Haemorrhoids

Essentials of diagnosis Rectal bleeding, protrusion, discomfort Mucoid discharge from rectum Secondary anaemia Characteristic findings on anal inspection and anuscopic examination

THE PROBLEM Nobody 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 – bleeding Grade 2 – prolaps with spontaneous reduction Grade 3 – prolaps that needs digital replacement Grade 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 RECTUM How 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 explain Severe iron deficiency anaemia Ischaemic cardiac disease due to low levels of oxygen transporter

MALPRAXIS = patients life and your money NEVER NEVER treat haemorrhoidal disease without clinical and digital examination of the rectum MALPRAXIS = patients life and your money

PRURITUS ANI Frequently associated with haemorrhoids Minute incontinence with local irritation of the skin Aggressive local cleaning may produce small lesions that will generate pruritus Tags Local edema

PAIN External thrombosed haemorrhoids Internal thrombosed haemorrhoids Round blue lesions (perianal haematoma) with significant edema and very tender Internal thrombosed haemorrhoids Pain is less severe Major pain in cases of strangulated prolaps of haemorrhoids

 EXAMINATION Speaking with the patient will create trust Offer an intimate room 

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

RECTOSCOPY ANUSCOPY 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 tonus Ginko 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 necrosis Detachment of necrotic area Scar 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 ELECTROCOAGULATION Criotherapt 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

RESULTS Very good Dependeing on the tpe of hemorrhoids and clnical signs Rational choice of therapy Better in the hands of a proffesional

FISSURA IN ANO ANAL 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 ELEMENTS Ulcer Hypertrophic pappila Sentinel tag

Clinical findings Symptoms and signs: Painful bowel movement associated with bright red bleeding Pain severe: after movement and sensation is described like burning Constipation

Clinical examination With anaesthesia Rectal: Tag Ulcer – in the middle Pappila Increased tonus Sigmoidoscopy should be deffered

Differential diagnosis Other ulcers: Syphilis Carcinoma TBC Granulomatous enetritis with ulcers NOT TYPICAL Biopsy Association with haemorrhoids

TREATMENT Medical: Surgical: Softening of the stool Topical cream with myorelaxant Hot bath Flavonoids Surgical: Lateral internal shpyncterotomy Anal 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 ani Ischiorectal – ischiorectal fossa Retrorectal Submucous Marginal – in the anal canal beneath the anoderm Pelvirectal Intermuscular

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 drainage Do not wait for the abscess to point externally Fistulotomy 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 signs Purulent drainage and discharge Palpation - cordlike tract in relation with the spincter Probe Rectal examination + rectoscopy – the internal opening

Exploration Contrast fistulography MRI Anatomy of the fistula for surgical excision Mostly in complex fistulas

Differential diagnosis Hidradenitis suppurativa Pilonidal sinus Granulomatous disease – Crohn Infected lesions (comedomes, sebaceous cyst, foliculitis, bartholinitis) Retrorectal dermooid tumor Coloperineal fistula Postraumatic sinuses or foreign body Etc.

Complications Recurrent abscess formation Generalized sepsis Carcinoma in a chronic untreated fistula is possible

Treatment SURGICAL Operations for fistula Primary opening must be found end excised Complete identification of the tract The tract must be unroofed on the entire length – open wound Careful 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: Chronic disease: Drainage Excision of all damaged tissue Cystotomy to excision

Malignant tumors of the anal canal

Epidermoid carcinoma 75% of all malignancies of the area Early: verucous, nodular lesion Late: ulcerated, indurated, nodular nmass Palpable inguinal nodes May invade the rectum: false imprssion of rectal carcinoma Lymphatic 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 disease carcinoma 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 condition Pale plaquelike condition with induration + nodular mass (not always) Nodular mass= coloid carcinoma from glands or other skin appendages Local excision (without mass) Radical surgery + chemo + RT for coloid carcinoma