• Blocked glands ➔ ↑ bx (usually GI flora) ➔ abscess (collection of pus)

    • Tract goes distally ➔ peri-anal ➔ tender abscess

    • Tract moves above external sphincter ➔ peri-rectal ➔ bloody/purulent rectal drainage, pain with BM

  • TX: I&D, sitz bath, ± pain control with stool softeners

Anal fistula

  • Half of untreated abscess will develop an epithelialized tract that connects gland to outside

  • SSX: Intermittent pain, chronic drainage and pruritus

  • TX: Surgical management - goal of fixing fistula without causing incontinence (from cutting some of sphincter)

    • ± Seton placement (thin string) placed in tract ⊣ abscess formation ➔ fistula healing


  • Longitudinal tear in anoderm distal the dentate line (MC)

    • Posterior midline (MC): Usually trauma, constipation/low fiber, anal sex, vaginal delivery

    • Or secondary to IBD (Crohn disease)

      • Anal fissure anywhere other than posterior midline warrants GI consult

  • SSX: Minimal bright red bleeding and pain with BM

    • Chronic fissure ➔ sentinel pile at distal end of fissure (skin tags at the bottom)

  • TX: ↑ fiber and water ±stool softeners - most heal spontaneously

    • Sitz bath, topical analgesics (lido jelly)

    • Topical vasodilators (NTG or CCB) or botox promotes healing

    • Sphincterotomy (lateral internal = GOLD)

      • Preserve external sphincter ➔ preserve continence

Hemorrhoids AKA piles

  • Dilated AV vessels that enlarge and can protrude (RF: using phone with BM)

  • SSX

    • Discomfort/pruritus around anus, bright red blood in bowl or on toilet paper

    • Extremely tender mass is likely thrombosed

Internal (above dentate line) ➔ painless bleeding, itching

    • May be tender or cause pain if thrombosed/incarcerated/strangulated

    • Grade 1: Do not prolapse

    • Grade 2: Prolapse with BM but reduces spontaneously

    • Grade 3: Prolapse with BM, only reduces manually

    • Grade 4: Irreducible (can be strangulated/thrombosed ➔ traumatic looking)

External (below dentate line) pain

    • Because there are pain receptors in that tissue

  • TX

    • ↑ fiber and water ±stool softeners, sitz bath, stop straining

    • ± 1 week of topical corticosteroids to help itch

    • Topical or suppository lido jelly to help pain of external

    • Topical or suppository NTG helps with pain from internal causing spasms

    • Grade 3 or refractory to conservative: outpt rubber band ligation

    • Grade 4 or refractory to ligation: Hemorrhoidectomy

    • Thrombosed external get excised

  • Hemorrhoids ARE NOT associated with portal HTN

  • Anorectal varices ARE associated with portal HTN

(they aren't the same thing)