BRUNICARDI SWARTZEAnorectal Diseases Hemorrhoids

7/29/2019 BRUNICARDI SWARTZEAnorectal Diseases Hemorrhoids

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Anorectal Diseases

Any patient with anal/perianal symptoms requires a careful history and physical, including a

digital rectal examination. Other studies such as defecography, manometry, CT scan, MRI,

contrast enema, endoscopy, or exam under anesthesia may be required to arrive at an accurate

diagnosis.

Hemorrhoids

Hemorrhoids are cushions of submucosal tissue containing venules, arterioles, and smooth-

muscle fibers that are located in the anal canal (see Fig. 28-4). Three hemorrhoidal cushions

are found in the left lateral, right anterior, and right posterior positions. Hemorrhoids are

thought to function as part of the continence mechanism and aid in complete closure of the

anal canal at rest. Because hemorrhoids are a normal part of anorectal anatomy, treatment is

only indicated if they become symptomatic. Excessive straining, increased abdominal

pressure, and hard stools increase venous engorgement of the hemorrhoidal plexus and cause

prolapse of hemorrhoidal tissue. Outlet bleeding, thrombosis, and symptomatic hemorrhoidalprolapse may result.

External hemorrhoids are located distal to the dentate line and are covered with anoderm.

Because the anoderm is richly innervated, thrombosis of an external hemorrhoid may cause

significant pain. It is for this reason that external hemorrhoids should not be ligated orexcised without adequate local anesthetic. Askin tagis redundant fibrotic skin at the anal

verge, often persisting as the residual of a thrombosed external hemorrhoid. Skin tags are

often confused with symptomatic hemorrhoids. External hemorrhoids and skin tags may

cause itching and difficulty with hygiene if they are large. Treatment of external hemorrhoids

and skin tags are only indicated for symptomatic relief.

Internal hemorrhoids are located proximal to the dentate line and covered by insensate

anorectal mucosa. Internal hemorrhoids may prolapse or bleed, but rarely become painful

unless they develop thrombosis and necrosis (usually related to severe prolapse, incarceration,

and/or strangulation). Internal hemorrhoids are graded according to the extent of prolapse.

First-degree hemorrhoids bulge into the anal canal and may prolapse beyond the dentate line

on straining. Second-degree hemorrhoids prolapse through the anus but reduce spontaneously.

Third-degree hemorrhoids prolapse through the anal canal and require manual reduction.

Fourth-degree hemorrhoids prolapse but cannot be reduced and are at risk for strangulation.

Combined internal and external hemorrhoids straddle the dentate line and havecharacteristics of both internal and external hemorrhoids. Hemorrhoidectomy is often

required for large, symptomatic, combined hemorrhoids.Postpartum hemorrhoids result from

straining during labor, which results in edema, thrombosis, and/or strangulation.

Hemorrhoidectomy is often the treatment of choice, especially if the patient has had chronic

hemorrhoidal symptoms.Portal hypertension was long thought to increase the risk of

hemorrhoidal bleeding because of the anastomoses between the portal venous system (middle

and upper hemorrhoidal plexuses) and the systemic venous system (inferior rectal plexuses).

It is now understood that hemorrhoidal disease is no more common in patients with portal

hypertension than in the normal population.Rectal varices, however, may occur and may

cause hemorrhage in these patients. In general, rectal varices are best treated by lowering

portal venous pressure. Rarely, suture ligation may be necessary if massive bleeding persists.


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Surgical hemorrhoidectomy should be avoided in these patients because of the risk of

massive, difficult-to-control variceal bleeding.

Treatment

Medical Therapy

Bleeding from first- and second-degree hemorrhoids often improves with the addition of

dietary fiber, stool softeners, increased fluid intake, and avoidance of straining. Associated

pruritus may often improve with improved hygiene. Many over-the-counter topical

medications are desiccants and are relatively ineffective for treating hemorrhoidal symptoms.

Rubber Band Ligation

Persistent bleeding from first-, second-, and selected third-degree hemorrhoids may be treated

by rubber band ligation.

Mucosa located 1 to 2 cm proximal to the dentate line is grasped and pulled into a rubber

band applier. After firing the ligator, the rubber band strangulates the underlying tissue,

causing scarring and preventing further bleeding or prolapse (Fig. 28-30). In general, only

one or two quadrants are banded per visit. Severe pain will occur if the rubber band is placed

at or distal to the dentate line where sensory nerves are located. Other complications of

rubber band ligation include urinary retention, infection, and bleeding. Urinary retention

occurs in approximately 1% of patients and is more likely if the ligation has inadvertently

included a portion of the internal sphincter.Necrotizing infection is an uncommon, but life-

threatening complication. Severe pain, fever, and urinary retention are early signs of infection

and should prompt immediate evaluation of the patient usually with an exam under anesthesia.

Treatment includes dbridement of necrotic tissue, drainage of associated abscesses, and

broad-spectrum antibiotics.Bleedingmay occur approximately 7 to 10 days after rubber band

ligation, at the time when the ligated pedicle necroses and sloughs. Bleeding is usually self-

limited, but persistent hemorrhage may require exam under anesthesia and suture ligation of

the pedicle.


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FIG. 28-30.

Rubber band ligation of internal hemorrhoids. The mucosa just proximal to the internal hemorrhoids is

banded. [Reproduced with permission from Schwartz SI, Shires GT, Spencer FC (eds): Principles of Surgery.

5th ed. New York: McGraw-Hill, 1989, p 1303.]

Infrared Photocoagulation

Infrared photocoagulation is an effective office treatment for small first- and second-degree

hemorrhoids. The instrument is applied to the apex of each hemorrhoid to coagulate the

underlying plexus. All three quadrants may be treated during the same visit. Larger

hemorrhoids and hemorrhoids with a significant amount of prolapse are not effectively

treated with this technique.

Sclerotherapy

The injection of bleeding internal hemorrhoids with sclerosing agents is another effective

office technique for treatment of first-, second-, and some third-degree hemorrhoids. One to 3

mL of a sclerosing solution (5-phenol in olive oil, sodium morrhuate, or quinine urea) areinjected into the submucosa of each hemorrhoid. Few complications are associated with

sclerotherapy, but infection and fibrosis have been reported.

Excision of Thrombosed External Hemorrhoids

Acutely thrombosed external hemorrhoids generally cause intense pain and a palpable

perianal mass during the first 24 to 72 hours after thrombosis. The thrombosis can be

effectively treated with an elliptical excision performed in the office under local anesthesia.

Because the clot is usually loculated, simple incision and drainage is rarely effective. After 72

hours, the clot begins to resorb, and the pain resolves spontaneously. Excision is unnecessary,

but sitz baths and analgesics are often helpful.


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Operative Hemorrhoidectomy

A number of surgical procedures have been described for elective resection of symptomatic

hemorrhoids. All are based on decreasing blood flow to the hemorrhoidal plexuses and

excising redundant anoderm and mucosa.

Closed Submucosal Hemorrhoidectomy

The Parks or Ferguson hemorrhoidectomy involves resection of hemorrhoidal tissue and

closure of the wounds with absorbable suture. The procedure may be performed in the prone

or lithotomy position under local, regional, or general anesthesia. The anal canal is examined

and an anal speculum inserted. The hemorrhoid cushions and associated redundant mucosa

are identified and excised using an elliptical incision starting just distal to the anal verge and

extending proximally to the anorectal ring. It is crucial to identify the fibers of the internal

sphincter and carefully brush these away from the dissection in order to avoid injury to the

sphincter. The apex of the hemorrhoidal plexus is then ligated and the hemorrhoid excised.

The wound is then closed with a running absorbable suture. All three hemorrhoidal cushionsmay be removed using this technique; however, care should be taken to avoid resecting a

large area of perianal skin in order to avoid postoperative anal stenosis (Fig. 28-31).

FIG. 28-31.

Technique of closed submucosal hemorrhoidectomy. A. The patient is in prone jackknife position. B. A Fansler

anoscope is used for exposure. C. A narrow ellipse of anoderm is excised. D. A submucosal dissection of the

hemorrhoidal plexus from the underlying anal sphincter is performed. E. Redundant mucosa is anchored to theproximal anal canal and the wound is closed with a running absorbable suture. F. Additional quadrants are

excised to complete the procedure. [Reproduced with permission from Schwartz SI, Shires GT, Spencer FC

(eds): Principles of Surgery. 5th ed. New York: McGraw-Hill, 1989, p 1304.]

Open Hemorrhoidectomy


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This technique, often called the Milligan and Morgan hemorrhoidectomy, follows the same

principles of excision described above, but the wounds are left open and allowed to heal by

secondary intention.

Whitehead's Hemorrhoidectomy

Whitehead's hemorrhoidectomy involves circumferential excision of the hemorrhoidal

cushions just proximal to the dentate line. After excision, the rectal mucosa is then advanced

and sutured to the dentate line. While some surgeons still use the Whitehead

hemorrhoidectomy technique, most have abandoned this approach because of the risk of

ectropion (Whitehead's deformity).

Stapled Hemorrhoidectomy

Stapled hemorrhoidectomy has been proposed as an alternative surgical approach. 8183

Unlike excisional hemorrhoidectomy, stapled hemorrhoidectomy does not aim to excise

redundant hemorrhoidal tissue. Instead, stapled hemorrhoidectomy removes a shortcircumferential segment of rectal mucosa proximal to the dentate line using a circular stapler.

This effectively ligates the venules feeding the hemorrhoidal plexus and fixes redundant

mucosa higher in the anal canal. Critics suggest that this technique is only appropriate for

patients with large, bleeding, internal hemorrhoids, and is ineffective in management of

external or combined hemorrhoids. Although stapled hemorrhoidectomy has not been widelyaccepted at this time, it remains a promising new technique.

Complications of Hemorrhoidectomy

Postoperative pain following excisional hemorrhoidectomy requires analgesia usually with

oral narcotics. Nonsteroidal anti-inflammatory drugs, muscle relaxants, topical analgesics,

and comfort measures, including sitz baths, are often useful as well. Several studies show that

stapled hemorrhoidectomy is associated with a significant decrease in postoperative pain.

Other complications are similar to those seen with excisional hemorrhoidectomy. Urinary

retention is a common complication following hemorrhoidectomy and occurs in 10 to 50% of

patients. The risk of urinary retention can be minimized by limiting intraoperative and

perioperative intravenous fluids, and by providing adequate analgesia. Pain can also lead to

fecal impaction. Risk of impaction may be decreased by preoperative enemas or a limited

mechanical bowel preparation, liberal use of laxatives postoperatively, and adequate pain

control. While a small amount ofbleeding, especially with bowel movements, is to be

expected, massive hemorrhage can occur after hemorrhoidectomy. Bleeding may occur in theimmediate postoperative period (often in the recovery room) as a result of inadequate ligation

of the vascular pedicle. This type of hemorrhage mandates an urgent return to the operating

room where suture ligation of the bleeding vessel will often solve the problem. Bleeding may

also occur 7 to 10 days after hemorrhoidectomy when the necrotic mucosa overlying the

vascular pedicle sloughs. While some of these patients may be safely observed, others will

require an exam under anesthesia to ligate the bleeding vessel or to oversew the wounds if no

specific site of bleeding is identified.Infection is uncommon after hemorrhoidectomy;

however, necrotizing soft-tissue infection can occur with devastating consequences. Severe

pain, fever, and urinary retention may be early signs of infection. If infection is suspected, an

emergent examination under anesthesia, drainage of abscess, and/or dbridement of all

necrotic tissue are required.


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Long-term sequelae of hemorrhoidectomy include incontinence, anal stenosis, and ectropion

(Whitehead's deformity). Many patients experience transient incontinence to flatus, but these

symptoms are usually short-lived and few patients have permanent fecal incontinence. Anal

stenosis may result from scarring after extensive resection of perianal skin. Ectropion may

occur after a Whitehead's hemorrhoidectomy. This complication is usually the result of

suturing the rectal mucosa too far distally in the anal canal and can be avoided by ensuringthat the mucosa is sutured at or just above the dentate line.

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BRUNICARDI SWARTZEAnorectal Diseases Hemorrhoids