The What, Why, and How of Perianal Symptoms

The What, Why, and How of
Perianal Symptoms
Dr. Akhtar Qureshi
Consultant General and Colorectal Surgeon
Sunway Medical Centre, Petaling Jaya Selangor
Email: akhtarq@hotmail.com
Common Perianal Symptoms
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Rectal Bleeding
Perianal Pain
Perianal Swelling
Perianal Itch
Assessment
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Frequency of BM
Time spent in toilet
Consistency of motions
Tenesmus
Change in bowel habit
Mass/swelling
– reducibility
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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!)
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Black
Maroon
Red blood mixed with stools
Red blood covering stools
Fresh blood separate from stools
Upper GI tract
Right colon
Left colon
Rectum
Anal
Bleeding
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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
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Constant?
When sitting?
At defecation?
Episodic?
Causes
• Constant
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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
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Ice finger
Lignocaine gel
Stool softners
Analgesia
• Anal Fissure
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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
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Eczema
Psoriasis
Dermatitis
Poor Hygiene
STD
Mycosis
Helminthiasis
• Local Disorder
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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:
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A
B
C
D
Anal Fissure
Haemorrhoids
Sigmoid Colon Cancer
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:
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•
•
•
A
B
C
D
Anal Fissure
Haemorrhoids
Sigmoid Colon Cancer
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:
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A
B
C
D
Anal Hematoma
Thrombosed Haemorrhoids
Perianal Fissure
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:
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•
A
B
C
D
Anal Hematoma
Thrombosed Haemorrhoids
Perianal Fissure
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:
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•
A
B
C
D
Anal Fistula
Anal Fissure
Anal Hematoma
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:
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•
A
B
C
D
Anal Fistula
Anal Fissure
Anal Hematoma
Haemorrhoids
Q 4 Spot Dx
• Painful Swelling
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A
B
C
D
Thrombosed Piles
Anal Hematoma
Perianal Abscess
Anal fissure
Q 4 Spot Dx
• Painful Swelling
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A
B
C
D
Thrombosed Piles
Anal Hematoma
Perianal Abscess
Anal fissure
Q 5 Spot Dx
• Severe Anal Itch
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A
B
C
D
Psoriasis
Anal Tags
Anal Warts
Anal Mycosis
Q 5 Spot Dx
• Severe Anal Itch
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A
B
C
D
Psoriasis
Anal Tags
Anal Warts
Anal Mycosis
Thank You