Rectum complaints

HAEMORRHOIDS
Hemorrhoids are dilated veins within the anal canal in the sub epithelial region form the radical of the superior middle and inferior rectal vein.

TYPES OF HEMORRHOIDS:
1. External hemorrhoids: Situated outside the anal orifice and covered by the skin.
2. Internal hemorrhoids:
Within the anal canal and internal to the anal orifice. Each primary internal hemorrhoids contains main terminal division of superior rectal vessels arranged in the left lateral, right anterior and right posterior positions. In lithotomy position these correspond with the 3, 7 and 11 O’ clock positions.

RISK FACTOR:
Dietary habits
• Low fibre diet
• Mixed diet
• Poor hydration
Bowel habits
• Chronic constipation
• Diarrhoea
• Straining during defecation
Amount of physical activity
• Low physical activity
Obesity
Pregnancy
Sedentary lifestyle
Habit of postponing the bowel movements,
Spinal cord injuries.

CLINICAL FEATURES:
1. BLEEDING
2. PROLAPSE: hemorrhoids are further graded based on their appearance and degree of prolapse:
Grade I: Non-prolapsing hemorrhoids;
Grade II: Prolapsing hemorrhoids on straining but reduce spontaneously;
Grade III: Prolapsing hemorrhoids requiring manual reduction; and
Grade IV: Non-reducible prolapsing hemorrhoids which include acutely thrombosed, incarcerated hemorrhoids.
3. MUCUS DISCHARGE
4. ANEMIA
5. PAIN

INVESTIGATION

• INSPECTION
Internal haemorrhoids without prolapse will not show any abnormal features. In fourth degree the prolapsed piles can be seen in 3, 7 and 11 O’clock position.

• DIGITAL EXAMINATION
Cannot feel an uncomplicated internal piles unless it is thrombosed


• PROCTOSCOPY
A proctoscope is passed to its fullest extend and the obturator is removed. The instrument is then slowly withdrawn. Just below the anorectal ring internal haemorrhoid if present will bulge into the lumen of the proctoscope.

COMPLICATION
• Excessive bleeding
• Thrombosis
• Ulceration
• Fibrosis
• Strangulation
• Gangrene
• Infection and suppuration
• Pylophlebitis and portal pyaemia - very rare

TREATMENT[8]
Treatment options mainly depend on the type and severity of hemorrhoids, patient’s preference, and the expertise of physicians. The current therapies can be grouped into
• CONSERVATIVE MANAGEMENT: Increased fiber intake, medical therapies, and lifestyle changes are included in the conservative treatment options for non-thrombosed hemorrhoids
• OFFICE-BASED PROCEDURES: Rubber-band ligation, injection sclerotherapy, laser photocoagulation, bipolar diathermy, cryotherapy, Doppler-guided hemorrhoidal artery ligation and infrared coagulation; still, they are not suitable for all grades of hemorrhoids and have recognized complications.
• SURGICAL TREATMENT: Hemorrhoidectomy, thrombectomy of external hemorrhoids, and stapled hemorrhoidectomy; however, no single technique has been universally accepted as superior.
Based on clinical practice, it is assumed that surgery is effective for severe prolapsing hemorrhoids, but it is difficult to deal with the post-operative complications. Thus, controversies and lack of agreement still exist on treatment strategies.
Homeopathic literature shows anecdotal data on the usefulness of homeopathic medicines in hemorrhoids. Although remarkable cure of hemorrhoids with homeopathic medicines in casual clinical experiences has been noted, research evidence remains seriously compromised.
ANAL FISSURE
Anal fissures occur at all ages but are more common in the third through the fifth decades. A fissure is the most common cause of rectal bleeding in infancy. The prevalence is equal in males and females. It is associated with constipation, diarrhea, infectious etiologies, perianal trauma, and Crohn’s disease.
Trauma to the anal canal occurs following defecation. This injury occurs in the anterior or, more commonly, the posterior anal canal. Irritation caused by the trauma to the anal canal results in an increased resting pressure of the internal sphincter. The blood supply to the sphincter and anal mucosa enters laterally. Therefore, increased anal sphincter tone results in a relative ischemia in the region of the fissure and leads to poor healing of the anal injury. A fissure that is not in the posterior or anterior position should raise suspicion for other causes, including tuberculosis, syphilis, Crohn’s disease, and malignancy.
A fissure can be easily diagnosed on history alone. The classic complaint is pain, which is strongly associated with defecation and is relentless. The bright red bleeding that can be associated with a fissure is less extensive than that associated with hemorrhoids. On examination, most fissures are located in either the posterior or anterior position. A lateral fissure is worrisome because it may have a less benign nature, and systemic disorders should be ruled out. A chronic fissure is indicated by the presence of a hypertrophied anal papilla at the proximal end of the fissure and a sentinel pile or skin tag at the distal end. Often the circular fibers of the hypertrophied internal sphincter are visible within the base of the fissure. If anal manometry is performed, elevation in anal resting pressure and a sawtooth deformity with paradoxical contractions of the sphincter muscles are pathognomonic. The management of the acute fissure is conservative. Stool softeners for those with constipation, increased dietary fiber and sitz baths are prescribed and will heal 60–90% of fissures. Chronic fissures are those present for >6 weeks.

FISTULA-IN-ANO
Fistula-in-ano is an inflammatory track which has an external opening (secondary opening) in the perianal skin and an internal opening (primary opening) in the anal canal or rectum. This track is lined by unhealthy granulation tissue and fibrous tissue.
The fistula usually originates from a perianal abscess ip the intersphincteric space of the anal canal from infection of the anal gland. As the anal gland is situated deep to the internal sphincter its duct passes through the internal sphincter to open in the crypts of Morgagni situated on the dentate line. Due to the tone the internal sphincter the duct cannot aptly discharge the contents of the gland. Stasis and secondary infection lead to abscess formation from the anal gland in the intersphincteric region. From here the internal opening
traverse through the internal sphincter to open into the anal canal and the abscess usually tracks down and in the perianal skin externally thus fistula-in-ano is formed. Several other disorders must be considered which may cause fistula-in-ano. These are :
(b) Ulcerative colitis, (c) Crohn’s disease, (d) Tuberculosis and (e) Colloid carcinoma of the rectum.
CLASSIFICATION.— Broadly, anal fistula can be divided into two groups — (I) low fistula and (II) high fistula depending on whether the internal opening is below or above the anorectal ring respectively.
(I) Low level fistula.— These fistulae open into the anal canal below the anorectal ring. These can be further subdivided into (i) subcutaneous type, (ii) submucous type, (iii) intersphincteric type, (iv) transphincteric type and (v) suprasphincteric type.
(II) High level fistula.— These fistulae open into the anal canal at or above the anorectal ring. These can be further subdivided into (i) extrasphincteric or supralevator type, (ii) transphincteric type (which
may be seen in low variety also) and (iii) pelvi-rectal fistula. The importance of deciding whether a fistula is a low or a high level type is that a low level fistula can be laid open without fear of permanent incontinence as the anorectal ring
Whereas in case of high level fistula one must diagnose the case before operation and it is usually treated by stages, lest damage to the anorectal ring may cause permanent incontinence.
A fistula may be single or multiple. When there is more than one external opening it is called a multiple anal fistula. In this case there may be one or more internal openings.
Clinical features.— Usually a past history of perianal abscess can be received. The abscess formed and ruptured by itself, the condition healed leaving a tiny discharging sinus. After a few month, again abscess formed, ruptured by itself and a discharging opening is left. After a few recurrent attacks the discharging fistula fails to heal and continues to discharge. This condition also develops when after abscess formation an inadequate incision is made for drainage. Similarly new abscesses may form to cause multiple fistulae.
Tuberculosis is a very common cause of multiple fistulae in this country. More common is solitary fistula with an external opening within 3.7 cm of the anus. Granulation tissue may be seen pouting out from the mouth the fistula. There is much induration of the skin and subcutaneous tissue around the fistula. When fistula forms
secondary to ischiorectal abscess, both the ischiorectal fossae may be involved. An external opening for each side of the ischiorectal fossa may be seen with intercommunicating track lying posterior to the anus. This is called horse-shoe fistula.
GOODSALL'S RULE.— This rule relates the location of the internal opening to the external opening. If the external opening is anterior to an imaginary line drawn-across the midpoint of the anus, the fistula runs straight directly into the anal canal. If the external opening is situated posterior to that line, the track usually curve and the internal opening will be on the midline posterior of the anal canal. An exception to this rule is the external opening is anterior to this imaginary line but is situated more than 1V2 inches (3.75 cm) away from the anus. In this case the track will curve posteriorly and end in the posterior midline.

The internal opening must be felt by digital examination. If it is above the anorectal ring it is a high fistula and the treatment is different from low fistula. Number of internal openings must be noted. Even if there are multiple external fistulae there may be one internal opening.
PROCTOSCOPY — is sometimes necessary to visualise internal opening of the fistula.
LIPIODOL INJECTION—into the eternal opening prior to radiography will show the track of fistula-in-ano. But its utility is in doubt as it seldom gives more information and on the contrary it causes a recrudescence of inflammation.
CHEST X-RAY to exclude tuberculosis is important as fistula-in-ano is often associated with tuberculosis in this country. If the surrounding skin of the fistula is discoloured and the discharge is watery, it strongly suggests a tuberculous origin. In this case, induration around the Fistula is lacking and the opening is irregular with undermined edge. If any doubt regarding cause of fistula-in-ano, the following conditions must be excluded. These are : (a) Tuberculous proctitis, (b) Ulcerative colitis, (c) Crohn’s disease, (d) Bilharziasis, (e) Lymphogranuloma inguinale and (f) Colloid carcinoma of the rectum.
TREATMENT
LOW level fistula.—Fistula track must be laid open. The patient is placed in lithotomy position. The bidigital examination is made under anaesthesia to reveal cord like induration representing the track. A probe is inserted through the Fistula track. Care must be taken not to create a false passage. A propointed director is now introduced through the external opening and its tip comes out through the internal opening. With a knife the track is now opened on the director. If there are multiple fistulae the probe-pointed director is passed through
individual external opening and brought out through the internal opening and the corresponding track is laid open with the knife. After the Fistula track has been laid open, (i) either the unhealthy granulation tissue on the wall of the fistula is scraped off with a Volkmann spoon or (ii) the whole track with the fibrous tissue is excised. The cavity is packed with roller gauze wrung with weak antiseptic lotion. Healing will take place by granulation
tissue from the depth. Some surgeons have advocated split skin graft of the wound resulting from fistulotomy. The grafts are taken
from the inner aspect of the thigh and applied to the anal wound by stitching to the skin edges. However this is not advised as a routine practice.
High level fistula.—
(i) Supralevator fistula is mostly secondary to Crohn’s disease or ulcerative colitis or carcinoma or foreign body. This requires treatment of the primary condition and the fistula is ignored. Any attempt to lay open the fistula will cause incontinence.
(ii) Transphincteric fistula with a perforating secondary track.— In this case there is almost always a low fistula and if care is not taken while inserting the probe-pointed director, the director will go into the high secondary track and if passed hard will open into the rectum above the anorectal ring transforming the condition into a high fistula. So in this type of fistula the lower track is opened as usual and the upper track opening is made wide with scraping the high fistula with Volkmann spoon. The upper track will heal by itself alongwith the low fistula. Alternatively the lower part of the track is treated by Fistulotomy. Then a seton of heavy black silk or a rubber band is passed round the deeper part of the track. This will include intact fibres of the sphincter and the anal canal mucous membrane. The silk is tied loosely outside and kept in situ for two weeks. This stimulates fibrosis adjacent to the sphincter muscle. In the second stage, after 6 weeks, the remaining part of the track including the fibres of the sphincter muscles incorporated within the tie is excised. Fibrosis, from the previous operation, prevents retraction of the freshly cut sphincteric fibres. So incontinence which is the most serious complication of this operation is avoided. This operation is known as Gabriel's two-stage operation. Instead of passing the silk, a stainless steel wire may be passed round the deeper part of the track. After two weeks, the knot is gradually tightened during subsequent dressings. The wire cuts through the shows use of Seton in case of high fistula. Healing occurs in parts as the new portion is cut and the old portion (iii) High intersphincteric fistula.— It is also treated in the similar fashion as described in the previous section.
Horse-shoe fistula is usually not treated by radical unroofing procedure (fistulotomy). Instead a posterior midline internal sphincterotomy combined with laying open the deep part of the fistula track is performed. lateral tracks are excised. This has proved effective. This is Wanley operation.