DIAGNOSIS AND MANAGEMENT OF BENIGN ANORECTAL DISORDERS

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DIAGNOSIS AND MANAGEMENT OF BENIGN ANORECTAL
DISORDERS

• Dennis Begos, MD

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Common Anorectal DisordersSYMPTOMS AND SIGNS

• Symptoms
• Pain
• Bleeding
• Protrusion
• Seepage Soilage
• Itching
• Change in BM

• Signs
• Tenderness
• Fluctuance
• Erythema
• Mass

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Common Anorectal DisordersSYMPTOMS

• Pain
• Sharp / dull / burning
• Associated with bowel movements
• Constant / intermittent
• Associated with activity
• Associated with bleeding

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Common Anorectal DisordersSYMPTOMS

• Bleeding
• Bright / dark
• Black, tarry stools
• Associated with bowel movements
• Associated with pain

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Common Anorectal DisordersEVALUATION

• Patient reluctance
• Fear of pain
• Fear of cancer
• Embarrassment
• Physician responsibility
• Place the patient at ease
• Dont hurt the patient
• Accurate diagnosis

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Common Anorectal DisordersEVALUATION

• Patients (and most PCPs) lack of knowledge of
  the anorectal region results in every symptom
  being attributable to hemorrhoids
• Exclusion of a proximal malignancy should be
  considered

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Common Anorectal DisordersSPECIFIC DISORDERS

• Hemorrhoids
• Anal Fissure
• Fistula abscess
• Condyloma
• Rectal Prolapse

• Fecal incontinence
• Pilonidal disease
• Hidradenitis suppurativa
• Pruritus ani
• Anal neoplasms

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Hemorrhoids
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Common Anorectal DisordersHEMORRHOIDS Anatomy

• External hemorrhoids
• Distal to the dentate line
• Squamous epithelium(skin)
• Nerve endings
• Internal hemorrhoids
• Proximal to the dentate line
• Columnar epithelium(mucosa)
• No nerve endings

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Common Anorectal DisordersHEMORRHOIDS Prevalence

• 4.4 of US populations seen by physician for
  symptomatic hemorrhoids
• 49/100k US population undergo hemorrhoidectomy
  annually

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Common Anorectal DisordersHEMORRHOIDS Function

• Aid in continence
• Act as a cushion
• Protect sphincters/anus from the trauma of
  defecation

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Common Anorectal DisordersHEMORRHOIDS Symptoms

• Internal
• Bleeding
• Protrusion
• Seepage/soilage
• Staining
• Pruritus
• Rarely painful

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Common Anorectal DisordersINTERNAL
HEMORRHOIDSIndications for Therapy

• conservative measures
• Increase fluids
• Fiber supplements
• Stool softeners
• Topical agents
• bowel habits

• Continued symptoms
• Bleeding
• Protrusion
• Pruritus/irritation
• Pain
• Seepage and soilage
• Difficulty with hygiene

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Common Anorectal DisordersINTERNAL
HEMORRHOIDSManagement

• Office based procedures
• Rubber band ligation(RBL)
• Injection sclerotherapy
• Infrared coagulation

• Surgical procedures
• Excisional hemorrhoidectomy
• PPH
• Sonographic ligator

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Rubber Band Ligation

• Indications
• 1 2, some 3
• Ligator applies two bands to the base of the
  hemorrhoid

• Complications
• Pain
• Bleeding
• Pelvic sepsis
• Recurrence

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Quicker Recovery

Source Stapled vs. Excision Hemorrhoidectomy,
Long-term Results of a Prospective Randomized
Trial, Hetzer N, Demartines N, Handschin AE,
2002, Archives of Surgery.
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Doppler Artery Ligation

• Doppler anoscope
• Ligate individual hemorrhoidal arteries
• Minimal pain
• Early results promising

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Doppler Artery Ligation

• Further studies needed
• Compare PPH, DHAL
• Long term results

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Spectrum of disease Spectrum of treatment

• Balance effectiveness/pain/complications

Excision
? DHAL
pain
PPH
RBL
effectiveness
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Common Anorectal DisordersThrombosed External
Hemorrhoids

• Rx depends on symptoms
• Excision
• Thrombectomy
• I D
• Observation

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Anal Fissure
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Common Anorectal DisordersANAL FISSURE Anatomy

• Females
• 90 posterior
• 10 anterior
• Males
• 99 posterior
• 1 anterior
• Distal to dentate line

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Common Anorectal DisordersANAL FISSURE Etiology

• Trauma
• Large hard stool
• Diarrhea
• Hypertonic/hyperspastic internal sphincter
• Diminished blood flow/Ischemia
• Probable combination of all

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Common Anorectal DisordersANAL FISSURE Symptoms

• pain with BM
• bleeding

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Common Anorectal DisordersANAL FISSUREManagement

• Conservative
• Topical
• nitro
• diltiazem
• nifedipine

• Lateral internal sphincterotomy
• Anoplasty
• Botox injection

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Fistula/Abscess
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Common Anorectal DisordersANORECTAL SUPPURATION
Etiology

• Cryptoglandular
• Carcinoma
• Crohns disease
• Foreign body
• Trauma
• Surgery

• Radiation
• Tuberculosis
• Actinomycosis
• LGV

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Common Anorectal DisordersANORECTAL SUPPURATION

• Abscess
• Perianal 20
• Intersphincteric 18
• Ischiorectal 60
• Supralevator 2

• Fistula
• Intersphincteric 70
• Transphincteric 23
• suprasphincteric 5
• Extrasphincteric 2

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Common Anorectal DisordersANORECTAL SUPPURATION
Management

• Abscess
• Drainage
• avoid packing
• Antibiotics
• Sepsis
• Cellulitis
• Immunosuppression
• Prostheses

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Common Anorectal DisordersANORECTAL SUPPURATION
Management

• Fistula
• Fistulotomy
• Seton
• Staged fistulotomy
• Mucosal advancement flap
• Fibrin glue
• Plug

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Rectal Prolapse
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Common Anorectal DisordersRectal Prolapse
Treatment

• Abdominal repair
• Rectal fixation
• LAR
• Combination of rectal fixation and sigmoid
  resection

• Perineal repair
• Full thickness resection
• Mucosal resection with muscular reefing