Management Overview

1. Recuscitate any patient with signs of sepsis or haemodynamic instability

Resuscitation

• Involve senior ED physician
• Deliver high-concentration oxygen via a variable deliver mask with reservoir bag
• Use two large-bore peripheral IV cannulae
• Take bloods
• Administer IV fluids (crystalloid) 1-2 litres immediately and reassess
• Give IV broad spectrum antibiotics if signs of sepsis
• Install urinary catheter and measure urine volumes
• Refer urgently to senior surgeon and critical care

2. Analgesia as required
3. Patients that do not require urgent surgical intervention can generally be discharged for either GP or surgical follow-up:

Haemorrhoids

Most patients can be discharged to either GP care or surgical follow-up. Urgent surgical referral or admission is required in the following cases:

• Profuse haemorrhoidal bleeding [4]
• Thrombosed haemorrhoids; although these are acutely painful most patients can be treated conservatively at home with analgesia, ice, bed rest, stool softeners. Symptoms usually settle within 2 weeks [3]. If the external haemorrhoid is necrotic or gangrenous then surgery may be needed to excise the haemorrhoid [4,7]
• Fourth-degree haemorrhoids (NHS)
• Suspected malignancy (NHS)

Anal fissure

Patients can normally be discharged home with analgesia, stool softeners and surgical follow-up.

Anorectal abscesses

All require surgical intervention. There is no role for the treatment of a closed abscess with antibiotics, incision and drainage is required and failing to ensure that this happens in a timely fashion risks worsening sepsis, fistula formation and serves only to delay surgery.

Rectal prolapse

All patients with rectal prolapse should be referred to the admitting surgical team [4].

Systemic causes

Patients should be admitted or followed up by the appropriate speciality (e.g. genito-urinary medicine for suspected STIs)

Learning bite

Most patients with anorectal conditions, except abscesses, can be managed as outpatients.