Rectal Disorders Victor Politi, M.D., FACP, FACEP Medical Director, St. John’s University, School of Allied Health Physician Assistant Program

Anatomy The rectum is the lower 10 to 15 cm of the large intestine. The anatomic anal canal is the outlet of the digestive system. It is a tube about 3.8 cm long running from the perianal skin of the buttocks to the mucosal lining of the rectum.

Anatomy Its external opening is the anus, which is tightly shut except during stool evacuation by two strong but sensitive rings of muscles: the internal sphincter and external sphincter.

Anatomy The sphincters are well supplied with blood vessels and nerves. Where the anal canal meets the rectum there is a ring of folds called the dentate line. Among these folds are the anal crypts, small tube-like depressions opening into the anal canal.

Anatomy The dentate line delineates where nerve fibers end. Above this line, this area is relatively insensitive to pain. Below the dentate line, the anal canal and anus are extremely sensitive.

Hemorrhoids Hemorrhoids are dilated, twisted (varicose) veins located in the wall of the rectum and anus.

Hemorrhoids occur when the veins in the rectum or anus become enlarged; they may eventually bleed. Hemorrhoids may also become inflamed or may develop a blood clot (thrombus).

Hemorrhoids that form above the boundary between the rectum and anus (anorectal junction) are called internal hemorrhoids. Those that form below the anorectal junction are called external hemorrhoids. Both internal and external hemorrhoids may remain in the anus or protrude outside the anus.

Hemorrhoids Cushions of vascular tissue found within the anal canal - when examined microscopically, lack a muscular wall The lack of muscular wall characterizes these vascular structures more as sinusoids and not veins

Etiology Most common cause - constipation Prolonged straining Pregnancy Heredity Increased intra-abdominal pressure Aging (due to thinning of supportive tissue)

The Liver and Hemorrhoids Look at the venous return for the external and internal hemorrhoidal veins External - systemic Internal - portal

Internal / External Hemorrhoid

Generalized Symptoms Bleeding on stool or in toilet Mucosal protrusion Discharge Soiled underwear - due to internal Sensation of incomplete evacuation

Prolapsed Hemorrhoid

Symptoms - external hemorrhoids External hemorrhoids, because they lie under the skin are usually very painful Result in tender blue swelling at the anal verge due to thrombosis of a vein in the external plexus - need not be associated with enlargement of the internal veins Spasm often occurs since the thrombus usually lies at the level of the sphincteric muscles

Diagnosis The diagnosis of internal or external hemorrhoids is made by inspection digital exam direct vision through the anoscope & proctosocpe

Diagnosis Exam- Prone, jack-knife position or lateral Sim’s position Location of the hemorrhoids should be described according to their anatomic position Visual inspection DRE- digital rectal exam

Treatment Most hemorrhoids respond to conservative therapy such as sitz baths or other forms of moist heat, suppositories, stool softeners, and bed rest

Medical Therapy Stool bulking agent Sitz baths Psyllium Methylcellulose Sitz baths probably most effective topical treatment for relief of symptoms

Surgical Therapy Operative hemorrhoidectomy Indicated for patients with symptomatic combined internal and external hemorrhoids

Anal Inflammation Perianal inflammatory lesions may be primary or may be associated with inflammatory bowel disease or diverticular disease Anal fissures are superficial erosions of the anal canal which usually heal rapidly with conservative therapy

Anal Inflammation Anal ulcers are more chronic and deep and give symptoms largely as the result of painful spasm of the external anal sphincter during and after defecation Bleeding may occur with either fissure or ulcer

Medical Treatment Fiber Water Sitz bath

Anal Itching Itchy skin around the anus (pruritus ani) can have many causes, including skin disorders such as psoriasis and atopic dermatitis, diseases such as diabetes or liver disease, anal disorders such as skin tags or draining fistulas, and cancers

Anorectal Abscess An anorectal abscess is a pus-filled cavity caused by bacteria invading a mucus-secreting gland in the anus and rectum

Anorectal Abscess An abscess may be deep in the rectum or close to the opening of the anus. An abscess develops when bacteria invade a mucus-secreting gland in the anus or rectum, where they multiply

Anorectal Abscess If an abscess is in the skin around the anus it can be directly visualized. When no external swelling or redness is seen, diagnosis is made by DRE. A tender swelling in the rectum indicates an abscess.

Anorectal Abscess Antibiotics have limited value except for people who have a fever, diabetes, or an infection elsewhere in the body. Usually, treatment consists of if I/D after a local anesthetic has been given.

Anal Cancer Anal cancers occur most commonly in individuals with a prior history of chronic anal irritation. Such irritation may result from condylomata acuminata (ie, viral lesions thought to be caused by papilloma virus infection), perianal fissures and/or fistulas, chronic hemorrhoids, and leukoplakia

Anal Cancer Occurs most commonly in middle aged individuals Develops more frequently in women than men Most often associated with bleeding,pain, the sensation of a perianal mass, and perianal pruritus at the time of diagnosis

Anal Cancer Increased risk - homosexual males, presumably due to trauma from anal intercourse No data to indicate that anal cancers are AIDS-related tumors associated with infection by the human immunodeficiency virus

Anal Cancer Until recently, radical surgery was tx of choice with poor result Now, alternative therapeutic approach combining external beam radiation with concomitant chemotherapy has resulted in biopsy-proven disappearance of all tumor in more than 80% of patients whose initial lesion was less than 5cm in size More than 80% of patients with anal cancers can be cured with nonoperative treatment

Proctitis Proctitis is inflammation of the lining of the rectum (rectal mucosa).

Proctitis Proctitis has several causes. Crohn's disease or ulcerative colitis. STD’s (gonorrhea, syphilis, Chlamydia trachomatis infection, herpes simplex virus infection, or cytomegalovirus infection). May also be caused by bacteria not transmitted sexually, such as Salmonella. Antibiotics that destroy normal intestinal bacteria. Radiation therapy directed at or near the rectum, which is commonly used to treat prostate and rectal cancer.

Proctitis Proctitis typically causes painless bleeding or the passage of mucus from the rectum. When the cause is gonorrhea, herpes simplex virus, or cytomegalovirus, the anus and rectum may be intensely painful.

Proctitis Antibiotics are the best treatment for Proctitis caused by a specific bacterial infection. Metronidazole (Flagyl) or vancomycin (Vancocin) when proctitis is caused by use of an antibiotic that destroys normal intestinal bacteria

Pilonidal Disease Pilonidal disease is an infection caused by a hair that injures the skin at the top of the cleft between the buttocks. A pilonidal abscess is a collection of pus at the infection site; a pilonidal sinus is a chronic draining wound at the site.

Pilonidal Disease To distinguish pilonidal disease from other infections, look for pits—tiny holes in or next to the infected area. Treatment for a pilonidal abscess consists of I/D. Usually, a pilonidal sinus must be removed surgically.

Rectal Prolapse Rectal prolapse is protrusion of the rectum through the anus.

Rectal Prolapse Rectal prolapse causes the rectum to turn inside out, so that the rectal lining is visible as a dark red, moist fingerlike projection from the anus. Less commonly, the rectum protrudes into the vagina

Rectal Prolapse A temporary prolapse of only the rectal lining (mucosa) often occurs in otherwise healthy infants, probably when the infant strains during a bowel movement, and is rarely serious.

Rectal Prolapse In infants and children, a stool softener eliminates the urge to strain. Strapping the buttocks together between bowel movements usually helps the prolapse heal on its own.

Rectal Prolapse In adults, surgery is usually needed to correct the problem. During one kind of abdominal operation, the entire rectum is lifted, pulled back, and attached to the sacral bone in the pelvis. In another, a segment of the rectum is removed, and the remainder of the rectum is stitched to the sacral bone.

Fecal Incontinence Fecal incontinence is the accidental loss of stool. Causes of fecal incontinence in adults include back trauma, sphincter disruption as a result of accidents, anorectal surgery, or obstetrical trauma, and medical illness such as multiple sclerosis and diabetes mellitus. Many women have suffered nerve or muscle injury to the anal sphincter caused by forceps-assisted delivery, prolonged second stage of labor, or delivery of large baby, and this can contribute to fecal incontinence.

Fecal Incontinence Treatments for incontinence include dietary modification, medicines, biofeedback, and surgery. Avoidance of foods that promote production of gas, and foods containing ingredients such as lactose, fructose, and sorbitol.

Foreign Objects Swallowed objects, such as toothpicks, chicken bones, or fish bones, may become lodged at the junction between the rectum and anus. Also, enema tips, thermometers, and objects used for sexual stimulation may become lodged unintentionally in the rectum after being passed through the anus.

Foreign Objects If the object can be felt, a local anesthetic is usually injected under the skin and lining of the anus to numb the area. The anus can then be spread wider with a rectal retractor, and the object can be grasped and removed. Natural movements of the wall of the large intestine (peristalsis) generally bring higher foreign objects down, making removal possible.

Foreign Objects If the object cannot be felt or cannot be removed through the anus, exploratory surgery is needed. The patient is given a regional or general anesthetic so that the object can be gently moved toward the anus or so that the rectum can be cut open to remove the object. After the object is removed, the doctor performs a sigmoidoscopy to determine whether the rectum has been perforated.

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