Perianal Poop-pourri:Perianal Poop-pourri:Disorders of the AnorectumDisorders of the Anorectum

Elizabeth Schaefer, M.D.Elizabeth Schaefer, M.D.

easchaef@stvincent.orgeaschaef@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

ObjectivesObjectives

• Review clinical presentations of classic perianal disorders

• Make the diagnosis• Review the management and identify

when and who to consult

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

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

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

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

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

Chronic Pruritis Ani

• Enterobius vermicularis

• Presentation: anal pruritis

• Dead parasites and eggs in the perianal area may also cause abscesses and granulomas

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

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

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.

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

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

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

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

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

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

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

More is not necessarily better

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