Zaky Jurnal Gastro

8/10/2019 Zaky Jurnal Gastro

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Stefano DUgo, Luana Franceschilii, Federica Cadeddu, Laura Lecessi, Giovanna Blanco

BMC 2 13

Medical and surgical treatment ofhaemorrhoids and anal fissure in rohns

disease a critical appraisal

Pradana Zaky Romadhon

Department of Internal Medicinedr Soetomo Teaching Hospital- Airlangga University School of Medicine

SURABAYA


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Background The original description of Crohns disease (CD) in 1932

included only regional ileitis and not perianal lesions However in 1938, when Penner and Crohn first reported a

perianal fistula in an affected patient, it became clear thatthe perianal pathology represented a common medicalproblem in CD px.

The actual incidence is not known, being reported inliterature as low as 3,8% and as high as 61-80%

The prevalence increases as the disease progresses distally,particulary if the rectum is affected.

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Background The presence of perianal CD is associated with a more

disabling natural history, with increased extraintestinalmanifestations and greater steroid resistance.

These subjects were found at greater risk of prostectomy,reported to be as high as 5% at first presentation ofperianal disease, incresing 8% after 10 years and doublingafter 20 years from diagnosis

At present, there is still no consensus in the scientificcommunity on the exact indications of surgery in CD pxpresenting with anal fissure or haemorrhoids, mainly dueto scany data to literature

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Methods Clinical records of px affected by perianal disease were

routinely and prospectively entered in database beetweenOct 2003 and Oct 2011 at the Dept of Surgery, Tor VergataUniversity Hospital in Rome

Retrospectively reviewed data on CD px included in thestudy, treated either medically or surgically for anal fissureor haemorrhoids

Exclusion criteria were the presence of concomitantsuppurative disease, perianal fistula or cancer.

Medical or surgical treatments were undertaken inagreement with gastroenterologist who followed px for thespesific pathology

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Methods The prospectively recorded data included demography, clinical

presentation of perianal pathology, type and results of medicaland/or surgical treatment, post-op course, complications,recurrence and symptoms at follow-up

Analysis of the results was made dividing the px in 2 groups,accordingly with the diagnosis of haemorrhoids or anal fissure

We compared in each group the outcomes between px withdiagnosis of CD made prior or after perianal main treatment

The diagnosis of CD was established in agreement with theEuropean Crohns and Colitis Organisation (ECCO)

Px underwent a full evaluation by means of clinical, laboratory,endoscopic, radiologic and histologic investigations

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Results Between Oct 2003 and Oct 2011, 86 px with diagnosis of

CD suffering from anal fissure or hemorrhoids, treatedeither medically and/or surgically, who fullfilled the studycriteria

Median follow up was 37 months Overall, 45 CD px were evaluated and followed up with the

diagnosis of hemorrhoids and the remaining 41 CD px forthe anal fissure.

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Haemorrhoids Conservative approach was initially adopted in all the px, in

absence of diarrhea, it included high fibre diet, fibresupplements and oral fluids intake in order to produce soft,well formed stools and regular bowel movement. Warm sitzbaths were also suggested

Oral diosmin was added to the first line theraphy if symptomspersisted after 12 weeks or in case of thrombosis at the firstoutpatient visit.

This conservative approach failed in 17 (37,8%) out 45 px. Indication to surgical tx in the nine px with known CD at the

time of evaluation was given only in case of stable intestinaldisease, without need of steroid medications and with

CDAI < 150 9


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Haemorrhoids Mean time to complete healing after surgery was 38 8 days The most common complication was postoperative bleeding,

observed in 3 (17,6%) px, during the first 4 days post-op. 1 pxself limiting, 2 px required ER and got local compression withhemostatic gauze

2 (11,8%) px got post-op anal fissures, effectively treatedwith topic glycerin trinitrate 0,4% for 8 weeks

2 (11,8%) px perianal sepsis was detected 1 month and 4odays after surgery, and successfully treated by drainage andfistulotomy.

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Anal Fissure Based on anatomic position in the anal canal, fissures were

posterior in 23 (56,1%) px, anterior in 9 (22.0%), lateral in 6(14,6%) and both (anterior and posterior) in 3 (7,3%)

First line tx was medical, with the topic application of CCB orGTN 0,4% ointment 2x/day for 8 weeks

Conservative treatment was effective in 27 px (65.8%).Indication for the operative procedure in the 6 px with knownCD was given only if the disease was in a remission state(CDAI < 150), with no steroid theraphy.

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Discussion In px without a diagnosis of IBD, after failure of medical

approaches, aggressive treatment of haemorrhoids and analfissure is usually uneventful.

On the other hand, the management of these pathologies insubjects with CD is though to be hazardous, despite literaturedata are suprisingly scant

This is due to the report of significant complications,including sepsis, stenosis, fistulas, faecal incontinence andnon-healing wounds.

We are aware of some limitations of the present study,primarily because it is a case series and our aim is not to givetherapeutic recommendation

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Haemorrhoids Haemorrhoids are relatively uncommon in CD px, who usually

report few symptoms. The estimated incidence is about 7%

Historically surgery was firmly obstructed; Jeffrey et alconcluded that absolutely no surgical treatment should begiven to CD px, reporting severe complications in more thanhalf of them

On the contrary, Wolkomir and Luchtefeld successivelypublished their series in which 88% of CD px, who underwentsurgery for symptomatic haemorrhoids, healed without anycomplication.

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Haemorrhoids

In our experience, conservative treatment was effective inmore than 60% px. Operative approach was required becauseof persisting symptoms, mainly bleeding (91%) and prolapse(62%)

Indication to surgery was not influenced by the diagnosis ofIBD, but only by the clinical condition Usually we preferred the open haemorrhoidectomy in both

subgroups; however in px with IBD diagnosis, also performedrubber band ligation associated with less operative risks buteffective in both of our cases

In our series the most common complication waspostoperatve bleeding, px have to be informed about thepossibility of haemorrhage usually during first hours or fewdays 17


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Haemorrhoids Based on these results it seems that surgery, in the form of

excisional haemorrhoidectomy or rubber band ligation, mayhave role after failure of medical treatments

More data are needed to confirm these outcomes and tocorrelate them with complications and disease activity

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Anal Fissure Anal fissures are more common than haemorrhoids in CD

patients and often associated with other perianal pathologies In non-IBD subjects anal fissures are usually symptomatic, in

CD px pain bleeding, and anal discomfort reported in only 44-70% of cases,.

Although conservative theraphy or simple observation is alsoindicated for the management of anal fissures, it should beconsidered that unhealed fissure may progress to fistula orabscess in up to 20% of the cases

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Anal Fissure Common local anorectal procedures such as sphincterectomy

or anal dilatation are infrequently performed in CD px, due toperception at risk of incotinence, underlying diarrheastaterisk of requiring add anal surgery in the future

Fleshner et al dilatation of sphincter should be avoided in CD,because of suboptimal healing and potential secondaryinfection or fistula

Wolff et al suggested that painful fissures should be convertedto a painless state by sphincterectomy

Cohen et al stated that a limited sphincterectomy may beperformed after failure of all medcal approaches

Wolkomir and Lutchfeld reported anal fissure healing inabout 90% of CD px after surgery 20


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Anal Fissure The idea would be create small wounds, minimizing the

damage to the mucosa and the external sphincter, and a closesubcutaneous LIS seems to be appropiate

Botox inj. Could be an alternative to LIS, avoiding damages toyhe sphincter apparatus, risk of incontinence and reducingwound healing comlications

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Conclusions The occurence of haemorrhoids and anal fissure associated to

Crohn disease has to be considered The main treatment of these conditions should be a medical

theraphy From the preeliminary results of this study it is conveciable,

in case of failure, a role of surgery in high selected px, alwaysevaluating the risk of post-op complications; howeverdefinitive conclusion cant be made.

Further studies, primarily randomized trials, are needed inorder to establish the efficacy of the surgical approach, givingtx recommendation and guidelines.

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Zaky Jurnal Gastro

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