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Hemorrhoids and Anal Fissures
9/1/2010
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Hemorrhoids
Cushions of specialized, highly vascular tissue inanal 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 tosubmucosa, contributing to bulk of hemorrhoid andsuspending 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
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Function
Contribute to anal continence Compressible lining that protects underlying
sphincters
Provide complete closure of the anus
Cushions engorge and prevent leakage with increasingintrarectal pressure
Account for15-20% of anal resting pressure
Supplies sensory information to discriminate
between solid, liquid, and gas
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Vascular Supply
Bleeding from disrupted presinusoidal arterioles thatcommunicate with sinusoids in the region
Bright red
Arterial pH
External plexus drains via inferior rectal veins intopudendal veins into internal iliacs
Also through middle rectal veins to internal iliacs
Internal hemorrhoid plexus drains through middle
rectal into internal iliacs
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Configurations
Three main cushions Left lateral
Right anterior
Right posterior
Additional smaller accessory cushions in betweenmain cushions
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Etiology
Constipation Prolonged straining
Irregular bowel habits
Diarrhea
Pregnancy
Heredity
Erect posture
Absence of valveswithin the hemorrhoidal
sinusoids
Increased
intraabdominal pressurewith obstruction of
venous return
Aging
Interior sphincterabnormalities
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Etiology
Patients usually have increased anal restingpressures
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
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Epidemiology
4.4% in the US Peak between 45-65 yoa
Increased in Caucasians and higher socioeconomic
status
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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
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Internal Hemorrhoid ClassificationFirst degree Second degree Third degree Fourth degree
Finding Bulge into lumen+/- painless
bleeding
Protrude with
BM
Reduce
spontaneously
Protrude
spontaneously
Require manual
reduction
Permanently
prolapsed and
irreducible
Symptoms
Painlessbleeding
Anal massw/defecation
Anal burning or
pruritis
TenesmusMucous leakage
Difficulty
cleaning
Irreduciblemass
Signs Bright red
bleedingBleeds at end of
BM
Drips or squirts
May be occult
Prolapse with
defecation
Reduce
manuallyPerianal stool or
mucous
Anemia rare
Always
prolapsed
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Symptoms
Presence, quantity, frequency, and timing of bleedingand prolapse
May complain of bleeding, mucosal protrusion, pain,
mucus, discharge, difficulties with perianal hygiene,
sensation of incomplete evacuation, cosmeticdeformity
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
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Symptoms
Internal hemorrhoids are painless unlessthrombosed, 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
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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
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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 ofblood vessels
Creams, ointments, foams, and suppositories have little
rationale in treatment
Prolonged use may cause local allergic effects or
sensitization of the skin
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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 of2 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
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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 createfibrosis, scarring, shrinkage and fixation
No anesthesia needed
First- and second-degree hemorrhoids
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Treatment
Nonoperative/Office Procedures
External hemorrhoids Acute thrombosis
Excision of entire thrombus under local anesthesia
Conservative management if pain is resolving
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Treatment
Operative Hemorrhoidectomy
Indicated in patients with symptomatic combinedinternal 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, andrecurrence
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
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Strangulated Hemorrhoids
From prolapsed third- or fourth-degree hemorrhoidsthat become incarcerated and irreducible due to
prolonged swelling
May present with pain and urinary retention
Treatment is urgent or emergent hemorrhoidectomyin the OR
Open or closed technique
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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 andprolapsed disease
Should be under local in left anterolateral position
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Hemorrhoids.
And Crohns disease Rate of severe complications is high (30%) and patient
selection is paramount
And the Immunocompromised
Challenging due to poor wound healing and infectiouscomplications
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
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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 diseaseprocessesCrohns, TB, syphilis, HIV/AIDS, or anal ca
Early (acute) fissures appear as a simple tear in theanoderm
Chronic fissures (symptoms more than 8-12 wks) haveedema and fibrosis
Sentinel pile distally, hypertrophied anal papillaeproximally
May be able to see fibers of the internal sphincter
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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 posteriormidline
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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 thetissue
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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
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Conservative Management
Almost half will heal
Sitz baths
Fiber supplement
+/- topical anesthetics or anti-inflammatory ointments
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Operative Treatment
Primary goal is to decrease abnormally high restinganal 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
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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
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Low Pressure Fissures
Not candidates for sphincterotomy
Impaired continence and fissure recurrence after
sphincterotomy
Island advancement flap
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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
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HIV
Necessary to differentiate between HIV-associated
ulcers
Better results with sphincterotomy, especially with
antiretrovirals