Thanks to Gabby Liu for presenting a patient with fever, anorectal pain and bleeding. Gabby gets a big shout out for presenting in report as an intern.
This is a great opportunity to highlight one of my favorite resources for outlining general approaches to all things outpatient. The American Family Physician Review Articles.
Why are they so great? 3 reasons.
1) All articles start with a list of evidence-based recommendations. They also grade evidence quality in a fancy table
2) They provide a well organized Ddx for common complaints
3) Focus on treatment as well as ddx
Ano-rectal complaints can be organized anatomically and differentiated based on whether a mass or other lesion is visible on exam
- thrombosed external hemorrhoids
- infections like…
- viral (HSV, condyloma d/t HSV)
- bacterial (typical bacterial organisms, gonorrhea, syphillis or chlamydia)
- Fungal (rare in immunocompetent people)
- parasites (pinworm, especially in children and immune competent adults)
- ano-rectal presentation of IBD
- anorectal fistula
All of the diagnoses listed above plus special considerations of…
- rectal prolapse
- proctitis – usually presents with pain, tenesmus, bloody diarrhea and/or fever
- gonorrhea proctitis is particularly common and very uncomfortable for patients
- see the pearls archive for some details on LGV proctitis, which was considered in this case
- foreign body
- proctalgia fugax
- sudden onset, severe rectal pain without an obvious trigger. Caused by sudden increase in internal anal sphincter tone. It’s like the esophageal spasm of the nether regions.
- severe constipation
- Dr Cello taught us about stercoral ulcers, where chronic constipation and hard stool causes ulceration of the rectal mucosa, leading to pain and iron deficiency anemia.
- internal hemorrhoid (usually don’t hurt)
All after fabulous history-taking, all ano-rectal complaints should be evaluated with an abdominal exam, external anal exam, and anoscopy, if tolerated.