Case Report: Acute Anal Pain and Rectal Bleeding Following High-Dose Laxative Use

Case at a Glance

A 20-year-old female presented with severe anal pain, rectal bleeding, and perianal skin changes after three days of using maximum-strength laxatives. The clinical diagnosis was a thrombosed external hemorrhoid, complicated by an acute anal fissure and severe perianal dermatitis.

Patient's Story

The patient, a 20-year-old female, presented with a three-day history of escalating anal pain. She reported self-administering maximum-strength stimulant laxatives for three consecutive days, a more potent regimen than she had used in the past. Initially, her symptoms were limited to abdominal cramping and diarrhea. However, over the past 24 hours, she began experiencing intense, lingering pain in the anal region during and after each bowel movement. Due to the frequency of diarrhea, she had been wearing adult diapers. The patient's condition worsened, prompting her to seek advice. She reported the new onset of rectal bleeding and noted visible changes in the perianal area, which she described as a 'bruise on top of my anus and a white spot underneath.'

Initial Assessment

Upon presentation, the patient was in considerable distress due to pain. Her history was significant for high-dose laxative use leading to frequent, forceful diarrhea. A physical examination of the perianal region was conducted. The area was erythematous and inflamed. A tense, tender, purplish nodule, consistent with a thrombosed external hemorrhoid, was identified at the superior anal margin, corresponding to the patient's description of a 'bruise.' Inferiorly, there was an area of severe skin maceration and a small linear tear, consistent with an acute anal fissure and dermatitis, which likely appeared as the 'white spot' she described. The bleeding was determined to be bright red, suggesting a source in the lower gastrointestinal tract, consistent with these findings.

The Diagnostic Journey

The diagnosis was primarily clinical, based on the classic presentation and physical examination findings. The patient’s history of induced, severe diarrhea provided a clear etiology for the acute perianal trauma. The sudden onset of a painful, palpable lump is pathognomonic for a thrombosed external hemorrhoid. The sharp pain during defecation combined with rectal bleeding strongly supported the concurrent diagnosis of an anal fissure. The widespread irritation and skin breakdown were attributed to chemical and mechanical irritation from frequent liquid stools and wiping. No further diagnostic imaging or procedures were deemed necessary at the initial visit.

Final Diagnosis

1. Thrombosed External Hemorrhoid
2. Acute Anal Fissure
3. Severe Perianal Dermatitis secondary to laxative-induced diarrhea.

Treatment Plan

The treatment plan focused on immediate cessation of the offending agent and multimodal symptom relief:

1. Cessation of Laxatives: The patient was instructed to immediately discontinue the use of all stimulant laxatives.
2. Pain and Inflammation Management: Warm sitz baths were recommended 3-4 times daily and after each bowel movement to soothe the area and promote healing. Over-the-counter analgesics (NSAIDs) and a topical anesthetic cream were prescribed for pain control.
3. Perianal Care: The patient was advised to stop wiping and instead use a peri-bottle or gentle shower spray for cleansing, followed by patting the area dry. A zinc oxide barrier cream was recommended to protect the irritated skin from moisture.
4. Bowel Management: To prevent straining during healing, a gentle osmotic laxative (polyethylene glycol) was recommended for short-term use to ensure soft stools. The patient received extensive counseling on the risks of laxative dependency and the importance of a high-fiber diet and adequate fluid intake for long-term bowel health.

Outcome and Follow-up

The patient was scheduled for a follow-up appointment in one week to assess healing. She was advised to return sooner if the pain worsened, bleeding increased, or she developed signs of infection. With adherence to the treatment plan, the thrombosed hemorrhoid was expected to resolve spontaneously over 1-2 weeks, and the fissure and dermatitis were expected to heal. The long-term focus of care is on patient education regarding healthy bowel habits to prevent recurrence.