Anorectal Emergencies
Anorectal Emergencies
Patients with anal diseases can be some of the most uncomfortable patients presenting to the emergency department. Embarrassment may delay presentation until the disease process has become advanced. Bleeding is the most common presenting complaint. In a recent study of 317 patients referred for anorectal signs/complaints, anal symptoms included bleeding (58.6%), itching (53.7%), pain (33.7%), burning (32.9%), and soreness (26.6%).1 This study also found, as one might imagine, that the diagnosis of anal disorders often can be predicted by symptomatology. Bleeding, weeping, and absence of pain predict internal hemorrhoids. Anal fissure is predicted by anal pain and anal bleeding, pruritus ani by anal pain, itching, and soreness.1 Pain without bleeding may represent an abscess or thrombosed external hemorrhoid. An understanding of these disorders, which patients can be easily treated in the emergency department or clinic, and when to refer to a specialist allows emergency physicians to improve the quality of life for patients with these markedly annoying, if not life-threatening, disorders.
The proper use of the anoscope will confirm the diagnosis in many cases. The anoscope has two parts the introducer and the scope. A light source is needed. The patient can be placed in either the left lateral decubitus position or the prone-jacknife position. The anoscope is lubricated and inserted into the anus. The introducer is removed, and the anoscope is slowly removed. The mucosa of one quadrant of the anus will be observed. The introducer is put back into position, the anoscope is rotated 90 degrees and re-introduced. The process is repeated until all four quadrants have been examined.
Hemorrhoids
Despite their proximity to each other, there are several differences between internal and external hemorrhoids. Delineated by the dentate line, internal hemorrhoids arise from endoderm and are lined with simple columnar epithelium, while external hemorrhoids arise from ectoderm and are composed of stratified squamous epithelium. Internal hemorrhoids have no sensory innervation; since external hemorrhoids are covered by skin, pain is transmitted through naked nerve endings in the epidermis. The venous drainage of internal hemorrhoids occurs through the superior rectal vein and portal system, and external hemorrhoids drain through the inferior rectal vein into the vena cava. (See Figure 1.) While the traditional teaching that hemorrhoids are simply varicosities of the hemorrhoidal vein plexuses is probably incorrect, the exact etiology is uncertain. Most likely, hemorrhoids are due to increased maximum resting anal pressure, which causes distal displacement of the anal cushions in the anal canal.
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Internal hemorrhoids typically present with painless rectal bleeding. The bleeding is bright red and coats the stool. Bleeding of a darker nature or mixed in with the stool should indicate a source higher in the GI tract. On digital rectal examination, internal hemorrhoids usually are not tender and not palpable unless they have prolapsed or thrombosed. Examination by anoscopy will reveal even nonprolapsing internal hemorrhoids and, by having the patient strain, the size and degree of prolapse can be assessed. (See Figure 2.) Stroking the surface of an internal hemorrhoid with a cotton-tipped applicator during anoscopy may demonstrate bleeding. Internal hemorrhoids are graded based on the degree of prolapse of the hemorrhoidal tissue into the anal canal and out of the anus. First-degree hemorrhoids project into the anal canal but do not prolapse. Second-degree hemorrhoids protrude on defecation but return spontaneously with cessation of straining. Third-degree hemorrhoids protrude with straining and are persistent, requiring intermittent manual reduction. Fourth-degree hemorrhoids have irreducibly prolapsed out of the anus. The treatment of internal hemorrhoids is based on the degree of internal hemorrhoid and the patient's symptoms. In patients with minor symptoms from internal hemorrhoids (e.g., intermittent bleeding, prolapsing but a reducible mass), initial conservative medical treatment can be used. Treatment should consist of a high-fiber diet, adequate fluid intake, sitz baths, stool softeners, proper anal hygiene, and topical steroids. Nonthrombosed prolapsed hemorrhoids can be manually reduced and conservative treatment should be initially used. The patient should be given a gastroenterology or surgical follow-up referral for possibly more definitive treatment and further evaluation of rectal bleeding. If a patient presents with a painful and edematous incarcerated fourth-degree hemorrhoid, reduction following local anesthetic infiltration can be attempted, and surgical consult should be obtained in the emergency department. Incarcerated hemorrhoids are associated with severe pain, possible tissue necrosis, severe infection, and urinary retention.
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External hemorrhoids, especially when thrombosed, are easy to identify as an enlarged, painful, bluish mass at the anal verge. (See Figure 3.) Bleeding is not common with external hemorrhoids, except if ulcerated or ruptured. External skin tags also may be noted around the anal verge, representing old thrombosed external hemorrhoids. Painful symptoms from a thrombosed external hemorrhoid are most acute over the first 48-72 hours, with symptoms resolving over a 7- to 10-day period of time. Surgical excision of a thrombosed external hemorrhoid is reserved for patients presenting during the first 48-72 hours after the onset of acute painful symptoms, if ulceration or rupture has occurred, or if medical treatment has failed and chronic symptoms persist. The area is cleaned and local anesthesia injected. An elliptical incision is made, being careful to avoid the anal sphincter. All of the clot is removed and any bleeding controlled by direct pressure or silver nitrate. If the patient is seen more than 48-72 hours after the onset of pain, medical treatment consisting of sitz baths twice a day, stool softeners, and analgesics, both systemic and topical, is usually effective.
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Anal Fissure
No evaluation of anorectal pain would be complete without consideration of anal fissure. While the etiology of the majority of anal fissures is idiopathic, predisposing risk factors include trauma to the anal canal (such as with passage of a hard stool or severe diarrhea) or infection. The fissure is a linear defect in the squamous epithelium of the distal anal canal. (See Figure 4.) Because of the extensive sensory innervation of this area, the pain the patient experiences can be exquisite. The extent of the fissure may be superficial or extend deep into the internal sphincter. With chronic injury, the fissure may develop secondary changes such as a sentinel skin tag located at the anal verge, enlarged anal papilla, or anal stenosis. In both sexes, the majority of fissures occur in the posterior midline wall of the anal canal. The next most prevalent site is the anterior midline, where it is more common in women than in men. If the fissure is in an atypical location or there are multiple fissures, specific underlying disease states should be sought, including inflammatory bowel disease, leukemia, tuberculosis, chlamydia, gonorrhea, herpes, syphilis, carcinoma, and immunodeficiency syndromes.
Patients present with the chief complaint of pain, especially with and following defecation. Patients may report avoidance of a bowel movement secondary to pain. The pain is out of proportion to the size and seriousness of the lesion; it is important to remember the extensive sensory network around the anus. Hematochezia can occur but is usually minimal. Other less common symptoms include pruritus and mucous discharge.
The patient's pain will often be an obstacle to a thorough physical examination. If tolerated, the patient's buttocks can be gently spread apart and the anal verge can be everted to visualize the distal anal canal. If a fissure can be observed by inspection, a digital rectal exam is likely unnecessary. Identification of a skin tag in a classic location should help differentiate an anal fissure from a thrombosed external hemorrhoid or perianal abscess. If the diagnosis remains uncertain after visual inspection, a digital rectal exam and anoscopy is necessary. Local anesthesia with lidocaine may facilitate the exam; however, the patient ultimately may require procedural sedation or even general anesthesia.
Treatment of anal fissures should be directed at pain control and promoting a regular, soft stool. This includes a high-fiber diet, bulk laxatives, warm sitz baths, stool softeners, topical anesthetics, and oral analgesics. Chronic anal fissures with secondary changes are commonly refractory to conservative management. Even so, most anal fissures respond to a nonsurgical approach. Follow-up care should be with a primary care physician or specialist depending on the severity/chronicity of the fissure.
Anorectal Abscess
The development of an anorectal abscess often begins in the intraluminal anal crypts located between the dentate folds in the terminal rectum. Ducts penetrate the internal anal sphincter and connect the crypts to the anal glands, which provide secretions during defecation. Organisms can penetrate these ducts and colonize the anal glands, possibly forming a localized infection that can evolve into an intersphincteric abscess. The infection can also spread through the tissue planes to form abscess in the perianal, ischiorectal, or supralevator spaces. (See Figure 5.) Once these abscesses drain, a fistula can be formed between the abscess and the anal crypt; unless this fistula is destroyed, it becomes easy for recurrent abscesses to form. The incidence of fistula formation was 66.8% in one study of patients with ischiorectal abscesses.2 The cryptogladular theory is the most accepted cause for the formation of these abscesses, but the emergency physician should not overlook other causes such as localized soft-tissue infections (furuncle, pilonidal abscess, hidradenitis suppurativa, decubitus ulcer, and infected sebaceous cyst), perivaginal infections such as infected Bartholin's gland, and supralevator abscesses that have an intra-abdominal or pelvic origin. Anorectal abscesses are found more commonly in men than women and in both sexes during the third and fourth decade of life. Interestingly, the incidence appears to have a seasonal variation with a higher prevalence in the spring and summer months.
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The largest risk factors for the development of anorectal abscesses are hemorrhoids (15%), diabetes mellitus (11%), previous anorectal surgery (7%), pregnancy (4%), inflammatory bowel disease (4%), and anorectal trauma.3 In addition, certain co-morbidities predispose patients for development of anorectal abscesses such as hematologic malignancies associated with neutropenia, AIDS, anorectal cancer, obesity, and infectious proctitis. Both aerobic and anaerobic organisms are typically present; cultures often reveal mixed flora. However, of the organisms identified most commonly found are E. coli (49%), Streptococcus (32%), Bacteroides fragilis (20%), other Bacteroides (26%), and Peptostreptococcus/Peptococcus (27%).3 Routine culture of abscesses is not recommended.
Anorectal abscesses are categorized based on anatomic location: perianal, ischiorectal, intersphincteric, and supralevator (above the levator ani). The most common type of anorectal abscess is perianal, (40% to 50%), and the least frequent is supralevator (2% to 9%).4
The presenting symptoms can vary widely, but perirectal pain is nearly universal (91%), associated with perirectal swelling (42%), discharge (25%), and fevers/chills (21%).3 The location and character of the pain should provide important clues to the origin and type of anorectal abscess. Often, procedural sedation may be required to facilitate the necessary examination to identify, localize, and assess the size of an anorectal abscess. Perianal abscesses are most easily discernible, as they tend to be superficial and present with localized swelling and pain at the anal verge. The patients often report that the pain is worsened with sitting and defecation. Like most superficial abscesses, the presence of fever and/or leukocytosis is not common. An abscess in the ischiorectal space more often produces pain in the buttocks area and possibly an indurated, erythematous, and tender mass in the same region. Digital rectal exam sometimes can localize pain in the buttocks but often has a deeper, more blunted sensation for the patient. This is in contrast to intersphincteric abscesses, which produce localized pain in the anal canal and rectum. On exam, a painful mass can be identified. This pain often is exacerbated by defecation and increased abdominal pressures. Sometimes, a mucus or exudative discharge may be noted. Of all the locations, the supralevator abscess may be the most difficult to definitively diagnose on exam. There often is no external sign, and while digital rectal exam may reveal a tender mass in the distal rectum and should be performed even for a suspected supralevator abscess, it is often inadequate in depth to palpate the abscess directly. However, in contrast to the other types, supralevator abscesses more often present with systemic signs such as fever and leukocytosis, and occasionally urinary retention. Anoscopy should be a routine part of the examination in suspected supralevator anorectal abscess, although definitive diagnosis ultimately may require CT, sigmoidoscopy, or surgical evaluation under anesthesia.5 An anal fistula requires surgical evaluation, although this often can be done as an outpatient and rarely requires emergent intervention.
The diagnosis of an anorectal abscess necessitates incision and drainage, debridement of necrotic tissue, and exploration of the abscess cavity. Without this definitive treatment, the risk is high for extension of the infection into deeper tissues along fascial planes and for the development of a serious systemic infection. Even without identified areas of induration or fluctuance, the surgical mantra "the presence of pain suggests the need to drain" points to historical experience that these abscesses often can be extensive and at high risk for complications if intervention does not take place promptly, even if they do not present with dramatic physical findings. Ultrasonography or needle aspiration can be used to confirm the diagnosis of perianal or superficial ischiorectal abscesses. CT scan is more useful in delineating the extent of deeper abscesses, especially those with minimal physical exam findings. It also may help identify intra-abdominal or pelvic sources of supralevator abscesses, such as diverticulitis or Crohn's disease. However, its sensitivity is less than either MRI or endoscopic ultrasonography, especially for evaluating fistulae.6,7
Given the variety of anorectal abscesses, it is critical that the emergency physician carefully differentiate those patients who may safely undergo incision and drainage in the emergency department from those who will require surgical intervention. The two most important factors that must be considered are the ability to achieve adequate anesthesia for the patient and the extent of the abscess. It is usually those patients who do not have systemic signs of infection and have smaller, more superficial abscess who can be managed safely in the emergency department. In practice, this generally means that perianal and superficial ischiorectal abscesses are most amenable to emergency department treatment.5
It is difficult to achieve complete anesthesia of the abscess cavity using local anesthetics because of the thin skin covering the abscess, decreased anesthetic activity at low pH found in infected areas, and further distention of the cavity with associated increased pain with infiltration of anesthetic. A suggested technique is to inject the dome of the abscess subcutaneously with local anesthetic using a 25-gauge needle to spread anesthesia through the subcutaneous layers into the surrounding skin. An alternate approach is to infiltrate intradermally around the periphery of the abscess. Opioid analgesics or procedural sedation may be needed to provide adequate analgesia. The incision should be made as close to the anal verge as possible to prevent the development of a long fistula tract should one develop. The incision should be large enough to allow adequate exploration and breaking up of loculations. The abscess then should be drained and packed like any other abscess. Wound cultures rarely change clinical management and should not be routinely obtained. The patient should return to the emergency department if there are signs of worsening infection. Given the high rate of fistula development, follow-up with a surgeon is recommended. Treatment with antibiotics for abscess alone is not indicated, though that may be appropriate if there are surrounding areas of erythema, systemic signs, or host factors such as immunocompromise. For those abscesses that are not amenable to treatment in the emergency department, surgical consultation should be obtained for evaluation and definitive treatment.
Infections
Chlamydia is the most common sexually transmitted disease in the United States, and anorectal infection occurs in both men and women. Inoculation usually occurs during anal or oral-anal intercourse.5 There are fifteen immunotypes of chlamydia which can be divided based on those responsible for proctitis (types D and K), and those that cause lymphogranuloma venereum (LGV, types L1, L2, L3). With both types, patients often present with rectal pain, tenesmus, inguinal lymphadenopathy, and fever. Examination of the rectal mucosa often reveals erythema, occasional ulceration, and generalized proctitis. LGV infections mainly occur in tropical and subtropical climates and usually demonstrate a more severe proctitis and ulceration, along with more pronounced and matted adenopathy. Untreated LGV infections may result in fistula formation, abscesses, or rectal strictures.8 Treatment options for Chlamydia proctitis include doxycycline 100 mg orally twice daily for 7 days. Azithromycin 1 g orally as a single dose is not recommended for proctitis.9 Patients with LGV should be treated for 21 days.5,9 The sexual partners of patients likewise should be treated, since up to 15% of infected individuals may be asymptomatic.
Unlike chlamydia, in which the majority of patients present with symptoms, gonorrhea anorectal infections are usually asymptomatic. Gonorrhea anorectal infection has been reported in 45-55% of men who have sex with men, mainly transmitted through anal intercourse.8 Women have incidence rates of anorectal gonorrhea of 45% in patients who have uncomplicated vaginal gonorrhea.10 While anal intercourse does contribute to these cases, contiguous spread from the vagina is far more common. The majority of infected individuals are asymptomatic, with only about 10% of infected patients displaying symptoms. When symptoms do occur, patients experience tenesmus, pruritus, and/or mild anal discharge. Disseminated disease can occur, resulting in perihepatitis, meningitis, arthritis, endocarditis, and pericarditis. Examination usually reveals erythematous, friable mucosa with superficial erosion and a mucopurulent discharge that can be expressed from the anal crypts.5 Therapy should be started prior to microbiologic confirmation if there is a suspicion of the disease.10 Treatment for uncomplicated infections includes a single dose of ceftriaxone 125 mg intramuscularly or cefixime 400 mg orally. Fluoroquinolones are no longer recommended for the treatment of Neisseria gonorrhea. Treatment with azithromycin 2 g orally once can be used in patients with severe penicillin and cephalosporin allergies.11 Routine use of azithromycin in gonoccocal infections is not recommended due to concern over development of resistance. Sexual partners should be treated, and because coinfection is very high, chlamydia should be treated routinely as well.
Chancroid presents with tender anogenital ulcers, painful lymphadenopathy, and perianal abscesses. It is caused by the bacteria Haemophilus ducreyi and is usually confirmed with culture. It is responsible for 5% of anogenital ulcers in the United States and is easily treatable if the diagnosis is made.5 Treatment options for chancroid include ceftriaxone 250 mg intramuscularly as a single dose or azithromycin 1 g orally in a single dose or erythromycin base 500 mg orally three times daily for 7 days. Ciprofloxacin also is a CDC-recommended option: 500 mg po bid for 3 days.9 If treatment is successful, ulcers usually improve symptomatically within 3 days and objectively within 7 days after therapy.
Perianal herpes simplex virus infections are transmitted through anal intercourse. Herpes simplex virus type 2 (HSV2) accounts for approximately 90% of anorectal herpes infections.12 Serologic tests indicate that more than 95% of male homosexual patients have been infected with HSV2.8 Symptoms usually develop 1-3 weeks after exposure, last 7-10 days, and present as rectal pain, tenesmus, inguinal lymphadenopathy, mucopurulent discharge, and constipation, which develops secondary to the pain of defecation. Occasionally, systemic signs such as fever, chills, and malaise may occur. Pruritus ani is a very common manifestation, reportedly present in as many as 85% of cases.5 Examination of the rectum demonstrates friable ulcerated mucosa in the distal rectum. Patients may experience sacral or dermatomal paraesthesias or pain, urinary retention, or impotence. Diagnosis usually is made clinically, although it can be confirmed by viral culture if needed. Recurrence rates after the initial infection are very high, with approximately 80% of patients having a second episode within one year. Recurrent episodes usually are milder than the initial infection. The goal for most patients is adequate analgesia during the symptomatic time-period. Treatment includes analgesics, stool softeners, and antiviral agents. Oral acyclovir 200 mg five times daily or 400 mg three times a day, famcyclovir 250 mg three times daily, or valacyclovir 1 g orally twice a day, all for 7-10 days, will reduce the duration of pain and viral shedding and enhance healing. Intravenous acyclovir can be used in severe cases of HSV infection. Topical anti-virals are not recommended.
Human papillomavirus (HPV) causes condylomata acuminata warts in many locations, including the anorectum. Human papillomavirus types 6, 11, 16, and 18 are most commonly associated with perianal condylomata. Of these, types 16 and 18 can lead to dysplasia, intraepithelial neoplasia, and invasive squamous cell carcinoma.13 Inoculation of the anorectum usually occurs during anal intercourse; clinical findings may not be evident for up to six months. Patients present with discrete, soft, fleshy growths on the skin in the perianal region and the squamous epithelium of the anal canal. These can be associated with pruritus, pain, and occasionally small amounts of bleeding. Up to 10% of patients will not have externally visible growths, which is why anoscopic examination of the anal canal and rectal mucosa should be a standard part of the examination.14 Diagnosis usually can be made based on the classic appearance of the lesions, although biopsies may help confirm the diagnosis in uncertain cases, especially if squamous cell carcinoma is considered. As with any diagnosis of a sexually transmitted disease, the patient should be evaluated for other STDs, including HIV, chlamydia, syphilis, gonorrhea, and HSV. There are numerous treatment modalities, including chemical therapy with podophyllin or trichloroacetic acid, surgical excision, electrocautery, laser ablation, cryotherapy with liquid nitrogen or nitrous oxide, and immunotherapy. There are patient-applied treatments for genital warts, but the location of perianal lesions makes this approach difficult. Referral to a specialist is recommended. Even with treatment, the recurrence rate approaches 40%.13 Complete eradication is difficult because the HPV can be present not only in the condylomata acuminata lesion, but also in surrounding normal-appearing skin.15 Available therapies may reduce but do not eradicate infectivity.9
The spirochete Treponema pallidum is the responsible organism for syphilis infections and shares many of the same features as HPV. It is spread most commonly by anal intercourse, and the initial clinical manifestations usually occur in 2-6 weeks, although they can take up to six months to appear. The chancre lesions of primary syphilis are classically painless irregular genital ulcers. However, when they occur in the anorectal area, they are usually painful and are easily misdiagnosed as an anal fissure due to their location on the anal verge or in the anal canal. The lesions may be multiple and may occur opposite each other in a "mirror image" or "kissing" configuration. Inguinal adenopathy may be present and may be mistaken for lymphoma. If they are not diagnosed and treated, as often happens, they will resolve spontaneously in 3-4 weeks, and the patient will go on to develop secondary syphilis.5 During this stage, the patient will exhibit a maculopapular rash on the palms and soles. This manifestation of secondary syphilis may be accompanied by condyloma latum a perianal, pale brown or pink, flat, verrucous lesion. This perianal mass usually is pruritic, malodorous, and mucus-secreting. The lesion is an infective lesion and must be differentiated from condylomata acuminata. Diagnosis can be made 4-6 months after infection by the fluorescent treponemal antibody (FTA) absorption test, which can be positive up to a month earlier than the Venereal Disease Research Laboratories (VDRL) or rapid plasma reagin (RPR) tests. If left untreated at this stage, the disease can progress to the tertiary phase after several years and can cause damage to the central nervous system and the cardiovascular system, especially the aorta.
Primary and secondary syphilis should be treated with a single dose of benzathine penicillin G 2.4 million units intramuscularly. Latent syphilis that can be confirmed to have infected the patient for less than one year can be treated with the previous regimen; otherwise it should be treated with benzathine penicillin G 2.4 million units intramuscularly weekly for three consecutive weeks. Treatment for HIV-infected patients with primary, secondary, or early latent syphilis is one dose of benzathine penicillin G 2.4 million units IM, although some experts still recommend three weekly injections.9 Serologic failures in the age of HAART therapy are much less common, so the longer course of therapy may no longer be needed.16,17 As for all of the diseases discussed so far, all sexual contacts of the patient also should be treated.
Entamoeba histolytica is a protozoan that exists in the colon as either a trophozoite or a cyst. The prevalence of E. histolytica in homosexual men who have sex with men is 20% to 32%, and oral-anal intercourse is usually responsible for transmission.8 Infected patients may be asymptomatic or may experience abdominal pain, bloody diarrhea, fever, tenesmus, and malaise. Sigmoidoscopy reveals a friable, erythematous mucosa with hourglass-appearing ulcers. The diagnosis is made by stool examination for ova and parasites. Treatment for mild to moderate infection is metronidazole 750 mg three times daily for 10 days. For patients with severe infections, oral diiodohydroxyquin 650 mg three times daily for 3 weeks is given following the metronidazole therapy.
A summary of the treatments for these diseases is found in Table 1.
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Pruritus Ani
Pruritus ani is a condition that affects 1-5% of the population, and it affects men more often than women.18 It is characterized by perianal itching. Typically, an instigating event causes the itching, leading to scratching, which leads to damaged perianal skin. This, in turn, leads to more itching in a self-sustaining and worsening cycle. Most cases are due to a precipitating factor, of which there are many. (See Table 2.) In children, the most common cause is infections, with pinworms being the most frequent. Dietary agents, such as coffee, cola, beer, chocolate, and milk, are frequent precipitating factors in adults. Skin disorders, such as contact and atopic dermatitis, fecal soiling from a variety of causes, and local irritation from soaps or creams, also have been implicated. A study of 109 adults (average age 52) with pruritus ani showed idiopathic as the most common cause (25%). Seventy-five percent had coexisting pathology in the colon or anorectum, including hemorrhoids (20%), anal fissures (12%), rectal cancer (11%), anal cancer (6%), adenomatous polyps (4%), and colon cancer (2%).18
The presentation is marked by perianal itching and scratching, but since the symptoms are worse at night, irritability and sleep disturbance can be seen. History should include systemic diseases and dietary habits. Examination of the anus and rectum should be done to evaluate an underlying cause. Anal fissures, external hemorrhoids, skin tags, or rectal prolapse may be evident. The Scotch-tape test may need to be done at night to help identify pinworms. In the case of chronic skin or systemic diseases, pruritus ani will be one manifestation of a more systemic process; a broader history, examination, and work-up may provide clues to the underlying etiology. Based on the findings of malignancy in the study mentioned above, these authors would recommend specialist follow-up for patients in whom a primary cause is not easily identified.
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Treatment of pinworm is a two-pronged approach: eliminate infestation and infection. The infection is spread by the fecal-oral route. Patient and family education may have significant impact in preventing spread to other family members. Infestation is controlled by hand-washing, keeping fingernails short, frequent laundering of bed linens, and daily cleaning of toilets. Two weeks of infestation control may be necessary. Infection is managed by pyrantel, mebendazole, or albendazole. Pyrantel pamoate is FDA-approved for over-the-counter treatment for pinworm, but it may have more side effects than the other two medications. Mebendazole is given 100 mg one time, which results in a 95% cure rate. Repeat dosing at two weeks can help prevent re-infection. Albendazole also is given as a single dose of 400 mg, repeated after two weeks. Although the disease is rare in children younger than 2 years, this population can be treated with a single 200 mg dose of albendazole; treatment may be repeated in three weeks. Treatment of pinworm is not listed on the product labeling for albendazole; however, it is used commonly for this indication. Treatment of household contacts is recommended.
If pinworm is not found, treatment is based on correcting the underlying etiology. General principles that can improve symptoms include limiting constipation or diarrhea with the use of stool softeners or a high-fiber diet. Alteration in diet (avoiding precipitating foods and beverages) may be tried if a primary diagnosis cannot be found. Stopping the scratching can stop the itching cycle; to this end, patient education is important. Perineal hygiene may improve symptoms. Topical capsaicin was shown to be an effective treatment in a randomized study in adults with idiopathic pruritus ani.19 The use of topical steroids brings some concerns; there may be early benefit, but there is concern of skin atrophy with prolonged use.20,21 These local treatments have not been well studied in children.
Rectal Trauma
While relatively uncommon, anorectal trauma nevertheless still accounts for serious morbidity for the patient. Except in gynecologic procedures, isolated anal and rectal injuries are rare. The most common cause of penetrating rectal trauma is gunshot wounds to the buttocks and perineum.22 Anorectal trauma is seen in 2.5-5% of cases presenting to the ED with blunt trauma, with motor vehicle collisions being the largest contributor.23 However, trauma from bicycle and motorized recreational vehicles (ATVs, personal water craft) has been increasing.24 The largest cause of rectal trauma is iatrogenic. This can occur during instrumentation and imaging procedures performed rectally. Perforation of the bowel occurs in up to 0.04% of patients who undergo a barium enema.25 This can be caused by local trauma from the enema tip or the retention balloon or excessive hydrostatic pressure acting on the bowel with underlying disease. The extravasated barium can lead to a chemical peritonitis, which causes hypotension. Treatment needs to be aggressive; there is an overall 50% mortality in these patients. Diagnostic colonoscopy has a 0.2% perforation rate, and during polypectomy, this rises to 0.29% to 0.42%.26 Hemorrhage also may complicate colonoscopy, occurring in 1% of patients.26 Rectal thermometers can easily cause perforations in the distal rectum. Numerous surgical procedures also can lead to injury, such as hemorrhoidectomy, anal fistulotomy, and anal sphincterotomy, as well as gynecologic procedures, such as uterine dilation and curettage and hysterectomy. The injury may result in infection, incontinence, or infertility.
Rectal trauma also can occur as a result of foreign bodies. The foreign bodies may be a result of either ingestion of solid objects such as toothpicks, chicken bones, fish bones, or sunflower seeds, or objects inserted through the anus into the rectum. Those patients who present with orally ingested foreign bodies usually are unaware that a foreign body is the source of their complaint. A wide range of injuries may be present in either type, including tears of the anal sphincter, mucosal lacerations, intestinal obstruction, peritonitis, or even sepsis. This type of injury should be suspected in children, psychiatric patients, victims of sexual assault, those seeking sexual gratification from the inserted object, and as a result of iatrogenic injury.
Whatever the source of rectal trauma, a history should be obtained, focusing on the exact mechanism and timing of injury and the presenting symptoms. Patients often fail to provide a thorough history because of embarrassment or judgment of behavior. Patients with rectal trauma most often report abdominal, perineal, or anal pain, rectal bleeding, or systemic signs such as fever. Although the cause and timing of anorectal injury are important in determining the possible complications and treatment, the location of injury also is important. Injuries below the peritoneal reflection are more likely to result in retroperitoneal injuries and, depending on their depth, may be amenable to conservative therapy. Injuries above the peritoneal reflection result in intraperitoneal perforation and contamination. These present with the typical signs of an acute abdomen fever, leukocytosis, abdominal pain, rectal bleeding, and peritoneal signs almost always necessitating laparotomy, debridement of devitalized tissue, sacral drainage, and possible colostomy.
The physical exam for anorectal trauma should occur during the secondary trauma survey and begins with inspection of the buttocks, perineum, and anus. Any evidence of injury, deformity, erythema, skin changes or lacerations, and bleeding should be noted. The position of the anus should be noted, as it is possible for the anus to detach from its muscular attachments. The entire area likewise should be palpated for tenderness, swelling, crepitans, or peritoneal signs. Crepitans may occur 24-48 hours after an unrecognized extraperitoneal perforation.
The digital rectal exam, while much maligned by some practitioners and overly praised by others, plays a central role in the evaluation of suspected rectal trauma. This remains true even if there is no evidence of injury externally. The digital exam is more than just an evaluation for gross or occult bleeding and should include assessment of the position of the prostate, the presence of any palpable luminal masses or defects, and neuromuscular tone of the anal sphincters. For patients with suspected rectal foreign bodies, abdominal plan films should be obtained and be evaluated before a rectal examination to define the position, shape, and number of foreign bodies. This represents an important safety precaution for the practitioner, as sharp objects easily could puncture skin during a rectal examination. Because of proximity, rectal trauma should raise the suspicion for associated genital trauma. Thus, a full genital exam should be done, paying special attention for blood at the urethral meatus, scrotal hematoma, and vaginal bleeding. A pelvic exam should be performed if there is any possibility of a pelvic or perineal injury.
After a thorough physical exam, imaging may be appropriate, depending on the suspicion for injury. X-ray plain films are helpful in several scenarios. Perforations that occur above the peritoneal reflection may demonstrate free air below the diaphragm, and a perforation below the reflection line could show retroperitoneal free air that tracks along the psoas muscle. Anteroposterior and lateral pelvic X-rays will show disruptions of the pelvic ring or other bony fracture which dramatically increase the likelihood of an anorectal injury, and can also demonstrate extraluminal air or hematoma. Widening of the symphysis pubis is an independent risk factor for rectal injury. Anteroposterior compression pelvic fractures have been seen in 75% of patients with rectal injury.27 The use of contrast enemas is rarely beneficial; however, if they are performed to evaluate for rectal perforations, a water-soluble contrast media should be used to prevent complications of extravasated barium.
The utility of CT in the diagnosis of anorectal trauma is not well established. One small study in children suggested that triple contrast CT is as sensitive as proctoscopy in identifying injury.28 Another group of authors suggests using triple contrast in penetrating trauma and IV contrast alone in blunt trauma, although these recommendations are not based on prospective studies.29 A finding on CT that can be helpful in penetrating trauma is finding a wound tract extending directly to the bowel. The specific findings in blunt trauma, including mural tears, mucosal hemorrhage, and extravasation of IV contrast into the bowel lumen, tend to be insensitive. More indirect signs of bowel injury, such as wall thickening, mesenteric stranding, and free intraperitoneal fluid, are less specific. In one series of 90 patients with isolated free fluid, only seven had bowel injury.30
A surgical consultation is suggested for any patient sustaining rectal trauma. The patient with anorectal trauma will require admission for all but rectal tears proven to be superficial by proctosigmoidoscopy. The treatments for these injuries, as described below, are primarily surgical. Surgeons should be involved early, and management decisions should be made collaboratively.
As always, patients who have a demonstrable acute abdomen on physical exam or have imaging evidence of an intra-abdominal projectile or free air require emergent laparotomy. Evidence of a deep rectal perforation or rectal defect on examination warrants emergent laparotomy as well. All patients undergoing laparotomy require broad-spectrum intravenous antibiotics. Since feces contain a large inoculum of Clostridium tetani, all patients with a suspected injury should receive appropriate tetanus prophylaxis.
If the management decision is uncertain and suspicion for rectal injury is high, the patient should be evaluated by proctosigmoidoscopy, which allows for more thorough evaluation of rectal bleeding and perforation. This typically is performed by a surgeon. Distal rectal injuries confined to the mucosa may be amenable to emergency department treatment with irrigation and repair or may not require treatment at all. More serious injuries require surgical intervention for debridement of devitalized tissue.
The management of the rectal perforations that occur during a barium enema depends on the location and extent of the perforation. Small perforations that are extra-peritoneal are best treated with broad-spectrum intravenous antibiotics and close observation. If there is a large amount of extravasated barium or the perforation appears to be intraperitoneal, treatment requires aggressive fluid resuscitation, intravenous antibiotics, and laparotomy for irrigation and debridement of the barium from the peritoneal surfaces and primary repair of the perforation. If the extravasation is extensive, a diverting colostomy and presacral drainage may be warranted.
Bowel perforation sustained during a colonoscopy may respond to conservative management because the perforations usually are small and the bowel was prepped. Management includes fluid resuscitation, broad-spectrum intravenous antibiotics, and close observation. However, should the patient develop evidence of peritonitis, surgical intervention likely will be needed.
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Patients with anal diseases can be some of the most uncomfortable patients presenting to the emergency department.Subscribe Now for Access
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