Are those hemorrhoids? Get to know the anorectal imitators

A colorectal surgeon sees a steady parade of primary care referrals for surgical evaluation of haemorrhoids.

The thing is, most of the time, the referred patients don’t have haemorrhoids. They have one of the other common anorectal disorders, including anal fissure, anoperineal abscess, fistula-in-ano, or an anorectal sexually transmitted infection.

At a conference on internal medicine sponsored by the University of Colorado, the surgeon explained how to tell these common disorders apart, which ones can be treated appropriately in a primary care office, and who needs referrals for surgery.

The diagnostic challenge stems from the fact that most common anorectal disease – whether benign or malignant – present with the same constellation of symptoms, pain, bleeding, itching or burning, swelling, and leakage.

The quality and intensity of the pain “down under” provides a useful clue in differentiating the disorders.

Hemorrhoids rarely cause legit pain. Excruciating pain, where the patients will only sit on one side, that’s typically an abscess, a fissure, or an STI.

The exceptions in the haemorrhoids realm are external thrombosed hemorrhoids, which are exceedingly painful but also readily identifiable, and incarcerated haemorrhoids, which are quite rare.

The pain associated with an anal fissure is distinct from that of an abscess or thrombosed hemorrhoids – it’s a throbbing pain lasting minutes to hours per episode.

These are the people who won’t sit down in a doctor’s office.

Anal fissure is a common condition in young and middle-aged adults, and especially in peripartum women. The pathophysiology involves microtrauma, typically either because of passing rock-hard stools, diarrhea, or the rigors of childbirth, any of which can cause a break in the anal mucosa. That break causes the internal sphincter muscle to go into spasm, temporarily choking off blood supply to the area of the fissure. Those wounds won’t heal on their own. Close to 90 percent of the fissure are located in the posterior midline; if the fissure is ectopic, it’s time to consider Crohn’s disease, HIV infection, tuberculosis, cancer, and other possibilities.

The patient with an anoperineal abscess presents with extreme pain, a sensation of fullness in the anus and rectum, erythema, fullness of the perineum, drainage, and sometimes fever.

This is legit pain, like with a fissure or thrombosed hemorrhoids. Patients with any of these conditions can tell you exactly when they went from feeling normal to when the pain started.

The abscess is caused by an infected anal gland. The location is most commonly perianal or ischioanal. If that’s not the suppuration site, the abscess is intersphincteric or supralevator, in which case a confirmatory CT scan is called for before proceeding with treatment.

Regardless of the suspected cause of a patient’s anorectal symptoms, any GI bleeding needs to be taken seriously. Young adults are the only segment of the population in whom the incidence of colorectal cancer is going up. In response, the American Society for Gastrointestinal Endoscopy and  other groups now recommend colonoscopy for all patients older than age 40 years with GI bleeding, even in their family histories for colorectal cancer are negative and they lack other high-risk factors. For those younger than age 40 years, flexible sigmoidoscopy is recommended, even if it is obvious that the patient has external thrombosed hemorrhoids that are bleeding.

I tell people that I will not do haemorrhoid surgery until they have the scope.

Office-based treatment of common anorectal disorders, nonoperative treatment of anal fissures and internal hemorrhoids is all about encouraging patient adherence.

“Patient expectation are often overlooked,” according to the surgeon. It’s rare that these patients actually need to go to surgery, but they oftentimes don’t do what we tell them to do, which is why they end up in our office.

With anal fissure, the goal is to relax the spastic sphincter muscle, allowing the fissure to heal. That can be accomplished medically or surgically. (To be continued)