Podcast #244 - Updated Guidelines on Anorectal Emergencies

There are a variety of anorectal emergencies that present to the emergency department.  Recently, there were updated guidelines made by the World Society of Emergency Surgery (WSES) and the American Association for the Surgery of Trauma (AAST).  In this post, we review some of the updated guidelines including for anorectal abscess, perineal necrotizing fasciitis (Fournier's gangrene), bleeding anorectal varices, complicated rectal prolapse (irreducible or strangulated), and retained anorectal foreign bodies.

These updated guidelines can be reviewed in their entirety free and open access through theWorld Journal of Emergency Surgery.   A PDF Version is also available at the bottom of this post.

Anorectal Abscess
Exam and labs:

• Perform a complete exam including a digital rectal exam.
• Recommended to check serum glucose, hemoglobin a1c, and urine ketones in order to identify for undetected diabetes mellitus.
• Assess for signs of systemic infection or sepsis including a CBC, serum creatinine, and inflammatory markers (CRP, procalcitonin, and lactate).

Imaging:

• MRI, CT, or endosonography depending on the availability of such imaging.
• Imaging is indicated for atypical presentations or in case of suspicion for occult supralevator abscesses, complex anal fistula, or perianal Crohn's disease.

Surgical management:

• In fit, immunocompetent patients with a small perianal abscess and without systemic signs of sepsis, consider outpatient management.
• Otherwise, surgical I&D is recommended with timing based on presence and severity of sepsis.
• No recommendations can be made regarding the use of packing after drainage.
• Further management such as fistulotomy may be needed in certain circumstances.

Antibiotics:

• Sampling of the drained pus in high-risk patients and/or in the presence of risk factors for multidrug resistance is recommended.
• In drained abscesses, it is recommended to administer antibiotics in the presence of sepsis, surrounding soft tissue infection, or in the case of disturbances of the immune response.

Perineal Necrotizing Fasciitis (Fournier's Gangrene)
Exam and labs:

• Perform a complete exam including a digital rectal exam.
• Recommended to check serum glucose, hemoglobin a1c, and urine ketones in order to identify for undetected diabetes mellitus.
• Assess for signs of systemic infection or sepsis including a CBC, serum creatinine, electrolytes, and inflammatory markers (CRP, procalcitonin, and lactate).
• It is also suggested to use theLaboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score for an early diagnosis and the Fournier's Gangrene Severity Index (FGSI) for prognosis and risk stratification.

Imaging:

• In stable patients with suspected Fournier's gangrene, consider performing a CT.
• Imaging should not delay surgical intervention.
• Recommend against obtaining imaging in patients with hemodynamic instability persisting after proper resuscitation.

Surgical management:

• Surgical intervention should be performed as soon as possible.
• Plan on repeat surgical revisions according to patient conditions.
• Seriated surgical revisions are needed until the patient is free of necrotic tissue.

Antibiotics:

• Start empiric antibiotics as soon as the diagnosis is suspected.
• Antibiotics should include coverage for Gram positive, Gram negative, aerobic and anaerobic, and anti-MRSA agents.
• Base antimicrobial de-escalation on clinical improvement, cultured pathogens, and results of rapid diagnostic tests (when available).

Bleeding Anorectal Varices​
Exam and labs:

• Perform a complete exam including a digital rectal exam.
• Recommended to check vital signs, hemoglobin, hematocrit, and coagulation to evaluate severity of bleeding
• In case of severe bleeding perform blood typing and cross-matching.

Imaging:

• Endosonography +/- Doppler as a second-line diagnostic tool, especially for deep rectal varices or when in doubt.
• Those with high-risk features or evidence of ongoing bleeding should have urgent colonoscopy (and upper endoscopy) within 24 hours of presentation.
• If risk factors for colon cancer or suspicion for a concomitant more proximal source of bleeding, full colonoscopy is suggested.
• Local procedures such as endoscopic variceal ligation, endoscopic band ligation, sclerotherapy, or endosonography-guided glue injection should be used to arrest bleeding in first instance where feasible.

Non-operative management:

• Multi-disciplinary management including early involvement of a hepatologist is recommended.
• For mild bleeding consider IV fluid replacement, blood transfusion if necessary, correction of coagulopathy, and optimal medication for portal hypertension.
• In severe bleeding, maintain a hemoglobin >7 g/dL during the resuscitation phase and a mean arterial pressure (MAP) >65 mm/Hg but avoid fluid overload.
• Endorectal placement of a compression tube as a bridging maneuver is suggested to help stabilization of the patient or to allow for transfer to a tertiary hospital.

Medications:

• Non-selective beta-adrenergic blockers for prevention/prophylaxis of first and/or recurrent variceal bleeding is suggested.
• In case of acute bleeding, temporarily suspend beta-blockers.
• Consider the use of vasoactive drugs such as terlipressin or octreotide to reduce splanchnic blood flow and portal pressure.
• Recommended to also use a short course of prophylactic antibiotics.

Angiography and surgery:

• If there is a failure of medical treatment and local procedures, suggested "step up" approach with radiological and then surgical procedures.
• Interventional radiology suggested to use embolization for short-term control of bleeding.
• Percutaneous TIPS, if not contraindicated, should be used to decompress the portal venous system and to reduce the risk of rebleeding.
• If these measures fail, "per anal" suture ligation by surgery to be considered.
• No recommendation regarding the role of Doppler-guided hemorrhoidal artery ligation and stapled anopexy in patients with persistent bleeding failing other techniques.

Complicated Rectal Prolapse (Irreducible or Strangulated)
Exam and labs:

• Perform a complete exam including visualizing the area of concern.
• Recommended to check a CBC, serum creatinine, and inflammatory markers (CRP, procalcitonin, and lactate).

Imaging:

• In hemodynamically stable patients, perform an urgent contrast enhanced CT of the abdomen and pelvis to detect for associated complications and to assess the presence of colorectal cancer.
• If hemodynamically unstable, do not delay appropriate and timely management with imaging.

Surgical management:

• If presenting with signs of shock or gangrene/obstruction of the prolapsed bowel, immediate surgical treatment is recommended.
• In cases with acute bowel obstruction or failure of non-operative management, urgent surgical treatment is suggested.

Medications:

• Administer empiric antibiotics because of the risk of intestinal bacterial translocation.
• A specific regimen should be based on the clinical condition of the patient, risk of MDRO, and local resistance patterns.

Retained Anorectal Foreign Bodies
Exam and labs:

• Perform a complete exam including a digital rectal exam.
• It is suggested to perform the digital rectal exam after obtaining abdomen X-ray whenever possible to prevent accidental injury from sharp objects.
• Routine laboratory testing is not recommended if there are no signs of bowel perforation, but if there is failure of manual extraction or it is not feasible then routine preoperative labs can be obtained.
• If there is a suspected bowel perforation, obtain a CBC, serum creatinine, and inflammatory markers (CRP, procalcitonin, and lactate).

Imaging:

• Obtain lateral and anteroposterior plain X-rays of the chest, abdomen, and pelvis to identify the foreign body position, shape, size, and location as well as to evaluate for pneumoperitoneum. 
• With a suspected perforation, obtain a CT of the abdomen and pelvis with contrast.
• If hemodynamically unstable, do not delay surgical treatment to perform imaging.

Non-operative and endoscopic management:

• In low lying retained foreign bodies without signs of perforation, attempt extraction at bedside.
• If unsuccessful, a pudendal nerve block, spinal anesthesia, IV conscious sedation, or general anesthesia may be used to improve chances of extraction.
• If the foreign body is high-lying, attempt at endoscopic extraction is first-line.
• Should drug concealment be suspected, avoid any maneuvers that can disrupt the drug packaging such as endoscopic retrieval.
• Evaluate the bowel wall status after foreign body removal by protoscopy or flexible sigmoidoscopy.
• Do not perform transanal extraction if there are signs of hemodynamic instability or perforation.

Surgical management:

• When there is failure of transanal extraction, a "step up" approach is recommended starting with downward milking and proceeding to colotomy only when milking/transanal extraction has failed.
  
• If skills and tools are available, consider a laparoscopic approach if there is no perforation.
  
• Primary suture only in case of small and recent perforation if the colonic tissues appear healthy and well vascularized with said approximation being without tension.
  
• If primary suture is not feasible, resection with primary anastomosis with or without diverting stoma should be used in clinically stable patients without risk factors for anastomic leakage.
  
• In critically ill patients, selected patients with extensive peritoneal contamination and risk factors for anastomic leakage it is suggested to perform a Hartmann's procedure.
  
• Patients that are hemodynamically unstable should have emergent laparotomy and damage control surgery approach. 

Antibiotics:

• Antimicrobial therapy generally not recommended.
• However, if there are signs of hemodynamic instability or bowel perforation, broad spectrum antibiotic therapy according to the WSES guidelines on intra-abdominal infections is recommended.

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Anorectal emergencies: WSES-AAST guidelines
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