Emergencies in proctology

Czech version

Authors: O. Vyčítal; J. Geiger; P. Novák; J. Rosendorf; R. Polák; V. Liška; J. Moláček
Authors‘ workplace: Chirurgická klinika LF UK a FN Plzeň
Published in: Rozhl. Chir., 2025, roč. 104, č. 9, s. 373-386.
Category: Review
doi: https://doi.org/10.48095/ccrvch2025373

Overview

Acute conditions in proctology refer to anorectal disorders presenting with symptoms such as acute anal pain and bleeding that may require immediate treatment. This publication discusses the diagnosis and management of common anorectal emergencies such as hemorrhoidal crisis, bleeding anorectal varices, anal fissure, anorectal abscess, strangulated rectal prolapse, Fournier gangrene and retained anorectal foreign bodies. Although many acute complications occurring in emergency cases are not life-threatening and can be successfully treated in an outpatient setting, accurate diagnosis and proper treatment can prevent serious complications such as sepsis or permanent functional impairment. A detailed medical history and careful physical examination, including digital rectal examination and anoscopy, are essential for a correct diagnosis and treatment plan. In some cases, some imaging tests such as computed tomography and ultrasonography are required. When in doubt, treating physicians should not hesitate to consult a specialist for diagnosis, proper treatment and appropriate follow-up, e.g. colorectal surgeon.

Keywords:

Rectum – anal fissure – hemorrhoidal crisis – perianal abscess – proctorrhagia – rectal prolapse

Sources

1. Goldstein JL, Foulkes-Arellano P. Materials and sustainability: building a circular future. London: Routledge/Taylor & Francis Group 2024.

2. Coccolino F, Catena F (eds). Texbook of emergency general surgery: anorectal emergencies. Springer International Publishing 2023.

3. Seifert B, Hoch J, Zimolová P et al. Hemoroidální nemoc: doporučený diagnostický a terapeutický postup pro všeobecné praktické lékaře 2021. Praha: Centrum doporučených postupů pro praktické lékaře, Společnost všeobecného lékařství ČLS JEP 2021.

4. Tarasconi A, Perrone G, Davies J et al. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg 2021; 16(1): 48. doi: 10.1186/s13017-021-00384-x.

5. Šlauf P, Antoš F, Marx J. Komplikace hemoroidů. Rozhl Chir 2014; 93(4): 223–225.

6. Allan A, Samad AJ, Mellon A et al. Prospective randomised study of urgent haemorrhoidectomy compared with non-operative treatment in the management of prolapsed thrombosed internal haemorrhoids. Colorectal Dis 2006; 8(1): 41–45. doi: 10.1111/j.1463-1318.2005.00910.x.

7. Chan KK, Arthur JD. External haemorrhoidal thrombosis: evidence for current management. Tech Coloproctol 2013; 17(1): 21–25. doi: 10.1007/s10151-012-0904-8.

8. Cavcić J, Turcić J, Martinac P et al. Comparison of topically applied 0.2% glyceryl trinitrate ointment, incision and excision in the treatment of perianal thrombosis. Dig Liver Dis 2001; 33(4): 335–340. doi: 10.1016/S1590-8658(01)80088-8.

9. Guy RJ, Seow-Choen F. Septic complications after treatment of haemorrhoids. Br J Surg 2003; 90(2): 147–156. doi: 10.1002/bjs.4008.

10. Becker de Moura H, Ribeiro-Silva A. Death resulting from fournier gangrene secondary to thrombosis of very large hemorrhoids: report of a case. Dis Colon Rectum 2007; 50(10): 1715–1718. doi: 10.1007/s10350-007-9054-x.

11. Chau NG, Bhatia S, Raman M. Pylephlebitis and pyogenic liver abscesses: a complication of hemorrhoidal banding. Can J Gastroenterol 2007; 21(9): 601–603. doi: 10.1155/2007/106946.

12. Salusso P, Testa V, Mochet S et al. Management of hemorrhoidal disease in special conditions: a word of caution. Rev Recent Clin Trials 2021; 16(1): 22–31. doi: 10.2174/1574887115666200406121308.

13. Őrhalmi J, Klos K, Jackanin S et al. Hemoroidy –⁠ konzervativní, či chirurgický přístup? Interní Med 2011; 13(7 a 8): 305–309.

14. Adamová Z, Slováček R. Diagnostika a léčba krvácení do dolní části zažívacího traktu. Med Praxi 2013; 10(11–12): 380–382.

15. Táborská J. Infekční průjmová onemocnění. Interní Med 2005; 7(9): 414–416.

16. Falt P, Cyrany J, Kunovský L et al. Doporučené postupy České gastroenterologické společnosti ČLS JEP pro diagnostickou a terapeutickou koloskopii –⁠ aktualizované vydání 2024. Gastroent Hepatol 2024; 78(3): 197–235. doi: 10.48095/ccgh2024197.

17. Ryska O. Divertikulární choroba tlustého střeva –⁠ nové trendy v léčbě. Kardiol Rev Int Med 2014; 16(3): 229–234.

18. Banerjee A, Shah SR, Abraham P. Rectal varices in extrahepatic portal vein obstruction. Indian J Gastroenterol 2015; 34(3): 280. doi: 10.1007/s12664-015-0567-2.

19. Kim KS, Suh GJ, Kwon WY. Successful bridging hemostasis using a sengstaken-blakemore tube in massive rectal variceal bleeding. Korean J Crit Care Med 2014; 29(3): 237–240.

20. Rodrigues SG, Mendoza YP, Bosch J. Beta-blockers in cirrhosis: evidence-based indications and limitations. JHEP Rep 2019; 2(1): 100063. doi: 10.1016/j.jhepr.2019.12.001.

21. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding –⁠ an updated Cochrane review. Aliment Pharmacol Ther 2011; 34(5): 509–518. doi: 10.1111/j.1365-2036.2011.04746.x.

22. Bittinger M, Probst A, Eberl T et al. Bleeding from rectal varices in patients with liver cirrhosis –⁠ an ominous event. Gastrointestinal Endoscopy 2004; 59(5): 270. doi: 10.1016/S0016-5107(04)01197-6.

23. Hawks MK, Svarverud JE. Acute lower gastrointestinal bleeding: evaluation and management. Am Fam Physician 2020; 101(4): 206–212.

24. Anděl P, Škrovina M, Ducháč V. Základy praktické proktologie. Galén 2011. https://www.bookport.cz/kniha/zaklady-prakticke-proktologie-3599/.

25. Salati SA. Anal fissure –⁠ an extensive update. Pol Przegl Chir 2021; 93(4): 46–56. doi: 10.5604/01.3001.0014.7879.

26. Nelson RL, Manuel D, Gumienny C et al. A systematic review and meta-analysis of the treatment of anal fissure. Tech Coloproctol 2017; 21(8): 605–625. doi: 10.1007/s10151-017-1664-2.

27. Novák J. Základy proktologie. Praha: Avicenum 1985.

28. Abcarian H, Cintron J, Nelson R (eds). Complications of anorectal surgery: prevention and management. Cham: Springer 2017.

29. Tan Tanny SP, Wijekoon N, Nataraja RM et al. Surgical management of perianal abscess in neonates and infants. ANZ J Surg 2020; 90(6): 1034–1036. doi: 10.1111/ans.15801.

30. Sartelli M, Guirao X, Hardcastle TC et al. 2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections. World J Emerg Surg 2018; 13(1): 58. doi: 10.1186/s13017-018-0219-9.

31. Schouten WR, Van Vroonhoven TJ. Treatment of anorectal abscess with or without primary fistulectomy. Results of a prospective randomized trial. Dis Colon Rectum 1991; 34(1): 60–63. doi: 10.1007/BF02050209.

32. Wang J, Boonpongmanee I, Ailabouni LD. Incision and drainage: perianal abscess. Dis Colon Rectum 2024; 67(4): e246–e247. doi: 10.1097/DCR.0000000000002949.

33. Hanley PH. Reflections on anorectal abscess fistula: 1984. Dis Colon Rectum 1985; 28(7): 528–533. doi: 10.1007/BF02554105.

34. Abcarian H. Anorectal infection: abscess-fistula. Clin Colon Rectal Surg 2011; 24(1): 14–21. doi: 10.1055/s-0031-1272819.

35. Kairaluoma MV, Kellokumpu IH. Epidemiologic aspects of complete rectal prolapse. Scand J Surg 2005; 94(3): 207–210. doi: 10.1177/145749690509400306.

36. Felt-Bersma RJ, Tiersma ES, Cuesta MA. Rectal prolapse, rectal intussusception, rectocele, solitary rectal ulcer syndrome, and enterocele. Gastroenterol Clin North Am 2008; 37(3): 645–668. doi: 10.1016/j.gtc.2008.06.001.

37. Sarpel U, Jacob BP, Steinhagen RM. Reduction of a large incarcerated rectal prolapse by use of an elastic compression wrap. Dis Colon Rectum 2005; 48(6): 1320–1322. doi: 10.1007/s10350-004-0913-4.

38. Schabl L, Hull TL, Ban KA et al. Recurrence rates and risk factors in the altemeier procedure for rectal prolapse: a multicenter study. Dis Colon Rectum 2024; 67(11): 1465–1474. doi: 10.1097/DCR.0000000000003439.

39. Eke N. Fournier’s gangrene: a review of 1726 cases. Br J Surg 2000; 87(6): 718–728. doi: 10.1046/j.1365-2168.2000.01497.x.

40. Sorensen MD, Krieger JN. Fournier’s gangrene: epidemiology and outcomes in the general us population. Urol Int 2016; 97(3): 249–259. doi: 10.1159/000445695.

41. Kolombo I, Poršová M, Pabišta R et al. Fournierova gangréna v současné urologické praxi. Urol Praxi 2011; 12(4): 234–237.

42. Singh A, Ahmed K, Aydin A et al. Fournier’s gangrene. A clinical review. Arch Ital Urol Androl 2016; 88(3): 157–164. doi: 10.4081/aiua.2016.3.157.

43. Rajan DK, Scharer KA. Radiology of Fournier’s gangrene. AJR Am J Roentgenol 1998; 170(1): 163–168. doi: 10.2214/ajr.170.1.9423625.

44. Ozturk E, Sonmez Y, Yilmazlar T. What are the indications for a stoma in Fournier’s gangrene? Colorectal Dis 2011; 13(9): 1044–1047. doi: 10.1111/j.1463-1318.2010.02353.x.

45. Kurer MA, Davey C, Khan S et al. Colorectal foreign bodies: a systematic review. Colorectal Dis 2010; 12(9): 851–861. doi: 10.1111/j.1463-1318.2009.02109.x.

MUDr. Ondřej Vyčítal, Ph.D.

Chirurgická klinika

LF UK a FN Plzeň

alej Svobody 80

323 00 Plzeň

vycitalo@fnplzen.cz

ORCID autorů

O. Vyčítal 0000-0001-7531-9751

J. Geiger 0000-0001-5577-997X

P. Novák 0000-0001-8688-529X

J. Rosendorf 0000-0003-2125-0685

R. Polák 0000-0001-7685-0923