Hemorrhoids and Anal Fissures

1. Hemorrhoids and Anal Fissures 9/1/2010

2. 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

3. 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

4. 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

5. Configurations • Three main cushions • Left lateral • Right anterior • Right posterior • Additional smaller accessory cushions in between main cushions

6. 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

7. 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

8. Epidemiology • 4.4% in the US • Peak between 45-65 yoa • Increased in Caucasians and higher socioeconomic status

9. 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

10. Internal Hemorrhoid Classification

11. 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

12. 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

13. TreatmentDietary 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

14. TreatmentNonoperative/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

15. TreatmentNonoperative/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

17. TreatmentNonoperative/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

18. TreatmentNonoperative/Office Procedures • External hemorrhoids • Acute thrombosis • Excision of entire thrombus under local anesthesia • Conservative management if pain is resolving

19. TreatmentOperative 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. Conservative Management • Almost half will heal • Sitz baths • Fiber supplement • +/- topical anesthetics or anti-inflammatory ointments

29. 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

31. 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

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

33. 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

34. HIV • Necessary to differentiate between HIV-associated ulcers • Better results with sphincterotomy, especially with antiretrovirals