Hemorrhoids and Anal Fissures

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

Hemorrhoidal disease should be reserved for abnormalities and symptoms

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

Supplies sensory information to discriminate between solid, liquid, and gas

Vascular Supply

Bleeding from disrupted presinusoidal arterioles that communicate with sinusoids in the region

Bright red Arterial pH

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

Three main cushions

Left lateral Right anterior Right posterior

Additional smaller accessory cushions in between main cushions

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

Patients usually have increased anal resting pressures

Return to normal after hemorrhoidectomy

Sliding downward of anal lining Repeated stretching of anal supporting tissues causes fragmentation and prolapse of cushions Straining and irregular bowel habits may engorge cushions making displacement more likely

Sliding anal cushion theory

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

Internal Hemorrhoid Classification

First degree Second degree Third degree Fourth degree

Finding

Bulge into lumen +/- painless bleeding

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

Permanently prolapsed and irreducible

Symptom s

Painless bleeding

Irreducible mass

Signs

Bright red bleeding Bleeds at end of BM Drips or squirts May be occult

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

External tags may be the result of prior thrombosis

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

Prolapse can manifest as mass, mucous discharge, or tenesmus

Treatment Dietary and Lifestyle Modification

Main goal is to minimize straining at stool

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

Treatment Nonoperative/Office Procedures

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

Treatment Nonoperative/Office Procedures

Rubber band ligation

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

Treatment Nonoperative/Office Procedures

Infrared photocoagulation, Bipolar Diathermy, DirectCurrent Electrotherapy

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

Treatment Nonoperative/Office Procedures

External hemorrhoids

Acute thrombosis Excision of entire thrombus under local anesthesia Conservative management if pain is resolving

Treatment Operative Hemorrhoidectomy

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.

And Crohns disease

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

And the Immunocompromised

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

Sustained resting hypertonia

Ischemia from decreased perfusion in the posterior midline

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

Lateral Internal Sphincterotomy

Advancement Flaps

Medical Management

Sphincter relaxants--Chemical sphincterotomy

Nitrate formulas

NTG, GTN, ISDN Predominant nonadrenergic, noncholinergic neurotransmitter

As effective as nitrates without the headache Lack of efficacy in studies Bethanechol

Oral and topical calcium channel blockers

Adrenergic antagonists

Topical muscarinic agonists

Phophodiesterase inhibitors Botulinum toxin

Low Pressure Fissures

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