Hemorrhoids and Anal Fissures 9/1/2010 Hemorrhoids Cushions of

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 (Treitz’s 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 anal cushion theory” 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 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 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 Internal 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

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 External tags may be the result of prior thrombosis 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 BM’s 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, Direct-Current Electrotherapy Rely on coagulation, obliteration, and scarring which leads to fixation Works best with small, bleeding, first- and second-degree hemorrhoids Less pain Sclerotherapy Injection of chemical agents into submucosa that create fibrosis, scarring, shrinkage and fixation No anesthesia needed First- and second-degree hemorrhoids

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 (0.5-5.5%), 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 In pregnancy Majority that intensify during delivery usually resolve Hemorrhoidectomy reserved for acutely thrombosed and prolapsed disease Should be under local in left anterolateral position

Hemorrhoids…. And Crohn’s disease Rate of severe complications is high (30%) and patient selection is paramount And the Immunocompromised 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 processes—Crohn’s, 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 BM’s 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 PCP’s 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% Lateral Internal Sphincterotomy Keyhole deformity if done in posterior midline Incontinence rates up to 36% but vary widely Open or closed technique Advancement Flaps No significant difference in healing rates

Medical Management Sphincter relaxants--“Chemical sphincterotomy” Nitrate formulas NTG, GTN, ISDN Predominant nonadrenergic, noncholinergic neurotransmitter Oral and topical calcium channel blockers As effective as nitrates without the headache Adrenergic antagonists Lack of efficacy in studies Topical muscarinic agonists Bethanechol Phophodiesterase inhibitors Botulinum toxin

Low Pressure Fissures Not candidates for sphincterotomy Impaired continence and fissure recurrence after sphincterotomy Island advancement flap

Crohn’s 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