Rosen & Barkin's 5-Minute Emergency Medicine Consult (51 page)

• Need for respiratory support
  
• Dehydration
  
• Unable to be cared for at home owing to progression of illness
  
• Complications (e.g., infection) or other diagnosis that requires admission
  

• Suspected ALS:
  Refer for outpatient evaluation if general condition permits and other serious conditions requiring admission are ruled out
  
• Complication of known ALS:
  Discharge if outpatient treatment available and stable respiratory status
  

If considering diagnosis of ALS, prompt follow-up with a neurologist should be arranged

• ALS is a progressive neurodegenerative disease affecting all components of the motor system
  
• Many patients with ALS have advanced directives—inquire prior to any aggressive intervention
  
• FVC <50% usually requires ventilatory support.
  

• EFNS Task Force on Diagnosis and Management of Amyotrophic Lateral Sclerosis, Andersen PM, Abrahams S, et al. EFNS guidelines on the clinical management of amyotrophic lateral sclerosis (MALS)–revised report of an EFNS task force.
  Eur J Neurol
  . 2012;19:360–375.
  
• Gregory SA. Evaluation and management of respiratory muscle dysfunction in ALS.
  NeuroRehabilitation
  . 2007;22:435–443.
  
• McGeer E, McGeer P. Pharmacologic approaches to the treatment of amyotrophic lateral sclerosis.
  Biodrugs
  . 2005;19:31–37.
  
• Mitchell JD, Borasio GD. Amyotrophic lateral sclerosis.
  Lancet
  . 2007;369:2031–2041.
  
• Servera E, Sancho J. Appropriate management of respiratory problems is of utmost importance in the treatment of patients with amyotrophic lateral sclerosis.
  Chest
  . 2005;127:1879–1882.
  

CODES

335.20 Amyotrophic lateral sclerosis

BASICS

• Hard stool passes and “cuts” anoderm
  
• Linear tear extends from dentate line to anoderm:
  
  • Posterior midline 95%
    
  • Anterior midline 5%
    
  • Externally: Forms skin tag or sentinel pile
    
  • Internally: Forms hypertrophied anal papilla
    
  • Chronic fissure may reveal fibers of internal sphincter with sentinel pile.
    

• Stress or an overly tight anal sphincter leads to local ischemia of posterior anoderm.
  
• Diarrhea or hard bowel movement tears anoderm.
  
• Local trauma from anal intercourse or sexual abuse may be the cause.
  
• Lateral fissures indicate underlying causative systemic disease:
  
  • Crohn's disease
    
  • Anal cancer
    
  • Leukemia
    
  • Syphilis
    
  • Previous anal surgery
    

DIAGNOSIS

• Bright red blood per rectum usually on toilet paper
  
• Sharp, cutting, throbbing or burning pain with bowel movement:
  
  • May last for hours
    
• Constipation; unable to pass stool owing to pain:
  
  • Hard, nondeformable stools
    

• Passage of hard stool or constipation
  
• Episode(s) of diarrhea
  
• Bright red blood on toilet paper
  

Anal exam:

• Gently retract buttocks and have patient bear down to visualize the fissure.
  
• Severe pain usually prevents a manual or digital exam:
  
  • Use lidocaine jelly or ELA-Max5, a topical lidocaine ointment, before attempting digital rectal exam.
    
  • Need to exclude abscess or tumor
    

A clear test tube may be used as an anoscope to visualize the anal canal/fissure.

Careful rectal exam

Hematocrit if severe bleeding by history

CT pelvis:

• To exclude anal rectal abscess/tumor if palpable mass on rectal exam
  

• Crohn's disease
  
• Chronic ulcerative colitis
  
• Anorectal carcinoma
  
• Perirectal abscess
  
• Thrombosed hemorrhoid
  
• Sexual abuse
  
• TB
  
• Syphilis
  
• Lymphoma
  
• Leukemia
  
• Previous anal surgery
  

TREATMENT

Establish IV access for patients with significant rectal bleeding.

Administer pain medications for patients with significant pain.

• IV/IM/PO pain medications:
  
  • NSAIDs
    
  • Acetaminophen
    
  • Muscle relaxants to relieve sphincter spasm:
    
    • Cyclobenzaprine
      
    • Diazepam
      
    • Diltiazem 2% ointment
      
    • Nifedipine ointment 0.3%
      
• Topical anesthetics:
  
  • ELA-Max5
    
  • Lidocaine jelly 2%
    
• Sitz baths (with warm water) to relieve sphincter spasm
  

• High-fiber diet instruction:
  
  • Fiber/bran: 20 g/d
    
  • Psyllium seeds (Metamucil or Konsyl): 1–2 tsp (peds: 0.25–1 tsp/d) PO q24h
    
• Encourage consumption of 10–12 oz glasses of water per day.
  

• Cyclobenzaprine (Flexeril): 10 mg (peds: Not indicated) PO TID
  
• Diazepam (Valium): 5 mg (peds: 0.12–0.8 mg/kg/d) PO TID PRN for spasm
  
• Diltiazem 2% ointment: Apply to fissure BID
  
• Docusate sodium (Colace): 50–200 mg (peds: younger than 3 yr, 10–40 mg/d; 3–6 yr, 20–60 mg/d; 6–12 yr, 40–150 mg/d) PO q12h
  
• ELA-Max5 (5% lidocaine anorectal cream): Apply to perianal area q4h PRN pain (pediatric dose: Not for those younger than 12 yr)
  
• Ibuprofen: 400–600 mg (peds: 40 mg/kg/d) PO q6h
  
• Nifedipine ointment 0.3%: Apply to fissure TID with Q-tip (peds: Not indicated)
  
• Nitroglycerin ointment 0.2%: Apply a small pea-sized dot to fissure BID—TID with cotton swab. (peds: Not indicated)
  

FOLLOW-UP

Severe abdominal pain/distention due to fecal impaction

• Initial treatment is conservative therapy for acute anal fissures as an outpatient.
  
• Operative referral for chronic fissures
  

Colorectal or GI follow-up for patients with symptomatic fissures

• Perform a careful physical exam of rectal area to delineate fissures and exclude other pathology.
  
• Provide combination of pain relief and muscle relaxants for patients with significant pain.
  
• Provide discharge medications/instructions to prevent constipation.
  

• Herzig DO, Lu KC. Anal Fissure.
  Surg Clinf North Am.
  2010;90(1):22–44.
  
• Nelson RL, Thomas K, Morgan J, et al. Non-surgical Therapy for Anal Fissure.
  Cochrane Database Syst Rev
  . 2012;2:CD003431.
  
• Orsay C, Rakinic J. Practice parameters for the management of anal fissures (revised).
  Dis Colon Rectum
  . 2004;47:2003–2007.
  
• Rakinic J. Anal fissure.
  Clin Colon Rectal Surg
  . 2007;20(2):133–138.
  

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