Diseases of The Anus Haemorrhoids

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Essentials of Diagnosis

Rectal bleeding, protrusion, and vague discomfort.

Mucoid discharge from rectum. Characteristic findings on external anal inspection or anoscopic examination.

General Considerations

Internal haemorrhoids are varices of that portion of the venous hemorrhoidal plexus which lies submucosally just proximal to the dentate margin. External hemorrhoids arise from the same plexus but are located subcutaneoasly immediately distal to the dentate margin. There are 3 primary internal haemorrhoidal masses: right anterior, right posterior, and left lateral. Three to 5 secondary haemorrhoids may be present between the 3 primaries. Straining at stool, constipation, prolonged sitting, and anal infection are contributing factors and may precipitate complications such as thrombosis. Diagnosis is suspected on the history of protrusion, anal pain, or bleeding, and confirmed by proctologic examination.

Carcinoma of the colon or rectum not infrequently aggravates haemorrhoids or produces similar complaints. Polyps may be present as a cause of bleeding which is wrongly attributed to haemorrhoids. For these reasons, the treatment of haemorrhoids is always preceded by sigmoidoscopy and barium enema. When portal hypertension is suspected as an etiologic factor, investigations for liver disease should be carried out. Haemorrhoids which develop during pregnancy or parturition tend to subside thereafter and should be treated conservatively unless persistent after delivery.

Clinical Findings

The symptoms of haemorrhoids are usually mild and remittent, but a number of disturbing complications may develop and call for active medical or surgical treatment. These complications include pruritus, incontinence, recurrent protrusion requiring manual replacement by the patient, fissure, infection, or ulceration, prolapse and strangulation, and secondary anemia due to chronic blood loss. Carcinoma has been reported to develop very rarely in haemorrhoids.

Treatment

Conservative treatment suffices in most instances of mild haemorrhoids, which may improve spontaneously or in response to low roughage diet and regulation of the bowel habits with mineral off or other nonirritating laxatives to produce soft stools. Local pain and infection are managed with warm sitz baths and insertion of a soothing anal suppository 2 or 3 times daily.

Ethyl aminobenzoate (benzocaine) and similar types of anal ointments should be avoided so as not to sensitize the patient to these agerits.

Prolapsed or strangulated haemorrhoids should be gently reduced with the lubricated gloved fingers, the buttocks strapped, and the prone position maintained for a few days; surgery is recommended when the local reaction has subsided.

For severe symptoms or complications, complete internal and external haemorrhoidectomy is advisable and is a highly satisfactory procedure when properly done. Excision of a single external haemorrhoid, evacuation of a thrombosed pile, and the injection treatment of internal haemorrhoids fall within the scope of office practice.

Evacuation of Thrombosed External Haemorrhoid

This condition is caused by the rupture of a vein at the anal margin, forming a clot in the subcutaneous tissue. The patient complains of a painful lump, and examinatioi'1 shows a tense, tender, bluish mass covered with skin. If seen after 24-48 hoilrs when the pain is subsiding-or if symptoms are minimal hot sitz baths are prescribed. If discomfort is marked, removal of the clot is indicated.

With the patient in the lateral position, the area is prepared with antiseptic and 1 per cent procaine or lidocaine (Xylocaine®) is injected intracutaneously around and over the lump.

A radial ellipse of skin is then excised and the clot evacuated. A dry gauze dressing is held in place for 12-24 hours by taping the buttocks together, and daily sitz baths are then begun.

Cryptitis & Papillitis

Anal pain and burning of brief duration with defecation is suggestive of cryptitis and papillitis. Digital and anoscopic examination reveals hypertrophied papillae and indurated or inflamed crypts.

Treatment consists of mineral oil by mouth, sitz baths, anal suppository after each bowel movement, and local application of 5 per cent phenol in oil or carbolfuchsin compound to the crypts. If these measures fail, surgical excision of involved crypts and papillae should be considered.

Fissure-In-Ano (Anal Fissure)

Acute fissures represent linear disruption of the anal epithelium due to various causes. They usually clear if bowel movements are kept regular and soft (eg, with mineral oil). The local application of a mild styptic such as 1-2 per cent silver nitrate or 1 per cent gentian violet solution may be of value.

Chronic fissure is characterized by (1) acute pain during and after defecation; (2) spotting of bright red blood at stool with occasional more abundant bleeding; (3) tendency to constipation through fear of pain; and (4) the late occurrence of a sentinel pile, a hyper trophied papilla, and spasm of the anal canal (usually very painful on digital examination). Regulation of bowel habits with mineral oil or other stool softeners, sitz baths, and anal suppositories (eg, Anusol®), twice daily, should be tried. If these measures fail, the fissure, sentinel pile, or papilla and the adjacent crypt must be excised surgically. Postoperative care is along the lines of the preoperative treatment.

Anal Abscess

Perianal abscess should be considered the acute stage of an anal fistula until proved otherwise. The abscess should be adequately drained as soon as localized. Hot sitz baths may hasten the process of localization. The patient should be warned that after drainage of the abscess he may have a persistent fistula. It is painful and fruitless to search for the internal opening of a fistula in the presence of acute infection. The presence of an anal abscess should alert the clinician to the possibility of inflammatory bowel disease.

Fistula-In-Ano

About 95 per cent of all anal fistulas arise in an anal crypt, and they are often preceded by an anal abscess. If an anal fistula enters the rectum above the pectinate line and there is no associated disease in the crypts, ulcerative colitis, regional ileitis, rectal tuberculosis, lymphogranuloma venereum, cancer, or foreign body should be considered in the differential diagnosis.

Acute fistula is associated with a purulent discharge from the fistulous opening. There is usually local itching, tenderness, or pain aggravated by bowel movements. Recurrent anal abscess may develop. The involved crypt can occasionally be located anoscopically with a crypt hook. Probing the fistula should be gentle because false passages can be made with ease, and in any case demonstration of the internal opening by probing is not essential to the diagnosis.

Treatment is by surgical incision or excision of the fistula under general anesthesia. If a fistula passes deep to the entire anorectal ring so that all the muscles must be divided in order to extirpate the tract, a 2-stage operation must be done to prevent incontinence.

Anal Condylomas

These wart-like papillomas of the perianal skin and anal canal flourish on moist, macerated surfaces, particularly in the presence of purulent discharge. They are not true tumors but are infectious and auto-inoculable, probably due to a virus. They must be distinguished from condyloma lata caused by syphilis. The diagnosis of the latter rests on the positive serologic test for syphilis or the discovery of Treponema pallidum on darkfield examination.

Treatment consists of accurate application of 25 per cent podophyllin in tincture of benzoin to the lesion (with bare wooden or cotton tipped applicator sticks to avoid contact with uninvolved skin). Condylomas in the anal canal are treated through the anoscope and the painted site dusted with powder to localize the application and minimize discomfort. Electrofulguration under local anesthesia is useful if there are numerous lesions. Local cleanliness and the frequent use of a talc dusting powder are essential.

Condylomas tend to recur. The patient should be observed for several months and advised to report promptly if new lesions appear.

Benign Anorectal Strictures

Congenital

Anal contracture or stenosis in infancy may result from failure of disintegration of the anal plate in fetal life. The narrowing is treated by careful repeated dilatation, inserting progressively larger Hegar dilators until the anus admits first the little and then the index finger.

Traumatic

Acquired stenosis is usually the result of surgery or trauma which denudes the epithelium of the anal canal. Haemorrhoid operations in which too much skin is removed or which are followed by infection are the commonest cause. Constipation, ribbon stools, and pain on defecation are the most frequent complaints. Stenosis predisposes to fissure, low grade infection, and occasionally fistula.

Prevention of stenosis after radical anal surgery is best accomplished by local cleanliness, hot sitz baths, and gentle insertion of the well lubricated finger twice weekly for 2-3 weeks beginning 2 weeks after surgery. When stenosis is chronic but mild, graduated anal dilators of increasing size may be inserted daily by the patient. For marked stenosis a plastic operation on the anal canal is advisable.

Inflammatory

A. Lymphogranuloma Venereum: This infectious disease is the commonest cause of inflammatory stricture of the anorectal region. Acute proctitis due to lymphatic spread of the organism occurs early, and may be followed by perirectal infections, sinuses, and formation of scar tissue (resulting in stricture). Frei and complement fixation tests are positive.

The tetracycline drugs are curative in the initial phase of the disease. When extensive chronic secondary infection is present or when a stricture, has formed, repeated biopsies are essential because epidermoid carcinoma develops in about 4 per cent of strictures. Local operation on a stricture may be feasible, but a colostomy or an abdominoperineal resection is often required.

B. Granuloma Inguinale: This disease may cause anorectal fistulas, infections, and strictures. The Donovan body is best identified in tissue biopsy when there is rectal involvement. Epidermoid carcinoma develops in about 4 per cent of cases with chronic anorectal granuloma. The early lesions respond to tetracyclines. Destructive or constricting processes may require colostomy or resection.

Anal Incontinence

Obstetric tears, anorectal operations (particularly fistulotomy), and neurologic disturbances are the most frequent causes of anal incontinence. When incontinence is due to surgery or trauma, surgical repair of the divided or torn sphincter is indicated. Repair of anterior laceration due to childbirth should be delayed for 6 months or more after parturition.

Squamous Cell Carcinoma of The Anus

These tumors are relatively rare, comprising only 1-2 per cent of all malignancies of the anus and large intestine. Bleeding, pain, and local tumor are the commonest symptoms. Because the lesion is often confused with hemorrhoids or other common anal disorders, immediate biopsy of any suspicious lesion or mass in the anal area is essential. These tumors tend to become annular, invade the sphincter, and spread upward into the rectum.

Except for very small lesions (which can be adequately excised locally), treatment is by combined abdominoperineal resection. Radiation therapy is reserved for palliation and for patients who refuse or cannot withstand operation. Metastases to the inguinal nodes are treated by radical groin dissection when clinically evident. The 5-year survival rate after resection is about 50 per cent.

Longevity Facts

A study published in the Journal of the American Medical Association reports that among 2,339 men and women over age 70 who were followed for a period of 12 years, those who ate a Mediterranean diet and adhered to a healthy lifestyle (regular exercise, not smoking, and moderate alcohol intake) had a more than 50 per cent lower death rate.

A Mediterranean diet is high in fiber and low in fat and features legumes, nuts, whole grains, fish, olive or canola oil, and plenty of fruits and vegetables.

A recent study suggests people with type 2 diabetes should be certain they are taking excellent care of their teeth and gums.

According to a study published in the journal Diabetes Care on the effects of periodontal disease on mortality, people with severe periodontal disease had more than three times the risk of dying of cardiac or renal disease.

The American Heart Association recommends that people with hypertension regularly monitor their blood pressure at home.

Home readings can help control for both white-coat hypertension (nor-mal blood pressure that spikes only in the doctor's office) as well as cases where people with hyper-tension have a normal blood pressure reading in the doctor's office.

People should monitor the effectiveness of their blood pressure medication and know if other medications, such as corticosteroids or over-the-counter decongestants, cause their blood pressure to rise.

Home monitoring devices are easy to use and widely available for under $100. Generally, the electronic models that use an arm cuff are more accurate than those that use a wrist cuff.

Source : Adopted From the writings of Rowe RJ.

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