Haemorrhoids

Essentials of diagnosis

Rectal bleeding, protrusion, discomfort

Mucoid discharge from rectum

Secondary anaemia

Characteristic findings on anal inspection and anuscopic examination

THE PROBLEMNobody likes them: patients and doctors

Very frequent

Major discomfort

Treated often by non-specialists

Well treated=good results

Sensitive area

DEFINITION

Normal structures of the rectal wall which are displaced from the original position Normal histological structures Plenty vascularization: both arterial (inferior

haemorrhoidal artery) and venous lakes which may be distended.

Chrinic constipation + straining on defecation + increased anal tonus – favor the development of haemorrhoids.

Symptomatic classification

Grade 1 – bleedingGrade 2 – prolaps with spontaneous

reductionGrade 3 – prolaps that needs digital

replacementGrade 4 – Prolaps - permanent

TRATAMENT – depending on symptoms

Anatomic classification

Symptoms

Painless bleeding

Pruritus

Prolaps

Pain (asociated with a complication – thrombosis or inflamation)

Incontinence

BLEDDING PER RECTUMHow to evaluate!!!

Small drops of blood on toilet paper Clinical examination + rectal + rectoscopy

Blood dropping in the toilet Rigid recto-sygnoidoscopy

Blood mixed with feces Rigid recto-sygnoidoscopy + barium enema OR

colonoscopy = complete examination of the colon

Dark blood Complet examination of the colon

Massive OR Chronic

May be massive and presents as an emergency

May be a cause of chronic anaemia

May explainSevere iron deficiency anaemia Ischaemic cardiac disease due to low

levels of oxygen transporter

NEVER

NEVER treat haemorrhoidal disease without clinical and digital examination of the rectum

MALPRAXIS = patients life and your money

PRURITUS ANI

Frequently associated with haemorrhoidsMinute incontinence with local irritation of the

skinAggressive local cleaning may produce small

lesions that will generate pruritus TagsLocal edema

PAIN

External thrombosed haemorrhoidsRound blue lesions (perianal haematoma)

with significant edema and very tender

Internal thrombosed haemorrhoidsPain is less severeMajor pain in cases of strangulated prolaps

of haemorrhoids

EXAMINATION

Speaking with the patient will create trust

Offer an intimate room

RECTAL EXAMINATIONBlind – use a hydro soluble gel Forts evaluate visually the perianal region Evaluate the tonicity of the sphincter in non contracting status and during contractionProstate Content

RECTOSCOPYANUSCOPY

SYGMOIDOSCOPY

RECTOSCOPY + ANUSCOPY

Masses that prolaps in the tube of the scope

Stigmata of recent bleeding

WHY COMPULSORY TO EVALUATE

Colonic cancer is frequently missed due to obvious haemorrhoidal disease

Main diagnosis is delayed for a long time – too late

CONSERVATIV TRATAMENT

Bleeding

Dietary suplements with fibers (larger volume + softer)

Increase vascular tonusGinko Biloba Flavonoids (Detralex)

CONSERVATIV TRATAMENT

PRURITUS

Hot bath – decreasing muscular tonus

Fibers in food

Analgetic creams

Corticoids locally (supositories or cream) but no more then 7 days

Changed local hygiene

CONSERVATIV TRATAMENT

THROMBOSIS OF HAEMORRHOIDS

Surgical thrombectomy – first 48 hours

Analgetics

Dietary changes

Hot bath

Surgical treatment 1 – Milligan - Morgan

Surgical treatment 2 – Ferguson

Surgical treatment 3 – Stappler haemorrhoiedctomy

NEW TECHNIQUES

BANDING

Principles:Elastic ligatures on the base of

haemorrhoid followed by necrosisDetachment of necrotic areaScar formation + sclerosis will fix the

mucosa

SCLEROTHERAPY

Irritative substances (Almond oil + phenol)

Slerosis + fixation of mucosa

Injection only around vessels

ANAL DILATION

Hypertony is a major cause of pain

Unde rgeneral anaesthesia

Make banding easier and better

Decreased the tonus of the sphincter – mechanism of hemorrhoid formation

Not in cases with low tonus

FOTOCOAGULATION

Infrared radiation directly over the hemorrhoid

Therncauterisation followed by sclerosis

In stages

CRIOCOAGULATION and ELECTROCOAGULATIONCriotherapt forceps – rapid cooling at -36 degree

Similar effects with infrared thermocoagulation

Lesions will shrink

More efficient for large hemorrhoids

CO2 LASER

Hemorrhoidectomy by vaporisation of tissue

Similar with surgical excision

Very expensive and difficult to use

Harmonic knife

Ultrasonic energy

Very little effects on the tissue around the area treated

No smoke, low temperatures (50-100 degrees)

Seals vessels and coagulates proteins

Harmonic knife

No burned tissue (doesn’t coagulate via dessictaion)

Coagulates even large vessels

Low chances for postoperative bleeding

Ligation of haemorrhoidal artery HAL

New technoque

Ligation of feeding artery

Good results

COMPLICATIONS OF ALL METHODS

Stenosis

Tags

Recurencies

Fissure

Incontinence

Impactation with feces

Postop bleeding

RESULTSVery good

Dependeing on the tpe of hemorrhoids and clnical signs

Rational choice of therapy

Better in the hands of a proffesional

FISSURA IN ANOANAL FISSURE

General considerations

Denuded epithelium of the anal canal overlying the internal sphincter

Painful – highly sensitive area

Typically single ulcerations

Hypertrophic papilla – chronic inflammation

Sentinel pile

Diagnosis

3 ELEMENTSUlcerHypertrophic pappilaSentinel tag

Clinical findings

Symptoms and signs:Painful bowel movement associated with

bright red bleedingPain severe: after movement and

sensation is described like burning Constipation

Clinical examinationWith anaesthesia

Rectal:Tag Ulcer – in the middle Pappila Increased tonusSigmoidoscopy should be deffered

Differential diagnosis

Other ulcers:SyphilisCarcinomaTBCGranulomatous enetritis with ulcers

NOT TYPICALBiopsy

Association with haemorrhoids

TREATMENTMedical:Softening of the stoolTopical cream with myorelaxantHot bathFlavonoids

Surgical:Lateral internal shpyncterotomyAnal dilation

PROGNOSIS

Very good if good care

Tend to become chronic

The do not become malignant

ANORECTAL ABSCESS

ESSENTIALS OF DIAGNOSIS

Persistent throbbing rectal pain

External evidence of absecss

Systemic manifestations of infection

General considerations

Invasion of pararectal spaces by pathogenic microorganisms (mixed infection + frequent anaerobs)

Infection starts from an infected cript

Classification is anatomical according to the spaces invaded

Classification

Perianal – bellow levator aniIschiorectal – ischiorectal fossaRetrorectalSubmucousMarginal – in the anal canal beneath the anodermPelvirectalIntermuscular

Clinical Findings

The more superficial, the more painful

PAIN – related to sitting and walking

Infection: swelling, redness, induration, tenderness

Deep abscess – limited local signs + sepsis

Complications

Spreading to adjacent spaces

Pelvic gangrene or necrotizing fasciitis when anaerobic infections spread without concern for anatomic bariers

Fistula formation

TREATMENT

SURGICAL Incision and drainageDo not wait for the abscess to point

externallyFistulotomy may come in discussion if a

fistula is found (caution for the quality of the remnant sphincter)

ANORECTAL FISTULA

Essentials of diagnosis

Chronic purulent discharge

TRACT: palpable or probed will lead in the rectum

General considerations

At least 2 openings

Most fistulas originate in the anal cript Subcutaneous Submucoasal Intramuscular Submuscular

Anatomical Anterior Posterior Single/complex Horseshoe

Clinical Findings

Symptoms and signsPurulent drainage and dischargePalpation - cordlike tract in relation with the

spincter Probe

Rectal examination + rectoscopy – the internal opening

Exploration

Contrast fistulography

MRIAnatomy of the fistula for surgical excisionMostly in complex fistulas

Differential diagnosis

Hidradenitis suppurativaPilonidal sinusGranulomatous disease – CrohnInfected lesions (comedomes, sebaceous cyst, foliculitis, bartholinitis)Retrorectal dermooid tumorColoperineal fistulaPostraumatic sinuses or foreign bodyEtc.

Complications

Recurrent abscess formation

Generalized sepsis

Carcinoma in a chronic untreated fistula is possible

Treatment

SURGICALPrimary opening must be found end

excisedComplete identification of the tractThe tract must be unroofed on the entire

length – open woundCareful construction of the wound to favor

healing

Operations for fistula

Pilonidal disease

Essentials in diagnosis

Abscess or chronic discharges from a sinus in the sacrococcigeal area

Pain, tenderness, induration

General considerations

Drainig sinus or abscess

Underlying cyst containg granulomatous inflammation, fibrosis + tufts of hair

Congenital vs aquired

CAUSE: infection + irritation and trapping hair in deep tissue of the area

Clinical Findings

Asymptomatic until becomes infected

Acute suppuration in sacrococcigean area

If drained spontaneously – sinus with intermittent discharge

Probe may pass in the sinus – in to the cyst

Complications

Infection + multiple tracts

Sepsis

Malignant degeneration - rarely

Treatment

Acute abscess: Drainage

Chronic disease:Excision of all damaged tissueCystotomy to excision

Malignant tumors of the anal canal

Epidermoid carcinoma

75% of all malignancies of the areaEarly: verucous, nodular lesionLate: ulcerated, indurated, nodular nmass

Palpable inguinal nodesMay invade the rectum: false imprssion of rectal carcinomaLymphatic spread: like rectal + inguinal nodes

Treatment

External radiation + concomitant chemotherapy

Radical surgery in case of failure

Malignant melanoma

Horrible prognosis

Dark mass protruding from the anus

50% pigmented

Lymph node MTS early

Treatment - not clear advantage of any alternative

Bowen’s diseasecarcinoma in situ

Like all other places of skin

Plaque-like eczematoid lesion + pruritus

Biopsy-carcioma in situ + hyperkeratosis and giant cells

Therapy: local excision with safety margins

Basal cell carcinoma

Ulcerating tumor (uncommon)

“Rodent ulcer” like every other place of skin exposed

Doesn’t spread distantly

Local excision

Paget’s disease

Rare conditionPale plaquelike condition with induration + nodular mass (not always)Nodular mass= coloid carcinoma from glands or other skin appendagesLocal excision (without mass)Radical surgery + chemo + RT for coloid carcinoma