Gastrointestinal Disorders:
Care of Patient with
Anorectal Disorders
(Hemorrhoids, anorectal fissure,
anorectal fistulas, anorectal abscess
and colorectal cancers)
BY: Shirin Rahim
September 16, 2016
Acknowledment: AHN Team
9/15/2016 1
Objectives
By the end of the session learners will be able to
• Discuss anorectal disorders in terms of their
• causes,
• pathophysiology
• manifestation
• Diagnostic tests
• medical and surgical management
• Apply nursing process to provide care to the clients with above disorders.
• Develop a teaching plan for a client experiencing above disorders.
9/15/2016 2
Anorectal Disorders
• A group of medical disorders that occur at the
junction of the anal canal and the rectum.
• The commonly reported anorectal disorders are
hemorrhoids, anorectal abscess, anorectal fissure
and anorectal fistula.
9/15/2016 3
9/15/2016 4
Anorectal Disorders :
Anatomy
• The anorectal area is the transition point from the rectosigmoid portion of the
intestines to the skin. The transition occurs at the dentate/ pectinate line.
• The first 1 to 2 cm distal to the dentate line constitute the anal canal. Distal to the
anal canal is the anal verge, which has the appearance of normal external skin, with
hair follicles, glands, and subcutaneous tissue.
• Proximal to the dentate line, the pleats of the rectum form the rectal ampulla with
multiple crypts.
• Tissues distal and proximal to the dentate line have different embryonic origins and
therefore have different blood supplies and innervation.
• Tissue proximal to the dentate line is insensate, whereas sensation distal to the
dentate line is supplied by the pudendal nerve and pelvic branches of S3 and S4
nerve roots.
9/15/2016 5
Anorectal Disorders:
Hemorrhoids
Definition:
• Hemorrhoids are perianal varicose veins or unnaturally
swollen or distended veins in the anorectal region. Are
common and not significant unless they cause pain or
bleeding.
• Hemorrhoids are downward displacements of the anal
cushions. These cushions are formed from loose connective
tissue, smooth muscle, and arterial and venous vessels.
Hemorrhoids form when these supporting structures
deteriorate, leading to venous dilatation, vascular thrombosis,
and inflammation.
9/15/2016 6
9/15/2016 7
Anorectal Disorders:
Hemorrhoids
Prevalence:
A common source of discomfort and
rectal bleeding, affecting 10 million to
23 million people. About half of them
are symptomatic.
Classification:
Hemorrhoids are classified as either
external or internal, based on their
location below or above the dentate line.
9/15/2016 8
Anorectal Disorders: Hemorrhoids
External Internal
• develop under the skin around the • occur in the lower rectum
anus and are the most
• usually painless, but often result
uncomfortable, because they
in bleeding, which may show up
irritate and erode the overlying
bright red on toilet paper or
skin.
dripping into the toilet bowl.
• The pain may be sudden and
• may also prolapse and extend
severe if a blood clot ( thrombus)
beyond the anus, causing potential
forms inside an external
problems
hemorrhoid. Thrombosed
hemorrhoids are easily visualized • They are graded based.
on examination. Acute thrombosis • It may collect small amounts of
appears as a blue, tender mass. mucus and microscopic stool
• The clot usually dissolves but may particles, leading to a condition
leave excess skin (a skin tag) that called pruritus ani (anal itching).
itches or becomes irritated.
9/15/2016 9
Anorectal Disorders:
Hemorrhoids
9/15/2016 10
9/15/2016 11
Classification on the basis of
degrees
9/15/2016 12
Anorectal Disorders:
Hemorrhoids
Risk Factors:
Patients with a history of constipation and prolonged straining are at risk for
hemorrhoidal disease. Those with diarrhea may also develop hemorrhoids as a
result of recurrent straining. Pregnancy is also a significant risk factor for
hemorrhoids, which usually resolve after giving birth.
Clinical Features :
• Rectal bleeding associated with bowel movements. This bleeding is often
painful with external hemorrhoids or painless with internal hemorrhoids.
The bleeding is usually described as bright red blood seen in the toilet bowl
or on wiping after a bowel movement. Melena is not consistent with
hemorrhoidal disease.
• Feeling of rectal fullness and perineal irritation.
9/15/2016 13
Anorectal Disorders:
Hemorrhoids
Diagnostic evaluation:
• Most patients are hemodynamically stable and require neither
laboratory analyses nor imaging.
• Some patients have a prolonged history of rectal bleeding from
hemorrhoids, which can lead to symptomatic anemia. In these
cases, a complete blood count may be
appropriate to assess the hemoglobin level.
• The physical examination requires optimal
positioning, adequate visualization, and a
digital rectal examination (DRE) followed by
Anoscopy when clinically indicated.
9/15/2016 14
Anorectal Disorders:
Hemorrhoids
Medical Treatment: Mostly directed at symptom control. In rare
instances, patients present with significant rectal bleeding that necessitates
resuscitation; in these cases, additional work-up and surgical evaluation are
warranted.
External Hemorrhoids Patients should be directed to
• start a high-fiber diet. This change can reduce symptoms by 50% but might
take up to 6 weeks for full effect.
• maintain adequate hydration and use stool softeners to avoid constipation
and straining.
• take sitz baths 2 to 4 times a day.
• Use topical corticosteroid creams but not use them beyond a few days
because of the risk of skin breakdown
9/15/2016 15
Anorectal Disorders:
Hemorrhoids
Medical Treatment: Internal Hemorrhoids
• Patients with internal hemorrhoids of grade 1, 2, or 3 can be
treated conservatively with sitz baths, fiber supplementation,
laxatives, and adequate hydration after reduction of the
hemorrhoids during the physical examination. They should be
referred for surgery then.
• Patients with grade 4 internal hemorrhoids have a high risk of
thrombosis and should always be seen by a surgeon.
9/15/2016 16
Anorectal Disorders:
Hemorrhoids
Surgical Treatment Options
• Sclerotherapy: Injection of a solution (generally a salt solution) directly
into the vein causing it to swell and stick together, and the blood to clot
• Rubber band ligation: A small rubber band is used to tie off the base of
the swollen vein to stop blood circulation and hemorrhoids then falls off.
Local pain and bleeding may occur
• Laser surgery: use of high intensity light beam at the tissue
• Cryosurgery: Involves freezing the hemorrhoid with a probe to cause
necrosis. Not commonly used
• Hemorhoidectomy: Surgicall disection of hemorrhoid ( grade 1,2,3 )
• Clot Excision: For thrombosed hemorrhoids ( grade 4 ), not intended for
children. Immunocompromised patients or patients with hemodynamic
instability, liver disease, or coagulopathy
9/15/2016 17
9/15/2016 18
Anorectal Disorders:
Anal Fissures
Definition:
An anal fissure is a split in the anoderm distal to the dentate line.
Description:
• Anal fissures are the most common cause of painful rectal bleeding in
young adults and infants.
• Fissures are considered chronic when they fail to resolve in 6 to 8 weeks.
• Fissures that are not properly treated may become chronic and develop the
classic triad consisting of sentinel pile, deep ulcer, and enlarged anal
papillae.
• Anal fissures start with the passage of a hard stool, which tears the
anoderm, causing spasm of the internal sphincter.
• Patients typically experience a fear of defecation and the subsequent spasm.
The spasm promotes mucosal ischemia, which delays healing.
9/15/2016 19
9/15/2016 20
Anorectal Disorders:
Anal Fissures
Prevalence:
• 90% of fissures in women and 99% of fissures in men occur in the posterior
midline, 10% to 15% occur in the anterior midline, and less than 1% occur
in the lateral position
Causes:
• Posterior midline anal fissures are typically caused by the passage of large,
hard stool through a tight anus.
• Anterior midline fissures are most common in postpartum women.
• Anal fissures in other areas can be caused by anal intercourse or may be
manifestations of conditions such as Crohn disease, cancer, tuberculosis,
HIV infection, and syphilis.
9/15/2016 21
Anorectal Disorders:
Anal Fissures
Clinical Features
On History
• Adults describe a sharp, cutting, or burning pain with defecation that can persist as
a nagging, dull pain for several hours but usually subsides between bowel
movements.
• A small amount of bright red blood may be noted on the stool or toilet paper.
• Sphincter spasm may also occur and cause further pain
On physical examination,
• The lower end of the fissure can be identified once the buttock is gently separated
• A skin tag from previous episodes of anal fissures might also be identified.
• Patients experience considerable pain on DRE because of the fissure and spasm.
9/15/2016 22
Anorectal Disorders:
Anal Fissures
Diagnostic Testing and Examination
• Diagnosis of an anal fissure must be made by physical examination, which
should be done very carefully to avoid further spasm and pain.
• Application of a topical anesthetic such as lidocaine jelly may be necessary
to facilitate the examination.
• Gentle retraction of the buttocks and perianal skin with the patient bearing
down may expose the distal end of the fissure.
• If the fissure is not located in the midline, the differential diagnosis and
consequent testing must be expanded to include more serious conditions
such as cancer, HIV disease, Crohn disease, sexually transmitted diseases,
and tuberculosis.
9/15/2016 23
Anorectal Disorders:
Anal Fissures
Management: Primary goal is to relax the anal sphincter, which allows patients to break the cycle
of fear of defecation and anal pain.
• Patients should use a bulking agent as well as warm sitz baths for symptomatic relief.
• The area should be kept clean and dry.
• Warm water has been reported to reduce anal pressure.
• Bulking agents and mild laxatives can help regularize bowel movements and have been
shown to be 87% effective by 3 weeks for acute anal fissure and can decrease recurrence from
68% to 16%.
• Rectal suppositories with local anesthetic and corticosteroids can be beneficial.
• If dietary and lifestyle modifications do not resolve symptoms, patients might require topical
nitroglycerin or topical calcium channel blockers to reduce sphincter spasm, initiated by a
primary care physician or gastroenterologist.
• If conservative methods do not work, patients need surgical treatment such as lateral internal
sphincterotomy (an operation performed on the internal anal sphincter muscle for the
treatment of chronic anal fissure.)
9/15/2016 24
Anorectal Disorders:
Anorectal Abscesses
Definition:
An infection in the anal glands that tracks through the planes of
the anorectal region.
Classification:
classified according to location. The four main types are perianal
(most common), ischiorectal, intersphincteric, and supralevator
(least common)
Causes:
caused by aerobic or anaerobic organisms, but most patients have
mixed flora.
9/15/2016 25
Anorectal Disorders:
Anorectal Abscesses
9/15/2016 26
Anorectal Disorders:
Anorectal Abscesses
Risk factors
middle-aged men with hemorrhoids, diabetes,
Immunosuppression, atypical infection (e.g.,
tuberculosis, actinomycosis, lymphogranuloma
venereum), inflammatory bowel disease (Crohn
disease), rectal trauma (e.g., foreign body), surgery
(e.g., anorectal, genitourinary, and gynecologic
procedures), malignancy (e.g., rectal carcinoma,
leukemia, lymphoma), radiation, and anal fissures.
9/15/2016 27
Anorectal Disorders:
Anorectal Abscesses
Clinical Features:
• persistent, throbbing anal pain, which can be aggravated by defection.
• swelling, drainage, or bleeding in the anal region.
• systemic symptoms such as fever and chills might present later in the course of the
disease, initially they are usually absent.
• On DRE, a fullness may be palpable near the sacrum.
Diagnostic Evaluation:
• computed tomography (CT) is the most usefully imaging modality.
• Ultrasonography can identify more superficial abscesses, such as perirectal and
ischiorectal abscesses, but deeper infections require a CT scan for evaluation.
• If the CT scan is negative and there is still a high suspicion for an anorectal
abscess, MRI should be used for evaluation.
9/15/2016 28
Anorectal Disorders:
Anorectal Abscesses
9/15/2016 29
Anorectal Disorders:
Anorectal Abscesses
Treatment: The treatment of all anorectal abscesses is incision and drainage
(I&D).
• Patients with perianal abscess of 10 cm or smaller and non complicating disorder
may be treated by I&D , under local sedation.
• Post-incision care consists of sitz baths, stool softeners, and a high-fiber diet.
• Patients can be discharged with arrangement made for packing changes , and
wound checks in 48 hours.
• Surgical consultation should be obtained for patients with all other anorectal
abscesses.
• Abscesses in immunocompromised patients (e.g., diabetes, human
immunodeficiency virus [HIV] infection, transplantation, chemotherapy) should be
treated in the operating room under general anesthesia.
• Antibiotics should be prescribed only if surrounding cellulitis is present or the
patient is immunocompromised.
9/15/2016 30
Anorectal Disorders:
Anal Fistula
Definition:
A chronic variant of a poorly healed anorectal abscess. Fistulas are tracts between the
anal canal (or rectum) and the skin that are lined with epithelial or granulation
tissue.
Causes:
Although anal fistulas typically arise from an anorectal abscess, they can also be
associated with inflammatory bowel disease, malignancies, infection (sexually
transmitted diseases, actinomycosis, tuberculosis, and diverticulitis), anal fissures,
or foreign bodies.
Signs and Symptoms
A blood-tinged, malodorous discharge and rectal pain that improves with an increased
discharge. An abscess may be located at the opening of the fistula. The fistula can
be palpated as a cord leading to the sphincter.
9/15/2016 31
9/15/2016 32
9/15/2016 33
Anorectal Disorders:
Anal Fistula
Diagnostic Testing and Examination
• Anal and rectal examinations with classic findings
• Abdominal and pelvic CT demonstration of a fistula tract
• Transanal ultrasonography (with or without hydrogen peroxide injected
into the tract)
Treatment
• Treatment of anal fistulas consists of surgical excision to eliminate the
fistula, prevent recurrent disease, and preserve sphincter function. Stable
patients may be referred for urgent outpatient surgical consultation.
9/15/2016 34
Colo-rectal Cancer
Description:
• Colon and rectal cancer are the third most common cancer in
both men and women.
• Approximately 20% of colon cancers develop in the cecum,
another 20% in the rectum, and an additional 10% in the
rectosigmoid junction and 25% in the sigmoid colon.
• The American Cancer Society estimates that colorectal cancer
will account for 8% of cancer deaths in men and 9% of cancer
deaths in women during 2015.
9/15/2016 35
Colo-rectal Cancer
Clinical Findings:
• Rectal bleeding is the most common symptom of rectal cancer,
occurring in up to 60% of patients, change in bowel habits
(most commonly diarrhea), occult bleeding, abdominal pain,
malaisepelvic pain.
• Late symptoms that increase concern for metastatic disease
include back pain, nerve trunk involvement, jaundice, and
peritonitis from bowel perforation.
• However, many cancers are asymptomatic and are discovered
during DREs or proctoscopic screening examinations.
9/15/2016 36
Colo-rectal Cancer
Diagnostic test: This diagnostic work-up can include
• DRE
• Basic blood work, to assess kidney, liver, electrolyte, and blood count
abnormalities.
• CT to rule out intra-abdominal causes of rectal bleeding.
Management: requires a multidisciplinary team approach, including
colorectal surgery, medical oncology, and radiation oncology.
9/15/2016 37
Anorectal Disorders:
Nursing care
Priority Nursing Diagnosis
• Altered bowel movement i-e constipation related to passage of hard stool
• Bleeding related to tissue trauma
• Alteration on comfort i-e anal pain related to inflammation, tissue trauma , spasm
Possible Nursing Interventions:
Add fiber.
• Boost the fiber in your diet with either highfi ber foods or a fiber supplement or
both.
• When taken with adequate fluid, fi ber softens stools and makes them easier to pass,
reducing pressure on hemorrhoids and the resulting risk of bleeding, infl ammation,
and swelling.
• High-fi ber foods include dates, apples, pears, strawberries, broccoli, carrots, peas,
spinach, legumes (for example, baked beans or kidney beans), bran cereals,
• Fiber can cause bloating or gas, so start slowly, and gradually increase your intake
to 25 to 30 grams of fi ber per day. Increase your fluid intake at the same time.
9/15/2016 38
Exercise.
• stimulate bowel function with moderate aerobic exercise, such as brisk walking 20
to 30 minutes a day.
Establish a regular bowel habit.
• When you feel the urge, go to the bathroom immediately; don’t wait for a more
convenient time. Stool can back up, leading to increased pressure and straining.
• Also, schedule a time each day—perhaps just after a meal—to sit on the toilet for a
few minutes.
Sit in a sitz.
• Often relieve itching, irritation, and spasm of the sphincter muscle with a warm
water bath for the buttocks (sitz bath).
• Sit in a regular bathtub with a few inches of warm water.
• Try a 20-minute sitz bath after each bowel movement and an additional two or three
times a day.
9/15/2016 39
Try something topical.
• A small ice pack placed against the anal area for a few minutes may also help and
sitting on cushions rather than hard surfaces can help reduce swelling.
Lifestyle changes:
• improving anal hygiene,
• corrective toilet positioning (knees higher than hips, leaninfg orwards, elbows
placed on knees),
• not sitting on the toilet for long periods of time
• not straining on the toilet during defecation.
Symptomatic and Palliative care for patients with ano-rectal cancer
9/15/2016 40
Thank You
9/15/2016 41
