The Rectum and You

The Rectum and You
Presentation lecture by:Robert Theobald III, D.O.
Vein Associates P.A.

Hemorrhoids

* Cushions of tissue and varicose veins located in and around the rectal area
* Usually swollen and inflamed due to precipitating factors
* Factors include constipation, diarrhea, pregnancy, straining, aging, and anal intercourse
* Approximately 89% of all Americans at some time in their lives
* Over 2/3 of healthy people report having hemorrhoids
* Hemorrhoids tend to become worse over the years, never better, unless intervention ensues
* They are located both inside and above the anus (internal) or under the skin around the anus (external)
* Hemorrhoids arise from congestion of internal and/or external venous plexuses around the anal canal

Hemorrhoids-Classifications

* 1st Degree: Bleeding occurs, but do not prolapse outside the anal canal
* 2nd Degree: Prolapse outside the anal canal upon defecation, but retract spontaneously
* 3rd Degree: Require manual reduction after prolapse
* 4th Degree: Can not be reduced, because of strangulation

* The major drainage of the hemorrhoidal plexus is through the superior hemorrhoidal vein, which drains into the inferior mesenteric vein and the portal system
* Hemorrhoidal veins have no valves
* Valveless veins exert maximal pressure at the lowest point
* Any process that impairs venous return will promote stasis
* Can be produced by either systemic or by portal venous hypertension (CHF or cirrhosis)
* Intra-abdominal pressure also impairs venous return (ascites, exercise, pregnancy, straining, and tumors)

* The most significant symptom is rectal bleeding!
* Usually bright red
* Internal hemorrhoids are NOT painful
* Bleeding can be significant because of an arteriovenous fistula formation in plexus
* Other symptoms are prolapse, pruritis, and perianal edema

Perianal Edema
Hemorrhoid Treatment

* Treatment starts conservatively
* Hydrocortisone Cream 2.5%
* Anusol HC Suppositories
* Rubber-Band Ligation
* Sclerotherapy (5% phenol)
* Infra-Red Coagulation
* Surgery

Hemorrhoidectomy
Thrombosed External Hemorrhoids

* Thrombosed hemorrhoids are an acute and very painful problem that develops rapidly
* Typically a perianal mass develops which is painful to palpate (and look at)
* The lesion is due to sudden clot formation in one of the subcutaneous or submucosal veins
* The diagnosis is easy to make by the violet discoloration of the lesion
* The overlying tissue is tense and shiney
* Treatment is with excision of the clot
* The body will eventually reabsorb the clot, but might takes weeks
* Easier to excise after a few days
* Adherence may occur if not excised within a few days

Abscesses

* A perianal abscess is a collection of pus in one of the anatomic spaces of the anal region
* The perianal anatomy is defined by the sphincter and the levator ani muscles
* The Iliococcygeus, Pubococcygeus, and Puborectalis
* Abscesses can be classified according to location
* Perianal, Supralevator, Intersphincteric
* The most common location is perianal
* It results from a blockage of the anal glands located just outside the anus
* According to the crypto-glandular theory, they often develop from cryptitis which may be associated with an enlarged papillae in the anal canal
* It starts as a cellulitis with only swelling and erythema
* Finally, the infecting organisms burrow in the anal glands producing the abscess
* The microorganisms are not specific or unique
* They are usually polymicrobial
* More than 90% will include E. coli
* Other organisms include streptococci, staphylococci, and a variety of anaerobic bacteria

Abscesses-Symptoms

* The patient will present with fever, local inflammation, and pain
* The initial manifestation is fever followed by pain
* In 24-48 hours a fluctuant mass will appear
* An abscess in the intramuscular space may be difficult to diagnose and treat
* Clinical assumption is needed to treat appropriately
* Treatment consists of surgically draining the infected cavity
* A cruciate incision is made to allow pus to drain for a few days
* Sometimes a catheter is left in the incision to assure adequate drainage
* A fistulous tract can arise if the abscess is not treated properly

Fistula

* Most fistulas begin as an anorectal abscess
* Anal fistulas is an abnormal passage or communication between the interior of the anal canal or rectum and the skin surface
* Rarer forms may communicate with the vagina, large bowel, and bladder

Fistula-Symptoms

* Are usually a purulent discharge and drainage of pus or stool near the anus
* Can irritate the outer tissues causing itching and discomfort
* Pain occurs when fistulas become blocked and abscesses recur
* Flatus may also escape from the tract
* Fistulas can be difficult to diagnosis
* A probe must be passed between the opening of the skin’s surface and the interior opening
* Goodsall’s Rule can be helpful
* Other causes include tuberculosis, inflammatory bowel disease, and cancer

Crohn’s Fistula
Fistula-Treatment

* Fistulas last until surgically removed
* Excision of the complete tract is called a fistulectomy
* Sometimes a seton is placed in the tract to elicit an inflammatory reaction in the tissue resulting in closure
* 80% success rate with surgery
* Remicade (infliximab) for persistent disease
Fissures

* An anal fissure is a tear causing a painful linear ulcer at the margin of the anus
* Can cause itching, pain, or bleeding
* 80% of fissures occur in the posterior midline
* 15% of fissures occur in the anterior midline
* 5% of fissures occur either right or left lateral
o Fissures that occur laterally think of Crohn’s, tuberculosis, lymphoma, leukemia, anal cancer, syphilis, and trauma
* When an anal fissure is suspected, physical examination is diagnostic
* The exam may be difficult due to pain and sphincter spasm
* The triad consists of a sentinel skin tag, a fissure and a hypertrophied papilla

Fissures-Treatment

* Treatment for superficial fissures includes Anusol HC or Canasa (mesalamine) suppositories
* If suppositories don’t heal fissure, then nitroglycerin cream 0.2% is used (headaches are major side-effect)
* If not responding to pharmacotherapy or chronic fissure, then surgery is recommended
* Surgery consists of a fissurectomy and sphincterotomy
* Helps the fissure to heal by preventing pain and spasm which interferes with healing
* 90% of patients will improve with the surgery
* Very small chance of anal incontinence

Auto-colonoscopy
Pilonidal Cysts

* The term pilonidal was derived from the Latin pilus meaning hair and nidus meaning nest
* The pathogenesis is unknown, but the most common theory is that they are a result of an embryonic malformation and results in a remnant of a neurocanal
* Men are more likely than women to have the cysts at a ratio of 4 to 1
* Infection of a pilonidal cyst is most commonly seen between puberty and age 30
* Hair growth and secretion of sebaceous glands reach their peak
* Some suggest that trauma to the gluteal area to be an important predisposing factor
* In WWI it was known as Jeep Rider’s Disease
* Unless they become infected or inflamed, they are asymptomatic
* When a cyst becomes infected, an abscess can develop, usually lateral or superior to the gluteal cleft and over the coccyx
* As the process becomes chronic, a fistula develops and creates a sinus tract
* Diagnosis can be made with pilonidal pores which are 2 or more openings located between the gluteal cleft

Pilonidal Cysts-Treatment

* The only way to cure pilonidal cysts is surgery
* The first episode can be treated with antibiotics (Keflex or Augmentin)
* If recurrent, then surgery is performed
* Open-technique is most successful
* Other techniques include closed, marsupialization, and Z-plasty
Condylomata Acuminata

* Condylomata Acuminata (anal or perianal warts) are the most common sexually transmitted disease of the anus and rectum
* Human papillomavirus (HPV) is responsible
* Over 40 subtypes of HPV
* Most common 6 and 11
* 16, 18, 31, and 32 are associated with squamous cell carcinoma

Condylomata Acuminata

* CDC reports a 500% increased in the incidence from 1981; 1/7 Americans
* Are epithelialized, raised wartlike lesions that arise alone or more often in groups
* They can range from a few millimeters to a cauliflower-like lesion
* Can occur in combination with genital lesions
* Mode of transmission is sexual intercourse, auto-inoculation may occur
* Rarely bleed or painful, mostly pruritis
* Although perianal condylomata can be seen in women and heterosexual men, typically the patients are homosexual males
* CDC reports that 60-70% of homosexual men have condylomata
* Women have increased risk of cervical carcinoma with HPV infection
* Successful therapy requires accurate diagnosis and eradication of all warts
* All patients undergo anoscopy and genital examination
* Once identified, there are many different treatments depending on disease progression
* Each treatment has advantages and disadvantages
* The treatment options consist of excisional, destructive, immunotherapy, and chemotherapy
* Condylomata can be excised either in the office with local anesthesia or in the operating room
* Preservation of the anoderm and anal canal mucosa to minimize pain and healing time
* The rate of recurrance is less than 10%
* Podophyllin is a resin that is cytotoxic to condylomas and very irritating to normal skin
* Can not be applied to anal canal lesions
* Local complications include necrosis, fistula, and anal stenosis
* Electrocautery, Cryotherapy, and Lasers are also used with frequency
* Two therapies that are more commonly practiced today are interferon injections and Aldara (imiquimod) cream
* Both therapies are very potent with many side-effects
* LFT’s should be checked routinely with interferon injections
* Aldara should be used every other day, because it can burn normal tissue and make it necrotic

Pruritis Ani

* More common in males than females
* Symptoms include itching, burning, and irritation
* Close examination of the perianal area is required; ulcerations and excoriation
* Can be associated with other diseases
o Infections (fungal, parasitic, bacterial)
o Irritants (soaps, coffee, ETOH, detergents)
o Dermatologic (psoriasis, dermatitis, pemphigus)
o Systemic disease (diabetes, SLE, liver dx)

* Treatment
o Avoiding the offending agents
o Creams (analpram lotion/cream 2.5%)
o Topical Steroids
o Corona ointment (lanolin/bees wax based)

Anal Cancer

* Very uncommon cancer, accounting for only 4% of all cancers of the lower GI tract
* Anal cancer is on the rise due to individuals with HPV
* The majority of patients are women in their seventh decade who present with bright red bleeding and pain







Anal Cancer

* Anal cancer is often curable
* 3 major factors include site, size, and differentiation
* Squamous cell carcinomas make up the majority of all primary cancers of the anus
* The others are adenocarcinoma, verrucous carcinoma, and malignant melanoma
* Colorectal cancers are primarily adenocarcinoma

Squamous Cell Carcinoma

Anal Cancer-Treatment

* Surgery is a common way to diagnose and treat anal cancer
* Local resection takes out only the cancer, it spares the internal anal sphincter muscle
* Abdominoperineal resection (APR) removes the anus and the lower part of the rectum by cutting into the abdomen and the perineum
* With an APR, the patient will have a colostomy
Anal Cancer-Treatment

* Radiation therapy and Chemotherapy are used together to shrink tumors
* All anal cancers respond very well to this combination therapy
* APR is now an unnecessary surgery for anal cancer, but still very common for distal rectal carcinoma
Levator Syndrome

* More commonly called Proctalgia fugax
* It is episodic rectal pain caused by spasm of the levator ani muscles
* A spasm is situated in the rectum approximately 10-15 cm above the anus
* The pain or spasm is related to sitting for long periods of time
* Pain is described as a sharp, knife-like, twisting inside the rectum

Levator Syndrome

* Physical examination is usually normal
* Emotional factors, sexual activity, or fatigue can trigger an attack
* Can also be triggered by an injury to coccyx or lower back
* Structural deviations of the lumbro-sacral area, sacro-iliac, coccyx, and supportive structures are also causes

OSTEOPATHIC TREATMENT

* A fracture or dislocation of the coccyx should be reduced by bi-manual manipulation
* Levator ani tenderness will readily respond to OMT
* Digital stretching of the ischiococcygeus tends to relax the entire structure, usually on the left lateral side
Beach Bum
The Rectum and You.ppt