WSES-AAST guidelines on anorectal emergencies released

• No recommendation can be made regarding the role of biochemical investigations in patients with suspected thrombosed or strangulated hemorrhoids, based on the available literature.
• In patients with suspected bleeding hemorrhoids, we suggest to collect a focused medical history and to perform a complete physical examination, including a digital rectal examination, to rule out other causes of lower gastrointestinal bleeding.
• In patients with suspected bleeding hemorrhoids, we suggest to check vital signs, to determine hemoglobin and hematocrit, and to assess coagulation to evaluate the severity of the bleeding. In case of severe bleeding, we suggest blood typing and cross-matching.
• In patients with suspected complicated hemorrhoids, we suggest to perform imaging investigation (CT scan, MRI, or endoanal ultrasound) only if there is suspicion of concomitant anorectal diseases.
• In patients with complicated hemorrhoids, we suggest to perform anoscopy as part of the physical examination, whenever feasible and well tolerated.
• In patients with complicated hemorrhoids, we suggest to perform colonoscopy in case of concern for inflammatory bowel disease or cancer arising from patient personal and family history, or from physical examination.
• In patients with complicated hemorrhoids, we recommend non-operative management as first line therapy, with dietary and lifestyle changes (i.e., increased fiber and water intake together with adequate bathroom habits).
• In patients with complicated hemorrhoids, we suggest to administer flavonoids to relieve symptoms.
• In patients with thrombosed or strangulated hemorrhoids, we suggest the use of topical muscle relaxant.
• No recommendation can be made regarding the role of NSAIDs, topical steroids, other topical agents, or injection of local anesthetics for complicated hemorrhoids, based on the available literature.
• No recommendation can be made regarding the role of office-based procedures (i.e., rubber band ligation, sclerotherapy, infrared coagulation) in complicated hemorrhoids, based on the available literature.
• No recommendation can be made regarding the role of surgery in patients with bleeding hemorrhoids, based on the available literature.

Bleeding anorectal varices

• In patients with suspected bleeding anorectal varices, we suggest to collect a focused medical history and to perform a complete physical examination, including a digital rectal examination, to rule out other causes of lower gastrointestinal bleeding.
• In patients with suspected anorectal varices, we suggest we suggest to check vital signs, to determine hemoglobin and hematocrit, and to assess coagulation to evaluate the severity of the bleeding.
• In patients with bleeding anorectal varices, we suggest EUS +/- color Doppler evaluation as a second-line diagnostic tool, especially for deep rectal varices or when in doubt.
• In patients with bleeding anorectal varices and failed detection of bleeding site at endoscopy and EUS, or whenever EUS is not available, we suggest to perform contrast enhanced CT-scan.
• In pregnant patients with bleeding anorectal varices and failed US detection of bleeding site, we suggest to perform MRI angiography, if available and if allowed by the clinical scenario.
• In patients with suspected bleeding anorectal varices, we suggest the use of ano-proctoscopy or flexible sigmoidoscopy as the first-line diagnostic tool.
• In patients with suspected bleeding anorectal varices and high-risk features or evidence of ongoing bleeding, we suggest to perform an urgent colonoscopy (plus upper endoscopy) within 24 hours of presentation.
• In patients with suspected bleeding anorectal varices and risk factors for colorectal cancer or suspicion of a concomitant more proximal source of bleeding, we suggest to perform a full colonoscopy.
• In patients with bleeding anorectal varices, we suggest to use local procedures, such as endoscopic variceal ligation, endoscopic band ligation, sclerotherapy, or EUS-guided glue injection, to arrest bleeding in first instance where feasible.
• In patients with bleeding anorectal varices, we suggest multidisciplinary management, early involving the hepatology specialist team and focusing on optimal control of comorbid conditions.
• In patients with anorectal varices and mild bleeding, we suggest intravenous fluid replacement, blood transfusion if necessary, correction of coagulopathy, and optimal medication for portal hypertension.
• In patients with anorectal varices and severe bleeding, we recommend to maintain an Hb level of at least > 7 g/dl (4.5 mmol/l) during the resuscitation phase and a mean arterial pressure > 65 mmhg, but avoiding fluid overload.
• In patients with bleeding anorectal varices, we suggest the endorectal placement of a compression tube as a bridging maneuver, to help stabilization of the patient or to allow the transfer to a tertiary hospital.
• In patients with anorectal varices, we suggest the use of non-selective beta-adrenergic blockers for prevention/prophylaxis of first and/or recurrent variceal bleeding. In case of acute bleeding, we suggest to temporarily suspended beta blockers.
• In patients with bleeding anorectal varices, we suggest to consider the use of vasoactive drugs, such as terlipressin or octreotide, to reduce splanchnic blood flow and portal pressure.
• In patients with bleeding anorectal varices, we recommend a short course of prophylactic antibiotic.
• In patients with bleeding anorectal varices and failure of medical treatment and local procedures, we suggest a “step up” approach with radiological and then surgical procedures.
• In patients with bleeding anorectal varices, we suggest to use embolization via interventional radiological techniques for the short-term control of bleeding.
• In patients with bleeding anorectal varices and severe portal hypertension, we suggest to use percutaneous TIPS, if not contraindicated, to decompress the portal venous system and to reduce the risk for rebleeding.
• No recommendation can be made regarding the superiority of one embolization technique over the others in case of bleeding anorectal varices , based on the available literature.
• In patients with bleeding anorectal varices and failure of medical treatment, local and radiological procedures, we suggest a “step up” approach with surgical procedures.
• In patients with bleeding anorectal varices and failure of medical treatment, local and radiological procedures, we suggest against the use of “per anal” suture ligation.
• No recommendation can be made regarding the role of Doppler-guided hemorrhoidal artery ligation and stapled anopexy in patients with bleeding anorectal varices and failure of medical treatment, local and radiological procedures, based on the available literature.

Complicated rectal prolapse (irreducible or strangulated)

• In patients with suspected complicated rectal prolapse, we suggest to request complete blood count and the dosage of serum creatinine, and inflammatory markers (e.g., C-reactive protein, procalcitonin, and lactates) to assess the status of the patient.
• In hemodynamically stable patients with irreducible or strangulated rectal prolapse, we suggest to perform an urgent contrast enhanced abdomino-pelvic CT-scan, whenever available and without delaying appropriate treatment, to detect possible associated complications and to assess the presence of a colorectal cancer.
• In hemodynamically unstable patients with irreducible or strangulated rectal prolapse, we suggest against delaying appropriate and timely management to perform imaging investigations.
• In patients with incarcerated rectal prolapse without signs of ischemia or perforation, we suggest to attempt conservative measures and gentle manual reduction under mild sedation or anesthesia.
• In patients with complicated rectal prolapse and signs of shock or gangrene/perforation of prolapsed bowel, we recommend immediate surgical treatment.
• In patients with complicated rectal prolapse and bleeding, acute bowel obstruction or failure of non-operative management, we suggest urgent surgical treatment.
• In patients with strangulated rectal prolapse, we suggest to administer empiric antimicrobial therapy because of the risk of intestinal bacterial translocation; the appropriate regimen should be based on the clinical condition of the patients, the individual risk for MDRO, and the local resistance epidemiology.

Retained anorectal foreign bodies

• In patients with suspected retained anorectal foreign body, we suggest to collect a focused medical history and to perform a complete physical examination
• n patients with suspected retained anorectal foreign body and no signs of bowel perforation, we suggest to request the routine preoperative blood tests only in case manual extraction fails/is not feasible.
• In patients with suspected retained anorectal foreign body, we recommend lateral and anteroposterior plain X-ray film of the chest, abdomen, and pelvis to identify the foreign body position and determine its shape, size, and location and the possible presence of pneumoperitoneum.
• In patients with retained anorectal foreign body and bowel perforation with limited peritoneal contamination, we suggest primary suture only in case of small and recent perforation and if the colonic tissues appear healthy and well vascularized, and an approximation of perforation edges could be performed without tension.
• In patients with retained anorectal foreign body and hemodynamic instability, we recommend an emergent laparotomy and a damage control surgery approach.

Acute and fissure

• No recommendation can be made regarding the role of biochemical investigations in patients with typical acute anal fissure, based on the available literature.
• In patients with atypical acute anal fissure, we suggest to collect a focused medical history, perform a complete physical examination and laboratory tests based on the suspected associated illness, to rule out other causes.
• No recommendation can be made regarding the use of imaging investigations in patients with typical acute anal fissure, based on the available literature.
• In patients with acute anal fissure, we suggest against surgical treatment.
• In patients with anal fissure, we suggest surgical treatment in the chronic phase, if non responsive after 8 weeks non-operative management,

Reference:

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