Anorectal Disease

Anorectal Disease
Cincinnati Colon and Rectal Surgeons

May 23, 2012
Or: It’s my hemorrhoids, Doc
-- NOT!
In What Way Are Your
Hemorrhoids Bothering You?
• Pain
• Bleeding
• Itching/burning
• Swelling
• Drainage
• Incontinence/leakage
Has anything you’ve done made
it better?
• Hot soaks
• Ice
• Laxatives
• Creams
• Hygiene
• Sitting on a tennis ball
Inspection: Look First!
• Quality of the skin
• Skin color
• Contours
• Lumps/bumps
• Tears/ulcers
Examination of the Perineum
• External thrombosis
• Prolapse
• Abscess
• Sentinel Tag and Fissure
• Warts
• Cancers
• Pruritus
• Incontinence
Palpation
Explain what you’re going to do
Spread skin/evert anus first
Then… and only then… insert a
finger
Gently!
Auscultation
24 y.o. anxious female
• Pain with bowel movements
• Blood on tissue
• I keep pushing the hemorrhoid up, and it
just comes back down
• My hemorrhoids are blocking my bowels
• Stool is hard
Anal fissure: Etiology
• Trauma
– Hard stool
– Diarrhea
– Chronic straining
• Hypertonic or spastic internal sphincter
• Increased intra-anal pressure
• Decreased blood flow anterior/ posterior
• Ischemic ulcer
Management of Anal Fissure
• Fiber supplement
• Warm tub soaks
• Anal nitroglycerine (0.2%)
• Topical nifedipine
• Botox
• Lateral internal sphincterotomy
45 y.o. female
• Spent Saturday raking leaves, planting

bulbs
• Sunday morning woke with painful anal
swelling
• Prep H hasn’t helped.
Thrombosed External
Thrombosed External
Acute Thrombosis: Management
• Expectant
• Excision not incision
• Avoid mucocutaneous junction
• Warn of potential for non-healing wound or
abscess
65 y.o. rectal bleeding
• 30 year history of protrusions with bowel
movements
• Pushes the tissue back up each time
• Bleeding is painless
• Colonoscopy negative
Classification of Hemorrhoids
• Location • Vascular
– Internal – Bleed not prolapse
• Sliding vascular pad • Mucosal
– External – Protrude and prolapse
• blood clot beneath skin
– Mixed
Internal Hemorrhoids
• 1˚ Bleeding
• 2˚ Bleeding and prolapse –
Spontaneous reduction
• 3˚ Bleeding and prolapse – manual
reduction
• 4˚ Irreducible prolapse
Must differentiate from Rectal Prolapse

Common Anorectal Disorders
Rectal Prolapse
Evaluation
Prolapse Hemorrhoids
Examination on the commode may be crucial

Management
1˚ Hemorrhoids Bowel regimen
Sclerotherapy
IRC
2˚ Hemorrhoids Elastic ligation
Excision (especially in patients
on anticoagulation)
3˚ Hemorrhoids Excision (traditional vs. new)
Stapled hemorrhoidopexy
4˚ Hemorrhoids Urgent surgical excision

INTERNAL HEMORRHOIDS
Management
Surgical
Hemorrhoidectomy
• Grade IV
• Mixed internal and
external
• Hemorrhoidal crisis
• Patient preference
• In conjunction with
another procedure
Complications
• Bleeding
– Acutely or delayed
• Infection
– Rare: requires high index of suspicion
• Can be lethal
• Incontinence
– Detailed questioning regarding continence PREOP
• Stricture or ectropian
– Increased risk with circumferential disease
• Urinary Retention
70 y.o. female
• Has had hemorrhoids for a long time
• They hang out all day, only go back up
when she lies down
• Incontinence of stool
• Chronic soiling
• Wears pad
This is NOT a hemorrhoid
Rectal Prolapse
• Elderly (nulliparous) female
• Chronic constipation
• Straining to have bowel movement
• Pelvic floor abnormality
• Associated uro-gyn symptoms
• Patulous anus
Rectal Prolapse
Treatment
Abdominal repair Perineal repair

• Rectal fixation • Full thickness
• Sigmoid resection resection
• Proctectomy • Mucosal resection
• Combination of with muscular
rectal fixation and reefing
sigmoid resection • Anal encirclement
25 y.o. male
• Long history of difficulty having BM
• Recent trauma, on narcotics
• No BM for 3 days
• Strained at stool
• Brought to ED by girlfriend, who found him
bleeding on floor of bathroom
This is not just the rectum:
Incarcerated Rectal Prolapse
• Surgical emergency
• Altemeier or perineal approach is
procedure of choice
• Necrosis of the dentate line may require
colostomy
45 y.o. male
• Cc: Doc, I’ve got this hemorrhoid that just
keeps getting bigger.
• It’s been there about a month.
• I can’t push it back in.
This is not a hemorrhoid:
After wide local excision
Flap outlined, elevation begun
Flap sutured in place
50 y.o. female
• “It’s my hemorrhoids. I’ve been dealing
with them a long time, and now they just
hurt constantly.”
Anal neoplasms
• Mass
• Pain
• Bleeding
• Itching
• Discharge
• Up to 30% will be misdiagnosed as a
benign anorectal condition
Anal margin v. anal canal
• Paget’s or Bowen’s • Cloacogenic
• Squamous cell carcinoma
carcinoma (squamous)
• Involves skin around • Involves anal canal
anus • Treatment is Nigro
• Often history of anal protocol
condylomata • Radiation, chemo (5-
• Treatment is wide FU + mitomycin-c)
local excision
68 y.o. female
• Complains of pain, discharge, decreased
calibre of stool
• Gastroentrologist has identified a “scar” on
the anus
• History of radiation and chemotherapy in
80’s. Received both external beam and
brachytherapy.
Recurrent anal cancer
How it all began…
After treatment…
18 y.o. male c/o hemorrhoid
• Several day history of increasing pain
• Swelling on anus
• (Fever)
• (Urinary retention)
• (Difficulty initiating bowel movement)
This is not…
What to do next:
• Further work-up?
• CT pelvis?
• None!
• Treatment?
• Antibiotics?
• Incision and drainage!
Abscess: Classification
• Perianal (~40%)
• Ischiorectal (~20%)
• Intersphincteric (~3%)
• Supralevator (<2.5%)
48 y.o. female pain for 5 days
• Swelling “burst” day before presentation
• Long history of Crohn’s disease
• Previous bowel resection
• Multiple drainage procedures
• Currently on no therapy
Next step: EUA
Drainage procedure
Fistula-in-Ano
• History:
– Abscess in past
– Discharge/excoriation (65%)
– Pain (34%)
– Swelling (24%)
– Bleeding (12%)
Fistula-in-Ano
• Differential Diagnosis:
– Crohn’s Dz
– HIV
– TB
– Lymphoma
– Malignancy
– Hydradenitis Suppurativa
– Bartholin’s gland abscess
Fistula-in-Ano
• Physical exam:
– Elevated granulation tissue with d/c
– Palpable chord
– Rectal exam:
• Internal opening
• Sphincter tone
– Anoscopy/Colonoscopy
Treatment:
• Fistulotomy
• Seton placement
• Anal fistula plug
• Sliding flap closure
Fistula-in-Ano:
Fistulotomy
• Complications:
– Incontinence 3-7%
– Delayed healing
– Anal stenosis
– Mucosal prolapse
Seton Placement
Endo-rectal flap
To Review:
Anal Symptoms/Pathology
Symptoms Pathology
1. Pain and bleeding Ulcer/Fissure
after bowel movement
2. Forceful straining to Pelvic floor Abnormality

have bowel movement
3. Blood mixed with stool Neoplasm/Inflammatory

bowel disease
4. Drainage of pus during Abscess/fistula
or after bowel
movement
Anal Symptoms/Pathology
Symptoms Pathology
5. Constant moisture Condyloma
Accuminata
6. Mucous drainage
and incontinence Rectal prolapse
7. Constant anal pain Abscess

8. +/- retention, fever
Open Invitation
• Office hours:
• University Pointe Wednesday morning
• Christ Hospital MOB Thursday 2-5
• University Pointe Friday 1-5.
• See gross stuff!
• Do procedures!
• Have fun!
Hemorrhoids
Prevalence
• 10 million people complain of hemorrhoids

yearly
• Prevalence rate of 4.4%
• Peak incidence - Age 45 to 65 years
• Rare before 20 years or after 70 years
• 60% of hospitalized patients are men
Symptoms
• Bright red rectal bleeding

• Protrusion / prolapse
• Pain / discomfort
• Mucous drainage / soiling
Acute Thrombosis: Indications for
Surgery
1. Inability to tolerate pain

2. Erosion of blood clot
3. Circumferential thrombosis and necrosis
4. Never as a primary procedure in the
chronic state
Complications
• Bleeding
– Acutely or delayed
• Infection
– Rare: requires high index of suspicion
• Can be lethal
• Incontinence
– Detailed questioning regarding continence PREOP
• Stricture or ectropian
– Increased risk with circumferential disease
• Urinary Retention
ANAL FISSURES
Anal Fissure
• History
– Severe pain with defecation
– Bleeding
• Exam
– Sentinel tag
– Eversion of the anal canal is all that is
required to make the diagnosis
• DON’T PROD AND PUSH
Risks of Sphincterotomy
• Recurrence/persistence of fissure (2-10%)

• Incontinence to flatus (10-40%)
• Seepage/soiling, chronic irritation(up to 10%)
• Abscess
Abscess/Fistula
Abscess/Fistula
• Incidence: 8 per 100,000 – population
based
• Male:Female – 3:1 to 2:1
• Seasonal incidence? Spring and summer
• Majority in 4th or 5th decade of life but
range from 2 months to 8th decade
Abscess: Pathogenesis
-Parks, Br Jrnl Surg 1976

Presentation
• Pain: Exacerbated by sitting, BM’s
• Fever/Malaise
• Nonspecific symptoms if intersphincteric or
supralevator
• Digital exam difficult due to pain
Treatment: Urgent I&D
• Local vs general
anesthesia
• Technique
– Where:
• Transrectal vs
percutaneous
• Zone of greatest
fluctuance
• As near anus as possible
Fistula-in-Ano
55-70% 20-25%
1-3% 2%
a. Intersphincteric, b. Transsphincteric, c. Suprasphincteric, d. Extrasphincteric
-Parks, Br Jrnl Surg 1976

Fistula-in-Ano:
Intersphincteric
Fistula-in-Ano:
Transphincteric
Fistula-in-Ano:
Extrasphincteric
Goodsall’s Rule
Goodsall’s Rule: Not So Good?
• Posterior opening: 90% followed rule

• Anterior opening: 49% followed rule
– 71% tracked to anterior midline
– 39% of men unpredictable course
– 10% of women unpredictable course
-Cirocco. Dis Colon Rectum 1992

Fistula-in-Ano:
Diagnosis
Fistula-in-Ano:
Diagnosis
Fistula-in-Ano:
Diagnosis
Draining Seton
Rectovaginal Fistula
• High fistula -
Diverticulitis
• Mid fistula – Crohn’s
Disease, radiation
• Low fistula –
cryptoglandular,
obstetric
Hidradenitis Suppurativa
• Prevalence
seborrheic skin type
obesity
heavy perspiration
cystic acne in face, neck, axillae, groin
• Treatment
incision, drainage, unroofing
excision of chronic disease
rare need for stoma
Miscellaneous
Conditions
“…and don’t forget,
abscess makes the
heart grow
fonder.”
-Groucho Marx

Anorectal Disease

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Anorectal Disease

Cincinnati Colon and Rectal Surgeons

• Spent Saturday raking leaves, planting

Must differentiate from Rectal Prolapse

Examination on the commode may be crucial

4˚ Hemorrhoids Urgent surgical excision

Abdominal repair Perineal repair

2. Forceful straining to Pelvic floor Abnormality

3. Blood mixed with stool Neoplasm/Inflammatory

7. Constant anal pain Abscess

• 10 million people complain of hemorrhoids

• Bright red rectal bleeding

1. Inability to tolerate pain

• Recurrence/persistence of fissure (2-10%)

-Parks, Br Jrnl Surg 1976

a. Intersphincteric, b. Transsphincteric, c. Suprasphincteric, d. Extrasphincteric

-Parks, Br Jrnl Surg 1976

• Posterior opening: 90% followed rule

-Cirocco. Dis Colon Rectum 1992

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