hemorrhoid NCBI by mikesanye


									Office Proctology-How I do it
                                                             the knee-chest position, allowing the buttocks to be
                      ABSTRACT                               drawn apart. It is very helpful to have the patient
     Several new concepts and some excellent                 'bear down' at this point so that the physician can
     new office procedures are brought out in                clearly see the external hemorrhoidal area and any
     the discussion of six of the commonest                  fissure-in-ano as well as any prolapsing internal hem-
     anorectal diseases seen in the family physi-            orrhoids.
     cian's office.                                            Then, the insertion of a well-lubricated, gloved
                                                             finger to check the sphincter, anal canal and prostate
                                                             (in a male); this prepares the anal canal for the an,-
                                                             scope, and the finger gives a good indication of the
THE FAMILY PHYSICIAN SHOULD        be   aware   of the im-   direction in which the anoscope should be inserted.
portant    facts that make the anorectal examination         I use the Welch-Allyn anoscope with a light-carrier,
easy and quick, and also of some exciting new de-            and insert this with the handle pointing toward the
velopments in office proctology. A complaint in the          posterior gluteal cleft.
anorectal area is particularly distressing to the patient.     After the tight sphincter has been passed, the tip
To alleviate this is a most rewarding part of office         of the anoscope is directed more posteriorly and in-
practice, since the results are so gratifying to both        serted to its fullest extent. This insertion is aided by
patient and doctor.                                          drawing each buttock apart with the other hand as one
                                                             advances, and also by asking the patient to take a
Anatomy                                                      deep breath in, and sigh out slowly; this helps relax
   For practical purposes the key to the anorectum           the patient's sphincter. The obturator is then with-
is the pectinate line. It is well worth the effort to look   drawn and if the scope is inserted far enough one
for this circular corrugated line, which is about 2 cm.      should see the rectal canal open above. All the infor-
from the anal orifice, and is made up of the serrated        mation is then gained on slow withdrawal of the
fringe produced by the anal valves. It is usually quite      instrument, which is facilitated by placing the index
easy to see the vertical depressions between the col-        finger of the free hand on the proximal rim of the
umns of Morgagni, just proximal and leading down             anoscope during withdrawal.
to these valves.                                               After the rectal mucosa is inspected, one must pause
   Above the pectinate line, the mucosa is a deep            at the rough area of the pectinate line and ask the
purple in color and is supplied by the autonomic             patient to strain down again; this will bring into view
nervous system which renders it painless. Any internal       the blue internal hemorrhoidal area. Upon further
hemorrhoids are located above this line.                     withdrawal, attention may be focussed posteriorly for
   Immediately below the pectinate line the anal canal       any fissures as the external hemorrhoidal area comes
is smooth, pale and stretched, and has the character-        into view.
istics of skin, including the somatic nervous system
supply with its pain fibres. Any external hemorrhoids
are located below this line, as are fissures-in-ano.
   If this anatomy is distorted by a prolapsing internal
hemorrhoid or a thrombosed external hemorrhoid, the
pectinate line is immediately above a groove created
by the suspensory ligaments which will be seen below                            Dr. Rudd is in private practice
the prolapsing internal hemorrhoid, or above a throm-                           limited to surgery of the colon and
bosed external hemorrhoid.                                                      rectum in Toronto.
Anorectal Examination
   Careful inspection requires that the patient's knees
be drawn up to the chest, either in the lateral or in
CANADIAN FAMILY PHYSICIAN       MARCH, 1970                                                                        51
   TIhis is one of the most common anorectal com-            tions, and the long term results are as good-or better
plaints seen in the doctor's office, and one of the most     -than in a standard hemorrhoidectomy.
neglected; yet it is often very easy to do something            An internal hemorrhoid is essentially a varicosity
about. The majority of cases are still idiopathic and        of the venous plexus of the wall of the anorectum, and
treatment is therefore symptomatic. Even if it is secon-     is covered by mucosa which is supplied by the auto-
dary, symptomatic treatment is necessary during the          nomic nervous system and not by the pain-sensitive
investigation.                                               skin. The pectinate line is seen below the internal
   Dramatic response will usually occur on the follow-      hemorrhoid. The theory currently in favor for the
ing strict routine: the perianal area must be kept          etiology of internal hemorrhoids is distension of the
clean and dry at all times. In addition to warm sitz        venous plexus, producing varicosities by obstruction
baths (with salt, if edema is present) the patient           to the venous return (but not of the arterial inflow)
should always wash himself with warm water follow-          by hard stool pressed against a tight sphincter; hence
ing each bowel movement, and pat (not scratch) him-         it is important for the patient to relax during bowel
self dry. Also, whenever the patient feels itchy, or if     movement. Over the years the distension increases and
the perianal area becomes moist, it is advisable to         varices become more marked and prolapsing.
apply talc powder quite liberally to the area. A steroid        A first degree hemorrhoid is just a bulge into the
cream should be applied sparingly, both morning and         lumen, whereas a second-degree hemorrhoid protrudes
night.                                                      through the sphincter on straining, but returns on
   Avoid mineral oil, as this may contribute to the         relaxing. Third degree hemorrhoids must be replaced
rectal discharge; instead, give a bulk forming stool        manually and those of fourth degree are completely
softener. Some patients should avoid eating spices          irriducible.
which can be irritating to the area. Then, if there's no       The varicosities are more obvious in the younger
improvement within a few days, further investigation        patient, but in older patients large amounts of re-
for an underlying cause of the pruitis ani should be        dundant prolapsing mucosa are often more obvious
immediately undertaken.                                     than the varicosities.
                                                               Typically, the patient complains of bright red
External Hemorrhoids                                        bleeding with constipated stools. Although discom-
   This is a misnomer, since the usual cause of this        fort is uusally present, beware of the patient who
is rupture of the external veins during straining at        complains of severe pain, since either the hemorrhoid
defecation, resulting in the formation of a sub-cutan-      is thrombosed, or the pain is due to an anal hema-
eous hematoma. The correct term is therefore anal           toma, fissure-in-ano or perianal abscess.
hematoma.                                                      The correct diagnosis is sometimes made on inspec-
   Usually dark blue in color, they are dome-shaped,        tion alone, asking the patient to 'bear down' while
with tense pain-sensitive skin covering them. Their         in the squatting position with the buttocks separated.
location is external to the pectinate line and inter-       However, internal hemorrhoids are best diagnosed
hemorrhoidal groove, and are easily seen by spread-         with the anoscope in place at the pectinate line, and
ing the buttocks. Their onset is usually sudden and         by asking the patient to 'bear down' and by visually
painful.                                                    observing the protruding hemorrhoids through the
   The best treatment, if they are seen within 24           anoscope.
hours (before the blood clot has a chance to adhere            The family physician need no longer postpone
to the side wall) is to inject a small amount of local      early treatment of hemorrhoids because of fear on
anesthetic using a very fine needle just under the          the patient's part. Grade I internal hemorrhoids are
skin over the dome of the hematoma, and incise it           still best treated by injection, but the result is only
with a scalpel. The blood clot will come out easily.        temporary, and very few give rise to symptoms in this
If done after 24 hours, incomplete evacuation of the        early stage. The treatment of choice for all other
clot is likely to result in an infection, abscess, and      internal hemorrhoids is the office hemorrhoidectomy
possibly a fistula. A complete excision of the hema-        ligation, which is not new and is now possible be-
toma is possible, but more involved, and leaves the         cause of the development of new instruments, high
patient with a painful wound for a number of days.          quality latex ligatures, and refinements in technique.
Following the great stretching of the perianal skin         The principle of this treatment is to place a latex
over the hematoma, the patient is often left with a         band carefully around the neck of the internal hemor-
skin tag, but this is of no consequence.                    rhoid, which is placed on stretch. Then, under careful
   Conservative therapy is more commonly required           direct vision in a clear field, the band is placed around
and consists of bed-rest for the first two days, apply-     the hemorrhoid just proximal to the pectinate line,
ing heat to the area; also the use of sitz baths, analge-   and must include the edges and the proximal redun-
sics, glycerine suppositories and stool softeners.          dant mucosa within the ligature (to avoid leaving
                                                            any tags behind). All this is done above the pectinate
Internal Hemorrhoids                                        line, where there are no pain fibres. Following the
  It is not generally realized that an internal hemor-      ligation, the hemorrhoid looks like a small balloon
rhoidectomy is now simply and effectively performed         tied off at its neck. This becomes cyanotic, and shrivels
in the office, in competent hands. Hospitalization,         up in 24 to 48 hours, falling off with the latex bands,
anesthetic, and loss of time from work are completely       taking an average of six days to separate. This leaves
unnecessary; there is no pain, there are few complica-      an intact granulating base with no possibility of stric-
52                                                                      CANADIAN FAMILY PHYSICIAN * MARCH, 1970
ture formation or surface infection and abscess forma-      anestlhetic is necessary, and the abscess should be open-
tion.                                                       ed at the dome and especially posteriorly in the skin,
   In our series of 360 hemorrhoidectomy ligations in       to make sure the cavity closes before the skin, to en-
110 consecutive patients, we have had no significant        sure good drainage. Never wait until the abscess has
bleeding, and only a few patients lost even one day         matured; never depend on antibiotics for this treat-
from work. In no case was even a local anesthetic           ment. The tract must be made externally through the
used, and all cases were done in the office-often           skin and not allowed to form a sinus or fistula spon-
during the patient's lunch hour.                            taneously into the bowel.
   Longer term follow up of these patients has sug-         Prolapse of the Rectum
gested the recurrence rate to be just as good if not           This is included in this paper not because it is
slightly better than in the standard hemorrhoidec-
tomy, and complications to be much less. Patient            common, but because there is an excellent new method
satisfaction is extremely gratifying, to say the least.     of treatment for each type of prolapse in the adult.
                                                               In incomplete prolapse, patients complain of rectal
Fissure-in-Ano                                              discharge, pruritis ani, slight incontinence, and diffi-
   This small lesion is located in the lower part of        culty keeping the anal area clean. It is sometimes
the anal canal in pain-sensitive skin, and despite its      confused with prolapsing internal hemorrhoids and
small size, may produce a great deal of pain. It is         is also sometimes associated with them. The current
practically always in the mid-line posteriorly, very        treatment is now extremely simple, using the office
occasionally in the mid-line anteriorly, and rarely else-   ligation technique described above under "internal
where It is nearly always single, starting as a simple      hemorrhoids". This gives perfect results, and usually
split in the skin of the anal canal. This may develop       the patient is unaware that anything has been done;
edematous and then fibrous overlapping edges, with a        the results are dramatic.
tag-like swelling of skin at the lower end of the fissure      Complete rectal prolapse is easy to diagnose in the
called a "sentinal pile."                                   advanced stage but more difficult in the early stage.
   The base of the fissure may erode through the            The diagnosis favors the complete prolapse whenever
submucosal tissues to lay bare the distal edge of the       there is a circumferential circular wrinkling of the
internal sphincter muscle; if this becomes fibrosed         mucosa of the prolapse, a feeling of thickness of the
following prolonged inflammation, it is known as the        muscular wall between the two layers of mucosa on
'pecten band'. The fissure may become infected, result      palpation, and laxity of the sphincter.
in a perianal abscess, and a low anal fissure.                 A great breakthrough has been achieved by the
   Treatment of the early acute fissure is simply sitz      Ripstein group who have shown by cine barium ene-
baths, bulk forming stool softeners, and anal hygiene.      ma studies that prolapse of the rectum is due to an
But if this pain continues, local anesthetic may be         anatomical defect, which allows the rectum to pull
injected into the tight sphincter and deep to the           away from the sacrum and straighten on defecation,
fissure, but only with great care and in small amounts.     resulting in great pressure along the length of the
   Treatment of chronic fissure with thickened edges,       rectum, and hence the prolapse. Normally, during
sentinal pile, or pecten band, is surgical. I feel that     defecation the rectum is pushed backwards against
the best method is anal dilatation under general             the hollow of the sacrum. This discovery has com-
anesthetic, with simple excision of the fibrous edges       pletely transformed surgical treatment from compli-
and the sentinal pile, and not sphinterotomy, to begin      cated procedures, which often involved combined ap-
with. The latter has a disturbing and unacceptably          proaches from above and below, bowel resections,
high incidence of anal incontinence not associated           suspension and repairing of the pelvic floor (which
with anal dilatation. Sphincterotomy may be required         in many cases was paper-thin to begin with). Now the
 in the few cases that fail with simple dilatation.         very simple approach of holding the rectum against
                                                             the sacrum with a Teflon mesh T-shaped sling, under
Anorectal Abscess                                            the proper tension against the sacrum, can be done
  This diagnosis should be considered whenever the           very quickly and safely, even on the elderly and de-
patient complains of severe pain in the ano-rectal           habilitated, with excellent results.
area. It must be stressed that this is a surgical emer-         A number of new concepts and methods of treat-
gency, since it is easy to do an incision and drainage       ment have been presented in the discussion of six of
on a simple abscess, but sometimes extremely difficult       the most common proctological problems seen in the
to deal with its serious complications of fistula-in-ano;    office. All but two of these treatments are best done in
                                                             the office.                                            4
the latter should be avoided at all costs. A general


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