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Perianal Poop-pourri: Disorders of the Anorectum Elizabeth Schaefer, M.D. St. Vincent Pediatric Gastroenterology 8402 Harcourt Rd.

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Presentation on theme: "Perianal Poop-pourri: Disorders of the Anorectum Elizabeth Schaefer, M.D. St. Vincent Pediatric Gastroenterology 8402 Harcourt Rd."— Presentation transcript:

1 Perianal Poop-pourri: Disorders of the Anorectum Elizabeth Schaefer, M.D. St. Vincent Pediatric Gastroenterology 8402 Harcourt Rd. Suite #402 Indianapolis, IN (317)

2 Objectives Review clinical presentations of classic perianal disorders Make the diagnosis Review the management and identify when and who to consult


4 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+/ –Male: anus-scrotum/coccyx- scrotum / % of infants Refer to surgery if severe constipation associated with API <2SD from the mean –<0.29 in girls, <0.40 in boys

5 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

6 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

7 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

8 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

9 Chronic Pruritis Ani Enterobius vermicularis Presentation: anal pruritis Dead parasites and eggs in the perianal area may also cause abscesses and granulomas

10 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

11 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

12 Infliximab in Patients with Fistulizing Crohn’s Disease Perianal Fistula Case Study Pretreatment2 Weeks 10 Weeks 18 weeks Present 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 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

15 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


17 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

18 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

19 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

20 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

21 More is not necessarily better

22 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. 3 rd 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;95:877 Gourgiotis 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. 5 th 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, 3 rd ed., 2006; Walker W, et al, eds. Pediatric Gastrointestinal Disease. 4 th ed. Hamilton, Ontario: BC Decker, 2004: Chapter 35

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