4 Is this normal?Document anal opening not in the center of the perineal pigmented areaAPI (Anal Position Index):Normal: halfway between coccyx and introitus or scrotumFemale: anus-fourchette/coccyx-fourchette 0.45+/- 0.08Male: anus-scrotum/coccyx-scrotum /- 0.074% of infantsRefer to surgery if severe constipation associated with API <2SD from the mean<0.29 in girls, <0.40 in boysAnterior Ectopic AnusAnteriorly displaced anus partially within the anal sphincter complexExamination of a newborn includes the inspection of the perineum. The absence of an anal orifice in the correct position leads to further evaluation. Mild forms of imperforate anus are often called anal stenosis or anterior ectopic anus. These are probably imperforate anus with a perineal fistula. The normal position of the anus on the perineum is approximately halfway (0.5 ratio) between the coccyx and the scrotum or introitus. Although symptoms, primarily constipation, have been attributed to anterior ectopic anus (ratio <0.34 in girls, <0.46 in boys), many patients have no symptoms.
5 What does this “bucket handle” bridge represent? Rectum passes through the levator aniFistulous tract extends to perineal regionPrognosis favorable for low lesions because they lie within the levator ani complexLow Imperforate AnusA spot of meconium is visible beneath a “bucket handle” bridge of skin in an infant with a low imperforate anus.These rectal anomalies are classified on the basis of the position of the rectum and the levator ani muscle complex. Low imperforate anus is associated with the passage of the rectum through the levator ani, and a fistulous tract extends to the perineal region ending in the center of a ridge of tissue on the anus (“bucket handle” deformity) or anterior to these structures as a perineal fistula (Fig ). In male infants the fistula may travel in the median raphe of the scrotum, and the meconium may be seen as a string of white or black beads (Fig ). The prognosis is generally favorable for low lesions because they lie within the levator ani complex.
6 Rectal FissureSuperficial tears of anoderm, inferior to the dentate line90% posteriorDue to constipation, although history only elicited in 25% of casesPresentation: pain, bleedingDiagnosis:acute fissures are typically smallchronic fissures assoc w/ skin tag or fibrosisRemember if fissure is large or there is bruising, consider abuse
8 Perianal Strep Presentation Diagnosis: Treatment: Well demarcated rash6 mo – 10 yrs oldCellulitis in 90%, pruritis in 80%Pain, pruritis, bleedingFamilial spread possibleDiagnosis:Group A B-hemolytic streptococcal infections found on perianal cxTreatment:10 days of oral penicillinEES for PCN allergic patientClindamycin +/- mupirocin40-50% recurrence rateContemporary Pediatrics, Publish date: Mar 1, 2011 By: Sapna Kansal Mukherjee, MD
9 Chronic Pruritis Ani Enterobius vermicularis Presentation: anal pruritisDead parasites and eggs in the perianal area may also cause abscesses and granulomasConditions Associated with Pruritus AniSystemic illnessDiabetes mellitusHyperbilirubinemiaLeukemiaAplastic anemiaThyroid diseaseMechanical factorsChronic diarrheaChronic constipationAnal incontinenceSoaps, deodorants, perfumesOver-vigorous cleansingHemorrhoids producing leakageProlapsed hemorrhoidsAlcohol-based anal wipesRectal prolapseAnal papillomaAnal fissureAnal fistulaTight-fitting clothesAllergy to dyes in toilet paperIntolerance to fabric softenerSkin sensitivity from foodsTomatoesCaffeinated beveragesBeerCitrus productsMilk productsDermatologic conditionsPsoriasisSeborrheic dermatitisIntertrigoNeurodermatitisBowen's diseaseVarious squamous disordersAtopic dermatitisLichen planusLichen sclerosisContact dermatitisInfectionsErythrasma (Corynebacterium)Intertrigo (Candida)Herpes simplex virusHuman papillomavirusPinworms (Enterobius)ScabiesLocal bacterial abscessGonorrheaSyphilisMedicationsColchicineQuinidineAdapted with permission from Zuber TJ. Diseases of the rectum and anus. In: Taylor RB, ed. Family medicine: principles and practice. 5th ed. New York: Springer-Verlag, 1998:792.
10 Perianal FistulaChronic track of granulation tissue connecting two epithelial lined surfacesMost fistulas originate below the dentate lineA fistulous abscess becomes a fistula when it rupturesSurgical drainageExcept in known or suspected Crohn’s diseasePack the cavity or catheter to drainSitz or tub baths, analgesicsAntibioticsWhen fistula present, surgeon inserts a probe in external opening; the internal opening in infants is radially opposite the external opening (unlike in adults where it is often in the posterior midline (Goodsall’s rule)
11 Perianal FistulaThe internal opening in children is on the pectinate line radially opposite the external orificeUnroof the fistulaKeep area clean with soap and water
12 Infliximab in Patients with Fistulizing Crohn’s Disease Perianal Fistula Case StudyPretreatment2 WeeksIn more complex forms of abscess and fistula in Crohn’s disease, frequency of fistula seen in 17-41% of Crohn’s pts; Simple fistula is low with single external opening, no pain or fluctuationComplex fistula is high and may have multiple external openings, assoc with perianal abscess, rectovaginal fistula, active rectal diseaseTreatment: antibiotics, immunomodulators, infliximab10 Weeks18 weeksPresent D, et al. NEJM. 1999; 340:
13 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
14 Perirectal Abscesses Management Presentation Sitz baths Antibiotics Surgical options:If chronic fistulae beyond 3 months despite medical managementFistulectomyFistulotomySeton loopConsider evaluation for neutropenia, leukemia, HIV, diabetes, IBDPresentationMales > Females98% report persistent perirectal painAbscesses identified in 95% of cases when an external perianal exam in combined with a digital rectal exam
15 Rectal Prolapse Mucosal vs full thickness Males > Females Etiologies:ConstipationDiarrheaCystic fibrosisOther: intra-abdominal pressure, polyps, parasites, malnutrition, pelvic floor weaknessUsually self limitedIf recurrent and pronouncedSweat chlorideScreen for parasitesRectal prolapse is an uncommon condition that is most often idiopathic in children (Fig ). The peak incidence of idiopathic rectal prolapse occurs in the second year of life, often precipitated by episodes of diarrheal illnesses, efforts to toilet train or severe constipation. This process responds spontaneously after the resolution of the acute illness or with dietary and medical manipulations to treat the constipation. Nonidiopathic cases are often related to neurologic conditions or chronic diseases. Abnormalities in the development of the muscles of the pelvic floor or the innervation occur in patients with spina bifida and related spinal cord abnormalities. Refractory cases should be evaluated for chronic hookworm infestation with stool evaluations for ova and parasites, which may cause severe tenesmus and straining. Rectal polyps may precipitate prolapse by acting as a lead point for this form of rectal intussusception. Evaluation by contrast enema and sigmoidoscopy are important components of the assessment of children with recurrent episodes. Cystic fibrosis is another common cause of prolapse and should be evaluated in patients with this condition. Surgery is rarely indicated. Circumferential submucosal injections with concentrated dextrose functions as a sclerosant that prevents prolapse from recurring.
17 Rectal ProlapseTreatment: Manual reduction, treat primary inciting factorIf persistent: surgical – injection of sclerosant or hypertonic saline submucosally or submuscularly above dentate linePrognosis generally good
18 Hemorrhoids Small asymptomatic: not uncommon Symptomatic: Due to chronic strainingAnal infection spreading to hemorrhoidal veinsUnderlying Crohn’s diseaseMale = FemalePresentation: Bleeding, pruritis, prolapse, painDiagnosis: Clinical history and careful exam
19 Hemorrhoids External Hemorrhoids Internal Hemorrhoids From ectoderm and arise distal to dentate lineStratified squamous epitheliumInferior rectal nerve - painfulInternal HemorrhoidsAbove the dentate line from embryonic endodermSimple columnar epitheliumPainlessClassified by the degree of prolapsePathogenesis: ?Low fiber dietsDecreased venous returnProlonged sitting on toiletaging
20 Hemorrhoids: Treatment Conservative OptionsIndication: Grade I & II internal; non-thrombosed externalSitz baths bid-tidHigh-fiber dietFluid intakeStool softenersTopical/systemic analgesicProper anal hygieneShort term topical steroid (hydrocortisone acetate 2.5% and pramoxine HCL1% cream)Non-surgical OptionsIndication: Recalcitrant hemorrhoidsRubber band ligation*Infrared coagulation*Injection sclerotherapyLaser therapyCryosurgerySurgical ManagementNonsurgical treatment failureGrade III & IV internal with severe symptoms5-10% eventually require surgeryHemorrhoidectomyProlonged steroid use can cause skin sensitization and rectal absorption may lead to systemic side effects
22 ReferencesBrowning 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; Chapter 72.Davari HA. The anal position index: a simple method to define the normal position of the anus in neonate. Acta Paediatr. 2006;95:877Gourgiotis S, Baratsis S. Rectal prolapse. Int J Colorectal Dis. 2007;22: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”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;Walker W, et al, eds. Pediatric Gastrointestinal Disease. 4th ed. Hamilton, Ontario: BC Decker, 2004: Chapter 35