34 A H E M O R R H O I D... A N D R E C T A...

34
H E M O R R H O I D S
A N D
R E C T A L
P R O L A P S E
CHARLES N. HEADRICK
M I C H A E L J . S TA M O S
A
lthough disparate topics, these two different pathologic entities are commonly misdiagnosed by both
layperson and physician alike. The inclusion of both topics in a single chapter allows us to examine their similarities and emphasize their differences. In the process, we
hope to clarify common misconceptions regarding these
anal/rectal disorders. We think you will see there is no
one common profile particular to either diagnosis.
CASE 1
RECTAL PROLAPSE
A 33-year-old white female, who was gravida 0, para 0, presented with a chronic history of constipation and straining.
She also gave a history of bright red blood per rectum and
passage of mucus and “tissue” with each bowel movement.
She denied any rectal pain. The prolapsed tissue reduced
spontaneously at the completion of each bowel movement.
She described these symptoms as lasting for the previous 4
months. She gave no history of any anal intercourse,
trauma, or other significant past medical history. There had
been no previous anorectal or abdominal surgery and she
had no significant family history. Social history revealed that
she did not smoke and was unmarried. Questions regarding
her bowel habits revealed that she moved her bowels, at
best, every other day, and occasionally every 3 days. There
had been no history of laxative use in the past.
Physical examination revealed a healthy appearing
young female. Her abdominal examination revealed a thin,
scaphoid abdomen. Examination of the perianus revealed
some slight effacement of the anus. There was normal cutaneous sensation, somewhat diminished spinchter tone,
and a good voluntary squeeze. There were no intra-anal
masses. Anoscopy revealed prominent rectal mucosal folds
with small internal hemorrhoids. These were moderately
erythematous and with occasional superficial ulceration.
Flexible sigmoidoscopy revealed a large rectal vault with
moderate inflammation extending to the mid-rectum. She
was also noted to have a redundant sigmoid colon. The remainder of her examination was normal.
The patient was asked to reproduce her symptoms by
sitting on the toilet and straining. The result revealed a 3to 5-cm circumferential prolapse that demonstrated circular, concentric folds consistent with rectal prolapse, or
procidentia. The prolapse reduced spontaneously.
At the end of her consultation, the patient was counseled regarding her diagnosis. She was advised to increase
the fiber in her diet and to take bulk fiber agents. A barium enema was ordered to evaluate the remainder of the
245
2 4 6
C O L O N ,
R E C T U M ,
A N D
A N U S
colon. The air contrast enema revealed a normal mucosal
outline without diverticula and a very redundant sigmoid
colon. Subsequently, her bowel regimen improved to one
bowel movement a day with only occasional straining during defecation. She continued to prolapse, however, with
each bowel movement. Surgery was indicated because of
her continued symptoms and the risk of sphincter damage. An abdominal approach was recommended as her
best option. She underwent laparotomy, sigmoid resection, low rectal dissection, and rectopexy. Her postoperative recovery was uneventful.
CASE 2
RECTAL PROLAPSE
IN AN ELDERLY PATIENT
A 79-year-old white female who was gravida 4, para 4, presented with a history of constipation, stating that her rectum “falls out.” She had a long history of taking laxative
products (senna, herbal tea, cascara, and magnesium
products). She was especially concerned because she
sometimes moved her bowels without warning and soiled
her undergarments. Other pertinent history revealed that
she had coronary artery disease and medically controlled
hypertension. She had previously undergone an abdominal hysterectomy and oophorectomy as well as an incidental appendectomy.
Physical examination revealed a moderately obese
white female with lower midline abdominal scars. Rectal
examination revealed both hemorrhoidal and rectal prolapse. The prolapse was easily reducible, but came back
out with a moderate increase in intra-abdominal pressure.
Digital examination revealed a diminished sphincter tone.
Some soilage of stool and mucus was noted on her undergarments. Preoperative workup included contrast enema
and flexible sigmoidoscopy. Anal manometry revealed a
low-resting sphincter pressure.
The patient was deemed to be at high risk of an abdominal operation, and a perineal approach was recommended. The patient subsequently underwent perineal
rectosigmoidectomy under spinal anesthesia. Postoperatively, the patient did well. Her prolapse was cured and
she had perceptible improvement in her continence.
CASE 3
HEMORRHOIDAL PROLAPSE
A 43-year-old Hispanic male with a history of straining and
constipation came in complaining of bright red blood per
rectum. He denied pain. He was found to have prolapse revealing radial folds (hemorrhoidal prolapse) and anemia of
8 g Hb. Preoperative workup included a colonoscopy, which
was normal, followed by surgical hemorrhoidectomy.
CASE 4
THROMBOSED EXTERNAL
HEMORRHOID
A 25-year-old male came in complaining of anal swelling
and a sudden onset of pain. The patient recently had severe gastroenteritis with diarrhea. Physical examination
revealed a thrombosed external hemorrhoid. Treatment
consisted of excision in the office under local anesthesia.
H
GENERAL CONSIDERATIONS
emorrhoidal disease is very common. The number of over-the-counter remedies available is proof
enough. Hemorrhoids are actually present in every person
and have a normal physiologic function. They cushion the
fecal bolus as it is expelled from the rectal reservoir and
contribute to normal continence. Poor diet and hygiene,
increases in intra-abdominal pressure, and family history
may contribute to the development of abnormal hemorrhoids, which usually manifest as enlargement and/or inflammation. Hemorrhoids are classified as internal or external, based on their relationship to the dentate line.
Distal to this junction of mucous membrane and anoderm
there is normal somatic sensation. Proximal to this line,
there is a transitional zone, measuring from 1 to 1.5 cm, in
which sensation is lessened as the somatic sensory apparatus is diminished. It is in this zone, proximal to the dentate
line, where internal hemorrhoids reside (Fig. 34.1). Symptomatic internal hemorrhoids may cause discomfort, prolapse, or even hemorrhage without pain to the individual
(painless bleeding). External hemorrhoids rarely bleed,
but may cause significant pain (Case 4) associated with
thrombosis. Hemorrhoids may also bridge this anatomic
boundary (mixed type) (Fig. 34.2).
Hemorrhoids have no sexual predilection, and span the
range of ages. Certain conditions may predispose toward
the formation of hemorrhoids: constipation, chronic diarrhea, and pregnancy. The most common causes of constipation are inadequate fluid intake, poor diet (low fiber intake), and infrequent exercise. There are also a number of
medications that can cause constipation (calcium channel
blockers, tricyclic antidepressants, diuretics).
Hemorrhoidal prolapse constitutes a special situation
in hemorrhoidal disease. The tissue has enlarged enough
to be partially expelled during defecation. A grading system is used to describe enlarged internal hemorrhoids: (1)
grade I—enlarged hemorrhoidal tissue, (2) grade II—
hemorrhoidal tissue that prolapses with straining but
spontaneously reduces, (3) grade III—hemorrhoidal prolapse that requires manual replacement, and (4) grade
IV—unreducible prolapse. Anatomic orientation is also
helpful as one person may have coexisting grades of hemorrhoids. Left, right, anterior, posterior, and lateral are the
FIGURE 34.1 Internal hemorrhoids, by definition, are lined by
mucosa and rise above the dentate line. External hemorrhoids
are lined by anoderm (skin).
FIGURE 34.2 The hemorrhoidal
plexus may engorge and form collaterals to develop into a combined
internal/external hemorrhoid.
2 4 8
C O L O N ,
R E C T U M ,
A N D
A N U S
labels used to describe hemorrhoidal location. The typical
distribution of hemorrhoids include left lateral, right anterior, and right posterior columns.
True rectal prolapse, or procidentia, can be confused
with prolapse of hemorrhoids or mucosal prolapse. In true
rectal prolapse, there is a full thickness prolapse. The rectum actually turns “inside out,” similar to an intussusception. This situation connotes a loss of pelvic support and
carries with it a risk of incontinence (Case 2)—either
through stretching of the pudendal nerve or direct physical trauma to the sphincter complex.
Unlike hemorrhoidal disease, rectal prolapse is more
common in women (Cases 1 and 2) (6:1 female/male) and
can occur at any age (even in the newborn). Historically, it
was thought to be associated with multiparous, elderly females, but may also occur in a young male or a nulliparous
young female (Case 1). Doctors and patients alike may be
confused by the symptoms and sensations of this ailment
and frequently attribute them to hemorrhoids.
K E Y
P O I N T S
• Hemorrhoids present in every person and have a normal
physiologic function
• Hemorrhoids classified as internal or external, based on relationship to dentate line
• Symptomatic internal hemorrhoids may cause discomfort,
prolapse, or even hemorrhage without pain to the individual
(painless bleeding)
• External hemorrhoids rarely bleed, but may cause significant
pain associated with thrombosis
D
DIAGNOSIS
iagnosis of these anorectal problems is based on a
careful history and thorough physical examination. Ancillary tests such as air contrast barium enema and anal
manometry may be helpful after the diagnosis is secure.
History taking for anal/rectal disorders can be very
helpful in making a diagnosis. Particular attention should
be directed toward the patient’s diet, bowel habits, and
description of any symptoms. This should include the average number of bowel movements per day or week, the
presence of straining or any sensation or prolapse, the
amount of time spent on the toilet, and the characteristics
of any blood found during the movement. Associated abdominal complaints and concurrent usage of medication
should also be discussed. Additionally, prior anorectal, abdominal, or pelvic surgery should be detailed, with particular attention given to vaginal childbirth, episiotomies,
and/or tears.
As with any anal/rectal disorder, the following elements
are essential to a good examination: (1) inspection of the
perianus, including rudimentary sensory examination, (2)
digital examination to evaluate the canal for masses, tenderness, and sphincter tone, (3) anoscopy to examine the anal
canal visually, (4) flexible sigmoidoscopy to visually examine
the rectum and lower colon, and (5) when prolapse is suspected, visual examination of the anus and perineum during
straining, preferably while sitting or squatting.
External hemorrhoids are visible on simple inspection,
and in the noninflamed state simply may appear as fleshy
skin covered protrusions (tags). They may become inflamed and edematous or may thrombose. Thrombosis
(usually an acute event brought on by straining, constipation, or diarrhea), is typically very painful (Case 4). A firm
tender mass is palpated adjacent to the anal canal. The
mass may have a dark, bluish appearance. The overlying
skin is usually normal although central ulceration is not
uncommon due to pressure necrosis. The tenderness is localized to the thrombosis itself, unlike an abscess.
Internal hemorrhoids can only be appreciated adequately by visualization, either by inspection if prolapsed
or by anoscopy. Palpation is unreliable in the diagnosis of
internal hemorrhdoids.
Rectal prolapse can be difficult to diagnose. Even
though the patient may report frequent prolapse, reproducing the event in the doctor’s office may be difficult.
Frequently, the experience can be embarrassing for the
patient and even the physician. Often, the patient can only
produce the prolapse while squatting and straining. A
bathroom adjacent to the examination room is helpful for
this part of the examination. When the prolapse is reproduced, it may protrude 1–2 cm or up to 15–20 cm. Rarely,
a patient will present with an incarcerated prolapse, which
should be treated as a surgical emergency.
Although flexible sigmoidoscopy is usually adequate, a
more thorough colonic examination (colonoscopy, air contrast enema) may be helpful. Rarely, a tumor can act as a
“bedpost” for intussusception or prolapse. Laboratory
studies are not helpful in making the diagnosis, although
the presence of anemia should mandate a full colonic
evaluation.
K E Y
P O I N T S
• As with any anal/rectal disorder, the following elements are
essential to good examination: inspection of perianus, digital examination, anoscopy, and flexible sigmoidoscopy
• Internal hemorrhoids can only be appreciated adequately by
visualization, either by inspection if prolapsed or by anoscopy
T
DIFFERENTIAL DIAGNOSIS
he main difficulty in diagnosing these conditions
is in distinguishing them from one another. True rectal
prolapse produces circumferential mucosal folds while
hemorrhoidal prolapse yields radial folds (Figs. 34.3 and
H E M O R R H O I D S
A N D
R E C T A L
P R O L A P S E
2 4 9
FIGURE 34.3 True rectal prolapse. Note the circumferential mucosal folds and the sulcus outside the
prolapse (fixation of the dentate line).
34.4). Likewise, true rectal prolapse does not include the
dentate line, leaving a deep sulcus outside of the prolapsed tissue.
Other tumors may also prolapse through the anal
canal and be mistaken for hemorrhoids. Rectal polyps, tumors, and hypertrophied anal papillae are the most common. These are readily identified by anoscopy or proctosigmoidoscopy.
S
TREATMENT
uccessful treatment of hemorrhoids requires an accurate diagnosis and elimination of other perianal disease
as the cause of the patient’s complaints. Since hemorrhoids are a normal part of human anatomy, they will invariably be present but may not be contributing to the patient’s problems. Indeed, other pathology (e.g., anal
fissures, proctitis) frequently will exacerbate existing hemorrhoids. Failure to appreciate and treat the primary disease process will likely lead to failure of therapy.
Internal hemorrhoids may be treated medically, with
office treatments, or with surgery. The decision rests on
the symptomatology and physical examination. For complaints of minor bleeding associated with bowel movements (“outlet bleeding”), dietary counseling and fiber
supplementation (psyllium) may be adequate, although
flexible sigmoidoscopy is mandatory to eliminate a distal
colon or rectal cancer as the possible cause of the bleeding. For prolapse, or bleeding associated with prolapse,
additional treatment is required. A variety of office treatments may be used, although sclerotherapy and rubber
band ligation are the most commonly employed. All of
these office based treatments are “fixation” techniques.
They work primarily by creating scar tissue locally that
“fixes” the mucosa overlying the hemorrhoid to the underlying internal sphincter muscle. Surgical treatment, including laser treatment, is reserved for more severe disease (Case 3) and for patients with associated external
hemorrhoids that are not amenable to office treatment.
Laser hemorrhoidectomy is identical to standard surgical
hemorrhoidectomy in every parameter studied. Its only
apparent advantage is in marketing. The disadvantage is
solely in cost.
External hemorrhoids may also be treated medically
or with surgery. Topically applied creams may help shrink
2 5 0
C O L O N ,
R E C T U M ,
A N D
A N U S
FIGURE 34.4 Hemorrhoidal or mucosal prolapse. Note the radial folds and absence of rectal wall
(muscle) within the prolapse.
edematous and inflamed tissue, but office surgery is sometimes required to solve an acute painful process such as
thrombosis (Case 4). On rare occasions, circumferential
thrombosis is best treated in the operating room with
anesthetic blockade.
As a rule of thumb, it should be remembered that
most hemorrhoidal problems can be solved without surgical intervention.
Treatment for procidentia, unfortunately, does not
enjoy the same success rate as hemorrhoidectomy. Once
diagnosed, the solution is surgical, but the choices for repair are numerous. They fall into three basic categories:
(1) anal encirclement procedures (Thiersch), (2) perineal
approaches (Altmeier or Delorme), and (3) abdominal approaches.
Historically, the circlage, or Thiersch procedure, has
been around the longest. The prolapse is reduced and
maintained by reinforcing the external sphincter mechanism with a permanent material placed outside of the
sphincter mechanism and underneath the skin. The recurrence and infection rates are high. It is now reserved for
the very infirm.
Perineal solutions have enjoyed a resurgence in popularity, particularly among the elderly patient population,
since the operation is performed under regional anesthesia. It involves resection or plication of the redundant
bowel via the anal canal. Although this does not treat any
underlying cause of the problem, the recurrence rate is
somewhat lower than an encircling procedure and the operation is quite safe.
The abdominal approach has the lowest recurrence
rate but also the greatest morbidity. Evaluation of the
anatomy is more complete and the operation can be combined with a resection, rectopexy, or very low dissection.
Most versions include a very low dissection in order to
create a plane of scarring in the retrorectal space. The
risks are the same as for low anterior resection. Choice of
operation is based on an individual’s activity, experience,
and preference of the surgeon.
It should be noted that the pathophysiology of procidentia is not completely understood. A weakening of the
pelvic floor leads to the intussusception or prolapse, but
the role of bowel function and motility is not fully appreciated as a precursor to this event.
H E M O R R H O I D S
K E Y
P O I N T S
A N D
R E C T A L
P R O L A P S E
2 5 1
SUGGESTED READINGS
• Successful treatment of hemorrhoids requires accurate diagnosis and elimination of other perianal disease as the cause of
patient complaint; since hemorrhoids are normal human
anatomy, will invariably be present, but may not be contributing to patient’s problem
Corman ML: Rubber band ligation of hemorrhoids. Arch Surg
112:1257, 1977
• Rule of thumb: majority of hemorrhoidal problems can be
solved without surgical intervention
Huber FT, Stein H, Siewert JR: Functional results after treatment of rectal prolapse with rectopexy and sigmoid resection. World Surg 19:138, 1995.
H
Simplified technical description of the most common technique used for internal hemorrhoid treatment.
Prospective study looking not just at anatomic but also functional results.
FOLLOW-UP
emorrhoid disease and symptoms tend to recur in
time if the inciting cause is not altered. The more conservative the therapy, the more likely the onset of recurrent
symptoms. Follow-up should therefore emphasize avoidance of constipation and include dietary counseling.
Postoperative follow-up, however, should be done in a
rigorous fashion to avoid the preventable complications—
stenosis, prolonged pain, and constipative bowel habit.
Counseling the patient on high fiber diet, hygiene, and
pain control should be done both in the pre- and postoperative phase. Postoperative examinations should be done
every 2 weeks until adequate healing has taken place to
avoid postoperative stricture and stenosis. This may last
up to 12 weeks. Additional informational exchanges can
also take place on the telephone to eliminate anxiety and
answer simple questions.
Rectal prolapse operations all carry a significant incidence of recurrence, perineal operations more so than
abdominal operations. Although the exact cause of prolapse is unknown, avoidance of constipation and straining
is felt to be important. Fecal incontinence is common in
patients with prolapse (Case 2), and improvement is seen
in approximately 50% of patients following operation.
However, optimal function may take up to 6 months to
achieve.
Loder KM, Kamm MA, Nicholls RJ, Phillips RKS: Hemorrhoids: pathology, pathophysiology and aetiology. Br J Surg
81:946, 1994
Comprehensive review focusing on pathophysiology.
Williams JG, Madoff RD: Perineal repair for rectal prolapse.
Prob Gen Surg 9:732, 1992
Outlines perineal approach and options.
QUESTIONS
1. Internal hemorrhoids?
A. Typically cause pain associated with bowel
movements.
B. Are universally present.
C. Are most appropriately treated with the laser.
D. Are readily diagnosed on digital examination.
2. Rectal prolapse?
A. Can be difficult to differentiate from internal
hemorrhoids.
B. Is best treated surgically.
C. Can lead to fecal incontinence.
D. May be treated via an abdominal approach.
E. All of the above.
(See p. 604 for answers.)
`