Anorectal Emergencies Clinical Practice Guidelines (WSES-AAST, 2021)

World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST)

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

October 01, 2021

Clinical practice guidelines on anorectal emergencies by the World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) were published in September 2021 in the World Journal of Emergency Surgery.[1]

The guidelines on anorectal emergencies published by the WSES and AAST include the following:

In patients who are suspected of having anorectal abscess, it is suggested to check serum glucose, hemoglobin A1C, and urine ketones to identify undetected diabetes mellitus.

In patients who are suspected of having anorectal abscess and who have signs of systemic infection or sepsis, it is suggested to request a complete blood count, serum creatinine, and inflammatory markers (eg, C-reactive protein, procalcitonin, and lactates).

In patients who are suspected of having anorectal abscess, it is suggested to use imaging in cases of atypical presentation and in cases of suspicion of occult supralevator abscesses, complex anal fistula, or perianal Crohn disease. Suggested techniques are MRI, CT scan, or endosonography.

In patients with anorectal abscess, a surgical approach with incision and drainage is recommended.

In patients who have an anorectal abscess and an obvious fistula, it is suggested to perform a fistulotomy at the time of abscess drainage only in cases of low fistula that does not involve sphincter muscle (ie, subcutaneous fistula).

In patients who are suspected of having Fournier gangrene and who have signs of systemic infection or sepsis, it is suggested to request a complete blood count and the dosage of serum creatinine and electrolytes, inflammatory markers (eg, C-reactive protein, procalcitonin), and blood gas analysis. It is also recommended to check serum glucose, hemoglobin A1C, and urine ketones to detect diabetes mellitus.

In patients with Fournier gangrene, surgical intervention is recommended as soon as possible.

In patients who are suspected of having complicated hemorrhoids, it is suggested to perform imaging investigation (CT scan, MRI, or endoanal ultrasound) only if there is suspicion of concomitant anorectal diseases (sepsis/abscess, inflammatory bowel disease, neoplasm).

In patients with thrombosed or strangulated hemorrhoids, it is suggested to use a topical muscle relaxant.

In patients who have anorectal varices and severe bleeding, it is recommended 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 mm Hg, but avoid fluid overload.

For more information, see Anorectal Abscess, Anorectal Abscess in Children, Anal Fistulotomy, Anoscopy, Fournier Gangrene, Hemorrhoids, and Rectal Foreign Body Removal.

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