0071643192.pdf

Anal Fissure

Superficial linear tear in the anal canal; common in children and young

adults; most common cause of rectal bleeding in infants due to passage of

large hard stool

SYMPTOMS

■ Sharp, cutting pain, especially during and immediately after bowel move-

ments; pain subsides between bowel movements

■ Small amounts of bright red bleeding, especially on toilet paper

EXAM

■ Anal fissures occur in the posterior midline (90%) or in the anterior mid-

line (10–40% women, only 1% of men)

■ May see characteristic “sentinel pile”: swollen papilla just distal to fissure

DIFFERENTIAL

■ Consider Crohn disease, ulcerative colitis, squamous cell carcinoma, ade-

nocarcinoma, localized anal cancer, leukemia, lymphoma, syphilis, gonor-

rhea, chlamydia, tuberculous ulcer

■ Definitive diagnosis requires biopsy of the ulcer edge.

TREATMENT

■ Meticulous anal hygiene

■ Stool softener stool-bulking agent

■ Local therapy: Analgesic ointment, hydrocortisone cream, nitroglycerin

ointment

■ Hot sitz baths to relieve sphincter spasm and bran to diet to prevent stric-

ture formation

■ May need surgery

Anal Fistula

Anal fistulas most commonly result from perianal/perirectal abscesses.

SYMPTOMS/EXAM

■ Persistent, blood-stained, malodorous discharge

■ Intermittent obstruction with inflammation and abscess formation

DIFFERENTIALDIAGNOSIS

■ Consider Crohn disease, cancers, STDs, anal fissures, TB, foreign bodies

■ Ultrasound, CT, or MRI for definitive diagnosis

Rectal Foreign Bodies

DIAGNOSIS

■ Digital rectal exam or proctoscopic exam will localize most foreign bodies.

■ X-rays are mandatory, not only to delineate the size, location, and number

of foreign bodies, but also to check for the most serious complication, eg,

visceral perforation.

ABDOMINAL AND GASTROINTESTINAL

EMERGENCIES

Anal fissures are the most

frequent cause of rectal

bleeding in infants due to

hard stools.

Goodsall’s rule: Fistulas with

anterior openings follow a

direct line to the anal canal,

whereas fistulas with posterior

openings tend to deviate and

curve.