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Case 245

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Forty-five years-old female patient, nulligravida, born and living in Belo Horizonte. She seeks medical attention complaining of intense anal pain, with sudden onset two days ago. It is associated with swelling in the anal region. She reports straining during the bowel movements in the day before the beginning of the symptoms, irregular bowel habits, low ingestion of fiber and water and smoking. She denies fever and reports small relieve of the pain after a spontaneous local haemorrhage. The physical exam does not show any alterations, except the finding in the figure 1.

Which is the most likely diagnosis, based on the clinical history and in the finding of the physical exam?

a) Perianal abscess

25%

b) Anal fissure

25%

c) Anal cancer

25%

d) Haemorrhoid thrombosis

25%
   

Image analysis

Image 1: Photo of the anal region showing a thrombosed haemorrhoid with eroded surface and elimination of the thrombus (blue).

Highlights

- Any anal discomfort is usually attributed to the haemorrhoidal plexus, which causes confusion and delay in the diagnosis of some anorectal diseases. This is why it is important to know others aetiologies and to perform history and physical examination correctly.

- The most common symptoms of haemorrhoid thrombosis are acute and constant anal pain, anal tumour with or without prolapse and sometimes bleeding in the underwear or in the toilet paper.

- The pain is more intense in the first 72 hours and may recede after that period. The spontaneous involution occurs in 7 to 10 days.

- It is important to ask about dietetic habits like ingestion of water and fiber, inflammatory bowel disease, portal hypertension, anorexia, weight loss and abdominal pain associated;

- The conservative treatment with correction of bowel habits and local care is usually enough, but in some cases, the hemorrhoidectomy can be necessary.

References

- Bleday R, Breen E. Hemorrhoids: Clinical manifestations and diagnosis. UpToDate 2016. [Acesso em Julho de 2016]. Disponível em: http://www.uptodate.com/contents/hemorrhoids-clinical-manifestations-and-diagnosis.

- Bleday R, Breen E. Treatment of hemorrhoids. UpToDate 2016. [Acesso em Julho de 2016]. Disponível em: http://www.uptodate.com/contents/treatment-of-hemorrhoids.

- Beck DE, Roberts PL, Saclarides TJ, Senagore AJ, Stamos MJ, Wexner SD. The ASCRS textbook of colon and rectal surgery. London: Springer; 2011.

- Lohsiriwat V. Treatment of hemorrhoids: A coloproctologist’s view. World J Gastroenterol. Aug 21, 2015; 21(31): 9245-9252.

- Lohsiriwat V. Hemorrhoids: From basic pathophysiology to clinical management. World J Gastroenterol. 2012 May 7; 18(17): 2009–2017.

- Martin I, Pereira JC. Supurações perianais abcessos e fístulas Anais. Rev Port Coloproct. 2010; 7(3): 118-124.

Author

Fábio Mitsuhiro Satake, 6th year medical student at Faculdade de Medicina da UFMG

E-mail: fabiosatake[at]gmail.com

Supervisor

Dr Magda Maria Profeta da Luz, expert coloproctology of the HC/UFMG.

E-mail: coloproctolifecenter[at]gmail.com

Reviewers

Luísa Bernardino, Débora Faria, Rafael Fusaro, Daniele Araújo Pires, profa Viviane Parisotto

Translated by

Ana Carina Breunig Nunes, 6th year studentent at Faculdade de Medicina da UFMG.

E-mail: anacbreunig[at]gmail.com

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