PANRE/PANCE – Gastroenterology part 7 – anal fissure, rectal abscess/fistula, hemorrhoids

by Isabella on June 29, 2012

Hello again everyone!  Again, I’ve been missing in action it seems :)  Life has been filled with baby adventures, visiting family and just trying to get sleep, so I decided to take a small break from studying, and as a result, you have taken a break as well :)  See what a good teacher I am, giving you all a well deserved summer vacation ;)

Anyways, for some reason a few days ago, a song got stuck in my head, and I couldn’t figure out what song it is.  It went something like this “something like a truck, what what, baby move your butt, butt butt”…and it wouldn’t leave my brain.  So I ask Simon what the song is, and he looks at me like I’ve lost my mind and says “there’s no song like that”.  But I knew that there’s a song like that, and I was determined to find it, and finally today it hit me…it’s the THONG song. I had the Thong song stuck in my head, literally for 3 days, and only God knows why :)  Thank heavens for feeding Eitan and the quiet moments it provides, otherwise I’d never be able to figure out the song in my head.

In light of that silliness, I decided to dedicate this GI lecture to butts and what ails them.  But before we continue, here’s a recap of GI lecture 5:  GI 6 review will be added later, I’m a bit behind on my drawings :)

as you can see, I drew this one, not nearly as good as Simon :)

Anal Fissure

  • Anal fissure is a linear tears/lesions
    • Most often found in the posterior mid line of the rectal wall
    • Usually caused by constipation, straining, hard stool, or high internal sphincter tone
  • Symptoms/Signs:
    • Pt usually complains of tearing pain with defecation
    • Hematochezia with bowel movements – BRBPR usually on tissue paper
    • Exam: increased sphincter tone, pain with rectal exam, and if anoscopy possible – visible fissure
  • Treatment:
    • Fiber powder, increase fluids
    • Stool softners, SITZ bath
    • Nitroglycerine ointment – warn patient about headache side effect

Anorectal Abscess

  • Abscess is usually a result of an infection
    • Most commonly perianal or perirectal
  • Symptoms and Signs:
    • Pain with defecation
    • Painful Swelling of anus or rectum
    • Exam will show a swollen, erythematous and fluctuant area that is tender to palpation
    • Usually no fever
  • Treatment:
    • Surgical drainage
    • WASH regimen : warm water, analgesics, stool softeners, high fiber diet

Anorectal Fistula

  •  Anal fistula is a connecting tract that forms between an abscess (usually a deeper one) and the outside (skin)
  • Symptoms/Signs:
    • recurrent perianal drainage – malodorous
    • Perianal pain – throbbing and constant – worse when tract is clogged
  • Treatment:
    • Surgical treatment is required – tract should not be explored otherwise due to risk of new tract formation


  • Hemorrhoids are swollen blood vessels in the lower rectal area
    • Internal hemorrhoids – above the dentate line – usually not painful as there’s no sensory innervation above the dentate line
    • External hemorrhoids – below the dentate line – usually painful due to sensory innervation
  • Predisposing factors:
    • Pregnancy, constipation, obesity
  • Signs/Symptoms:
    • External hemorrhoids : visible perianally on exam
    • Grade I internal hemorrhoid: project into anal canal, no prolapse, sometimes bleed
    • Grade II internal hemorrhoid: protrude past anal canal with straining or defecating, but reduce spontaneously, bleeding and mucus
    • Grade III internal hemorrhoid: protrude past anal canal spontaneously or with straining and require manual reduction
    • Grade IV internal hemorrhoid: chronically prolapse and cannot be reduced – at risk for strangulation
  • Treatment:
    • Stage I/II : fiber supplement, fluids, occasionally topical anesthetic or steroidal suppository
    • Stage III – conservative or surgical
    • Stage IV – usually always surgical

Hope you enjoyed this butt focused lecture, hopefully I’ll have more interesting songs stuck in my head in the future :)

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