out of proportion to physical findings or if the extent of the abscess is uncertain. Ischiorectal abscesses can be problematic and complicated as the ischiorectal fossa forms a large potential space on either side of the rectum, communicating behind it through the deep postanal space. Ischiorectal abscesses may be palpable through the rectal wall or on the overlying skin. Intersphincteric, submucosal, postanal, and supralevator abscesses may not demonstrate edema but are often associated with constitutional symptoms. Infections in this area are insidious and extensive and can spread to an area some distance from the anal verge. If a complicated abscess is suspected, obtain CT or MRI (Figure 85-13, A–B). Perianal abscesses are easily palpable at the anal verge, whereas deeper perirectal abscesses may be palpated through the rectal wall or more lateral to the anal verge, on the buttocks.

can spread to an area some distance from the anal verge. If a complicated abscess is suspected, obtain CT or MRI (Figure 85-13, A–B). Perianal abscesses are easily palpable at the anal verge, whereas deeper perirectal abscesses may be palpated through the rectal wall or more lateral to the anal verge, on the buttocks. Initially, the patient notices a dull, aching, throbbing pain that becomes worse immediately before defecation, is lessened after defecation, but persists between bowel movements. Pain is exacerbated by movement and sit ting. Perianal abscesses, unlike more complicated perirectal abscesses, are usually not accompanied by fever, leukocytosis, and sepsis in the immunocompetent patient. Pain is aggravated by straining or cough ing, particularly when due to intersphincteric abscesses. Ischiorectal abscesses are often painful on rectal examination and are lateral to the anal verge. Intersphincteric abscesses, painful with defecation, may be associated with rectal discharge and fever, and a tender mass may be palpable on digital examination of the rectal canal, often in the posterior midline. Supralevator abscesses, often an extension of an intersphincteric abscess, frequently present with few outward signs. Generalized, nondistinct perirectal pain with fever, malaise, leukocytosis, and urinary retention may occur. Tender inguinal adenopathy is often a clue to these deeper abscesses. Supralevator abscesses may be palpable on vaginal examination.  TREATMENT All perirectal abscesses (ischiorectal, submucosal, intersphincteric, and supralevator) should be drained in the operating room. Simple, isolated, fluctuant perianal abscesses may be drained in the ED using local anesthetics and, occasionally, procedural sedation. Adequate patient positioning, preparation, and good exposure are necessary. Lidocaine with epinephrine should be administered with a small-gauge needle. Needle aspiration (18-gauge) over the painful region may be done to localize the purulent pocket. US can delineate the size and depth of the abscess. Drainage can be accomplished with a linear or cruciate incision. If using a linear incision, loosely pack the abscess cavity with strips of gauze to prevent premature closure of the skin edges. To ensure adequate drainage, a cruciate incision can be made over the fluctuant part of the abscess. Trimming the flaps is suggested to prevent closure, and packing is not required (Figure 85-14, A and B). Cover the wound with a bulky dressing, and have the patient take frequent warm baths starting the next day. Antibiotics are not necessary after adequate drainage in healthy patients. Twenty-four hour followup is recommended. For the elderly or those with fever, leukocytosis, diabetes, valvular heart disease, cellulitis, or immunosuppression, give broad-spectrum antibiotics (e.g., piperacillin-tazobactam, 3.375 grams IV), obtain surgical consultation, provide tetanus prophylaxis as needed, and admit to the hospital. PROCTITIS Proctitis is inflammation of the rectal mucosa. Clinical manifestations often include anorectal pain, itching, discharge, ulcers, diarrhea, bleed ing, or lower abdominal cramping. Anoscopic examination may reveal mucosal inflammation, erythema, bleeding, ulcerations, and/or discharge. Proctitis may develop from prior radiation treatments, autoim mune disorders, vasculitis, ischemia, and infectious diseases, including enteric pathogens and sexually transmitted infections (Table 85-1). If the patient has an anorectal infection caused by a sexually trans mitted organism, screen for other sexually transmitted organisms. Also, obtain appropriate blood tests, specimens from anoscopy for Gram stain and cultures (viral and bacterial), and start empiric therapy.

sexually transmitted infections (Table 85-1). If the patient has an anorectal infection caused by a sexually trans mitted organism, screen for other sexually transmitted organisms. Also, obtain appropriate blood tests, specimens from anoscopy for Gram stain and cultures (viral and bacterial), and start empiric therapy. For detailed discussion of sexually transmitted infections, see Chapters 153, “Sexually Transmitted Infections, ” and 252, “Skin Disorders: Groin and Skinfolds. ”  ANORECTAL ACQUIRED IMMUNODEFICIENCY SYNDROME–RELATED INFECTIONS Patients rendered immunodeficient by human immunodeficiency virus are subject to a variety of opportunistic infections that affect the intestinal, anorectal, and other body systems ( Table 85-2). Severe rectal pain, diarrhea, and hematochezia are common presenting symptoms. Anoscopy confirms anal canal ulcers and acute proctitis. Obtain serology for syphilis, and start antibiotic therapy. Stool softeners, sitz baths, careful anal hygiene, and pain medi cations will provide some relief. Enteric pathogens may require antibiotics such as trimethoprim and sulfamethoxazole (Isospora ), metronidazole (Entamoeba , Giardia), azithromycin (Campylobacter ), acyclovir (herpes), or fluoroquinolones (Salmonella, Shigella). Provide empiric therapy against gonorrhea, nonlymphogranulomatous chlamydia, and incubating syphilis for human immunodeficiency virus– associated acute proctitis. Refer for appropriate follow-up, further evaluation, and definitive treatment. RECTAL PROLAPSE Rectal prolapse is the circumferential protrusion of part or all layers of the rectum through the anal canal. Basically, there are three types of rectal prolapse: (1) prolapse involving the rectal mucosa only, (2) prolapse Tintinalli_Sec09_p0473-0562.indd 543 8/2/19 6:50 PM

on, and definitive treatment. RECTAL PROLAPSE Rectal prolapse is the circumferential protrusion of part or all layers of the rectum through the anal canal. Basically, there are three types of rectal prolapse: (1) prolapse involving the rectal mucosa only, (2) prolapse Tintinalli_Sec09_p0473-0562.indd 543 8/2/19 6:50 PM 544 SECTION 9: Gastrointestinal Disorders Supralevator space Peritoneum Ischiorectal space Submucosal space Intersphincter space Perianal space Retrorectal space Supralevator space Deep postanal space Superficial postanal space Higher intermuscular Ischiorectal Perianal Intersphincteric Pelvirectal Submucosal FIGURE 85-11. A and B. Anatomic classification of anorectal spaces. C. Anorectal abscesses. D. Perianal abscess. E. Complicated perirectal abscess. [A and B: Reproduced with permission from Reichman EF, Simon RR: Emergency Medicine Procedures, © 2010, McGraw-Hill, Inc., New York. D: Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 4th ed. © 2016, McGraw-Hill, Inc., New York. E: Photo contributor: Lawrence B. Stack, MD. Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 4th ed. © 2016, McGraw-Hill, Inc., New York. Figure 9-35.] Tintinalli_Sec09_p0473-0562.indd 544 8/2/19 6:50 PM

ergency Medicine, 4th ed. © 2016, McGraw-Hill, Inc., New York. E: Photo contributor: Lawrence B. Stack, MD. Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 4th ed. © 2016, McGraw-Hill, Inc., New York. Figure 9-35.] Tintinalli_Sec09_p0473-0562.indd 544 8/2/19 6:50 PM CHAPTER 85: Anorectal Disorders 545 FIGURE 85-12. CT scan, postanal abscess (arrow). FIGURE 85-13. MRI of left ischiorectal abscess (arrows) in a pregnant woman, early second trimester. A. MRI of left ischiorectal abscess, T1 coronal view. B. MRI of left ischiorectal abscess, T1 axial view. FIGURE 85-14. A and B. Technique to drain a perianal abscess. involving all layers of the rectum (complete), and (3) intussusception of the upper rectum into and through the lower rectum so that the mucosal apex of the intussusception nearly extends to the anus (incomplete or internal). Rectal prolapse in children is generally mucosal and occurs more commonly in males less than 3 years old. The prolapse may appear as a painless, maroon-colored, protruding mass with possible mucus and blood. The mucosal prolapse rarely protrudes more than 5 cm beyond the anal verge. 10 With children, parents often mistakenly believe that the prolapsed mucosa is a hemorrhoid. Mucosal prolapse is believed to occur due to a lack of the natural sacral curve reducing the anorectal angulation. With increased intra-abdominal pressure from coughing, diarrhea, vomiting, and straining, mucosal prolapse can develop. Incomplete/internal and full-thickness prolapses occur because of the laxity of the pelvic fascia and muscles, in addition to a generalized weakening of the anal sphincters.  CLINICAL FEATURES Patients with partial prolapse may experience stool seepage or constipation. With more advanced cases, patients are able to detect the presence of a mass, especially after defecation or strenuous activity, or even with standing or walking. Irritation to the rectal mucosa caused by recurrent prolapse results in a mucous discharge along with bleeding. Associated anal sphincter weakness may result in fecal incontinence. With complete prolapse, the anus appears normal in contrast to a mucosal prolapse in which the anal edges appear everted. Pain is not a significant feature with complete prolapse, but abdominal or pelvic discomfort may be present. 10 Digital rectal examination reveals a thick muscular wall with decreased tone, in contrast to a much thinner wall from a mucosal pro lapse. Complete prolapse appears as a red, ball-like mass, with concen tric folds in the protruding mucosa (Figure 85-15, B and C). Prolapsing internal hemorrhoids may be confused with mucosal or rectal prolapse. A distinguishing feature of prolapsed hemorrhoids are the radially directed folds (Figure 85-15A). With complete prolapse, a sulcus may be palpated between the extruded bowel and anus, compared to no sulcus with a mucosal prolapse.  TREATMENT In young children, after appropriate analgesia and sedation, the pro lapse can be reduced manually by first gently spreading the buttocks and then replacing the protruding mucosa, proximal to the anorectal ring of sphincter muscles, with a slow, steady pressure applied to the prolapsed segment. Digital rectal examination should then be per formed. Every effort should be made to prevent constipation. Refer the Tintinalli_Sec09_p0473-0562.indd 545 8/2/19 6:50 PM

en replacing the protruding mucosa, proximal to the anorectal ring of sphincter muscles, with a slow, steady pressure applied to the prolapsed segment. Digital rectal examination should then be per formed. Every effort should be made to prevent constipation. Refer the Tintinalli_Sec09_p0473-0562.indd 545 8/2/19 6:50 PM 546 SECTION 9: Gastrointestinal Disorders TABLE 85-1 Anorectal Sexually Transmitted Infections Bacteria Viruses Neisseria gonorrhoeae* Herpes simplex type 2* Chlamydia trachomatis* Human immunodeficiency virus Treponema pallidum* Human papillomavirus *Most common sexually transmitted pathogens TABLE 85-2 Anorectal Acquired Immunodeficiency Syndrome–Related Infections Herpes simplex virus types 1 and 2 Campylobacter Mycobacterium avium-intracellulare Entamoeba Cytomegalovirus Cryptosporidium Salmonella enterocolitis Isospora Shigella Giardia FIGURE 85-15. Differentiation: Prolapsed internal hemorrhoids from rectal prolapse. A. Prolapsing internal hemorrhoids with radial folds. B. Complete rectal prolapse with con centric folds. C. Complete rectal prolapse with a sulcus. [ B: Photo contributor: Lawrence B. Stack, MD. C: Photo contributor Alan B. Storrow, MD. Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 4th ed. © 2016, McGraw-Hill, Inc., New York.] child for further evaluation due to a possible underlying condition such as cystic fibrosis, polyps, pelvic floor weakness, diarrhea, and malnutrition. In adults, a complete prolapsed rectum can sometimes be reduced with gentle continuous pressure, which may take several minutes. The buttocks may be taped apart while the prolapsed segment is grasped in such a way that the thumbs are placed over the luminal surfaces medially while the fingers grasp the outer walls laterally. Continuous pressure, starting with the thumbs followed by an internal rolling force of the fingers, will aid in reduction (Figure 85-16). After reduction, perform a digital rectal examination to ensure that reduction is complete and to evaluate for a rectal mass or polyp. Obtain surgical consultation for repair, or refer for colonoscopy and dietary changes depending on the clinical circumstances. Once the rectal walls become edematous, reduction is difficult. Prolonged prolapse may lead to venous engorgement, thrombosis, superficial ulcerations, rectal incarceration, strangulation, and ischemia. An effective technique is the early application of generous amounts of granulated sugar over the entire prolapsed segment. Synthetic sweeteners are not effective. After 15 minutes or so of sugar applica tion, the edema reduces, allowing for easier prolapse reduction. Gauze with lubricant can be placed over the anal verge after reduction and taped in place for a few hours. If the prolapse cannot be reduced, is severe, or recurs after reduction, or if ischemia or gangrene of the pro lapsed segment is suspected, emergency surgical consultation and hos pitalization are needed for reduction or surgical treatment (rectopexy). ANORECTAL TUMORS Carcinoma of the anal area is uncommon. Factors such as smoking, anal intercourse, human immunodeficiency virus, and human papillomavi rus, particularly types 16 and 18, resulting in genital warts, have been associated with the development of anorectal cancer (Figure 85-17). At the level of the dentate line and extending approximately 1 cm proximal is a transitional zone of epithelium connecting the squamous cell epithelium of the anoderm with the columnar epithelium of the rectum. This transition zone includes columnar, cuboidal, transitional, and squamous epithelial cells that represent the source for a variety of malignancies that arise in the anal canal.

imal is a transitional zone of epithelium connecting the squamous cell epithelium of the anoderm with the columnar epithelium of the rectum. This transition zone includes columnar, cuboidal, transitional, and squamous epithelial cells that represent the source for a variety of malignancies that arise in the anal canal. Anorectal malignancies can generally be divided into two regions: (1) malignancies of the portion proximal to the dentate line and including the transitional zone, which are referred to as anal canal neoplasms , and (2) tumors arising in the anoderm distal to the dentate line, which are referred to as anal margin neoplasms (Table 85-3). Anal margin neoplasms have a low-grade malignant potential and are slow to metastasize, with the exception of melanoma. Anal canal neoplasms are far more virulent, metastasize early, and have a poor prognosis. Squamous cell carcinoma of the anal canal has a much poorer Tintinalli_Sec09_p0473-0562.indd 546 8/2/19 6:50 PM

nal margin neoplasms have a low-grade malignant potential and are slow to metastasize, with the exception of melanoma. Anal canal neoplasms are far more virulent, metastasize early, and have a poor prognosis. Squamous cell carcinoma of the anal canal has a much poorer Tintinalli_Sec09_p0473-0562.indd 546 8/2/19 6:50 PM CHAPTER 85: Anorectal Disorders 547 the patient experiences anorexia, bloating, weight loss, diarrhea, constipation, narrowing of the caliber of the stool, and, eventually, tenesmus with or without a bowel movement. Anal canal tumors may produce partial rectal prolapse and hemorrhoidal dilatation. More advanced malignancies may present as perirectal abscesses, fistulas, and bloody mucous discharge. Villous adenomas, which arise from the rectal columnar epithelium, frequently produce clear, watery diarrhea and a profuse rectal discharge, with secondary excoriation of skin and pru ritus. Watery diarrhea may cause hypokalemia or hyponatremia. Anal margin neoplasms tend to be circumferential and may present with bleeding, persistent ulcers, or chronic dermatologic conditions such as eczema or mycotic infections. Any ulcer that fails to heal within 30 days or any discrete skin lesion that fails to improve with appropriate therapy must be biopsied to rule out the presence of malignancy. Virtually all anorectal tumors can be detected by careful visual examination of the perianal area, digital palpation of the distal rectum and anal canal, and proctoscopic or sigmoidoscopic examination. Specific diagnosis and treatment require surgical consultation and referral. RECTAL FOREIGN BODIES The medical literature is replete with the variety of foreign bod ies that have been reported to have been inserted into the rectum (Figure 85-18). FIGURE 85-16. Reduction of complete rectal prolapse. FIGURE 85-17. Perianal human papillomavirus–induced squamous cell carcinoma in situ. [Reproduced with permission from Wolff K, Johnson RA: Color Atlas and Synopsis of Clinical Dermatology, © 2009, McGraw-Hill, Inc., New York.] TABLE 85-3 Anorectal Tumors Anal Canal Neoplasms Anal Margin Neoplasms Adenocarcinoma of glands and ducts Bowen’s disease Transitional cell carcinoma Squamous cell carcinoma (SCC) Melanoma, SCC Basal cell carcinoma Kaposi’s sarcoma Melanoma Villous adenoma Paget’s disease prognosis than its anal margin counterpart. Anal margin neoplasms generally metastasize to femoral and inguinal lymph nodes, whereas anal canal malignancies metastasize to the perirectal, mesenteric, and paravertebral lymph nodes via the portal circulation. The anal canal is the third most common site of malignant melanoma (after the skin and the eye), which, when it occurs there, may not be pigmented and is frequently missed.  CLINICAL FEATURES Early anal canal malignancies usually cause nonspecific symptoms, such as pruritus, pain, and bleeding admixed with stool, but may be asymptomatic. Rectal pain may also be referred from retrorectal tumors and pelvic vessel aneurysms. As the tumor progresses, rectal fullness develops. The sensation and presence of a lump in the anal canal may be erroneously diagnosed as a hemorrhoid. As the neoplasm progresses, FIGURE 85-18. Rectal foreign body. [Photo contributor: Kevin J. Knoop, MD. Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 4th ed. © 2016, McGraw-Hill, Inc., New York.] Tintinalli_Sec09_p0473-0562.indd 547 8/2/19 6:50 PM

as a hemorrhoid. As the neoplasm progresses, FIGURE 85-18. Rectal foreign body. [Photo contributor: Kevin J. Knoop, MD. Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 4th ed. © 2016, McGraw-Hill, Inc., New York.] Tintinalli_Sec09_p0473-0562.indd 547 8/2/19 6:50 PM 548 SECTION 9: Gastrointestinal Disorders  CLINICAL FEATURES Patients may complain of abdominal pain and cramping, anorectal bleeding, discharge, and discomfort and may not initially be forthcoming with an accurate history. Most foreign bodies are in the rectal ampulla and are therefore palpable through careful digital examina tion. Anoscopy may detect signs of trauma and should replace the digital exam when sharp objects are suspected. Foreign bodies lodged above the rectosigmoid junction are usually not palpable. Injuries may consist of hematoma formation, various lacerations with potential per foration, and ischemic segments (particularly a delayed presentation). Radiographs of the abdomen may demonstrate not only the position, shapes, and number of foreign bodies, but also the possible presence of free air. Perforation of the rectum or colon, although uncommon, is a serious complication. Perforation of the rectum below the peritoneal reflection often causes retroperitoneal injuries, and plain radiographs may demonstrate extraperitoneal air along the psoas muscles. Perfo ration above the peritoneal reflection usually reveals intraperitoneal free air under the diaphragm noted on an upright chest radiograph. CT scan is useful when the foreign body is radiolucent and for the detection of free air. Fever, leukocytosis, abdominal pain, rectal bleeding, and peritoneal signs are clinical manifestations sugges tive of perforation. Both can result in life-threatening sepsis, although perforation below the peritoneal reflection may be managed with more conservative therapy.  TREATMENT Although some distal rectal foreign bodies can be removed by the emergency physician, many objects require surgical intervention, par ticularly if they are made of glass, have sharp edges, or show signs of perforation. 11 Foreign bodies with greater success of being removed in the ED are those that are located in the mid to lower rectum. When assessing the likelihood of removal in the ED, determine the type of object inserted and likelihood of injury to the GI tract or sphincter from removal. Prior to removal, consider infiltration of local anesthetic circumferentially around the anus. Sims, lithotomy, or knee-chest posi tion with application of suprapubic pressure while the examiner digi tally grasps the foreign body may help expulse the foreign body. After anal lubrication and with the aid of obstetric forceps, ask the patient to assist extraction by bearing down ( Figure 85-19A). If the foreign body is removed in the ED and is of a size or shape that could cause perfora tion or laceration, proctoscopic examination and radiograph studies must be performed. In questionable cases, observation for at least 12 hours should be done to ensure that perforation has not occurred. Rec tal and anal lacerations may be present and require repair. For removal of large foreign bodies, surgical consultation or emergency colonoscopy by a gastroenterologist is usually required. Large bulbar objects create a vacuum-like effect in the rectal ampulla, making it difficult to retrieve the object by simple traction. The vacuum can be overcome by passing a 20- to 26-French, three-way catheter beyond the object and inject ing up to 30 mL of air. Inserting Foley catheters around the foreign body may then be used as traction devices to deliver the foreign body or manipulate it into a more accessible position ( Figure 85-19B).

raction. The vacuum can be overcome by passing a 20- to 26-French, three-way catheter beyond the object and inject ing up to 30 mL of air. Inserting Foley catheters around the foreign body may then be used as traction devices to deliver the foreign body or manipulate it into a more accessible position ( Figure 85-19B). If there is a risk of sphincter injury, ischemia, or perforation, or if excess manipulation will be needed to remove the foreign body (potential for bacteremia), obtain emergent surgical evaluation and appropriate laboratory studies, initiate IV therapy with crystalloid solution, and administer a broad-spectrum antibiotic (e.g., piperacillin-tazobactam, 3.375 grams IV). PRURITUS ANI Pruritus ani is a symptom complex that occurs secondary to a variety of anal and systemic problems ( Table 85-4). Primary or idiopathic disease occurs when no cause is identified. Pruritus ani is the second most common anorectal condition after hemorrhoids. 12 It affects 1% to 5% of the population; men are affected four times more often than women; and it most commonly occurs in the fourth to sixth decades of life.  CLINICAL FEATURES Symptoms are often worse at night. The skin becomes macerated by constant mucous and purulent discharge. Bacterial infections, such as staphylococci and streptococci, in addition to all sexually transmitted organisms, can cause pruritus. Pinworms (Enterobius vermicularis ) are a common cause of anal pruritus in children. Institutionalized adults may also develop pinworms. 12 Candida albicans , particularly in diabetic patients, is commonly found on the perianal skin, but is not usually associ ated with pruritus; the Trichophyton species, on the other hand, are associated with pruritus. Fecal contamination resulting from loose bowel movements, diarrhea, and poor anal hygiene is a frequent irritant to the perianal skin. Excessive anal cleansing and wearing of synthetic, tight-fitting underwear that retains moisture can cause pruritus. Any of the anal margin neoplasms may initially cause pru ritus. Systemic conditions, such as diabetes mellitus, psoriasis, pem phigus, leukemia, lymphoma, thyroid disorders, hepatic diseases, renal failure, iron deficiency anemia, and certain vitamin deficiencies (vitamins A and D and niacin), because of their secondary effect on the perianal skin, can cause pruritus. Lumbosacral radiculopathy has been associated with idiopathic pruritus ani. 12 The skin appears normal with early, mild cases. Superficial cracks seen on examina tion do not extend to the dentate line, as do fissures. With acute, more severe exacerbations, the perianal skin will appear reddened, edematous, excoriated, and moist. In chronic cases, the perianal skin takes on a thickened, almost leathery, depigmented appearance. The normal radiating folds of skin thicken into rugae and may produce factitiously induced superficial fissures.  TREATMENT Diagnose and treat the underlying cause. Perianal streptococcal der matitis ( Figure 85-20) is well known in children, where it can cause systemic infection, but is also recognized and can cause serious infec tion in adults. Obtain cultures and treat empirically with penicillin or erythromycin. 14 Pinworms can be identified by touching the perianal skin with transparent tape to collect the worm and then viewing under a microscope. Idiopathic causes may be treated by adding fiber to the diet, which can bulk the stools and help prevent persistent soiling and irritation when the patient is plagued by frequent loose stools. To avoid scratching at night, the patient can wear gloves at bedtime. Warm baths are recommended for at least 15 minutes two to three times a day for hygiene, instead of soap, followed by thorough drying.

the stools and help prevent persistent soiling and irritation when the patient is plagued by frequent loose stools. To avoid scratching at night, the patient can wear gloves at bedtime. Warm baths are recommended for at least 15 minutes two to three times a day for hygiene, instead of soap, followed by thorough drying. Zinc oxide ointment can provide a protective covering for the perianal skin and may promote healing, while athlete’s foot powder may enhance drying. One percent hydrocortisone cream is effective for the allergic compo nent of the inflammation. Fungicidal creams, antibiotics, and antiviral and antiparasitic medications should be prescribed for patients with infectious causes. Hydroxyzine hydrochloride may be used as an effective bedtime sedative. Refer to a proctologist or dermatologist for resistant symptoms. PILONIDAL SINUS Pilonidal sinus is an acquired problem formed by the penetration of the skin by an ingrown hair, which causes a foreign body granuloma reac tion. The sinus is perpetuated by the presence of the hair and repeated bouts of infection.  CLINICAL FEATURES Pilonidal sinuses or cysts occur in the midline in the upper part of the natal cleft, which overlies the lower sacrum and coccyx. Because of their proximity to the anus, infected pilonidal cysts (abscesses) are sometimes mistakenly diagnosed as perirectal abscesses ( Figure 85-21, A–C). Occasionally, an inflamed cyst may refer pain to the coccygeal region. An abscessed pilonidal sinus is almost always located in the posterior midline over the sacrum and coccyx. Although there may be secondary fistulous openings on either side of the midline, they Tintinalli_Sec09_p0473-0562.indd 548 8/2/19 6:50 PM CHAPTER 85: Anorectal Disorders 549 FIGURE 85-19. A. Foreign body exposure. B. Removal techniques. [Reproduced with permission from Reichman EF: Emergency Medicine Procedures, 2nd ed. McGraw-Hill, Inc., 2013. Figures 72-3, 72-4.] Tintinalli_Sec09_p0473-0562.indd 549 8/2/19 6:50 PM

Zinc oxide ointment can provide a protective covering for the perianal skin and may promote healing, while athlete’s foot powder may enhance drying. One percent hydrocortisone cream is effective for the allergic compo nent of the inflammation. Fungicidal creams, antibiotics, and antiviral and antiparasitic medications should be prescribed for patients with infectious causes. Hydroxyzine hydrochloride may be used as an effective bedtime sedative. Refer to a proctologist or dermatologist for resistant symptoms. PILONIDAL SINUS Pilonidal sinus is an acquired problem formed by the penetration of the skin by an ingrown hair, which causes a foreign body granuloma reac tion. The sinus is perpetuated by the presence of the hair and repeated bouts of infection.  CLINICAL FEATURES Pilonidal sinuses or cysts occur in the midline in the upper part of the natal cleft, which overlies the lower sacrum and coccyx. Because of their proximity to the anus, infected pilonidal cysts (abscesses) are sometimes mistakenly diagnosed as perirectal abscesses ( Figure 85-21, A–C). Occasionally, an inflamed cyst may refer pain to the coccygeal region. An abscessed pilonidal sinus is almost always located in the posterior midline over the sacrum and coccyx. Although there may be secondary fistulous openings on either side of the midline, they Tintinalli_Sec09_p0473-0562.indd 548 8/2/19 6:50 PM CHAPTER 85: Anorectal Disorders 549 FIGURE 85-19. A. Foreign body exposure. B. Removal techniques. [Reproduced with permission from Reichman EF: Emergency Medicine Procedures, 2nd ed. McGraw-Hill, Inc., 2013. Figures 72-3, 72-4.] Tintinalli_Sec09_p0473-0562.indd 549 8/2/19 6:50 PM 550 SECTION 9: Gastrointestinal Disorders TABLE 85-4 Some Secondary Causes of Pruritus Ani •   Anorectal disease: Draining perirectal abscess, fissures, hemorrhoids, rectal prolapse, fistulas •   Dietary factors: Caffeine, cola, calcium, chocolate, citrus, alcohol, tomatoes, spices, peanuts •   Local infection: Bacteria, viruses, fungi, worms, lice, scabies, bed bugs, hidradenitis •   Local irritants: Perfumed toilet tissue, soaps, detergents, hygiene sprays •   Dermatologic: Atopic dermatitis, lichen planus, psoriasis, seborrheic dermatitis •   Systemic illness: Diabetes, various malignancies, Crohn’s disease, acanthosis •   Psychogenic: Stress, obsessive compulsive disorder FIGURE 85-20. Example of pruritus ani. Pruritus ani from perianal strep infection. [Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 2nd ed. © 2002, McGraw-Hill, Inc., New York.] FIGURE 85-21. A. Pilonidal sinus. B. CT scan of a pilonidal sinus with abscess (arrow). C. Pilonidal sinus. [A: Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 4th ed. © 2016, McGraw-Hill, Inc., New York. C: Photo contributor: Lawrence B. Stack, MD. Reproduced with permission from Knoop K, Stack L, Storrow A, Thurman RJ: Atlas of Emergency Medicine, 4th ed. © 2016, McGraw-Hill, Inc., New York. Figure 9.43.] do not communicate with the anorectum. On the other hand, long, horseshoe-type fistulas emanating from a perirectal abscess may drain close to the location of a pilonidal sinus but not in the midline. Fistu lous tracts most commonly ascend superiorly. Pilonidal disease may present as a painless cyst, an acute abscess, or chronic recurring cysts with draining sinuses. Alternate causes for draining fistulas should be considered, such as anal fistulas, syphilitic and tuberculous granu lomas, simple furuncles, fungal infections, and sacral osteomyelitis. Carcinoma is a rare complication of chronic, recurring pilonidal sinus disease. It is more frequent in men and is usually a well-differentiated, dermal-type squamous cell carcinoma.  TREATMENT Treatment is incision and drainage, and antibiotics are needed only if cellulitis is present. Ultrasonography can delineate the extent of the abscess. Following incision and drainage in the ED, refer to a surgeon for definitive care. HIDRADENITIS SUPPURATIVA In postpubertal males and females (the second to fourth decades of life), the perianal surface containing hair follicles and apocrine sweat glands may become blocked, which generally occurs in the perineal, groin, axillary, or inframammary regions. Perineal disease is more common in males, whereas axillary disease is more common in females.  CLINICAL FEATURES Fistulas with a malodorous discharge may develop, but do not extend to the intersphincteric plane, and the abscesses are quite superficial and do not originate at the dentate line. Fistulas that extend above the dentate line may suggest coexisting cryptoglandular or Crohn’s disease. Chronic inflammation, edema, tissue induration, fibrosis, and signifi cant pitted scarring may occur (Figure 85-22). Tintinalli_Sec09_p0473-0562.indd 550 8/2/19 6:51 PM