Anatomy Recall

Illustration: Rectum and Anal Canal

 ANAL DISORDERS
Evaluating Patient with Anorectal pain
► Pains in the anorectal area may arise from many
sources

Pain that occurs:

during and
after a bowel movement and
that is described as sharp
usually is associated with
an anal fissure or
an abrasion of the anal canal
 ANAL DISORDERS
Evaluating Patient with Anorectal pain
►Tenesmus, which is a symptom complex of straining
and the urge to defecate:
frequently is associated with:
inflammatory or
neoplastic conditions of the anorectum

Pain is likely to be described as:

sharp
burning or
stinging
 ANAL DISORDERS
Evaluating Patient with Anorectal pain
► The pain associated with perianal abscess usually
is described as throbbing

► Pain that increases in intensity when the patient

coughs or sneezes often is associated with an
intersphincteric abscess
 ANAL DISORDERS

Evaluating Patient with Anorectal pain

► Anorectal pain that is experienced other than with
the passage of stool rarely is anal in origin

An example is the classic history of levator ani muscle

spasm, better known as proctalgia fugax
 ANAL DISORDERS

Evaluating Patient with Anorectal pain

► Coccygeal pain rarely is anal in origin; most
patients who complain of this type of pain have
sustained some trauma to the:
ligaments or
periosteum of the coccyx
 ANAL DISORDERS

Evaluating Patient with Anorectal pain

► Workup should start with an examination of the
anal area
an anal fissure
perianal skin abrasion
mass or
bulging
usually can be recognized
 ANAL DISORDERS

Evaluating Patient with Anorectal pain

► Digital examination easily can detect:
the point of tenderness or
a mass
both intraluminal and extraluminal,
especially in the anorectal area
 ANAL DISORDERS
Evaluating Patient with Anorectal pain
Proctoscopy and flexible sigmoidoscopy should be
performed to rule out:
anorectal or
sigmoid lesions or
abnormalities

A barium enema is indicated if an extraluminal

mass is detected or suspected

A CT scan and US of the pelvis should also ordered

as indicated
 ANAL DISORDERS

Problem: HEMORRHOIDS
The definition of “hemorrhoid” has changed
Hemorrhoids are not varicose veins

►In the upper anal canal, there are three bulging, soft
masses in the:
left lateral
right posterior and
right anterior quadrants
 ANAL DISORDERS
Problem: HEMORRHOIDS
“Hemorrhoids” is a pathologic term, used to described
an anal cushion that has:
lost its elasticity and
has slid or
prolapsed to or through the anal canal

Frequency:
The peak age is 45-65 years, however, hemorrhoids
plague all age groups
 ANAL DISORDERS
Problem: HEMORRHOIDS
►Etiology

The cause of hemorrhoids is still unknown

Presumably, repeated straining at defecation

causes disruption of the mucosal Treitz’s muscle
 ANAL DISORDERS
Problem: HEMORRHOIDS
►Etiology
Patients with the following diseases and conditions
have increased risk of hemorrhoidal complaints:
1) Inflammatory bowel disease and hemorrhoidal problem
occur frequently

Hemorrhoidal presentations and findings should alert the

clinician to the potential inflammatory bowel disease

2) Pregnancy is associated with many anorectal problems,

such as hemorrhoids
 ANAL DISORDERS
Problem: HEMORRHOIDS
►Pathophysiology
The term hemorrhoid is usually related to symptoms
caused by hemorrhoids

Hemorrhoids are present in healthy individuals

In fact, hemorrhoidal columns are present in utero

 ANAL DISORDERS
Problem: HEMORRHOIDS
►Pathophysiology
When these vascular cushions produce
symptoms, they are referred to as hemorrhoids

Hemorrhoids generally cause symptoms when they

become
enlarged
inflamed
thrombosed or
prolapsed
 ANAL DISORDERS
Problem: HEMORRHOIDS
►Pathophysiology
Most authors agree that low-fiber diets cause small-
caliber stools, which result in straining with
defecation

This increased pressure causes engorgement of the

hemorrhoids, possibly by interfering with venous
return
 ANAL DISORDERS
Problem: HEMORRHOIDS
►Pathophysiology
Pregnancy and
abnormally high tension of the internal sphincter
muscle
can also cause hemorrhoidal problems,
presumably by means of the same mechanism
 ANAL DISORDERS
Problem: HEMORRHOIDS
►Pathophysiology
Decreased venous return is thought to be the
mechanism of action

Prolonged sitting on a toilet (e.g., while reading) is

believed to cause a relative venous return problem in
the perianal area (a tourniquet effect), resulting in
enlarged hemorrhoids
 ANAL DISORDERS

Problem: HEMORRHOIDS
►Pathophysiology
Aging causes weakening of the support structures,
which facilitates prolapse

Weakening of support structures can occur as early as

the third decade of life
 ANAL DISORDERS

Problem: HEMORRHOIDS
►Pathophysiology
straining and
constipation
have long been thought of as culprits in the
formation of hemorrhoids

This may or may not be true

 ANAL DISORDERS

Problem: HEMORROIDS
►Pathophysiology
Portal hypertension has often been mentioned in
conjunction with hemorrhoids

Hemorrhoidal symptoms do not occur more frequently

in patients with portal hypertension than in those
without
 ANAL DISORDERS

Problem: HEMORRHOIDS
►Clinical
Most laypersons and many practitioners attribute all
perianal symptoms to hemorrhoids

The astute clinician can often listen to a

patient's description of symptoms and ascertain
the source of the problem or condition before
confirmatory examination
 ANAL DISORDERS

Problem: HEMORRHOIDS
►Clinical
Nonhemorrhoidal causes of symptoms
e.g.:
Fissure
abscess
fistula
pruritus ani
condylomata viral and bacterial skin infections
need to be excluded
 ANAL DISORDERS

Problem: HEMORRHOIDS
►Clinical
Hemorrhoidal symptoms are divided into internal and
external sources

Internal hemorrhoids cannot cause cutaneous pain,

as they are above the dentate line and are not
innervated by cutaneous nerves
►Clinical (Internal hemorrhoids)
They
can: * bleed
* prolapse and
cause * perianal itching and * irritation

can cause perianal pain by prolapsing and causing

spasm of the sphincter complex around the
hemorrhoids
 ANAL DISORDERS
Problem: HEMORRHOIDS
►Clinical
Internal hemorrhoids can also cause acute pain
when:
incarcerated and
strangulated

Again, the pain is related to the sphincter complex

spasm
 ANAL DISORDERS

Problem: HEMORROIDS
►Clinical
Strangulation with necrosis may cause more deep
discomfort

When these catastrophic events occur, the sphincter

spasm often causes concomitant external
thrombosis
 ANAL DISORDERS

Problem: HEMORROIDS
►Clinical
External thrombosis causes acute cutaneous pain

This consternation of symptoms is referred to as

acute hemorrhoidal crisis

It usually requires emergent treatment

 ANAL DISORDERS
Problem: HEMORROIDS
►Clinical
Internal hemorrhoids most commonly cause
painless bleeding with bowel movements

Internal hemorrhoids can deposit mucus onto the

perianal tissue with prolapse. This mucus with
microscopic stool contents can cause a localized
dermatitis, which is called pruritus ani
 ANAL DISORDERS
Problem: HEMORROIDS
►Clinical
External hemorrhoids cause symptoms in 2 ways

First, acute thrombosis of the underlying external

hemorrhoidal vein can occur

Acute thrombosis is usually related to a specific

event, for example, physical exertion, straining with
constipation, about of diarrhea, or a change in diet
 ANAL DISORDERS
Problem: HEMORROIDS
►Clinical
External hemorrhoids
These are acute, painful events

Pain results from rapid distension of innervated skin

by the clot and surrounding edema

The pain lasts 7-14 days and resolves with resolution

of the thrombosis
 ANAL DISORDERS

Problem: HEMORRHOIDS
►Clinical
With resolution of the thrombosis, the stretched
anoderm persists as excess skin or skin tags

External thromboses can occasionally erode the

overlying skin and cause bleeding
Illustration: Anal Skin Tags
 ANAL DISORDERS
Problem: HEMORRHOIDS
►Clinical
Recurrence occurs approximately 40-50% of the
time, at the same site

This occurs at the same site because the

underlying damaged vein remains present

Simply removing the blood clot and leaving the

weakened vein in place, compared with excision of
the offending vein with the clot, will predispose to
recurrence
 ANAL DISORDERS

Problem: HEMORRHOIDS
►Clinical
External hemorrhoids can also cause trouble with
hygiene

The excess redundant skin left after an acute

thrombosis (skin tags) is actually accountable for
these problems
 ANAL DISORDERS
Problem: HEMORRHOIDS
►Indications
Treat hemorrhoids only when the patient
complains of them

The old adage that it is hard to make an

asymptomatic patient better, applies here

No matter how bad the hemorrhoids look to the

practitioner, they should not be treated unless
they bother the patient
Problem: HEMORRHOIDS
►Contraindications
Care must be taken to ensure that symptoms are not
caused by other perianal diseases
e.g: fissure
fistula
infectious
inflammatory bowel
parasite

Obviously, treating hemorrhoids will not improve these

conditions. Frequently, a thorough history can
eliminate the above conditions
 ANAL DISORDERS

Problem: HEMORRHOIDS
►WORKUP
Hematocrit testing
Is suggested if excessive bleeding with
concomitant anemia is suspected

Coagulation studies
Are indicated if the history and physical
examination suggest coagulopathy
 ANAL DISORDERS

Problem: HEMORRHOIDS
►Imaging Studies
Barium enema study or virtual colonoscopy is
suggested if proximal:
colonic and
intestinal diseases
must be:
excluded and
if endoscopy is not helpful