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Anorectal Disease

1) A38yearoldwomancomestoyourofficebecauseofa4weekhistoryofpainfulbowelmovements
associatedwithasmallamountofbloodonthetoilettissuewithwiping.Shehasnohistoryofsimilar
episodesbutisveryconcernedbecausehergrandfatherdiedofcoloncancer.Shehasoccasional
constipationbuthasotherwisebeenhealthy.Thepatientisinamonogamousrelationshipwithherhusband.
Withtheexceptionoftopicalhemorrhoidointment,shetakesnomedications.

Onphysicalexamination,hertemperatureis98.6F(37.0C),pulseis80/minandregular,respirationsare
14/min,andbloodpressureis110/70mmHg.Physicalexaminationshowsaposteriormidlineskintagthat
istendertopalpation.Digitalrectalexaminationcannotbecompletedbecauseofseverepainandsphincter
spasm.

Whichofthefollowingisthemostlikelycauseofthispatientssymptoms?
Squamouscarcinomaofanus
Chronicanalfissure
Thrombosedhemorrhoid
Condylomaaccuminata
Perianalabscess
Youransweriscorrect
Thispatienthasaclassichistoryforachronicanalfissure.Minoranaltraumafromconstipation(usual
history)ordiarrheacanleadtoanacuteanalfissure.Thepatientmaynothavepaininitiallybutmaysee
brightredbloodonthetoilettissue.Painmayoccurwithrepeatedepisode.Initiallythepainiswith
defecation.Withtimethepainmaybeinitiatedbydefecationbutlingerslongafterwardduetosphincter
spasmwhichleadstoischemiaoftheanodermwhichinturnsleadstoachroniculcerandscarringintothe
internalanalsphincter.Patientsavoiddefecatingduetothepainleadingtomoreconstipationand
propagationoftheproblem.Chronicanalfissuresareusuallylocatedintheposteriormidline,theleast
distensibleareaofthesphinctermechanism.Painandsphincterspasmmakesitverydifficulttodoadigital
rectalexamwithoutanesthesia.Thereisoftenaprominentskintagorsentinelpilethatisdistaltothe
fissurethatliesintheanalcanal.Thismayappearedematousandbepainfulwhenpalpated,andisoften
confusedasathrombosedhemorrhoidoranalwarts(condylomaaccuminata)byinexperiencedclinicians.
Carefullyspreadingtheanalskinandsphincterwillrevealthesmallulcerproximaltothetag,butthiscan
bedifficulttoaccomplishwithoutanesthesiainmanypatients.
Thrombosedhemorrhoidshaveanacuteonsetandthepatientcanusuallyfeelanoduleadjacenttotheanal
canal.Usuallyoneseesablueblackcolorednodulethatistendertotouch.Thereusuallyisnoevidenceof
sphincterspasmorantecedenthistoryofbloodonthetissue.
Aperianalabscesswillalsocausepain,andthepatientoftencanfeelatenderlumpinthearea.Defecation
maybepainfulwithanabscess,sincetheseusuallystartasananalcryptabscessandcancommunicate
throughaportionofthesphinctertothesubcutaneousperianaltissue.Thesemayappearasafluctuantarea
witherythematousoverlyingskinorasjustatenderinduratedarea.Intramuscularabscessesshowno
perianalskinchanges,buttheyusuallyareassociatedwithverypainfuldigitalrectalexams.
CondylomaaccuminataoranalwartsduetoHPVinfectionappearassolitaryormultiplepapulesthat
sometimescanbequitelargeandbulky.Theyareusuallyassociatedwithlessseverepainbutbulkywarts
canbecomeverypainful.Analwartsareassociatedwithariskfordevelopingsquamouscellcarcinoma.

Squamouscellcarcinomacanoccurinandaroundtheanalcanal.Theseareoftenpainfulandcanbe
confusedwithchronicfissures.Analcancerscanoccuranywherearoundtheanusandachroniculcerthat
isnotintheposteriormidlineshouldalwaysbesuspiciousforcancer.Chronicposteriormidlinefissures
thatdonotrespondtotreatmentshouldbebiopsiedtoruleoutmalignancy.

2) Apreviouslyhealthy27yearoldmancomestotheemergencydepartmentbecauseofperianalpain,
swelling,anddrainageofasmallamountofpusforthepast2weeks.Hereportsa10pound(4.5kg)
weightloss,abdominalcramping,andintermittentmucusinhisstools.Hereportshaving7to8stoolsper
day.Hisonlymedicationisloperamide.

Onphysicalexamination,histemperatureis99.0F(37.2C),pulseis88/minandregular,respirationsare
14/min,andbloodpressureis120/80mmHg.Theabdomenisflatandsoftwithmildtendernessto
palpationovertherightlowerquadrant.Rectalexaminationshowsachronicappearingfistulainano.

Whichofthefollowingisthemostlikelydiagnosis?

Colorectalcancer
Squamouscarcinomaofanus
Irritableboweldisease
Crohn'sdisease
Ulcerativecolitis
Youransweriscorrect
ThispatienthasaclassichistoryforCrohnsdisease,oneofthechronicinflammatoryboweldiseases.
Chronicdiarrhea,crampingandmucusinthestoolisafindingoftenassociatedwitheitherCrohnsdisease
orulcerativecolitis.Ulcerativecolitis(UC),ischaracterizedbymucosabasedinflammationandalways
involvestherectumwithvaryingdegreesofproximalextensioninthecolon.Perianaldiseaseandfistulas
areusuallynotassociatedwithUC.
CrohnsdiseaseischaracterizedbyfullthicknessinflammationintheGItract.Therecanbeareasof
normaltissuebetweenareasofinflammation(skipdisease)andrectalsparingiscommon.Perianaldisease,
(includingabscesses,fissuresandfistulae)iscommonwithCrohnsdisease,andsomepatientsdevelop
severediseasewithmultiplefistulae(wateringcananus).
Patientswithcolorectalcanceroftenareasymptomatic.Grossrectalbleedingwithoutdiarrheacanbeasign
ofadistalcolorectalcancer.Obstructivesymptomsaremorecommon,andcanbeassociatedwith
paradoxicaldiarrhea,butthisisusuallylesssevereandnotassociatedwithsignificantamountsofmucous.
Perianaldiseaseisusuallynotassociatedwithcolorectalcancer.Patientswithcolorectalcancerareusually
olderunlessthereisageneticrisksuchaswithfamilialpolyposis.
Perianalsquamouscellcancerscanoccurinyoungindividuals,particularlythosewithahistoryofHCV
infections.Theothersymptomsmanifestedinthispatientarerarelypresent.
Diarrheacanbeaprominentsymptominsomepatientswithirritablebowelsyndrome(IBS),butperianal
diseaseisnotamanifestationofIBS.

3)A28yearoldwomancomestoyourofficewithcomplaintsofhemorrhoids.Shestatesthatshehas
hadintermittentbleedingforthepast3months,andshereportssomethingisfallingoutofmyrectumwith
everybowelmovementandIhavetopushitbackin.Hersymptomshavenotrespondedtotopical

hemorrhoidointments.Thepatienthas3childrenbornbythevaginalroutewithoutcomplications.Her
medicalhistoryisotherwiseunremarkable.
Onphysicalexamination,hertemperatureis98.6F(37.0C),pulseis60/minandregular,respirationsare
12/min,andbloodpressureis100/60mmHg.Physicalexaminationshowsrectalmucosathatprotrudes
fromtheanusintheleftlateralpositionwhenshestrains.

Whichofthefollowingisthemostlikelydiagnosis?

Rectalprolapse
Externalhemorrhoids
Internalhemorrhoids
Hypertrophiedanalpapilla
Rectalpolyp
Youransweriscorrect
Thisyoungwomanpresentswithprolapsinginternalhemorrhoids.Theintermittentbrightredbleeding
associatedwithprolapsingtissueisacommonhistory.Hemorrhoidsarecommonlyassociatedwitha
historyofpregnancyandstrainingatdefecation.Thereisusuallyminimaltonopaininvolvedsincethe
prolapsinginternalhemorrhoidsarewithintherectalmucosaandreceiveentericinnervation.Thedilated
hemorrhoidsandoverlyingrectalmucosaaresusceptibletobleedingfromstraininganddefecation.
Externalhemorrhoidsarenotreducible.Theyarecoveredwithsquamousmucosaandarelocatedunder
theanodermintheanalcanal.Anodermhassomaticinnervation,andthrombosisandinflammationof
externalhemorhhoidscausesmoderatetoseverepain.Bleedingfromthrombosedhemorrhoidsoccurswhen
thecloterodesthroughtheskin.Externalhemorrhoidsthatarenotthrombosedarenotlikelytobleed.
Prolapsedinternalhemorrhoidsconsistofthesubmucosaltissuewiththedilatedhemorrhoidsandthe
overlyingrectalmucosa.Therearethreemaincolumnsofhemorrhoidsrightanterior,rightlateralandleft
posterior.Oneorallthreeofthecolumnsmaybeenlargedandprolapse.
Rectalprolapsereferstofullthickness(mucosa,submucosaandmuscularis)prolapseoftherectumthrough
theanus.Thispresentsasaconcentriccone,andasmallsegmentofrectumcanprolapseaswellasvery
largesegments.
Rarely,apedunculatedrectalpolypcanprolapseandcausesimilarsymptomstoaprolapsedhemorrhoid,
butiseasilydistinguishedonphysicalexamincludinganoscopy.
Hypertrophiedanalpapillaeoccuratthedentatelineandareusuallycausedfromanalinflammation,
crytotitsandpapillitis.Smallhypertrophiedpapillaearecommonandassociatedwithhemorrhoiddisease.
Occasionallyonecangetquitlargeandprolapse.Theyappearasafirm,tannishwhitetissue,andareeasily
identifiedbypalpationordirectvisualization
4)Apreviouslyhealthy21yearoldmancomestotheemergencydepartmentwithsevereanalpainthat
began24hoursagoandhasworsenedduringthepast3hours.Hetakesnomedications.

Onphysicalexamination,histemperatureis99.0F(37.2C),pulseis105/minandregular,respirationsare
16/min,andbloodpressureis120/80mmHg.Examinationoftheperineumshowsnoabnormalities.Rectal
examinationcannotbecompletedbecauseofseverepain.

Whichofthefollowingisthebestnextstepinmanagement?

Examinationunderanesthesiainoperatingroom
Antibioticsfor7days
Applicationoftopicalxylocainejelly
Computedtomographyofthepelvis
Endorectalultrasound
Youransweriscorrect
Acuteanalpainshouldalwaysinitiateanexaminationandnotbetreatedoverthetelephone.Thispatients
historyandphysicalfindingsarehighlysuspiciousforanintramuscularperirectalabscess.Athorough
examinationisnecessary,andbecauseofpainshouldbeperformedurgentlyunderanesthesiainthe
operatingroomwiththepatientconsentedtodrainanabscessordoothermeasurestoobtainthediagnosis
andtreattheproblem.
Empirictherapywithantibioticsaloneisnotappropriateforaperirectalabscesswhichalsoneedstobe
drained.Anurgentexaminationisnecessarytoconfirmthediagnosis.
Computedtomography(CT)scansshouldbedoneonlytoinvestigateaproblemidentifiedonacomplete
examination,andshouldnotbedonefirsttoruleoutdisease.
Endoscopicultrasonographyshouldneverbedonebeforeacompleteanorectalexamination.
Topicalanestheticssuchaslidocaine(Xylocaine)jellyareusuallyinadequatetocontrolpaininordertodo
acompleteanorectalexamination.Treatingthepainwithtopicalanestheticswithoutdeterminingthecause
ofthepainisnotappropriate.
5)A40yearoldmancomestotheemergencydepartmentbecauseofa10dayhistoryofperianalpain
withdischarge.Hismedicalhistoryisunremarkable,andhetakesnomedications.

Onphysicalexamination,histemperatureis99.5F(37.5C),pulseis90/minandregular,respirationsare
14/min,andbloodpressureis130/80mmHg.Examinationshowsa2cmholefromtheanalvergeinthe
leftposteriorlateralposition;theopeningisdrainingasmallamountofpus.Thesurroundingtissueis
mildlytender.

Perioperativeexaminationoftheanalcanalismostlikelytorevealaninternalopeningtoafistulaatwhich
ofthefollowinglocations?
Leftanteriorrectum
Leftposteriordentateline
Anteriormiddentateline
Leftposteriorrectum
Posteriormiddentateline
Youranswerisnotcorrect
Thismanhasafistulainanooranalfistula,afistulabetweentheanorectaljunctionandtheskin.These
fistulausuallyariseafterdrainageofaperianalorperirectalabscessandrepresentatubeofchronic
granulationtissuesthatfailstohealafterdrainageoftheabscess.Perirectalabscessesusuallystartinthe
analcryptsanderodethroughthesphinctermuscle.Aperianalabscessoccursiftheinfectionerodestothe
perianalskinthroughthesubcutaneousportionofthesphincter.Aperirectalabscessoccurswhenthe
abscesserodesthroughthedeeperportionsofthesphincterintotheperirectalandischiorectalspaces.
Sometimestheabscessesdrainspontaneouslybutoftenrequireincisionanddrainage.Anypatientwitha

perianalorperirectalabscessshouldbeadvisedthatafistulaisverylikelyafterdrainage,andthiscanoccur
evenmonthslaterafterpresumedhealing.Theopeningontheperianalorperirectalskinisthesecondary
opening.Theprimaryopeningisatthedentatelinewheretheinitiatingcryptoglandularabscessoccurred.
ThepaththatthefistulatakesispredictableaccordingtoGoodsallsrule.Whenthesecondaryopening
(external)isanteriortothemidtransverseplaneoftheanus,thefistulafollowsaradialcoursetotheanus
andtheprimaryopeningatthedentateline.Ifthesecondaryopeningisposteriortothetransverseplane,
thefistulawillfollowacoursebacktotheposteriormidlinedentateline.Themechanismforthisisnot
clearbutmayberelatedtofailureoffusionofthelongitudinalmuscleandtheexternalsphincterinthe
posteriormidline.Forsecondaryopeningsmorethan2cmfromtheanalverge,Goodsallsrulemaynot
applyasevenanterioropeningsmaytrackbacktotheposteriormidlineanus.Goodsallsruledoesnot
applytopatientswithCrohnsdisease.
6)Threemonthsfollowingdrainageofaperianalabscess,a33yearoldmancomestoseethephysician
becauseofintermittentperianalpainanddrainage.Henoticesanoccasionaldropofblood.Thedrainage
doesnotseemrelatedtothetimingofdefecation.Hispostoperativecoursehadbeenuneventfuluntil
approximately3weeksago.

Onphysicalexamination,histemperatureis98.6F(37.0C),pulseis70/minandregular,respirationsare
14/min,andbloodpressureis120/70mmHg.

Whichofthefollowingwillmostlikelybediscoveredonrectalexamination?
Analfissure
Internalhemorrhoids
Externalhemorrhoids
Fistulainano
Recurrentabscess
Youransweriscorrect
Thismanhasafistulainanooranalfistula,afistulabetweentheanorectaljunctionandtheskin.These
fistulausuallyariseafterdrainageofaperianalorperirectalabscessandrepresentatubeofchronic
granulationtissuesthatfailstohealafterdrainageoftheabscess.Perianalandperirectalabscessesusually
startintheanalcryptsanderodethroughthesphinctermuscle.Aperianalabscessoccursiftheinfection
erodestotheperianalskinthroughthesubcutaneousportionofthesphincter.Aperirectalabscessoccurs
whentheabscesserodesthroughthedeeperportionsofthesphincterintotheperirectalandischiorectal
spaces.Sometimestheabscessesdrainspontaneouslybutoftenrequireincisionanddrainage.Anypatient
withaperianalorperirectalabscessshouldbeadvisedthatafistulaisverylikelyafterdrainage,andthis
canoccurevenmonthslaterafterpresumedhealing.Theopeningontheperianalorperirectalskinisthe
secondaryopening.Theprimaryopeningisatthedentatelinewheretheinitiatingcryptoglandularabscess
occurred.
Arecurrentabscessusuallyoccursforthesamereasonasafistula,however,thesecondaryopening(skin)
hashealedandspontaneousdrainagehasnotoccurred.
Internalhemorrhoidsconsistofsubmucosaltissuewithdilatedhemorrhoidsandoverlyingrectalmucosa.
Therearethreemaincolumnsofhemorrhoidsrightanterior,rightlateralandleftposterior.Oneorall
threeofthecolumnsmaybeenlargedandprolapse.Thehemorrhoidsareoccasionallyassociatedwith
painlessdischargeofmucousandintermittentbleedoftenwithdefecation.
Externalhemorrhoidsarecoveredwithsquamousmucosaandarelocatedundertheanodermintheanal
canal.Anodermhassomaticinnervation,andthrombosisandinflammationofexternalhemorhhoidscauses

moderatetoseverepain.Bleedingfromthrombosedhemorrhoidsoccurswhenthecloterodesthroughthe
skin.
Minoranaltraumafromconstipation(usualhistory)ordiarrheacanleadtoanacuteanalfissure.The
patientmaynothavepaininitiallybutmayseebrightredbloodonthetoilettissue.Painmayoccurwith
repeatedepisode.Initiallythepainiswithdefecation.Withtimethepainmaybeinitiatedbydefecationbut
lingerslongafterwardduetosphincterspasmwhichleadstoischemiaoftheanodermwhichinturnsleads
toachronicanalfissurewhichismanifestedasasmallulcerandscarringintotheinternalanalsphincter.
Patientsavoiddefecatingduetothepainleadingtomoreconstipationandpropagationoftheproblem.
Chronicanalfissuresareusuallylocatedintheposteriormidline,theleastdistensibleareaofthesphincter
mechanism.Painandsphincterspasmmakesitverydifficulttodoadigitalrectalexamwithoutanesthesia.
Thereisoftenaprominentskintagorsentinelpilethatisdistaltothefissurethatliesintheanalcanal.This
mayappearedematousandbepainfulwhenpalpated,andisoftenconfusedasathrombosedhemorrhoidor
analwarts(condylomaaccuminata)byinexperiencedclinicians.Carefullyspreadingtheanalskinand
sphincterwillrevealthesmallulcerproximaltothetag,butthiscanbedifficulttoaccomplishwithout
anesthesiainmanypatients.

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