Anorectal emergencies

Table 1 Technical notes for urgent hemorrhoidectomy

Preoperative intravenous antibiotics

Surgery under general anesthesia, regional anesthesia, or intravenous sedation plus perianal infiltration of local anesthetic agent(s)

Prone jackknife position

Manual reduction of prolapsing hemorrhoids

Compression of hemorrhoids to reduce edema

During an operation, use of large-diameter anoscope e.g., Fansler anoscope

Anoderm or mucosa-sparing hemorrhoidectomy (preferably semi-closed technique)

Allowance of at least 1-cm mucosal bridge between surgical wounds and at least 50% of good circumferential mucosa

Use of long-lasting absorbable sutures e.g., polyglactin 910 for mucosal approximation

If applicable, instead of hemorrhoidectomy, plication of hemorrhoid may be applied to small lesions

Oral postoperative antibiotics against anaerobes for 1 wk

Table 2 Diagnosis and treatment of common infectious organisms causing sexually transmitted proctitis (by the frequency of occurrence)

Disease (causative organism)	Common symptoms and signs	Suggested investigations	Recommended first line treatment
Chlamydia (Chlamydia trachomatis serovars D-K)	Commonly asymptomatic, mild proctitis, cervicitis, vaginitis, urethritis	Nucleic acid amplification test (NAAT) from rectal, endocervical or urethral swab specimens	Azithromycin 1 g orally in a single dose
			OR
			Doxycycline 100 mg orally twice a day for 7 d
Gonorrhea (Neisseria gonorrhoeae)	Lower abdominal pain, diarrhea, rectal bleeding, tenesmus, purulent rectal discharge, urethral discharge and/or pharyngeal infection	Gram stain (Gram-negative diplococci) and bacterial culture from anogential and pharyngeal swab	Ceftriaxone 250 mg IM in a single dose
			PLUS
			Azithromycin 1 g orally in a single dose
Herpes simplex virus (Herpes simplex virus)	Painful multiple vesicular or ulcerative lesions at perianal skin and anal canal, painful defecation, fever	Viral culture or polymerase chain reaction (PCR) from vesicular lesions	Acyclovir 400 mg orally three times a day for 7-10 d
			OR
			Acyclovir 200 mg orally five times a day for 7-10 d
Syphilis (Treponema pallidum)	Depending on the stage of infection - Primary syphilis: painless ulcers or chancre in the anorectal region	Darkfield examination and test to detect T. pallidum from lesion exudate or tissue	Benzathine penicillin G 2.4 million unit IM in a single dose
	Secondary syphilis: maculopapular rash, condyloma lata, snail-track ulcer and mucous patch at the rectum, lymphadenopathy		OR
			Ceftriaxone 1-2 g either IV or IM for 10-14 d
			OR
			Doxycycline 100 mg orally twice a day for 14 d
Lymphogranuloma venereum (Chlamydia trachomatis serovars L1, L2 and L3)	Anal pain, mucous or bloody rectal discharge, anorectal ulcer, fever, inguinal or femoral lymphadenopathy	Culture, direct immunofluorescence or nucleic acid detection form rectal lesion and lymph node specimen	Doxycycline 100 mg orally twice a day for 21 d
			OR
			Erythromycin base 500 mg oral four times a day for 21 d

Table 3 Common anorectal disorders presenting with delay or failure to pass meconium in the neonates

Diagnosis	Rate	Common physical findings	Suggested investigation: expected findings	Initial management
Meconium plug syndrome	1/500-1000	Abdominal distension, normal anus and anal sphincter complex	Contrast enema radiologic examination: meconium plug in colon	Rectal stimulation with finger or saline enema
Hirschsprung’s disease	1/4000	Abdominal distension, tight anal sphincter, empty rectum, sudden evacuation of stool on digital rectal examination if “transitional zone” is reached	Contrast enema radiologic examination without colonic preparation: transitional zone separating aganglionic segment and dilated proximal colon	Intravenous hydration, gastric decompression, rectal washout with warm saline, and consider colostomy in high-grade obstruction and intravenous board-spectrum antibiotics in those with suspected diagnosis of Hirschprung-associated enterocolitis
Imperforate anus (IA)	1/5000	Absence or stenosis of anus, perineal fistula (low IA), meconium in urine (rectourinary fistula: low or high IA), flat or not well formed median raphe (high IA), cloaca (high IA), VACTERL anomalies1	Inverted lateral radiography (invertography) or transperineal ultrasonography: differentiation between low IA and high IA	Anal or fistula dilatation for temporary relief of obstruction and plan for elective posterior sagittal anorectoplasty (low IA), loop sigmoid colostomy (high IA or some low IA)
- Low IA = distal rectal pouch lining below or at the puborectalis muscle
- High IA = distal rectal pouch lining above the puborectalis muscle

¹VACTERL anomalies include vertebral anomalies (V), anorectal malformations (A), congenital cardiac anomalies (C), tracheoesophageal fistula or esophageal atresia (TE), renal and urinary anomalies (R), limb lesions (L).