Anal pain, bleeding and bulging

Transcription

1 Anal pain, bleeding and bulging Is there anything else besides hemorrhoids? M. SOPHIA VILLANUEVA, MD Colorectal Surgeon Bangor, ME

2 Disclosures I have no disclosures

3 Objective Describe how to appropriately evaluate patients with anorectal complaints Identify the common differential diagnosis for common anorectal complaints: pain, bleeding and bulging Identify other pathology that are not common but need immediate referral

4 FACTS There are 1.9 to 3.5 million physician visits and 168,000 hospitalizations yearly for hemorrhoidal related symptoms Nearly two million prescriptions written annually for hemorrhoid therapies accounting for over $43 million

5 Fact or Myth? Hemorrhoidal Cream (Preparation H) is in the top 5 of the most frequently shoplifted OTC medication

6 But not all anal pain, bleeding and bulging are hemorrhoids

7 REMEMBER You recognize only what you KNOW and find only what you look for!

8 WARNING!! Some pictures may not be suitable for young audiences!

9 Outline Evaluating patients with anorectal complaints How to get a thorough history in 5 mins How to do a proper exam Case scenarios Anal Pain Anal Bulge Anal/ Rectal Bleeding

10 Evaluating patient with anorectal complaints HISTORY is important by getting a more detailed history you can already make a short list of diagnosis. Don t be mislead! Patients always think they have hemorrhoids Chief complaint it is important to ask patient what is the most bothering symptom (pain, bleeding or bulging?) ANAL PAIN Ask when did the pain begin? Describe the pain? Is there an raised or hard areas? Did you have that pain before? Have you seen any blood or discharge?

11 Anorectal Exam: More Than A Digital! 3 components Inspection Perianal lesions, muscle movement, skin, perineal body External palpation Tenderness DRE Muscle tone, squeeze, tenderness, mass, rectocele, prostate (+/-) Anoscopy Mucosa, hemorrhoids, masses STOP!

12 Anorectal Case Scenarios

13 Case of Anal pain #1 45 y.o male, healthy comes in with acute onset of anal pain Describe the pain? Sharp stabbing pain, feels like passing glass or razor blades from their rectum When do you feel the pain? Having a bowel movement Are there an raised or hard spots? None / may a small bump Did you have that pain before? No Have you seen any blood or discharge? Spots of blood with wiping or sometimes drips at the toilet bowl

14 ANAL FISSURE Painful linear ulcer overlying the distal margin of the anal sphincter Evaluate by spreading the anal opening apart with both hands Defer doing a DRE if fissure is found very painful for patients 90% will be in the posterior midline (highest resting pressure and lowest blood supply)

15 Anal Fissure Treatment: Conservative measures 50% of will heal with supportive tx with Psyllium fiber, sitz bath, topical anesthetics (5% Lidocaine OTC) Sphincter relaxants Topical nitroglycerin 0.2% - can induce headache Topical Calcium channel blockers (Diltiazem 2%) - less side effects Botox injection Surgery Lateral internal sphincterotomy

16 Case of Anal Pain #2 45 y.o male, healthy comes in with acute onset of anal pain When did the pain begin? 2-3 days ago Describe the pain? Sharp continuous pain, I can not stand sitting down What were you doing at the time? Driving home from the gym Are there an raised or hard spots? Yes and its very tender Did you look at that painful site? Yes, it s a lump on the side of the anus Have you seen any blood or discharge? No

17 Thrombosed External Hemorrhoids

18 Thrombosed External Hemorrhoids PAINFUL (External Hemorrhoids are not painful until they thrombose), peaks at 48 hrs Presents on the lateral margin of the anus If the onset has been <72 hrs incision and drainage No surgical treatment if symptoms have begun to resolve Expect spontaneous resolution clot may be reabsorbed or erode the skin and extrude the clot Conservative Treatments: warm compress or sitz bath, fiber/ stool softeners, analgesics (topical or oral)

19 Case of Anal Pain #3 45 y.o male, healthy comes in with acute onset of anal pain When did the pain begin? 4 days ago Describe the pain? Aching and throbbing What were you doing at the time? sleeping Are there an raised or hard spots? Hard and tender on the side of my anus Have you seen any blood or discharge? No How does the pain compare to 4 days ago? It s getting worse! I can not sit!

20 Anorectal abscess Sometimes there is no obvious overlying redness, but just tenderness and fluctuance If patient is presenting with pain and tenderness around the rectum but without fluctuance and redness, Consider a CT scan to check for deep space abscess

21 Anorectal Abscess Typically from cryptograndular infection Symptoms: pain, swelling +/- fever Needs surgical drainage If one will drain in the office drain close to the anal canal with a cruciate or elliptical incision Most of the time there is no need for antibiotics after drainage unless with cellulitis, valvular heart disease, diabetic or immunocompromised Cover with antibiotics that will treat bowel flora (gram negatives and anaerobes)

22 Differentials for Acute Anal Pain Think: ANAL FISSURE THROMBOSED EXTERNAL HEMORRHOIDS PERIRECTAL ABSCESS

23 Case of Anal Bulging #1 65 y.o female, G5P5 comes in for anal bulge When did you notice it? When I was having a bowel movement Can you describe to me what bulges? This pink ball of mass coming out of my bottom Do you have any bleeding? Yes, small amounts Are you able to push it back in? Sometimes it goes back on its own but sometimes I have to push it back in

24 Rectal prolapse REMEMBER TO EXAMINE PATIENTS WHILE BEARING DOWN Circular edges (vs hemorrhoids with radial edges) If seen acutely, just manually push it in gently If swollen and cannot be reduced, put table sugar on the rectal prolapse in order to reduce it Surgery is the only treatment

25 Case of Anal Bulging #2 When did you notice it? Its been awhile, it bulges and get swollen sometimes when I strain but gets smaller sometimes Can you describe to me what bulges? I think its my hemorrhoids Do you have any bleeding? Yes, small amounts What other symptoms do you have? It itches and burns Are you able to push it back in? Sometimes it goes back on its own but sometimes I have to push it back in

26 Prolpased Internal Hemorrhoids

27 Hemorrhoids Everyone has hemorrhoids! normal anatomic component of the anus Vascular cushions contained within the submucosal space of the anal canal Serve to maintain closure of the anal canal contributing to fecal continence

28 Internal hemorrhoids Symptoms : bright red blood on the toilet bowl or paper, itching, burning, Not Painful Only incarcerated prolapsed internal hemorrhoids and thrombosed external hemorrhoids are painful Asymptomatic hemorrhoids do not need treatment Medical treatment: psyllium fiber, stool softeners, sitz bath, lidocaine and hydrocortisone ointments/ suppositories Surgical treatments: rubber band ligation, Hemorrhoidectomy, hemorrhoid artery ligation

29 Mucosal rectal prolapse vs True Rectal prolapse Radial folds Prolpased hemorrhoids Rectal prolapase

30 Case of Anal Bulge #3 38 y.o male comes in with anal bulge When did you notice it? Months ago. Can you describe to me what bulges? It started out as small nodules around the anus and it has gotten bigger Do you have any bleeding? Yes, small amounts Are you able to push it back in? No

31 Anal Condyloma Buschke-Lowenstein Tumor

32 Anal Condyloma Lesions caused by HPV virus Presents with pruritus, bleeding, chronic drainage and difficulty with hygiene Transmitted via sexual contact Perianal involvement can occur in the absence of receptive anal intercourse Evaluation : Anoscopy, Screen for HIV Treatment is surgical removal Topical agents (Podofilox and Imiquimod/Aldara) are not approved for use in the anal canal but can be used outside the anal canal Clearance rate with topical agents are only 50% and takes 16 wks to take effect

33 Case of anorectal bleeding #1 42 y.o female healthy comes in for rectal bleeding How long has this been going on? 6-8 months Can you describe to me the bleeding? Mixed with stool but occasionally passes blood with mucous Do you have any pain? Initially no pain, however now she has constant pain even with sitting down

34 Case of anorectal bleeding #1 Inspection of her anus appears pretty normal? Internal hemorrhoids?? Fissure? Would you send her for a colonoscopy?

35 Mostly likely diagnosis Grade 1-2 internal hemorrhoids that you do not see any external component (only seen in anoscopy) However do not assume until you have done a complete exam!

36 Do not miss this! DON T FORGET TO DO A DIGITAL EXAM! Your mighty fingers could have caught this and saved her life! Colonoscopy does NOT replace a DRE This is Anal cancer unless proven otherwise! Needs immediate surgical referral for colonoscopy, biopsy and staging

37 Anal cancer don t miss this! NOT A FISSURE OR A HEMORRHOID! Presents with bleeding and persistent anal pain Immediate referral for a biopsy

38 Case of anal Bleeding #2 28 y.o female comes in with anal bleeding How long has this been going on? 6-8 months Can you describe to me the bleeding? Comes on and off. I feel a sense of fullness and then something burst and then it drains blood with a little bit of pus and mucous. It seems to be coming from the side of the anus near the buttock Do you have any pain? Not really

39 Anal Fistula Presents as a small opening (appears like a cyst) adjacent to the anal canal Develops from prior perirectal abscesses 40-50% of patients with abscess develop a fistula Patient c/o of intermittent feeling of fullness then after a couple of days it drains Drainage can be bloody, mucous or mucopurulent Needs referral for surgical treatment

40 Case of Anal Bleeding #3 48 y.o male, obese comes in with anal bleeding How long has this been going on? 2 months Can you describe to me the bleeding? Scant in the toilet paper with wiping, Never mixed with stool Do you have any pain? I have a burning and itching around my anus

41 Pruritus Ani Latin term for itchy anus Undesirable sensation that produces the desire to itch and results in skin irritation Can be idiopathic or secondary to other conditions Appearance: Lichenification, fissuring of skin Potential causes of irritation: stool, sweat, mucus, overzealous cleaning or wiping causing trauma to skin Open skin areas can bleed with wiping

42 Warning signs for anorectal bleeding Age >50 without any recent colonoscopy Family history of Colorectal cancer History of IBD Physical exam does not match up with the history (amount/ severity and quality of bleeding) Associated weight loss and acute changes in bowel habits (constipation, diarrhea) Persistent bleeding despite treatment of anal pathology

43 Anorectal Bleeding Guide Bright/ Dark? When? (during/after) Where? (toilet/tp) How often? How much? Pain? Other Sxs? Int Hemorrhoids bright either either intermittent +/+++ + to ++ prolapse Ext Hemorrhoids either after TP periodic lump Fissure bright after either intermittent tag Abscess either after TP periodic + ++ pus Fistula bright after TP intermittent + 0/+ clear to purulent drainage Pruritus ani bright after TP most itching Radiation either during toilet intermittent +/+++ 0/+ mucous/ urgency Infection/Ulcer bright after TP periodic + + Drainage? Rectal prolapse bright either either intermittent +/++ + Mucous/prolapse Tumor either rectal- during anal- either either intermittent +/++ 0/+ mucous/ urgency Diverticulosis/AVM either during toilet periodic +/+++ 0 none

44 Conclusion Getting a thorough history and anorectal exam will allow you to make an accurate diagnosis of most anorectal complaints Most common differential of anal pain: fissure, thrombosed external hemorrhoids and anorectal abscess Most common differential of anal bulging: prolapsed internal hemorrhoids, rectal prolapse, perianal neoplasm (benign or malignant Most common differential for bleeding: internal hemorrhoids, anal fissure and malignancy Least common cause of bleeding: anal fistula, pruritus ani

45 Don t forget to do digital rectal exam! and of course wear gloves

46 Thank you! Ad Majorem Dei Gloriam