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9/1/2010
Hemorrhoids
Cushions of specialized, highly vascular tissue in anal canal in the submucosal space
Thickened submucosa contains blood vessels, elastic tissue, connective tissue, and smooth muscle
Anal submucosal smooth muscle (Treitzs muscle) pass through internal sphincter and anchor to submucosa, contributing to bulk of hemorrhoid and suspending vascular cushions
Lack of muscular wall on some structures classifies more as sinusoids and not veins
Function
Contribute to anal continence Compressible lining that protects underlying sphincters Provide complete closure of the anus
Cushions engorge and prevent leakage with increasing intrarectal pressure Account for 15-20% of anal resting pressure
Vascular Supply
Bleeding from disrupted presinusoidal arterioles that communicate with sinusoids in the region
External plexus drains via inferior rectal veins into pudendal veins into internal iliacs Also through middle rectal veins to internal iliacs Internal hemorrhoid plexus drains through middle rectal into internal iliacs
Configurations
Etiology
Constipation Prolonged straining Irregular bowel habits Diarrhea Pregnancy Heredity Erect posture
Absence of valves within the hemorrhoidal sinusoids Increased intraabdominal pressure with obstruction of venous return Aging Interior sphincter abnormalities
Etiology
Increased AV communications, vascular hyperplasia, increased neovascularization with increased CD105 immunoactivity
Epidemiology
4.4% in the US Peak between 45-65 yoa Increased in Caucasians and higher socioeconomic status
Classification
External
Internal
Distal 1/3 of anal canal Distal to dentate line Covered by anoderm or by skin Somatically innervated Sensitive to touch, pain, stretch, and temp
Proximal to dentate line Covered by columnar or transitional epithelium Not sensitive to touch, pain, temperature Subclassified into degrees based on size and symptoms
Finding
Protrude with BM Reduce spontaneously Anal mass w/defecation Anal burning or pruritis
Prolapse with defecation
Protrude spontaneously Require manual reduction Tenesmus Mucous leakage Difficulty cleaning
Reduce manually Perianal stool or mucous Anemia rare
Symptom s
Painless bleeding
Irreducible mass
Signs
Always prolapsed
Symptoms
Presence, quantity, frequency, and timing of bleeding and prolapse May complain of bleeding, mucosal protrusion, pain, mucus, discharge, difficulties with perianal hygiene, sensation of incomplete evacuation, cosmetic deformity External complaints are usually due to thrombosis associated with acute pain
Can bleed secondary to pressure necrosis and ulceration May interfere with anal hygiene and burn or itch
Symptoms
Internal hemorrhoids are painless unless thrombosed, strangulated, gangrenous, or prolapsed with edema
Bleeding is bright red and associated with BMs at the end of defecation Blood may drip or squirt into the toilet or be seen on the toilet tissue
Increase fluid and fiber (20-35 g/day) Adding supplemental fiber (psyllium)
Compliance improved by starting at lower doses and slowly increasing until stool consistency is good Stop reading on commode Must rule out proximal source of bleeding
Medical therapy
Most effective topical treatment is warm (40) sitz baths Ice packs may also relieve symptoms Bioflavinoids (widely used in Europe) are thought to work by increasing venous tone and strengthening the walls of blood vessels Creams, ointments, foams, and suppositories have little rationale in treatment Prolonged use may cause local allergic effects or sensitization of the skin
Can be used for first-, second-, and third-degree hemorrhoids Rubber band is placed on redundant mucosa Minimum of 2 cm above dentate line Causes strangulation of blood supply Sloughs in 5-7 days Leaves small ulcer that heals and fixes tissue to underlying sphincter Anesthesia not required May have pressure or feeling of incomplete evacuation Contraindicated in patients on coumadin or heparin Complications: pain, thrombosis, bleeding, life-threatening perineal or pelvic sepsis, abscess, band slippage, priapism, urinary dysfunction
Rely on coagulation, obliteration, and scarring which leads to fixation Works best with small, bleeding, first- and second-degree hemorrhoids Less pain
Injection of chemical agents into submucosa that create fibrosis, scarring, shrinkage and fixation No anesthesia needed First- and second-degree hemorrhoids
Sclerotherapy
External hemorrhoids
Acute thrombosis Excision of entire thrombus under local anesthesia Conservative management if pain is resolving
Indicated in patients with symptomatic combined internal and external hemorrhoids who have failed or are not candidates for nonoperative treatments Multiple techniques (open, closed, stapled excision) show similar rates of pain, complications, and recurrence Complications: urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.55.5%), and incontinence (2-12%) Serious complications with stapled hemorrhoidopexy include rectal perforation, retroperitoneal sepsis, and pelvic sepsis
Strangulated Hemorrhoids
From prolapsed third- or fourth-degree hemorrhoids that become incarcerated and irreducible due to prolonged swelling May present with pain and urinary retention Treatment is urgent or emergent hemorrhoidectomy in the OR Open or closed technique
Hemorrhoids.
In portal hypertension
Must be distinguished from anorectal varices Rarely bleed but if do, can be massive Direct suture ligation, stapled anopexy, TIPS, ligation of IMV, inf mesocaval shunt, inf mesorenal vein shunt, sigmoid venous to ovarian vein shunt Majority that intensify during delivery usually resolve Hemorrhoidectomy reserved for acutely thrombosed and prolapsed disease Should be under local in left anterolateral position
In pregnancy
Hemorrhoids.
Rate of severe complications is high (30%) and patient selection is paramount Challenging due to poor wound healing and infectious complications Does not increase mortality with hematologic malignancies but should be performed as a last resort for pain and sepsis Stapled hemorrhoidopexy may offer alternative, avoiding external wounds
Anal Fissure
Oval, ulcer-like, longitudinal tear in the anal canal Distal to the dentate line 90% in the posterior midline 25% anterior midline in women, 8% in men 3% have anterior and posterior fissures Lateral positions should raise concern for other disease processesCrohns, TB, syphilis, HIV/AIDS, or anal ca Early (acute) fissures appear as a simple tear in the anoderm Chronic fissures (symptoms more than 8-12 wks) have edema and fibrosis Sentinel pile distally, hypertrophied anal papillae proximally May be able to see fibers of the internal sphincter
Etiology
Trauma due to passage of a hard stool History of constipation or diarrhea Associated with increased resting pressures
Symptoms
Hallmark is pain during, and particularly after, a BM May be short-lived or last hours or all day Described as passing razor blades or glass shards May often fear BMs Bleeding usually limited to bright red blood on the tissue
Diagnosis
Confirmed by physical exam May be noted on initial inspection Most may be too tender to tolerated digital rectal exam or anoscopy Frequently misdiagnosed as hemorrhoids by PCPs Lateral fissures may require EUA and biopsy/cultures
Conservative Management
Almost half will heal Sitz baths Fiber supplement +/- topical anesthetics or anti-inflammatory ointments
Operative Treatment
Primary goal is to decrease abnormally high resting anal tone Anal Dilatation
93-94% healing with few complications Long term outcomes sparse Incontinence can occur in around 12-27% Keyhole deformity if done in posterior midline Incontinence rates up to 36% but vary widely Open or closed technique No significant difference in healing rates
Advancement Flaps
Medical Management
Nitrate formulas
Adrenergic antagonists
Not candidates for sphincterotomy Impaired continence and fissure recurrence after sphincterotomy Island advancement flap
Crohns
20-30% incidence 60% may heal with medical management Initial treatment should control diarrhea Limited sphincterotomy can be performed Anal dilatation has been reported with some success
HIV
Necessary to differentiate between HIV-associated ulcers Better results with sphincterotomy, especially with antiretrovirals