The Rectum and You

1. The Rectum and You Robert Theobald III, D.O. Vein Associates P.A.

3. Napolean

4. Jimmy Carter

5. George Brett

6. 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

7. Hemorrhoids • 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

8. Hemorrhoids • 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 • Are classified into four degrees

9. 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 • This is a medical emergency!

10. Hemorrhoids

11. Hemorrhoids • The major drainage of the hemorrhoidal plexus is through the superiorhemorrhoidal 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

12. Hemorrhoids • 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)

13. 3rd Degree Prolapse

14. 4th Degree Prolapse

15. Hemorrhoids • 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

16. Perianal Edema

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

18. Hemorrhoidectomy

19. 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

20. Thrombosed External Hemorrhoids

21. Thrombosed External Hemorrhoids • 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

23. 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

24. Abscesses • 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

25. Abscesses • 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

26. Abscesses • 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

27. 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

28. Abscess

29. Abscesses • 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

30. 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

31. Fistula

32. 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

33. Fistula • 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

34. Crohn’s Fistula

35. 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

37. 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 • Fissures that occur laterally think of Crohn’s, tuberculosis, lymphoma, leukemia, anal cancer, syphilis, and trauma

38. Fissures • 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

39. Fissures

40. 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

41. Fissures-Treatment • 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

42. Auto-colonoscopy

43. 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

44. Pilonidal Cysts • 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

45. Pilonidal Cysts • 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

46. Pilonidal Cysts

47. Pilonidal Cysts

48. 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

49. 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

50. 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