Transcript Hemorrhoids and Anal Fissures

Rectal Disorders
Victor Politi, M.D., FACP
Medical Director, SVCMC School of Allied Health
Physician Assistant Program
Anatomy
• The rectum is the lower 10 to 15 cm of the
large intestine.
• The anatomic anal canal is the outlet of the
digestive system. It is a tube about 3.8 cm
long running from the perianal skin of the
buttocks to the mucosal lining of the
rectum.
Anatomy
• Its external opening is the anus, which is
tightly shut except during stool evacuation
by two strong but sensitive rings of
muscles: the internal sphincter and external
sphincter.
Anatomy
• The action of the internal sphincter is
controlled subconsciously (it is always
contracted to prevent accidental loss of
stool), whereas the action of the external
sphincter is voluntary.
Anatomy
• The sphincters are well supplied with blood
vessels and nerves.
• Where the anal canal meets the rectum there
is a ring of folds called the dentate line.
• Among these folds are the anal crypts, small
tube-like depressions opening into the anal
canal.
Anatomy
• The dentate line delineates where nerve
fibers end.
• Above this line, this area is relatively
insensitive to pain.
• Below the dentate line, the anal canal and
anus are extremely sensitive.
Anatomy
• The veins from the rectum and anus drain
into the portal vein, which leads to the liver,
and then into the general circulation.
• The lymph vessels of the rectum drain into
lymph nodes in the lower abdomen; those of
the anus drain into the lymph nodes in the
groin.
Rectal Exam
• Inspect the skin around the anus for any
abnormality.
• With a gloved finger, probe the rectum.
• For women, this is often done along with a
manual examination of the vagina.
Rectal Exam
• An anoscope or proctoscope (a 3- to 10-inch rigid
viewing tube) can also be used.
• A sigmoidoscope (a longer, flexible tube) can
observe as much as 2 or more feet of the large
intestine.
• An anoscopy or sigmoidoscopy is generally
uncomfortable but not painful; however, if the
area in or around the anus proves to be painful
because of an abnormal condition, a local,
regional, or even general anesthetic may be given
before examination proceeds.
Rectal Exam
• Sometimes a cleansing enema to rid the
lower part of the large intestine of stool is
given before sigmoidoscopy.
• Tissue and stool samples for microscopic
examination and cultures may be obtained
during sigmoidoscopy.
• A barium enema x-ray may also be
performed.
The Lower Digestive Tract
Hemorrhoids
• Hemorrhoids are dilated, twisted (varicose)
veins located in the wall of the rectum and
anus.
• Hemorrhoids occur when the veins in the
rectum or anus become enlarged; they may
eventually bleed.
• Hemorrhoids may also become inflamed or
may develop a blood clot (thrombus).
• Hemorrhoids that form above the boundary
between the rectum and anus (anorectal
junction) are called internal hemorrhoids.
• Those that form below the anorectal
junction are called external hemorrhoids.
• Both internal and external hemorrhoids may
remain in the anus or protrude outside the
anus.
Hemorrhoids
• Cushions of vascular tissue found within the
anal canal - when examined
microscopically, lack a muscular wall
• The lack of muscular wall characterizes
these vascular structures more as sinusoids
and not veins
• Hemorrhoidal bleeding is actually arterial although many still call it venous bleeding
• Hemorrhage from disrupted hemorrhoids
occurs from presinusoidal arterioles
• Hemorrhoidal tissue is thought to contribute
to anal continence and functions as a
compressible lining that provides complete
closure of the anus
• The main cushions are primarily found
anatomically in the left lateral, right
anterolateral, and right posterolateral
positions, with smaller accessory cushions
in other quadrants
Etiology
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Most common cause - constipation
Prolonged straining
Pregnancy
Heredity
Increased intra-abdominal pressure
Aging (due to thinning of supportive tissue)
The Liver and Hemorrhoids
• Look at the venous return for the external
and internal hemorrhoidal veins
• External - systemic
• Internal - portal
Classification
• Internal Hemorrhoid
– Whenever the internal hemorrhoidal plexus is
enlarged, there is associated increase in
supporting tissue mass with resultant venous
swelling
• External Hemorrhoid
– The veins in the external hemorrhoidal plexus
become enlarged or thrombosed, the resultant
bluish mass is called an external hemorrhoid
Internal / External Hemorrhoid
Classification
• Both types of hemorrhoids are very
common and are associated with increased
hydrostatic pressure in the portal venous
system such as during pregnancy, straining
at stool, or with cirrhosis
Classification
• Internal vs. external
• External are distal to the dentate line
• Internal are proximal to the dentate line
– Internal hemorrhoids are further sub-classified
by their physical characteristics
Classification of Internal
Hemorrhoids
• Grade I
– Seen on anoscopy, may bulge a short way into anal
canal; does not extend below dentate line
• Grade II
– Prolapses out of anal canal with straining or defecation;
reduces spontaneously
• Grade III
– Prolapses out of anal canal with straining or defecation;
reduces manually
• Grade IV
– Irreducible;may strangulate
Generalized Symptoms
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Bleeding on stool or in toilet
Mucosal protrusion
Discharge
Soiled underwear - due to internal
Sensation of incomplete evacuation
Generalized Symptoms
• Hemorrhoids are painless unless
thrombosed
• Bleeding from internal hemorrhoids is
bright red - from external - darker
Symptoms - Internal
Hemorrhoids
• When internal hemorrhoids enlarge pain is
not a usual feature until complicated by
thrombosis, infection, or erosion of the
overlying mucosal surface
• Most persons complain of bright red blood
on the toilet tissue, or coating the stool, with
a feeling of vague anal discomfort
Symptoms - Internal
Hemorrhoids
• The discomfort is increased when the hemorrhoid
enlarges or prolapses through the anus
• Prolapse is often accompanied by edema and
sphincteric spasm
• Prolapse, if not treated, usually becomes chronic
as the muscularis stays stretched - the patient c/o
constant soiling of underwear and very little pain
Symptoms - Internal
Hemorrhoids
• Prolapsed hemorrhoids may become
infected or thrombosed; the overlying
mucous membrane may bleed profusely as
the result of trauma of defecation
Prolapsed Hemorrhoid
Symptoms - external
hemorrhoids
• External hemorrhoids, because they lie under the
skin are usually very painful
• Result in tender blue swelling at the anal verge
due to thrombosis of a vein in the external plexus need not be associated with enlargement of the
internal veins
• Spasm often occurs since the thrombus usually
lies at the level of the sphincteric muscles
Diagnosis
• The diagnosis of internal or external
hemorrhoids is made by
– inspection
– digital exam
– direct vision through the anoscope &
proctosocpe
Diagnosis
• Exam– Prone, jack-knife position or lateral Sim’s
position
– Location of the hemorrhoids should be
described according to their anatomic position
– Visual inspection
– DRE- digital rectal exam
Diagnosis
• Since hemorrhoids are very common, they must
not be regarded as the cause of rectal bleeding or
chronic hypochromic anemia until a through
investigation has been made of the more proximal
GI tract
• Acute blood loss can occasionally be attributed to
internal hemorrhoids
• Chronic anemia in the presence of a large but not
bleeding hemorrhoid should provoke a search for
a poly, cancer or ulcer
Treatment
• Treatment includes medical as well as
surgical modalities
• With medical therapy, bleeding and pain
usually improve over a 6 week period
Treatment
• Most hemorrhoids respond to conservative
therapy such as sitz baths or other forms of
moist heat, suppositories, stool softeners,
and bed rest
Medical Therapy
• Stool bulking agent
– Psyllium
– Methylcellulose
• Sitz baths
– probably most effective topical treatment for
relief of symptoms
Treatment
• Internal hemorrhoids that remain
permanently prolapsed are best treated
surgically; milder degrees of prolapse or
enlargement with pruritus ani or
intermittent bleeding can be successfully
handled by banding or injection of
sclerosing solutions
Treatment
• External hemorrhoids which become
acutely thrombosed are treated by incision,
extraction of the clot, and compression of
the incised area following clot removal
• No surgical procedure should be carried out
in the presence of acute inflammation of the
anus, ulcerative proctitis, or ulcerative
colitis
Treatment
• Both proctoscopy and barium enema should
always be performed before a patient is
subjected to hemorrhoidectomy
Surgical Therapy
• Rubber Band Ligation
– One of most widely used techniques
– Approximately 5-7 days after procedure the
banded tissue sloughs-off
• Infrared Photocoagulation
– Laser not often used
• Sclerotherapy
– Phenol 5%
– Sodium tetradecyl sulfate
Surgical Therapy
• Operative hemorrhoidectomy
– Indicated for patients with symptomatic
combined internal and external hemorrhoids
Anal Inflammation
• Perianal inflammatory lesions may be
primary or may be associated with
inflammatory bowel disease or diverticular
disease
• Anal fissures are superficial erosions of the
anal canal which usually heal rapidly with
conservative therapy
Anal Inflammation
• Anal ulcers are more chronic and deep and
give symptoms largely as the result of
painful spasm of the external anal sphincter
during and after defecation
• Bleeding may occur with either fissure or
ulcer
• Healing of the ulcer is often associated with
a hypertrophied anal papilla and some
degrees of anal contracture
Anal Inflammation
• Fistula in ano, a tract leading from the rectal
lumen to the perianal skin, usually results
from local crypt abscesses
– fewer than 5% of these lesions found in the US
are due to TB or cancer
– The fistula is a chronically inflamed canal made
up of fibrous tissue surrounding granulation
tissue
Anal Inflammation
• Perirectal abscesses often represent the
tracking down of purulent material escaping
form the rectosigmoid; diverticulitis,
Crohn’s disease, ulcerative colitis, or
previous surgery may be the underlying
cause
Anal Inflammation
• Fistulas between the rectum and vagina or
rectum and the bladder represent serious
complications of granulomatous, septic, or
malignant disorders and require the patient
to be hospitalized for definitive diagnostic
and therapeutic procedures
Anal Fissures
• A tear in the anoderm below the
mucocutaneous junction (dentate line)
• In most cases, the fissure is located over the
posterior midline
– however, it can occur over the anterior midline,
particularly in females
Diagnosis
• Best made by careful history and gentle
examination
• Most distinctive symptom - pain associated with bowel evacuation,
described as sharp or knifelike, lasting
minutes or hours afterward
• Bleeding is minor
Pathogenesis
• Repeated trauma to the anal canal
(including, but not limited to, large stools)
• Theory of ischemia to posterior commissure
Physical Exam
• Lateral decubitus position
• Gentle spreading of the buttocks show the
characteristic tear
– Telltale sign - is that the mere spreading of the
buttocks causes a great deal of discomfort,
accompanied by obvious anal spasm
• Sentinel tag is often indicative of a chronic
anal fissure
Three Types of Fissures
• 1st Type (most benign)
– Healthy individual
– First time
– No internal sphincter hypertrophy
• 2nd Type
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Pain with defecation
Deep
History of bowel irregularily
High-strung personality
Three Types of Fissures
• 3rd Type
– Long history of recurrent anorectal discomfort
– Fibrotic sentinel tag and hypertrophied anal
papilla, posterior midline scarring, and anal
stenosis
• In the 2nd and 3rd types, patients are
typically afraid to go to the bathroom
Medical Treatment
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Fiber
Water
Sitz baths
0.2% nitroglycerin paste on peri-anal area
3-4 times a day
Medical Treatment
• For patients with recurrent fissure with
marked internal sphincter hypertrophy and
spams, as well as chronic changes such as
sentinel tag, hypertrophied anal papilla,
posterior midline anal scarring or even anal
stenosis, medial management is unlikely to
succeed.
Surgical Treatment
• Lateral internal sphincterotomy
– the most important complication to avoid is
incontinence. The rate has been quoted to be as
high as 36%
Anal Itching
• Itchy skin around the anus (pruritus ani) can
have many causes, including skin disorders
such as psoriasis and atopic dermatitis,
diseases such as diabetes or liver disease,
anal disorders such as skin tags or draining
fistulas, and cancers such as Bowen's
disease.
Anal Itching
• Allergic reactions such as contact dermatitis
caused by anesthetic preparations applied to the
skin, various ointments, or chemicals used in soap
are another cause.
• Infections with fungi, bacteria, or parasites (such
as pinworms and, less commonly, scabies or lice)
can produce anal itching.
• Itching can also be a side effect of antibiotics,
especially tetracycline.
Anal Itching
• Spices, citrus fruits, coffee, beer, and cola as
well as vitamin C tablets can cause irritation
of the anus when they are expelled in feces,
causing itching.
Anal Itching
• Poor hygiene that leaves stool residue
(especially in people with large external
hemorrhoids) or overly meticulous hygiene
with excessive rubbing and use of soap can
also lead to irritation and itching.
Anal Itching
• Excessive sweating because of pantyhose,
tight underwear (especially non-cotton
underwear), obesity, or hot weather may be
a factor.
Anal Itching - Tx
• After bowel movements, the anal area
should be cleaned with absorbent cotton or
soft, plain toilet or facial tissue, which may
be moistened with warm water.
• Dusting with cornstarch or a small amount
of talc may combat moisture.
Anal Itching - Tx
• Corticosteroid creams, antifungal creams
such as miconazole, or soothing
suppositories may be used.
Anorectal Abscess
• An anorectal abscess is a pus-filled cavity
caused by bacteria invading a mucussecreting gland in the anus and rectum
Anorectal Abscess
• An abscess may be deep in the rectum or
close to the opening of the anus.
• An abscess develops when bacteria invade a
mucus-secreting gland in the anus or
rectum, where they multiply
Anorectal Abscess
• Although the anus is an area that is rich in
bacteria, infection generally does not occur
because the internal sphincter acts as a
barrier and blood flow to the area is rich.
Anorectal Abscess
• When infection does occur, it usually is
caused by a combination of different types
of bacteria. An abscess can cause substantial
damage to nearby tissues and may lead to
incontinence of stool.
Anorectal Abscess
• Abscesses just under the skin can be
swollen, red, tender, and very painful.
• Abscesses higher in the rectum often cause
fewer symptoms but may produce fever and
pain in the lower abdomen.
Anorectal Abscess
• If an abscess is in the skin around the anus
it can be directly visualized.
• When no external swelling or redness is
seen, diagnosis is made by DRE.
• A tender swelling in the rectum indicates an
abscess.
Anorectal Abscess
• Antibiotics have limited value except for
people who have a fever, diabetes, or an
infection elsewhere in the body.
• Usually, treatment consists of if I/D after a
local anesthetic has been given.
Anorectal Abscess
• Even with proper treatment, in about 2/3 of
people, an abscess leads to the formation of
an anorectal fistula.
Anal Cancer
• Anal cancers occur most commonly in
individuals with a prior history of chronic
anal irritation.
• Such irritation may result from condylomata
acuminata (ie, viral lesions thought to be
caused by papilloma virus infection),
perianal fissures and/or fistulas, chronic
hemorrhoids, and leukoplakia
Anal Cancer
• Occurs most commonly in middle aged
individuals
• Develops more frequently in women than
men
• Most often associated with bleeding,pain,
the sensation of a perianal mass, and
perianal pruritus at the time of diagnosis
Anal Cancer
• Increased risk - homosexual males,
presumably due to trauma from anal
intercourse
• No data to indicate that anal cancers are
AIDS-related tumors associated with
infection by the human immunodeficiency
virus
Anal Cancer
• Until recently, radical surgery was tx of choice
with poor result
• Now, alternative therapeutic approach combining
external beam radiation with concomitant
chemotherapy has resulted in biopsy-proven
disappearance of all tumor in more than 80% of
patients whose initial lesion was less than 5cm in
size
– More than 80% of patients with anal cancers can be
cured with nonoperative treatment
Proctitis
• Proctitis is inflammation of the lining of the
rectum (rectal mucosa).
Proctitis
• Proctitis has several causes.
– Crohn's disease or ulcerative colitis.
– STD’s (gonorrhea, syphilis, Chlamydia trachomatis
infection, herpes simplex virus infection, or
cytomegalovirus infection).
– May also be caused by bacteria not transmitted
sexually, such as Salmonella.
– Antibiotics that destroy normal intestinal bacteria.
– Radiation therapy directed at or near the rectum, which
is commonly used to treat prostate and rectal cancer.
Proctitis
• Proctitis typically causes painless bleeding
or the passage of mucus from the rectum.
• When the cause is gonorrhea, herpes
simplex virus, or cytomegalovirus, the anus
and rectum may be intensely painful.
Proctitis- Exam/Diagnosis
• DRE
• Anoscope or sigmoidoscope
• Tissue sample of rectal lining -the
bacterium, fungus, or virus that may be
causing the Proctitis can be identified.
• Colonoscopy or barium enema x-rays.
Proctitis
• Antibiotics are the best treatment for
Proctitis caused by a specific bacterial
infection.
• Metronidazole (Flagyl) or vancomycin
(Vancocin) when proctitis is caused by use
of an antibiotic that destroys normal
intestinal bacteria
Proctitis
• When the cause is radiation therapy or is
unknown, anti-inflammatory drugs such as
hydrocortisone or may provide relief.
• Both hydrocortisone and mesalamine can be
administered as either an enema or a
suppository.
Proctitis
• Mesalamine and other anti-inflammatory
drugs, such as sulfasalazine, and olsalazine,
may be taken by mouth at the same time
that drugs are administered rectally, for
added benefit.
Procitis
• If these forms of treatment do not relieve
the inflammation, formalin can be applied
directly to the area or oral corticosteroids
may be used.
• Laser or Argon plasma coagulation has also
been used.
Pilonidal Disease
• Pilonidal disease is an infection caused by a
hair that injures the skin at the top of the
cleft between the buttocks.
• A pilonidal abscess is a collection of pus at
the infection site; a pilonidal sinus is a
chronic draining wound at the site.
Pilonidal Disease
• Pilonidal disease usually occurs in young,
hairy white men but can also occur in
women.
• A pilonidal sinus can cause pain and
swelling.
Pilonidal Disease
• To distinguish pilonidal disease from other
infections, look for pits—tiny holes in or
next to the infected area.
• Treatment for a pilonidal abscess consists of
I/D.
• Usually, a pilonidal sinus must be removed
surgically.
Rectal Prolapse
• Rectal prolapse is protrusion of the rectum
through the anus.
Rectal Prolapse
• Rectal prolapse causes the rectum to turn
inside out, so that the rectal lining is visible
as a dark red, moist fingerlike projection
from the anus.
• Less commonly, the rectum protrudes into
the vagina
Rectal Prolapse
• A temporary prolapse of only the rectal
lining (mucosa) often occurs in otherwise
healthy infants, probably when the infant
strains during a bowel movement, and is
rarely serious.
Rectal Prolapse
• In adults, prolapse of the rectal lining tends
to persist and may worsen, so that more of
the rectum protrudes.
• A complete prolapse of the rectum is called
procidentia; this occurs most often in
women older than age 60.
Rectal Prolapse
• To determine the extent of a prolapse, a
DRE is done after the patient strains.
• By examining the anal sphincter,
diminished muscle tone is often detected.
• A sigmoidoscopy and barium enema x-rays
may reveal underlying disease.
Rectal Prolapse
• In infants and children, a stool softener
eliminates the urge to strain.
• Strapping the buttocks together between
bowel movements usually helps the
prolapse heal on its own.
Rectal Prolapse
• In adults, surgery is usually needed to correct the
problem.
• Surgery often cures procidentia.
• During one kind of abdominal operation, the entire
rectum is lifted, pulled back, and attached to the
sacral bone in the pelvis.
• In another, a segment of the rectum is removed,
and the remainder of the rectum is stitched to the
sacral bone.
Rectal Prolapse
• For people who are too weak to undergo surgery
because of extreme old age or poor health, surgery
to the rectum is preferred to surgery to the
abdomen.
• One type of surgery to the rectum is performed by
inserting a wire or plastic loop to encircle the
sphincter in a technique called the Thiersch
procedure.
• Alternatively, a segment of the rectum or the
excess lining of the rectum may be excised.
Fecal Incontinence
• Fecal incontinence is the accidental loss of stool.
• Causes of fecal incontinence in adults include
back trauma, sphincter disruption as a result of
accidents, anorectal surgery, or obstetrical trauma,
and medical illness such as multiple sclerosis and
diabetes mellitus.
• Many women have suffered nerve or muscle
injury to the anal sphincter caused by forcepsassisted delivery, prolonged second stage of labor,
or delivery of large baby, and this can contribute
to fecal incontinence.
Fecal Incontinence
• Visualize the anorectal area to see if there
are any changes, scarring, fissures, or
prolapse (protrusion) of the rectum.
• DRE should be performed to determine if
there is an impaction of stool, to assess
muscle tone at rest and with squeeze effort,
and to exclude a rectal mass.
Fecal Incontinence
• Anal manometry is a specialized test that can measure the
pressures generated by the anal sphincter muscles at rest
and with maximal squeeze effort.
• X-rays may identify physical abnormalities of muscle
function.
• This examination involves the placement of barium paste
simulating stool into the rectum and asking the patient to
defecate, strain, or squeeze while taking x-ray pictures.
• Ultrasound can be used to evaluate the muscles and other
structures of the anal area.
Fecal Incontinence
• Treatments for incontinence include dietary
modification, medicines, biofeedback, and
surgery.
• Avoidance of foods that promote production
of gas, and foods containing ingredients
such as lactose, fructose, and sorbitol.
Fecal Incontinence
• Fiber supplements can increase bulk and add form to the
bowel movement and result in improved control.
• Kegel exercises to strengthen the pelvic floor muscles may
improve anorectal control.
• Loperamide HCl, Imodium, or diphenoxylate HCl, Lomotil
may decrease stool volume and frequency, improve stool
consistency, or perhaps directly affect the sphincter
muscles.
Foreign Objects
• Swallowed objects, such as toothpicks,
chicken bones, or fish bones, may become
lodged at the junction between the rectum
and anus.
• Also, enema tips, thermometers, and objects
used for sexual stimulation may become
lodged unintentionally in the rectum after
being passed through the anus.
Foreign Objects
• Sudden, excruciating pain during bowel
movements suggests that a foreign object,
usually at the anorectal junction, is
penetrating the lining of the anus or rectum.
Foreign Objects
• Other symptoms depend on the size and
shape of the object, how long it has been
there, and whether it has perforated the anus
or rectum or caused an infection.
Foreign Objects
• A DRE, abdominal examination,
sigmoidoscopy, and x-rays may be needed
to make sure the wall of the large intestine
has not been perforated.
Foreign Objects
• If the object can be felt, a local anesthetic is
usually injected under the skin and lining of the
anus to numb the area.
• The anus can then be spread wider with a rectal
retractor, and the object can be grasped and
removed.
• Natural movements of the wall of the large
intestine (peristalsis) generally bring higher
foreign objects down, making removal possible.
Foreign Objects
• If the object cannot be felt or cannot be removed
through the anus, exploratory surgery is needed.
• The patient is given a regional or general
anesthetic so that the object can be gently moved
toward the anus or so that the rectum can be cut
open to remove the object.
• After the object is removed, the doctor performs a
sigmoidoscopy to determine whether the rectum
has been perforated.
Questions