perianal poop-pourri: disorders of the anorectum elizabeth schaefer, m.d. [email protected] st....
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Perianal Poop-pourri:Perianal Poop-pourri:Disorders of the AnorectumDisorders of the Anorectum
Elizabeth Schaefer, M.D.Elizabeth Schaefer, M.D.
[email protected]@stvincent.org
St. Vincent Pediatric GastroenterologySt. Vincent Pediatric Gastroenterology8402 Harcourt Rd. Suite #4028402 Harcourt Rd. Suite #402
Indianapolis, IN 46260Indianapolis, IN 46260(317) 338-9450(317) 338-9450
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ObjectivesObjectives
• Review clinical presentations of classic perianal disorders
• Make the diagnosis• Review the management and identify
when and who to consult
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Is this normal?• Document anal opening not in
the center of the perineal pigmented area
• API (Anal Position Index):– Normal: halfway between coccyx
and introitus or scrotum– Female: anus-fourchette/coccyx-
fourchette 0.45+/- 0.08– Male: anus-scrotum/coccyx-
scrotum 0.54 +/- 0.07
• 4% of infants• Refer to surgery if severe
constipation associated with API <2SD from the mean
– <0.29 in girls, <0.40 in boys
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What does this “bucket handle” bridge represent?
• Rectum passes through the levator ani
• Fistulous tract extends to perineal region
• Prognosis favorable for low lesions because they lie within the levator ani complex
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Rectal Fissure
• Superficial tears of anoderm, inferior to the dentate line
• 90% posterior• Due to constipation, although
history only elicited in 25% of cases
• Presentation: pain, bleeding• Diagnosis:
– acute fissures are typically small– chronic fissures assoc w/ skin tag
or fibrosis– Remember if fissure is large or
there is bruising, consider abuse
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Rectal Fissure
• Management– Decrease trauma
• Stool softeners• Lubricant laxative• Fiber
– Reduce anal sphincter tone
• Warm sitz baths
– Good hygiene– >80% heal
• Chronic fissures– >6 weeks– Uncommon in kids– Dilation to reduce
anal spasm– Nitric oxide (0.2%
glycerol trinitrate)– Botulism toxin – Surgery:
• lateral internal sphincterotomy
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Perianal Strep• Presentation
– Well demarcated rash– 6 mo – 10 yrs old– Cellulitis in 90%, pruritis in 80%– Pain, pruritis, bleeding– Familial spread possible
• Diagnosis: – Group A B-hemolytic
streptococcal infections found on perianal cx
• Treatment: – 10 days of oral penicillin– EES for PCN allergic patient– Clindamycin +/- mupirocin
• 40-50% recurrence rate
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Chronic Pruritis Ani
• Enterobius vermicularis
• Presentation: anal pruritis
• Dead parasites and eggs in the perianal area may also cause abscesses and granulomas
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Perianal Fistula• Chronic track of granulation
tissue connecting two epithelial lined surfaces
• Most fistulas originate below the dentate line
• A fistulous abscess becomes a fistula when it ruptures
• Surgical drainage – Except in known or suspected
Crohn’s disease
• Pack the cavity or catheter to drain
• Sitz or tub baths, analgesics• Antibiotics
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Perianal Fistula
• The internal opening in children is on the pectinate line radially opposite the external orifice
• Unroof the fistula• Keep area clean
with soap and water
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Infliximab in Patients with Infliximab in Patients with Fistulizing Crohn’s DiseaseFistulizing Crohn’s Disease
Perianal Fistula Case StudyPerianal Fistula Case Study
Pretreatment 2 Weeks
10 Weeks 18 weeks
Present D, et al. NEJM. 1999; 340:1398-405.
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Perirectal Abscess
• Majority result from a crypt of Morgagni infection• Classification determined by anatomic location of lesion
relative to the levator ani and sphincteric muscles
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Perirectal Abscesses
• Presentation– Males > Females– 98% report persistent
perirectal pain– Abscesses identified
in 95% of cases when an external perianal exam in combined with a digital rectal exam
• Management– Sitz baths– Antibiotics– Surgical options:
• If chronic fistulae beyond 3 months despite medical management
• Fistulectomy• Fistulotomy• Seton loop
– Consider evaluation for neutropenia, leukemia, HIV, diabetes, IBD
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Rectal Prolapse
• Mucosal vs full thickness • Males > Females• Etiologies:
– Constipation– Diarrhea– Cystic fibrosis– Other: intra-abdominal pressure,
polyps, parasites, malnutrition, pelvic floor weakness
• Usually self limited• If recurrent and pronounced
– Sweat chloride– Screen for parasites
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Rectal Prolapse
• Treatment: Manual reduction, treat primary inciting factor• If persistent: surgical – injection of sclerosant or hypertonic
saline submucosally or submuscularly above dentate line• Prognosis generally good
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Hemorrhoids
• Small asymptomatic: not uncommon
• Symptomatic: – Due to chronic straining– Anal infection spreading to
hemorrhoidal veins– Underlying Crohn’s disease
• Male = Female• Presentation: Bleeding,
pruritis, prolapse, pain• Diagnosis: Clinical history
and careful exam
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Hemorrhoids• External Hemorrhoids
– From ectoderm and arise distal to dentate line
– Stratified squamous epithelium– Inferior rectal nerve - painful
• Internal Hemorrhoids– Above the dentate line from
embryonic endoderm– Simple columnar epithelium– Painless– Classified by the degree of
prolapse– Pathogenesis: ?
• Low fiber diets• Decreased venous return• Prolonged sitting on toilet• aging
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Hemorrhoids: Treatment
• Conservative Options– Indication: Grade I & II internal;
non-thrombosed external– Sitz baths bid-tid– High-fiber diet– Fluid intake– Stool softeners– Topical/systemic analgesic– Proper anal hygiene– Short term topical steroid
(hydrocortisone acetate 2.5% and pramoxine HCL1% cream)
• Non-surgical Options– Indication: Recalcitrant
hemorrhoids– Rubber band ligation*– Infrared coagulation*– Injection sclerotherapy– Laser therapy– Cryosurgery
• Surgical Management– Nonsurgical treatment failure– Grade III & IV internal with
severe symptoms– 5-10% eventually require
surgery– Hemorrhoidectomy
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More is not necessarily better
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References• Browning J, Levy M. Cellulitis and Superficial Skin Infections. In: Long SS, Pickering LK, Prober
CG, ed. Principles and Practice of Pediatric Infectious Diseases. 3rd ed. Hamilton, Ontario: Churchill Livingstone; 2008. Chapter 72.
• Davari HA. The anal position index: a simple method to define the normal position of the anus in neonate. Acta Paediatr. 2006;95:877
• Gourgiotis S, Baratsis S. Rectal prolapse. Int J Colorectal Dis. 2007;22:231-243
• Langer M, Modi BP: Benign Perianal Lesions. In Kleinman RE, Goulet O, et al, eds. Pediatric Gastrointestinal Disease. 5th ed. Hamilton, Ontario: BC Decker Inc; 2008” 368-369.
• Pfefferkorn M, Fitzgerald J. Disorders of the Anorectum: fissures, fistulae, prolapse, hemorrhoids, tags. In: Wyllie R, Hyams JS, eds. Pediatric Gastrointestinal and Liver Disease, 3rd ed., 2006; 801-807.
• Walker W, et al, eds. Pediatric Gastrointestinal Disease. 4th ed. Hamilton, Ontario: BC Decker, 2004: Chapter 35