the what, why, and how of perianal symptoms · the what, why, and how of perianal symptoms dr....

The What, Why, and How of Perianal Symptoms

Dr. Akhtar QureshiConsultant General and Colorectal Surgeon

Sunway Medical Centre, Petaling Jaya Selangor

Email: akhtarq@hotmail.com

Common Perianal Symptoms

• Rectal Bleeding

• Perianal Pain

• Perianal Swelling

• Perianal Itch

Assessment

• Frequency of BM

• Time spent in toilet

• Consistency of motions

• Tenesmus

• Change in bowel habit

• Mass/swelling

– reducibility

• Job

• Stress

• FHx

• Other illnesses

• Medications

Physical Examination

Physical Examination

• Inspection

• Palpation

• Digitation

Rectal Bleeding

• Acute lower GI bleeding is defined as bleeding distal to the ligament of Trietz

• Massive bleeding from the upper GI tract can also present with rectal bleeding

Causes of Rectal Bleeding• UGIT

– PUD

– Angiodysplasia

• Small Bowel

– Meckels

– Jejunal Diverticulosis

– Aorto-enteric fistula

• Colonic

– Angiodysplasia

– DD

– CRC/Polyps

– Colitis

– Trauma

• Rectal

– CRC

– Prolapse

– Polyps

– SRU

– Trauma

– Proctitis

• Anal

– Haemorrhoids

– Fissure

• Miscellaneous

– Telangectasia

– Coagulopathy

Rectal Bleeding

Types of blood per anum

Melena Hematochezia

NO SUCH THING AS FRESH MELENA

Rectal Bleeding

• Hematochezia (Not fresh malena!)

• Black Upper GI tract

• Maroon Right colon

• Red blood mixed with stools Left colon

• Red blood covering stools Rectum

• Fresh blood separate from stools Anal

Bleeding

• Amount

• Colour

• Mixed or separate from stools

• ? After stools passed

• Painful or Painless

Clinical Features

• Abdominal Pain• Inflammatory Bowel Disease

• Ischaemic Bowel Disease

• Anal Pain• Fissure

• Painless Bleeding• Haemorrhoids

• Diverticular Disease

• Angiodysplasia

• Constipation• CRC

• Haemorrhoids

Perianal Pain

• Constant?

• When sitting?

• At defecation?

• Episodic?

Causes

• Constant

– Swelling

– Unable to sit

– ? Fever

– Relief after discharge

• At defecation

– Onset

– Lasts min to hours after

Management

• Perianal abscess– I&D

– Identify fistula

• Thrombosed Piles– Ice finger

– Lignocaine gel

– Stool softners

– Analgesia

• Anal Fissure– Stool softners

– Lignocaine gel

– Analgesia

– (topical GTN)

– Ca antagonist

Perianal Swelling

• Painful

– Perianal hematoma

– Thrombosed piles

– Abscess

• Painless

– Piles

– Tags

• Sudden onset

– Perianal Hematoma

Perinal Itch

• Skin Related– Eczema

– Psoriasis

– Dermatitis

– Poor Hygiene

– STD

– Mycosis

– Helminthiasis

• Local Disorder– Haemorrhoids

– Fistula

– SRU

– Incontinence

• Systemic Disorder– Diabetes Mellitus

– Lymphoma

– Cholestasis

Puritus Ani

• Limit maceration

• Limit contact with bacteria

• Eliminate cause of irritation

• Treat psychogenic component

• Treat inflammation of skin

• Second line

– Topical capsaicin

– Subcut methylene blue

Q 1 Bleeding

• A 56 year old lady presents with passing dark red blood mixed with stools. The most likely cause is:

• A Anal Fissure

• B Haemorrhoids

• C Sigmoid Colon Cancer

• D Peptic Ulcer Disease

Q 1 Bleeding

• A 56 year old lady presents with passing dark red blood mixed with stools. The most likely cause is:

• A Anal Fissure

• B Haemorrhoids

• C Sigmoid Colon Cancer

• D Peptic Ulcer Disease

Q 2 Swelling

• A 35 year old man presents with a painful perianal swelling of 5 days duration. He is unable to sit. He feels feverish since yesterday. The likely cause is:

• A Anal Hematoma

• B Thrombosed Haemorrhoids

• C Perianal Fissure

• D Perianal Abscess

Q 2 Swelling

• A 35 year old man presents with a painful perianal swelling of 5 days duration. He is unable to sit. He feels feverish since yesterday. The likely cause is:

• A Anal Hematoma

• B Thrombosed Haemorrhoids

• C Perianal Fissure

• D Perianal Abscess

Q 3 Pain

• A 23 year old man presents with perianal pain. This starts at defecation and lasts for several hours. He has noticed some bleeding. The likely cause is:

• A Anal Fistula

• B Anal Fissure

• C Anal Hematoma

• D Haemorrhoids

Q 3 Pain

• A 23 year old man presents with perianal pain. This starts at defecation and lasts for several hours. He has noticed some bleeding. The likely cause is:

• A Anal Fistula

• B Anal Fissure

• C Anal Hematoma

• D Haemorrhoids

Q 4 Spot Dx

• Painful Swelling

• A Thrombosed Piles

• B Anal Hematoma

• C Perianal Abscess

• D Anal fissure

Q 4 Spot Dx

• Painful Swelling

• A Thrombosed Piles

• B Anal Hematoma

• C Perianal Abscess

• D Anal fissure

Q 5 Spot Dx

• Severe Anal Itch

• A Psoriasis

• B Anal Tags

• C Anal Warts

• D Anal Mycosis

Q 5 Spot Dx

• Severe Anal Itch

• A Psoriasis

• B Anal Tags

• C Anal Warts

• D Anal Mycosis

Thank You