More about ... General surgery The five common symptoms of Peri-anal haematoma anal disease is is caused by the rupture of a subcutaneous blood vessel in the peri- A Boutall,1 MB ChB, FCS (SA), Cert anal region and is sometimes incorrectly Gastroenterology, R J Baigrie,2 BSc, called an ‘external pile’. is purple pea- MB ChB, MD, FRCS (Eng) sized swelling is tender but not inamed. It is easily managed by scalpel incision 1Consultant Surgeon, Groote Schuur Hospital, aer instillation of local anaesthetic via an Cape Town, South Africa insulin syringe. Success is conrmed by the 2Professor of Surgery, Kingsbury and Groote expression of a blood clot and a grateful Schuur Hospitals, Cape Town, South Africa Fig. 1. Anal ssure with sentinel tag. patient. Scalpel incision should be reserved for acute lesions as delayed presentation Corresponding author: A Boutall (boutall@ anal. e symptoms are severe pain with results in a more diuse swelling which is icloud.com) point tenderness. Examination will reveal best managed conservatively. an obvious abscess or tender induration Pain and swelling. An internal or submucosal Anorectal cancer is is usually caused by: abscess is an unusual variant, which is Occasionally a low-lying cancer arising • anal ssure frequently missed because the peri-anal from the anus or rectum can cause severe • peri-anal abscess region appears normal. Digital examination anal pain due to sepsis or sphincter invasion • prolapsed thrombosed piles is exquisitely painful and mandates EUA. (Fig. 3). However, it is important to realise • peri-anal haematoma e management remains incision and that the absence of pain does not exclude • cancer invading the sphincters. drainage, with antibiotics occasionally used cancer. Any abnormality palpable in the as an adjunct to surgery in a few selected anal canal must be regarded as cancer until Anal fissure patients. An important point to remember proven otherwise. Internal haemorrhoids is typically presents with pain on when deciding to prescribe antibiotics is are not palpable on digital examination and defecation and blood spotting on toilet that, unlike other cutaneous abscesses, the are diagnosed with a proctoscope. paper. ese symptoms are due to an causative organisms are enteric ora and ischaemic mucosal ulcer within a high- not skin ora. Antibiotics that cover Gram- pressure sphincter. e ssure is usually negatives and anaerobes (e.g. co-amoxiclav) visible at inspection of the gently distracted are required. anus (Fig. 1). Defecation is exquisitely painful, ‘it’s like passing razor blades’, Acutely prolapsed thrombosed piles resulting in a cycle of fear of defecation, e primary symptom is severe pain, oen constipation, mucosal trauma and sphincter requiring hospital admission. Examination spasm. Digital examination is intolerable reveals a tender, oedematous, haemorrhoidal and should be avoided. Management mass protruding from the anus (Fig. 2), which requires laxatives, analgesia and internal is oen circumferential and occasionally sphincter relaxation, which can be achieved mistaken for a rectal prolapse. Treatment can with a nitrate ointment or a limited internal be conservative or surgical. A randomised sphincterotomy. Nitrate ointment applied to control trial comparing surgery to Fig. 3. Fistula with seton and abscess scar. the anus at least 3 times daily for 6 weeks conservative management demonstrated that is appropriate rst-line treatment. A mono- conservative management is appropriate for Prolapse nitrate ointment avoids the side-eect of many patients.[2] ree things may prolapse through the anus headaches associated with tri-nitrates. – polyps, the rectum and haemorrhoids, Persistent symptoms or atypical features, which are the most common. e treatment such as rolled edges or a lateral location, of prolapsing haemorrhoids is either require examination under anaesthetic rubber-band ligation as an outpatient (EUA) and biopsy. Botox has not been or surgical removal in theatre. Surgical shown to be superior to topical therapy.[1] removal provides durable results, but at the cost of signicant postoperative pain and Peri-anal abscess the possibility of surgical complications. ese develop from an obstructed anal Rubber-band ligation is ideal for grade 2 crypt gland at the dentate line. ey and 3 haemorrhoids and generally provides are named according to their location: excellent results, with very low morbidity ischiorectal (ischio-anal), peri-anal or intra- Fig. 2. Prolapsed thrombosed piles. (Table 1).[3] 218 CME June 2013 Vol. 31 No. 6 More about... Table 1. Clinical ndings and treatment Classication Clinical ndings Treatment Grade 1 Bleeding but no prolapse Stool soeners, reassurance Grade 2 Prolapse but reduces spontaneously Rubber-band ligation Grade 3 Prolapse requiring manual reduction Rubber-band ligation or haemorrhoidectomy Grade 4 Permanent prolapse Haemorrhoidectomy Rectal prolapse is most commonly seen in anal complaint, and those with an underlying elderly women and occasionally in young sinister cause. Unfortunately both cancer and women, but is rare in men. e management haemorrhoids are common and can co-exist. is surgical, which can be via a perineal approach or an abdominal rectopexy, which All patients with anorectal bleeding require is well suited to the laparoscopic approach. a careful history, digital examination, proctoscopy and sigmoidoscopy. If the patient Discharge cannot tolerate this, then ssure or cancer is is a symptom of anal stula, mucosal/ is likely. A suspicion of cancer mandates haemorrhoidal prolapse or incontinence, an EUA. When a fissure is confidently which is beyond the scope of this article. Fig. 4. Anal squamous carcinoma. diagnosed, an examination can be avoided at Hidradenitis and pilonidal sinus are not the rst consultation. A failure of ssure to usually in the immediate peri-anal region opening is usually easy to identify and respond to topical therapy also mandates an but should also be considered. gentle pressure around the lesion will oen EUA. Remember ‘piles are impalpable’. produce a bead of pus. ese lesions can be Anal stulae present a major proctological associated with a cycle of abscess formation, Indications for colonoscopy in patients with challenge. e primary symptom is a spontaneous drainage and persistent rectal bleeding: purulent discharge from an external peri- discharge. Diagnosis of a cryptoglandular • no local cause identied anal opening. It is painless unless associated stula requires exclusion of Crohn’s disease, • a patient 50 years or older with an underlying abscess. Fistulae tuberculosis, or cancer. e majority of • any alert symptoms: result from a peri-anal abscess forming a stulae are supercial and can be laid open • change in bowel habit granulation-lined tract between the anal with the division of an inconsequential • loss of weight canal and the peri-anal skin. e external amount of sphincter. In complex stulae • iron deciency anaemia this approach can result in incontinence • family history of colorectal cancer. and other strategies are required. ese e yield of sinister pathology in patients include long-term seton drainage and/or under 50 is low. However, sinister ndings stulae repair such as mucosal advancement are possible in this group and a high index ap (Fig. 4). A steady stream of new repair of suspicion must be maintained. techniques is testimony to the demands of this challenging condition. Itch Pruritus ani refers to itching of the anus. Bleeding is troublesome symptom can be caused Bleeding per rectum (PR) is a common by many conditions but is most commonly complaint, which can range from a few self-inicted. Over-zealous cleaning can spots on the tissue to frank blood in the cause micro-abrasions of the delicate peri- toilet. Haemorrhoids classically present with anal skin and removal of protective oils bright red painless bleeding. Fissures and secreted by the anal glands, resulting in a bleeding due to excessive wiping (which cycle of inammation, irritation and itch. causes micro-abrasions) will result in blood History and examination will reveal any on the paper. Bleeding from the rectum underlying pathology. Particular attention or more proximally will present as altered should be paid to a history of dermatological blood mixed with the stool and mandates conditions and the use of potential allergens. colonoscopy. e common causes are cancer, Examination should focus on excluding colitis, a diverticular bleed or angiodysplasia. anatomical abnormalities like mucosal e major problem with PR bleeding is trying prolapse, skin tags, etc. to distinguish between those patients who can be safely diagnosed as having bleeding ‘e anus thrives on neglect’ is a useful adage from haemorrhoids or another minor peri- when treating pruritus. Patients should be CMECArvetrendIslandJune2013.indd 1 6/4/13 2:31 PM 219 CME June 2013 Vol. 31 No. 6 More about... discouraged from repeated wiping and over- better quality of life for these patients than Patients are presented at a panel meeting, cleansing. Washing using a hand shower, dialysis. But transplantation in South Africa which consist of physicians, surgeons, sponge or cotton cloth should be encouraged. is far more than just kidney transplantation. transplant co-ordinators and other nursing Soap, topical preparations, toilet paper and Liver transplantation has become more sta as well as social workers and psychologists. tight-tting garments are discouraged.[4] common over the last 10 years, with In the state sector, where dialysis is limited, Donald