hemorrhoids and fissure

7/29/2019 hemorrhoids and fissure

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Hemorrhoids and Anal Fissures

9/1/2010


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Hemorrhoids

Cushions of specialized, highly vascular tissue inanal canal in the submucosal space Thickened submucosa contains blood vessels, elastic

tissue, connective tissue, and smooth muscle

Anal submucosal smooth muscle (Treitzs muscle)

pass through internal sphincter and anchor tosubmucosa, contributing to bulk of hemorrhoid andsuspending 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


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Function

Contribute to anal continence Compressible lining that protects underlying

sphincters

Provide complete closure of the anus

Cushions engorge and prevent leakage with increasingintrarectal pressure

Account for15-20% of anal resting pressure

Supplies sensory information to discriminate

between solid, liquid, and gas


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Vascular Supply

Bleeding from disrupted presinusoidal arterioles thatcommunicate with sinusoids in the region

Bright red

Arterial pH

External plexus drains via inferior rectal veins intopudendal veins into internal iliacs

Also through middle rectal veins to internal iliacs

Internal hemorrhoid plexus drains through middle

rectal into internal iliacs


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Configurations

Three main cushions Left lateral

Right anterior

Right posterior

Additional smaller accessory cushions in betweenmain cushions


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Etiology

Constipation Prolonged straining

Irregular bowel habits

Diarrhea

Pregnancy

Heredity

Erect posture

Absence of valveswithin the hemorrhoidal

sinusoids

Increased

intraabdominal pressurewith obstruction of

venous return

Aging

Interior sphincterabnormalities


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Etiology

Patients usually have increased anal restingpressures

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


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Epidemiology

4.4% in the US Peak between 45-65 yoa

Increased in Caucasians and higher socioeconomic

status


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Classification

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


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Internal Hemorrhoid ClassificationFirst degree Second degree Third degree Fourth degree

Finding Bulge into lumen+/- painless

bleeding

Protrude with

BM

Reduce

spontaneously

Protrude

spontaneously

Require manual

reduction

Permanently

prolapsed and

irreducible

Symptoms

Painlessbleeding

Anal massw/defecation

Anal burning or

pruritis

TenesmusMucous leakage

Difficulty

cleaning

Irreduciblemass

Signs Bright red

bleedingBleeds at end of

BM

Drips or squirts

May be occult

Prolapse with

defecation

Reduce

manuallyPerianal stool or

mucous

Anemia rare

Always

prolapsed


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Symptoms

Presence, quantity, frequency, and timing of bleedingand prolapse

May complain of bleeding, mucosal protrusion, pain,

mucus, discharge, difficulties with perianal hygiene,

sensation of incomplete evacuation, cosmeticdeformity

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


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Symptoms

Internal hemorrhoids are painless unlessthrombosed, strangulated, gangrenous, or prolapsed

with edema

Bleeding is bright red and associated with BMs 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


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Treatment

Dietary 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


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Treatment

Nonoperative/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 ofblood vessels

Creams, ointments, foams, and suppositories have little

rationale in treatment

Prolonged use may cause local allergic effects or

sensitization of the skin


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Treatment


Rubber band ligation

Can be used for first-, second-, and third-degree hemorrhoids

Rubber band is placed on redundant mucosa

Minimum of2 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


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Treatment


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 createfibrosis, scarring, shrinkage and fixation

No anesthesia needed

First- and second-degree hemorrhoids


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Treatment


External hemorrhoids Acute thrombosis

Excision of entire thrombus under local anesthesia

Conservative management if pain is resolving


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Treatment

Operative Hemorrhoidectomy

Indicated in patients with symptomatic combinedinternal 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, andrecurrence

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


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Strangulated Hemorrhoids

From prolapsed third- or fourth-degree hemorrhoidsthat become incarcerated and irreducible due to

prolonged swelling

May present with pain and urinary retention

Treatment is urgent or emergent hemorrhoidectomyin the OR

Open or closed technique


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Hemorrhoids.

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 andprolapsed disease

Should be under local in left anterolateral position


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Hemorrhoids.

And Crohns disease Rate of severe complications is high (30%) and patient

selection is paramount

And the Immunocompromised

Challenging due to poor wound healing and infectiouscomplications

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


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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 diseaseprocessesCrohns, TB, syphilis, HIV/AIDS, or anal ca

Early (acute) fissures appear as a simple tear in theanoderm

Chronic fissures (symptoms more than 8-12 wks) haveedema and fibrosis

Sentinel pile distally, hypertrophied anal papillaeproximally

May be able to see fibers of the internal sphincter


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Etiology

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 posteriormidline


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Symptoms

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 BMs

Bleeding usually limited to bright red blood on thetissue


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Diagnosis

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 PCPs Lateral fissures may require EUA and

biopsy/cultures


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Conservative Management

Almost half will heal

Sitz baths

Fiber supplement

+/- topical anesthetics or anti-inflammatory ointments


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Operative Treatment

Primary goal is to decrease abnormally high restinganal 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


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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


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Low Pressure Fissures

Not candidates for sphincterotomy

Impaired continence and fissure recurrence after

sphincterotomy

Island advancement flap


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Crohns

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


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HIV

Necessary to differentiate between HIV-associated

ulcers

Better results with sphincterotomy, especially with

antiretrovirals

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hemorrhoids and fissure