Hemorrhoids Course Materials

Hemorrhoids Prolapse of the submucosal veins located in the RT anal canal Can be classified Internal - Covered by Columnar mucosa Above dentate line Has 4 degrees (see below) External - Covered by Anoderm below dentate line Mostly asymptomatic unless thrombosed male = female RFs Constipation > pregnancy > ↑ pelvic pressure (ascites, tumor) > Portal HTN General SxS: bleeding, anal mass & prolapse, itching, pain Grades of internal Hemorrhoids I prolapse into lumen, No prolapse Bleeding non palpable mass II Prolapse with straining - Spontaneous return Bleeding III Prolapse requiring manual reduction Bleeding, prolapse Mucus discharge Partial some may need excision IV Prolapse Cannot be reduced Pain Excision Q External hemorrhoids Usually asymptomatic unless thrombosed with severe pain (Severe pain in young pt, associated with bluish lump at the anal orifice in 1st week) * If it was acute <48-72h * Surgical excision of thrombosed hemorrhoid * under local anesthesia * If it was chronic >48-72h * conservative treatment Diagnosis: Hx, physical examination (PR), Anoscopy (proctoscopy, flexible sigmoidoscopy) In Case of Bleeding -> Do Endoscopic evaluation with Complete Colonoscopy -> to rule out Colorectal cancer or other causes of bleeding like IBD, Colitis, Diverticular disease and angiodysplasia Management options Diet + lifestyle modification non operative office procedures hemorrhoidectomy 2-3y Indications Correct Constipation ↑ fiber diet ↑ water intake sitz bath=warm water Topical Cream salt 3 times day Rubber band ligation schlerotherapy Pain less than 40-72 h Failed office treatment Med hyp External with thrombosis & pain Persistent bleeding Incarceration Contraindication Chronic Disease Surgery close (Ferguson) mucosa with suture fles removal of hemorrhoidal tissue open (milligan-morgan) leave mucosa open Complications of Surgery Pelvic infections anal stricture Exsanguination (Bleeding may pool proximally in the lumen colon without any sign of external bleeding) Injury to sphincter -> incontinence Anal Fissure Painful linear tear in the anal mucosa below dentate line Due to Constipation or excessive diarrhea or hyperactive sphincter or disease ALC in posterior midline Signs and symptoms Severe pain Bright red blood on toilet tissue (no huff) Extreme pain on digital examination, markedly ↑ sphincter tone (anal spasm) Visible fissure upon gentle lateral retraction of anal tissue. Chronic fissures * Hypertrophy of anal papilla * Sentinel pile (thickened mucosa/skin at the distal end of an anal fissure that can be confused with small hemorrhoid) *Note: in chronic fissure exclude Crohn's, UC, anal cancer, STD, AIDS Diagnosis: Hx & examination Treatment: Acute (<6 w) * Pain Control - sitz bath - ↑ fibers - ↑ fluid * Other options -> topical nitroglycerin (anesthetic) -> topical Diltiazem -> Botulinum toxin Chronic or failed treatment -> lateral internal sphincterotomy (Relax sphincter by opening internal part) Complications: Incontinence of flatus or fecal soiling - liquid stool in clothes Anorectal Abscess obstruction of anal crypt with resultant bacterial growth and abscess formation within intersphincteric space Can be: perianal ischiorectal supralevator post anal space Risk factors: constipation/diarrhea/IBD Immunocompromised Hx of recent surgery or trauma Hx of colorectal carcinoma Hx of previous anorectal abscess Signs & symptoms: Pain Mass (in rectal exam) Perianal swelling, erythema, warmth of overlying skin Systemic symptoms: Fever, chills, leukocytosis Diagnosis: CBC, leukocytosis H&E examination Treatment: Surgical drainage +/- antibiotic in DM, immunocompromised, cellulitis, heart value abnormalities Note: 50% will develop fistula after drainage -> intersphincteric fistula Anorectal Fistula → communication between 2 epithelium Tissue tract (abnormal connection between 2 areas) originating in glands of anal canal at dentate line usually due to chronic sequale of Anorectal infection (Abscess) Classifications Inter sphincteric MC fistula tract stays within intersphereric plane Trans sphincteric connects intersphereric plane with ischiorectal space by perforating external sphincter Supra sphincteric similar to trans sphincteric but fistula loops Above the external sphincter to penetrate the levator ani muscle Extra sphincteric fistula passing from rectum to perineal skin without penetrating sphincter complex Goodsall's rule To predict the course of anorectal fistula Anterior to Transverse imaginary line → Direct (straight tract) Posterior to Transverse imaginary line → Curved tract → any fistula diverged from this rule ↑ suspicion of IBD Chrons Signs & symptoms Recurrent or persistent perianal drainage Discharge painful if it become occluded Abscess Opening in perineal skin Diagnosis Bidegital rectal exam to see the tract MRI Injecting a mixture of methylene blue and peroxide into tract Treatment fistulotomy (excision by probe under anesthesia and percuide into tract) seton (thick suture placed in fistula to stimulate fibrosis and keep tract open for drainage) flap advancement (suture to occlude and stimulate fibrosis) marsupialization of fistula Pilonidal Disease cystic inflammatory process generally occurring at or near cranial edge of Gluteal Cleft or buttocks as result from trauma to hair follicles in gluteal region with resultant infection MC in young men (back hair's 3rd decade) SxS abscess (fluctuant mass) or chronically draining sinus with pain treatment Incision & drain + Removal of involved hair Pruritus Ani Discomfort and itching in the area around anus. predisposing factors personal hygiene (Related to incontinence, diarrhea, excessive hair) hemorrhoid, fistula, fissure resistance to infection injury to perianal skin Risk factor is Skin Cancer evaluation: Rule out anal cancer!! Hx & examination Inspection: mass, ulcers Digital rectal examination anoscope and proctoscope Treatment: Dry area - Avoid trauma - Avoid cream hydrocortisol cream - antifungal treatment Biopsy (in certain situations)