Acute Proctology

Abstract

For all patients presenting with swelling, pain, tenderness, itching, and bleeding symptoms of the anal region:

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For all patients presenting with swelling, pain, tenderness, itching, and bleeding symptoms of the anal region:

• Take a thorough history.

• After obtaining informed consent, examine the patient usually in the left lateral or the Sims position, and more rarely in prone jackknife position.

• Rectal examination should detect external hemorrhoids, fistula, anal carcinoma, anal condylomas, anorectal abscess, and anal discharge.

• Anorectal examination may reveal anal stenosis, anal sphincter problems, gross blood, and anorectal abscess.

1 Lower Gastrointestinal Bleeding

• Incidence: assumed to be 20/100,000 and constitutes 25 % of all gastrointestinal bleedings with a male predominance

• Defined as bleeding from the bowel distal to the ligament of Treitz

• Usually manifests with maroon stools or bright red blood per rectum

  • Bright red blood per rectum strongly suggests a lower gastrointestinal (GI) source of bleeding.

  • However, hemorrhage may originate from a source proximal to the ligament of Treitz in which case the patient is usually unstable.

• Diagnosis

  • After digital rectal examination.

  • Place a nasogastric tube to rule out an upper GI source of bleeding.

  • Order immediate colonoscopy, the urgency depending on the degree of hypovolemia.

    • Should detect the source of bleeding in 69 % (48–90 %) of patients

  • Elderly (older than 65 years) and the patients with comorbidities warrant hospitalization because of high morbidity and mortality rates (10–20 %).

  • It is strongly recommended to carry out an upper gastrointestinal endoscopy if a bleeding site cannot be detected during colonoscopy.

2 Anal Pain

• Causes: acute anal fissures, thrombosed hemorrhoids, herpesvirus infection, anal condylomas, anorectal abscess, and proctalgia fugax

• Treatment: warm sitz baths, diltiazem, glyceryl trinitrate ointment, and nonsteroid anti-inflammatory drugs (NSAIDs) (helpful in 60–70 % of cases)

3 Acute Anal Fissure

• Signs: severe anal pain and rectal bleeding with defecation.

• Initial treatment: pain relief, anal hygiene, and warm sitz baths. Topical application of anesthetic jelly, 0.2–0.4 % nitroglycerin ointment or glyceryl trinitrate, diltiazem, nifedipine, or L-arginine; bulking and softening the stool with psyllium seed are useful in acute conditions.

4 Acute Hemorrhoidal Disease

• Signs: bleeding, usually red and usually after defecation, and masses of dilated venules.

• Grading of hemorrhoids (Table 23.1).

  Table 23.1 Grading of hemorrhoids

• If untreated, prolapsed hemorrhoids may end up with ulceration and necrosis.

• Presentations and treatment.

  • Thrombosed external hemorrhoids

    • Cause unknown

    • Usually preceded by abrupt onset of anal mass and pain within 48 h

      • Pain diminishes after the fourth day and if left alone dissolves spontaneously in a few weeks.

    • Treatment:

      • Pain relief

      • Excision under local or general anesthesia

        • Quicker recovery than with medical treatment

        • Prevention of recurrent thrombosis

        • Prevention of residual skin tags

5 Strangulated Hemorrhoids

• Usually arise from prolapsed grade 3 or 4 hemorrhoids that cannot be reduced due to excessive swelling

  • Edema may progress to ulceration or necrosis if not treated with urgent three quadrant hemorrhoidectomy.

  • Stapled hemorrhoidopexy without decompressing the edematous tissue is associated with more immediate pain (vs conventional hemorrhoidectomy technique in the immediate postoperative period) but subsides within 6 weeks.

6 Hemorrhoids in Pregnancy

• Thrombosed or strangulated hemorrhoids due to hormonal changes and the pressure of the fetus on pelvic veins can cause a serious problem in pregnant and postpartum women.

• Mild laxatives are helpful in the last 3 months of pregnancy.

• Traumatic deliveries, such as perineal tear and heavy babies, are associated with thrombosed external hemorrhoids.

• Requires hemorrhoidectomy under local anesthesia, ideally in the immediate postpartum period.

7 Hemorrhoids and Portal Hypertension

• Quite common (almost 60 %).

• Often associated with large esophageal varices but bleed less.

• Bleeding from anorectal varices can be controlled with absorbable running sutures.

• Bleeding hemorrhoids in patients with portal hypertension must be distinguished from anorectal varices, true consequence of portal hypertension.

8 Hemorrhoids in Inflammatory Bowel Disease

• The treatment of hemorrhoids is accepted as safe in patients with ulcerative colitis, whereas is relatively contraindicated in patients with Crohn’s disease.

• Hemorrhoidectomy may be performed in patients with Crohn’s disease in a quiescent stage.

9 Hemorrhoids in Leukemia

• Surgery

  • May be difficult because of:

    • Abscesses

    • Poor healing

  • Indicated to relieve pain and sepsis usually caused by Escherichia coli and Pseudomonas aeruginosa

  • Does not increase the mortality in these high-risk patients

10 Proctitis

• Defined as inflammation limited to the rectum

• May cause bleeding and mucous secretion

• Signs and symptoms:

  • Diarrhea is more frequent than constipation.

  • Urgency.

• Untreated, may spread proximally (as proctocolitis)

11 Anorectal Abscess

• More common in men than in women (ratio of 2:1–5:1)

• Most common cause: obstruction and infection of anal glands and crypts

  • Predominant organisms are Escherichia coli, Enterococcus, and Bacteroides fragilis

• Signs and symptoms

  • Initial sign is usually severe anal pain, swelling and tenderness.

  • Pus may be seen exuding from a crypt.

• Location

  • Perianal, intersphincteric, ischioanal, intersphincteric, and supralevator

• Confirmation of diagnosis in difficult cases: intrarectal ultrasound (IRUS), endoscopic rectal ultrasound (ERUS), pelvic magnetic resonance imaging (MRI)

• Treatment:

  • Anorectal abscess require prompt drainage which is favored. The abscess may be drained under local or general anesthesia according to conditions. Detailed rectal examination under general anesthesia may reveal the problem. Neglect only allows extension of the abscess and may lead to ischioanal and supralevator abscesses and possibly to horseshoe extensions, with each of these conditions more difficult to manage than the simple intersphincteric abscess. If an abscess is detected, preferably it is drained via the anal canal or by removing a skin anal region or placing a mushroom catheter (Thompson-Fawcett). Lay-open technique may end up with several complications. Antibiotics are not generally necessary if the abscess is drained adequately; however, in patients with Crohn’s disease, immune deficiency, and cardiac valve abnormalities, antibiotics should be administered.

Anal canal involvement is present in 30–70 % of patients with Crohn’s disease; however, only 3–5 % require surgical intervention.

12 Fournier’s Gangrene

Necrotizing fasciitis of the perineal area (Fournier’s gangrene) is a rare soft tissue infection, primarily involving the superficial fascia and resulting in extensive undermining of the surrounding tissues. The incidence of such extensive infection has been estimated as less than 1 % of all anorectal sepsis. If untreated, it is invariably fatal, and thus a high index of suspicion for the diagnosis is required. Mortality remains still high in necrotizing fasciitis despite the use of modern powerful antimicrobial drug regimens and advances in the care of the critically ill patients. Overall mortality ranges from 25 to 73 % in the published literature. The disease’s manifestation can range from a fulminant presentation to a subtle and insidious development. After initial fluid and electrolyte corrections and administration of broad-spectrum antibiotics, radical debridement involving extensive excision of all involved skin, fascia, and muscles is performed. Extension may reach the abdominal wall, thighs, chest wall, and axilla. Testicular involvement is rare and the only indication for orchiectomy is testicular gangrene. Repeat exploration should be conducted as necessary until the necrotizing process has been interrupted.

13 Perianal Sepsis in Immunocompromised Patients

Perianal infection in patients with acute leukemia has been associated with mortality rates of 45–78 %. If the granulocyte counts are increased above 1000 cell/mm³, the postoperative course was uncomplicated, otherwise; if surgery is performed with severe granulocytopenia (<500 polymorphonuclear leukocytes/mm³), the survival rate does not increase (Fig. 23.1).

Fig. 23.1

Strangulated hemorrhoids