hemorrhoids and anal fissures n.
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Hemorrhoids and Anal Fissures. 9/1/2010. Hemorrhoids. Cushions of specialized, highly vascular tissue in anal canal in the submucosal space Thickened submucosa contains blood vessels, elastic tissue, connective tissue, and smooth muscle

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  • Cushions of specialized, highly vascular tissue in anal canal in the submucosal space
    • Thickened submucosa contains blood vessels, elastic tissue, connective tissue, and smooth muscle
  • Anal submucosal smooth muscle (Treitz’s muscle) pass through internal sphincter and anchor to submucosa, contributing to bulk of hemorrhoid and suspending vascular cushions
    • Lack of muscular wall on some structures classifies more as sinusoids and not veins
  • “Hemorrhoidal disease” should be reserved for abnormalities and symptoms
  • Contribute to anal continence
  • Compressible lining that protects underlying sphincters
  • Provide complete closure of the anus
    • Cushions engorge and prevent leakage with increasing intrarectal pressure
    • Account for 15-20% of anal resting pressure
  • Supplies sensory information to discriminate between solid, liquid, and gas
vascular supply
Vascular Supply
  • Bleeding from disrupted presinusoidal arterioles that communicate with sinusoids in the region
    • Bright red
    • Arterial pH
  • External plexus drains via inferior rectal veins into pudendal veins into internal iliacs
  • Also through middle rectal veins to internal iliacs
  • Internal hemorrhoid plexus drains through middle rectal into internal iliacs
  • Three main cushions
    • Left lateral
    • Right anterior
    • Right posterior
  • Additional smaller accessory cushions in between main cushions
  • Constipation
  • Prolonged straining
  • Irregular bowel habits
  • Diarrhea
  • Pregnancy
  • Heredity
  • Erect posture
  • Absence of valves within the hemorrhoidal sinusoids
  • Increased intraabdominal pressure with obstruction of venous return
  • Aging
  • Interior sphincter abnormalities
  • Patients usually have increased anal resting pressures
    • Return to normal after hemorrhoidectomy
  • “Sliding anal cushion theory”
    • Sliding downward of anal lining
    • Repeated stretching of anal supporting tissues causes fragmentation and prolapse of cushions
    • Straining and irregular bowel habits may engorge cushions making displacement more likely
  • Increased AV communications, vascular hyperplasia, increased neovascularization with increased CD105 immunoactivity
  • 4.4% in the US
  • Peak between 45-65 yoa
  • Increased in Caucasians and higher socioeconomic status
  • External
    • Distal 1/3 of anal canal
    • Distal to dentate line
    • Covered by anoderm or by skin
    • Somatically innervated
    • Sensitive to touch, pain, stretch, and temp
  • Internal
    • Proximal to dentate line
    • Covered by columnar or transitional epithelium
    • Not sensitive to touch, pain, temperature
    • Subclassified into degrees based on size and symptoms
  • Presence, quantity, frequency, and timing of bleeding and prolapse
  • May complain of bleeding, mucosal protrusion, pain, mucus, discharge, difficulties with perianal hygiene, sensation of incomplete evacuation, cosmetic deformity
  • External complaints are usually due to thrombosis associated with acute pain
    • Can bleed secondary to pressure necrosis and ulceration
  • External tags may be the result of prior thrombosis
    • May interfere with anal hygiene and burn or itch
  • Internal hemorrhoids are painless unless thrombosed, strangulated, gangrenous, or prolapsed with edema
    • Bleeding is bright red and associated with BM’s at the end of defecation
    • Blood may drip or squirt into the toilet or be seen on the toilet tissue
  • Prolapse can manifest as mass, mucous discharge, or tenesmus
treatment dietary and lifestyle modification
TreatmentDietary and Lifestyle Modification
  • Main goal is to minimize straining at stool
    • Increase fluid and fiber (20-35 g/day)
    • Adding supplemental fiber (psyllium)
  • Compliance improved by starting at lower doses and slowly increasing until stool consistency is good
  • Stop reading on commode
  • Must rule out proximal source of bleeding
treatment nonoperative office procedures
TreatmentNonoperative/Office Procedures
  • Medical therapy
    • Most effective topical treatment is warm (40°) sitz baths
    • Ice packs may also relieve symptoms
    • Bioflavinoids (widely used in Europe) are thought to work by increasing venous tone and strengthening the walls of blood vessels
    • Creams, ointments, foams, and suppositories have little rationale in treatment
    • Prolonged use may cause local allergic effects or sensitization of the skin
treatment nonoperative office procedures1
TreatmentNonoperative/Office Procedures
  • Rubber band ligation
    • Can be used for first-, second-, and third-degree hemorrhoids
    • Rubber band is placed on redundant mucosa
    • Minimum of 2 cm above dentate line
    • Causes strangulation of blood supply
    • Sloughs in 5-7 days
    • Leaves small ulcer that heals and fixes tissue to underlying sphincter
    • Anesthesia not required
    • May have pressure or feeling of incomplete evacuation
    • Contraindicated in patients on coumadin or heparin
    • Complications: pain, thrombosis, bleeding, life-threatening perineal or pelvic sepsis, abscess, band slippage, priapism, urinary dysfunction
treatment nonoperative office procedures2
TreatmentNonoperative/Office Procedures
  • Infrared photocoagulation, Bipolar Diathermy, Direct-Current Electrotherapy
    • Rely on coagulation, obliteration, and scarring which leads to fixation
    • Works best with small, bleeding, first- and second-degree hemorrhoids
    • Less pain
  • Sclerotherapy
    • Injection of chemical agents into submucosa that create fibrosis, scarring, shrinkage and fixation
    • No anesthesia needed
    • First- and second-degree hemorrhoids
treatment nonoperative office procedures3
TreatmentNonoperative/Office Procedures
  • External hemorrhoids
    • Acute thrombosis
    • Excision of entire thrombus under local anesthesia
    • Conservative management if pain is resolving
treatment operative hemorrhoidectomy
TreatmentOperative Hemorrhoidectomy
  • Indicated in patients with symptomatic combined internal and external hemorrhoids who have failed or are not candidates for nonoperative treatments
  • Multiple techniques (open, closed, stapled excision) show similar rates of pain, complications, and recurrence
  • Complications: urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), and incontinence (2-12%)
  • Serious complications with stapled hemorrhoidopexy include rectal perforation, retroperitoneal sepsis, and pelvic sepsis
strangulated hemorrhoids
Strangulated Hemorrhoids
  • From prolapsed third- or fourth-degree hemorrhoids that become incarcerated and irreducible due to prolonged swelling
  • May present with pain and urinary retention
  • Treatment is urgent or emergent hemorrhoidectomy in the OR
  • Open or closed technique
  • In portal hypertension
    • Must be distinguished from anorectal varices
    • Rarely bleed but if do, can be massive
    • Direct suture ligation, stapled anopexy, TIPS, ligation of IMV, inf mesocaval shunt, inf mesorenal vein shunt, sigmoid venous to ovarian vein shunt
  • In pregnancy
    • Majority that intensify during delivery usually resolve
    • Hemorrhoidectomy reserved for acutely thrombosed and prolapsed disease
    • Should be under local in left anterolateral position
  • And Crohn’s disease
    • Rate of severe complications is high (30%) and patient selection is paramount
  • And the Immunocompromised
    • Challenging due to poor wound healing and infectious complications
    • Does not increase mortality with hematologic malignancies but should be performed as a last resort for pain and sepsis
    • Stapled hemorrhoidopexy may offer alternative, avoiding external wounds
anal fissure
Anal Fissure
  • Oval, ulcer-like, longitudinal tear in the anal canal
  • Distal to the dentate line
  • 90% in the posterior midline
  • 25% anterior midline in women, 8% in men
  • 3% have anterior and posterior fissures
  • Lateral positions should raise concern for other disease processes—Crohn’s, TB, syphilis, HIV/AIDS, or anal ca
  • Early (acute) fissures appear as a simple tear in the anoderm
  • Chronic fissures (symptoms more than 8-12 wks) have edema and fibrosis
  • Sentinel pile distally, hypertrophied anal papillae proximally
  • May be able to see fibers of the internal sphincter
  • Trauma due to passage of a hard stool
  • History of constipation or diarrhea
  • Associated with increased resting pressures
    • Sustained resting hypertonia
  • Ischemia from decreased perfusion in the posterior midline
  • Hallmark is pain during, and particularly after, a BM
  • May be short-lived or last hours or all day
  • Described as passing razor blades or glass shards
  • May often fear BM’s
  • Bleeding usually limited to bright red blood on the tissue
  • Confirmed by physical exam
  • May be noted on initial inspection
  • Most may be too tender to tolerated digital rectal exam or anoscopy
  • Frequently misdiagnosed as hemorrhoids by PCP’s
  • Lateral fissures may require EUA and biopsy/cultures
conservative management
Conservative Management
  • Almost half will heal
  • Sitz baths
  • Fiber supplement
  • +/- topical anesthetics or anti-inflammatory ointments
operative treatment
Operative Treatment
  • Primary goal is to decrease abnormally high resting anal tone
  • Anal Dilatation
    • 93-94% healing with few complications
    • Long term outcomes sparse
    • Incontinence can occur in around 12-27%
  • Lateral Internal Sphincterotomy
    • Keyhole deformity if done in posterior midline
    • Incontinence rates up to 36% but vary widely
    • Open or closed technique
  • Advancement Flaps
    • No significant difference in healing rates
medical management
Medical Management
  • Sphincter relaxants--“Chemical sphincterotomy”
    • Nitrate formulas
      • NTG, GTN, ISDN
      • Predominant nonadrenergic, noncholinergic neurotransmitter
    • Oral and topical calcium channel blockers
      • As effective as nitrates without the headache
    • Adrenergic antagonists
      • Lack of efficacy in studies
    • Topical muscarinic agonists
      • Bethanechol
    • Phophodiesterase inhibitors
    • Botulinum toxin
low pressure fissures
Low Pressure Fissures
  • Not candidates for sphincterotomy
  • Impaired continence and fissure recurrence after sphincterotomy
  • Island advancement flap
crohn s
  • 20-30% incidence
  • 60% may heal with medical management
  • Initial treatment should control diarrhea
  • Limited sphincterotomy can be performed
  • Anal dilatation has been reported with some success
  • Necessary to differentiate between HIV-associated ulcers
  • Better results with sphincterotomy, especially with antiretrovirals