Best Remedies for Hemorrhoids
Patients who present with acutely thrombosed external hemorrhoids will typically complain of an intensely painful anal mass. Inspection of the perianal skin reveals the diagnosis with a swollen, tense external hemorrhoid. If such a lesion is not present, anal fissure or perianal abscess must be ruled out. Excision is recommended for a thrombosed hemorrhoid manifested with intense pain if duration is within 48 hours of onset, or if ulceration or rupture occurs. If pain is improving, symptomatic therapy with sitz baths, bulking agents, and analgesics is preferred. Excision may be performed in the office using local anesthetic. The wound is left open to heal by secondary intention. Larger, more broadly based thromboses may be managed by incision and evacuation of the clot to avoid creation of a large skin defect.
Operative hemorrhoidectomy and rubber band ligation are the two most-common interventions for symptomatic hemorrhoids today. Both are highly effective when utilized properly. Hemorrhoidectomy refers to the operative excision of the hemorrhoids, usually in the outpatient surgical suite, whereas rubber band ligation is performed in the office setting. Hemorrhoids are generally symptomatic with either bleeding (typically bright red, painless, and commonly dripping into the toilet bowl) or protrusion (occasionally associated with discomfort, itching, or irritation and burning). Pain is usually not a symptom of hemorrhoids unless thrombosis or strangulation has occurred.
Rectal prolapse is an uncommon condition defined as complete protrusion of the entire thickness of the rectal wall through the anus. It is seen far more commonly in women than in men and generally after the age of 40 (15). Pathologic defects noted are a diastasis of the levator ani muscles, an abnormally deep cul de sac, an elongated sigmoid colon, and loss of the rectal fixation to the sacrum. Prolapse can secondarily result in incontinence caused by a patulous anus. Numerous procedures have been described for correction of rectal prolapse, including both abdominal and perineal approaches. Neither approach requires specialized facilities and the choice of approach is generally determined by patient risk factors. One of the most common abdominal operations employed is the Ripstein procedure. It is indicated for the repair of complete rectal prolapse in a patient considered being an acceptable risk for abdominal surgery. Contraindications include an excessively redundant sigmoid colon...
Physiologic mechanism of advanced hemorrhoidal disease. By promoting tissue fibrosis in various ways, the vascular cushions become fixed to the underlying muscular tissue. Injection sclerotherapy has been used for hemorrhoidal disease treatment for over 100 years. Indicated to treat bleeding first, second, or early third degree internal hemorrhoids, a small amount of a sclerosing agent is injected above the dentate line. Five percent phenol in vegetable oil has been traditionally used, but other agents such as quinine, urea hydrochloride, and sodium morrhuate, are available. It is a straightforward, quick, painless, and inexpensive method, with success reported in up to 75 of patients. Although complications of pelvic sepsis and perianal necrosis have been reported, sloughing of the overlying mucosa, local infections, and allergic reactions to the injected material are more commonly described side effects. Rubber Band Ligation Rubber band ligation is probably the most commonly used...
The anorectum is a frequent source ofsignificant lower GI bleeding. It frequently manifests with small amounts of bright red blood noted on the toilet paper, coating the stool, or dripping into the toilet bowl. Many causes of anorectal bleeding, such as hemorrhoids and fissures, are recurrent. Constipation occasionally causes stercoral ulcers due to fecal impaction or the solitary rectal ulcer syndrome from mucosal trauma, rectal prolapse, or direct digital trauma to aid evacuation, which can lead to anorectal hemorrhage. In patients with portal hypertension, rectal varices can cause life threatening hemorrhage which often requires rectal packing or even emergent surgery to control. The finding of very prominent hemorrhoids should always prompt the question Does this patient have portal hypertension There is a separate chapter on hemorrhoids (see Chapter 92, Hemorrhoids ).
Is it prudent to perform a hemorrhoidectomy in a CD patient In the past, complications such as fistula, stricture, abscesses, and need for proctectomy (Jeffery et al, 1977) precluded hemorrhoidectomy in patients with CD. In contrast, Wolkomir reported successful outcomes in healing in 15 of 17 patients undergoing hemorrhoidectomy. Nonetheless, hemorrhoids generally are not removed in patients with CD, because of potential imperfect wound healing and stricture formation. There is a separate chapter on hemorrhoids (see Chapter 92, Hemorrhoids ).
The word prolapse comes from the Latin term prolapsus and means falling down. Rectal prolapse was described in 1500 BC in the Ebers papyrus, and Mr. Frederick Salmon, the founder of the famous St. Marks Hospital in London, wrote his classic article Practical observations on prolapsus of the rectum in 1831. Rectal prolapse is a benign disorder that is frequently associated with disturbed bowel function. Rectal prolapse can be treated surgically by many different techniques and results regarding recurrence rate and mortality are generally good. Unfortunately, anal incontinence and or constipation sometimes continue to bother the patients after otherwise successful correction of the prolapse.
The most commonly complained of rectal pain is intermittent severe rectal pain that is not associated with defecation but may wake the sleeping patient. It is difficult to explain and does not usually result from organic disease. In men prostatitis is a common cause of rectal pain symptoms include perianal pain. Rectal pain will be worse on defecation (Hopcroft & Forte, 2003).
Rubber band ligation is performed for internal hemorrhoids with bleeding or minor degrees of protrusion. It is not performed for external hemorrhoids in patients with coagulopathies, or generally in patients taking anticoagulants (banding is performed in the office or the outpatient clinic and requires no specific preparation). The patient is placed in the knee-chest or lateral position, an anoscope is inserted, and the hemorrhoidal group to be ligated is visualized. Using a ligator placed through the anoscope, the redundant portion of the mucosa at the upper portion of the hemorrhoid is grasped and a constricting elastic band is placed around it. If the band is placed lower, significant pain may result (Fig. 6). The hemorrhoid will slough in 7-10 d leaving a small, ulcerated area to heal.
The classic triad of symptoms includes abdominal distention, bilious vomiting, and bloody stools. Most patients, however, present with less specific symptoms. The onset of acute NEC has a bimodal pattern. It generally occurs in the first week of life (in newborns more than 34 weeks of gestational age), but in some it may be delayed to the second to the fourth week (mostly in those less than 30 weeks of gestational age). The affected term neonate is usually systemically ill with other predisposing maternal and individual conditions (see above). Premature babies are at risk for several weeks after birth, with the age of onset inversely related to their gestational age. The typical infant with NEC is premature and recovering from some form of stress, but is well enough to begin gavage feedings. Initial symptoms may include progressive subtle signs of feeding intolerance, and subtle systemic signs. In advanced disease, a fulminant systemic collapse and consumption coagulopathy occurs....
Endoscopic variceal ligation (EVL), also referred to as variceal banding, is an endoscopic therapy for acute esophageal variceal bleeding, and for elective eradication of varices after the initial episode of hemorrhage. EVL technique for the esophageal varices is similar to endoscopic treatment of rectal hemorrhoids. The ligation is accomplished by placement of an elastic band on the varix, which strangulates a blood vessel, resulting in vessel thrombosis. The thrombosed varix undergoes necrosis and sloughs off, to be replaced by fibrous tissue in the process of mucosal healing.
Multiple hemorrhoidal ligation a prospective, randomized trial evaluating a new technique. Dis Colon Rectum 2003 46 179-86. Guy RJ, Seow-Choen F. Septic complications after treatment of haemorrhoids. Br J Surg 2003 90 147-56. Johanson JF. Nonsurgical treatment of hemorrhoids. J Gastrointest Surg 2002 6 290-4. Johanson JF, Rimm A. Optimal nonsurgical treatment of hemorrhoids a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. Am J Gastroenterol 1992 87 1600-6. Loder PB, Kamm MA, Nicholls RJ, Phillips RK. Hemorrhoids pathology, pathophysiology and aetiology. Br J Surg 1994 81 946-54. Sardinha TC, Corman ML. Hemorrhoids. Surg Clin North Am 2002 82 1153-67. Sutherland LM, Burchard AK, Matsuda K, et al. A systematic review of stapled hemorrhoidectomy. Arch Surg 2002 137 1395-406. The Standards Task Force American Society of Colon and Rectal Surgeons. Practice parameters for the treatment of hemorrhoids. Dis Colon Rectum 1993 36...
Hemorrhoids are cushions of vascular tissue that are present from birth and are therefore considered normal anatomy. Internal hemorrhoids arise from the superior hemorrhoidal vascular plexus cephalad to the dentate line and are covered by mucosa. External hemorrhoids are dilations of the inferior hemorrhoidal plexus. Located below the dentate line, they are covered with anoderm and perianal skin. Because these plexuses communicate, a combination of external and internal hemorrhoid (mixed hemorrhoids, Figure 92-1) is often seen. There are three major hemorrhoidal cushions, which appear in the left lateral, right anterior, and right posterior positions however, intervening minor hemorrhoidal complexes may obscure this order. Although the exact role of hemorrhoidal cushions has yet to be defined, it is generally accepted that these vascular cushions contribute to continence by partially occluding the anus. Additionally, they may protect the anal canal during defecation.
Hemorrhoidal disease is a very common medical disturbance, equally distributed among males and females. Incidence peaks at middle age, and declines after the age of 65 years. Because many patients attribute anorectal symptoms to hemorrhoids, the precise occurrence of hemor-rhoidal disease is difficult to compute. The probable prevalence of this condition as estimated by questionnaires is between 4 to 40 , with approximately 1,100 medical office visits per 100,000 persons annually (Sardinha and Corman, 2002).
In all patients with lower GI bleeding, fluid resuscitation and correction of coagulopathy or thrombocytopenia take precedence over diagnostic or therapeutic procedures. Nasogastric (NG) lavage is performed looking for fresh blood, clots, or coffee grounds suggestive of an upper GI source. The absence of blood on NG lavage does not exclude upper GI bleeding, unless bile is obtained. Evaluation of the anorectum should include digital rectal exam and anoscopy. The latter will allow identification of internal hemorrhoids, fissures, or fistulas. After this point, the decision between further diagnostic studies will depend on the severity of bleeding, overall condition of the patient and comorbid diseases, and the availability of each diagnostic tool in a specific hospital. Available options include colonoscopy, tagged red blood cell (RBC) scan, and
Verification of the rectal prolapse and differentiating it from hemorrhoids and or mucosal prolapse is usually the first step in the examination of patients with a history suggestive of rectal prolapse. Rectal prolapse is identified as a circular, full-thickness prolapse extending outside the anal verge when the patient strains. Occasionally the patient is unable to reproduce their prolapse at clinical examination in the left lateral position. Examination in the sitting position on a commode or diagnosis using defecography may then be quite helpful (Mellgren et al, 1994). The patient history should include preoperative constipation and incontinence symptoms, bowel frequency, obstetric history, and other associated pelvic floor disorders, such as co-existing urinary incontinence or genital prolapse. Patients with rectal prolapse are at an increased risk for other concomitant pelvic floor abnormalities.
Blood spotting after anal sex and or blood spotting on the toilet paper is a common compliant in the GU clinic, and is usually the symptom of minor conditions such as haemorrhoids, anal fissures, genital trauma, or genital warts -which can be associated with pruritus (Rhodes & Hsin, 1995). Blood separate from faeces is most commonly due to haemorrhoids, but may also be due to a variety of other causes, including rectal carcinoma and proctitis, which can be associated with a mucous discharge. Is the blood fresh - bright red, or old - darkish brown this can help indicate where the bleeding is from. When does the patient notice it A proctoscopy should be carried out, but it may be that further investigation may be needed outside of our realm of care, in which case refer appropriately. Blood mixed with faeces may be due to Crohn's disease, or inflammatory bowel disease, carcinoma or vascular abnormalities, and the patient should be referred for careful investigation via a...
As noted, an adequate history and physical examination is essential. If the patient has an abscess, it should be adequately drained before proceeding with medications. Not all patients require a colorectal surgeon, that is if the abscess has either drained spontaneously or been drained by incision. On the other hand, if there is persistent rectal pain and or tenderness, or there are multiple draining sites, then a colorectal surgeon should be consulted to be certain that all pus has been adequately drained. In this situation, an EUA and or MRI is indicated.
Approximatively 50 of patients with rectal tumors are asymptomatic. Other patients mainly present with rectal bleeding, constipation, rectal syndrome, or rectal pain. Carcinoid syndrome is very rare because it is very unusual for the tumors to release serotonin into the circulation, despite their capacity to synthesize this amine. About 75 of the lesions are within 8 cm of the anal verge and are possible to reach with digital palpation. Luckily, only about 14 of patients with rectal carcinoids present with metastasis. Local excision or transanal resection is recommended for tumors measuring 1 cm in diameter because these tumors are at low risk for recurrence or metastasis ( 2 ). For tumors between 1 and 2 cm in size (10 of cases) without evidence of lymph node metastasis, wide excision with a meticulous evaluation to exclude muscular invasion is usually recommended. Transanal endosonography may be particularly useful in this intermediate group to assess tumor extension. In doubtful...
Year in some studies and have acceptable complication rates. Migration of stents is the most common issue and rates have been reported as 15 (Fernandez et al, 1999 Baron, 2001). Migration rates appear to be higher with covered stents, which have been successfully used in palliation of rectovaginal or rectovesical fistulas resulting from the rectal cancer. Patients with stents placed too distally may experience tenesmus, rectal pain, and fecal incontinence. Stent occlusion resulting from tumor ingrowth can be treated with argon beam coagulation, laser, or restenting. The relationship of stents and radiotherapy and chemotherapy has not been clearly defined. However, a few patients with stents have been reported to have undergone successful subsequent radiation therapy. There is a separate chapter on intestinal and colonic strictures (see Chapter 85, Intestinal and Colonic Strictures ).
Lower GI bleeding usually presents as hematochezia, or passage of maroon or bright red blood or blood clots per rectum. This is different from upper Gi bleeding, which usually presents with hematemesis and or melena. Although helpful, these distinctions are not absolute. in up to 11 of patients with hematochezia, the culprit lesion is identified in the upper GI tract. Conversely, 19 of patients with lower GI bleeding can present with melena. Overall, the acuity and severity of lower Gi bleeding is less than upper Gi bleeding. According to a survey of members of the American College of Gastroenterology (ACG), patients with lower GI bleeding were less likely to present to the physician with shock or orthostasis compared with patients with upper GI bleeding (19 versus 35 , respectively) and less likely to require blood transfusions (36 versus 64 , respectively). Lower GI bleeding is self-limiting in approximately 80 of cases, although intermittent bleeding episodes do occur. The...
Tinal blood loss (hematochezia, ortarrystools) or as a result of abnormal blood tests indicating anemia or elevated carcinoembryonic antigen (CEA). Once discovered or suspected, confirmation and simultaneous staging are the roles most often conferred on CT, MR imaging, ultrasound, CTC, and DCBE. The radiologist must describe tumor size location depth of local wall penetration, if feasible involvement of nodes spread to other organs and associated complications, such as obstruction, hemorrhage, abscess formation, inflammation, perforation and the like (within the limitations of the modality). In the following subsections, each modality is reviewed with respect to expected appearances and pitfalls in detecting and staging CRC and its relative accuracy in staging.
Upper abdominal pain or distress of insidious onset, often localized to the midepigastrium is the most frequent symptom (4). Expansion of the pseudocyst may likewise result in duodenal or biliary obstruction, vascular occlusion, or fistula formation into adjacent structures such as the viscera, pleura, or pericardium (6). Leakage from the pseudocyst or pancreatic duct with concomitant fistula formation can result in pancreatic ascites or a pleural effusion. Pseudocyst rupture occurs in less than 3 of patients (7), and may be clinically asymptomatic. However, rupture into the peritoneum can present as an acute abdominal event necessitating emergent surgery, which is often fatal (8). Erosion into the gastrointestinal tract may result in hematemesis, melena, or massive hematochezia (9). Massive bleeding into the gastrointestinal tract occurs in approx 5-10 of patients (10,11), and occurs as a result of pseudocyst erosion into a major pancreatic or peripancreatic vessel, leading to free...
Pain is a subjective experience there are no diagnostic tests that can determine the quality or intensity of an individual's pain. Regardless of whether there is an apparent so-called organic cause of the pain or not, the physician should bear in mind that pain often dominates the lives of patients in a negative fashion. Unfortunately, the patient with chronic abdominal pain is increasingly perceived as a clinical liability by the busy practitioner, with his or her symptoms either trivialized or perhaps worse, dismissed as representative of either malingering , psychosomatic , or drug-seeking behavior. These and various other, rather unscientific euphemisms of a similar nature are reflective of the physician's lack of understanding of the biological basis, as well as the psychosocial dimensions, of chronic pain and the consequent frustration of not being able to place the symptom in a conceptually familiar frame of reference (as compared with a symptom such as hematochezia). This has...
Laparoscopic abdominal repair represents a new development in rectal prolapse surgery. Laparoscopy offers improved patient comfort, better cosmetic result, and decreased lengths of hospital stay and disability (Solomon and Eyers, 1996 Kellokumpu et al, 2000) and most of the procedures described above may be performed with this technique. In two recent studies (Heah et al, 2000 Zittel et al, 2000), it was reported that functional outcome after laparoscopic rectopexy was comparable with open surgery.
Laparoscopic surgery for diseases of the colon and rectum has been one of the more controversial applications of the innovations which have resulted from the technological revolution surrounding laparoscopic surgery. The controversy ranges from the relatively mild, e.g. resectional versus non-resectional rectopexy for rectal prolapse, versus the extremes of dogma, e.g. the completeness of surgical resection of colorectal cancer. The purpose of this section is not to resolve the controversies which are the subject of clinical trials, but to briefly describe some of the techniques being studied. It should be emphasized that at the time of writing, in the opinion of the authors, these techniques should not be applied outside the context of a clinical trial. Accordingly we would not necessarily advocate them as the procedure of choice. Rectal prolapse. For patients with rectal prolapse the options lie between resectional rectosigmoidectomy and laparoscopic mesh rectopexy. The details of...
Avoidance of the exposure required to perform the posterior sagittal approach can lead to inadvertent injuries, such as injury to the bladder neck, urethra, or an ectopic ureter. Precise understanding of the anatomic relationships between the pelvis and the laparo-scopic view is vital to avoid these problems. Like the transabdominal approach, there is potential for leaving behind the distal rectal cuff, leading to a posterior urethral diverticulum, particularly for malformations below the peritoneal reflection, such as rectobulbar fistula. Finally, to avoid rectal prolapse, a pelvic hitch is employed if this step is omitted or done incorrectly, the incidence of prolapse will probably be significant. With the avoidance of the posterior sagittal incision, the described laparoscopic operation omits several key steps of the PSARP that are very important to avoid prolapse 24 , particularly tacking of the posterior rectal wall to the muscle complex.
The presence of an abdominal mass or tenderness suggests the presence of concomitant conditions causing diarrhea, such as inflammatory bowel disease (IBD) or a neoplasm. Since up to 20 of tertiary referral patients with diabetes may experience fecal incontinence, an anorectal examination should be performed (Camilleri, 1996). The anorectal examination includes inspection of the external anal area for the presence of rectal prolapse, digital assessment of the sphincter tone at rest and during squeeze, and assessment of alterations in sensation (eg, pinprick around anal verge).
Easily be identified by electrical stimulation and are usually situated in a line between the ischial tuber-osities. However, they can also be antepositioned. There are no longitudinal muscle fibers penetrating the smooth muscle fibers of an internal anal sphincter, as in normal individuals, and inserting into the skin. Therefore, there is no corrugator ani muscle for the so-called fine continence helping to avoid staining or smearing, and fixing the mucosa to the surrounding tissue, which avoids mucosal prolapse. Rectal prolapse with a protrusion of all muscle layers of the pulled-down rectum, on the other hand, is unusual if the lateral wings continue to fix the neorectum inside the pelvis or the colon is fixed to the presacral fascia. The hemorrhoidal plexus is developed on a higher level and therefore not supporting fine continence by obstructing the lower anal canal by filling its vessels.
Goligher and Hughes 30 , in studies in adults using balloon distention of the bowel brought down in pullthrough operations, also concluded that the response to distention probably arose in structures surrounding the bowel. Similarly, Parks et al. 31 and Porter 32 , in studies on the pelvic floor muscles in rectal prolapse, suggested that the receptors lie in the rectal wall and the surrounding pelvic floor muscles. Kiesewetter and Nixon 33 , in their anatomic and physiologic studies of rectal sensation in patients following surgical correction of ARM, considered that the sensory receptors responsible for a measure of rectal sensation were probably present in the pu-borectalis muscle.
During the initial stage of evaluation, mucosal biopsies should be obtained to determine the chronicity of disease and to exclude other causes of colitis. The principle alternative diagnosis that needs to be considered in the first attack of UC is acute self-limiting colitis (ASLC). The endoscopic appearance is indistinguishable from idiopathic UC, but the microscopic changes are more acute and the mucosal atrophy and the crypt changes of chronic colitis (crypt branching) are absent. ASLC may last for several months, but the long term prognosis is excellent with no chronic disease issues that need to be considered. For the consultant, it is often impossible to reconstruct the initial illness. Long term remission following an acute attack raises the possibility of ASLC and supports a trial period of management without maintenance therapy. C. difficile may masquerade as chronic colitis or may cause relapse of symptomatic disease. The characteristic explosive volcano seen microscopically...
The posterior limit of the muscle complex must also be reapproximated behind the rectum. These stitches must take part of the rectal wall to anchor it to avoid rectal prolapse (Fig. 20.7 b). An anoplasty is performed with 16 interrupted long-lasting absorbable stitches (Fig. 20.8). The ischiorectal fossa and the subcutaneous tissue are reapproximated and the wound is closed with a subcuticular absorbable monofilament.
Once the dissection has been completed, the peri-neal body is repaired (Fig. 21.4). The anterior edge of the muscle complex is reapproximated as described previously. The muscle complex must be reconstructed posterior to the rectum, with the stitches including the posterior edge of the muscle complex and the posterior rectal wall to avoid rectal prolapse (Fig. 21.5). The anoplasty is then performed (Fig. 21.6).
Surgical hemorroidectomy. (A) Exposure of the hemorrhoid. (B) Excision of the hemorrhoid and exposure of submucosal vascular plexuses. (C) Dissection of the hemorrhoidal plexuses. (D) Wound closure. (E) Completed procedure. Fig. 7. Surgical hemorroidectomy. (A) Exposure of the hemorrhoid. (B) Excision of the hemorrhoid and exposure of submucosal vascular plexuses. (C) Dissection of the hemorrhoidal plexuses. (D) Wound closure. (E) Completed procedure. up to 17 have been reported (25), but the incidence can be minimized by limiting intraoperative fluids to less than 300 cm3. Bleeding can be immediate, i.e., in the recovery room, or delayed, at between 7-16 d postoperatively (25). If hemodynamically significant, this must be addressed in an operating room with suture ligation or cautery. Anal stenosis and incontinence are both the result of overzealous excision-stenosis from the failure to preserve native tissue between excision sites and incontinence from excision of sphincter...
Newly forming vessels are also visible on the surface of the hemorrhoids. Hemangiomas have a tendency to bleed and patients become symptomatic through hematochezia or chronic anemia. Therapeutic potential for large and infiltrative hemangiomas is limited, though endoscopic removal can be attempted with 3. Azizkhan RG. Life-threatening hematochezia from a rectosigmoid vascular malformation in Klippel-Trenaunay syndrome long-term palliation using an argon laser. J Pediatr Surg 1991 26 1125-7. 40. Wang TF et al. Relationship of portal pressure, anorectal varices and hemorrhoids in cirrhotic patients. J Hepatol 1992 15 170-3.
GI complaints associated with the abuse of laxatives, particularly the stimulant laxatives, such as bisacodyl and phe-nolphthalein, and the anthracene derivatives (senna, cascara, danthron), include nonspecific complaints such as constipation, diarrhea, abdominal cramping or pain, nausea and vomiting, and distention and bloating. Other sequelae of laxative abuse include steatorrhea, protein-losing enteropathy, osteomalacia and melanosis coli. Rectal prolapse secondary to severe laxative abuse can also be seen in eating disorder patients.
Fig. 13.25 Diversion proctitis in a rectal stump in a patient who had undergone a Hartmann procedure. The patient presented with recurrent anal bleeding. Fig. 13.25 Diversion proctitis in a rectal stump in a patient who had undergone a Hartmann procedure. The patient presented with recurrent anal bleeding. HIV infection. The causes of lower gastrointestinal bleeding in patients with HIV differ from those in other patients. The most common are cytomegalovirus colitis (25 ), lymphoma (12 ), and idiopathic (unidentifiable) colitis (12 ) (7). The first two causes are especially pronounced in patients with a CD4 lymphocyte count below 200 mm3. If cell count is greater than 200 mm3 the most common bleeding sources are idiopathic colitis, diverticula, and hemorrhoids. Rebleeding is not uncommon. Thirty-day mortality related to bleeding is around 14 , whereby patients with concomitant medical problems, rebleeding and those requiring operative intervention are especially at risk. In a study by...
The application of heat by iron cauteries is noted by Hippocrates, principally as a method of counter-irritation against internal diseases, or to dry up ulcers and wet gangrene, to destroy tumours and to treat haemorrhoids he does not describe heat coagulation of bleeding vessels. Celsus in the 1st century a.d.15 and Archigenes in the 2nd century a.d.16 give early references to the application of heated cauteries to control haemorrhage this is mentioned again by Paul in the 7th
This infant, in addition, had a rectal prolapse. Note the wrinkled, loose skin associated with marked lack of adipose tissue. Figure 3.93. This infant, in addition, had a rectal prolapse. Note the wrinkled, loose skin associated with marked lack of adipose tissue.
Internal rectal intussusception is sometimes labeled occult rectal prolapse as the conditions are quite similar at defecography, with the only difference that rectal intussusception does not extend beyond the anal verge. Internal intussusception is associated with several different functional complaints. Johansson and colleagues (1985) examined 190 patients with rectal intussusception and found that 57 of patients experienced a sensation of obstruction, 44 had fecal incontinence, 43 had painful defecations, and 27 had anal bleeding. Mucous discharge and diarrhea have also been reported.
The examination begins with an inspection of the perianal region. The patient should be in the left lateral position with his knees bent and pulled up. A simple inspection can detect skin changes, scars, anal skin tags, hemorrhoids, anal fissures, anal venous thromboses, fistula, injuries, or prolapse (anal or rectal prolapse). Any findings must be noted later in the examination report. Figures 5.1, 5.2 show examples of pathologies detected during inspection. The diagnostic report should include exact localization for example, distance from the anus or a description of location as if the patient were in the dorsal recumbent position (at the 12-o'clock position ventral to the anus). Hemorrhoids
Neoplasms of the small intestine are uncommon and often remain clinically unrecognized. Bleeding occurs in 25 to 50 of patients with small bowel tumors (Bashir and Al-Kawas, 1996) and comprises approximately 5 to 10 of cases of bleeding of obscure origin. Benign tumors are more likely to bleed than malignant lesions. When recognized, most will warrant endoscopic resection or, when not amenable to endoscopic resection, surgical evaluation and resection. Benign small bowel lesions include adenomas, leiomyomas, lipomas, hamartomas, and rarely neural tumors. Occasionally, pain or obstructive-type symptoms may lead to their diagnosis. Although a pattern of obscure-occult bleeding is more characteristic of benign small bowel tumors, lesions in the duodenum may present with frank hematemesis and those in the ileum with hematochezia. Adenomas are usually found proximal to the ligament of Treitz and account for 25 of benign lesions. All adenomas in the small bowel should be viewed as...
Recently, an alternative technique has been developed and tested that is associated with markedly reduced postoperative pain (Sutherland et al, 2002). The procedure for prolapse and hemorrhoids (PPH), or stapled hemorrhoidectomy, employs a circular stapler with a hollow head to excise a cuff of tissue at the most superior aspect of hemorrhoidal complexes and create a superficial end-to-end anastomosis (Figure 92-2). During this procedure, a submucosal purses-tring is placed 4 cm above the dentate line and is secured to the post of the anvil of the stapler. The excess tissue is pulled into the hollow head of the stapler as the stapler is closed. As the stapler is fired, a circumferential cuff of tissue is excised, and the superficial anastomosis is created. In effect an anopexy is performed which lifts the prolapsed tissue into the anal canal. Randomized trials have reported significantly lower pain scores when compared to conventional hemor-rhoidectomy procedures. Although higher...
Bleeding was recommended in the treatment of inflammation, fevers, a multitude of disease states, and hemorrhage. Patients too weak for the lancet were candidates for milder methods, such as cupping and leeching. Well into the nineteenth century, no apothecary shop could be considered complete without a bowl of live leeches, ready to do battle with afflictions as varied as epilepsy, hemorrhoids, obesity, tuberculosis, and headaches (for very stubborn headaches leeches were applied inside the nostrils). Enthusiasm for leeching reached its peak during the first half of the nineteenth century. By this time, leeches had to be imported because the medicinal leech, Hirudo medicinalis, had been hunted almost to extinction throughout Western Europe. Francois Victor Joseph
Qing Hao is a herb commonly used in China with a long history of use as an antipyretic to treat the alternate chill and fever symptoms of malaria and other heat syndromes in the traditional Chinese medical system. The name Qing Hao first appeared in a silk book excavated from the tomb at Mawangdui belonging to the Han dynasty it was entitled Wu Shi Er Bin Fang (Prescriptions for Fifty-two ailments) and dated from as early as 168 BC, and described the use of Qing Hao for the treatment of haemorrhoids. In 340 AD, Qing Hao was recorded for the first time as a treatment for fevers in a medical book, Zhou Hou Bei Ji Fang (Handbook of Prescriptions for Emergency Treatment). In this work, the author, Ge Hong, recommended that, to reduce fevers one should soak a handful of Qing Hao in one sheng (approx. 1 L) of water, strain the liquor and drink it all. Li Shi-Zhen, the author of the famous materia medica Ben Cao Gang Mu (1596 AD), based on the former medical text records and his own...
Pruritus ani, perianal warts, perianal abscess, perianal haematoma, prolapsing haemorrhoids, thrombosed haemorrhoids, skin tags, anal discharge, anal fistulas, anal fissures, anal cancer, rectocele, rectal prolapse, threadworms, faecal soiling of the perineum are all possible findings (Rhodes & Hsin, 1995 Barkauskas, 2002). The anal tone can be observed at rest and on voluntary contraction. The patient should be asked to strain down as if opening bowels to show perianal descent, prolapsing haemorrhoids or protruding lesions such as tumours or rectal prolapse (Barkauskas, 2002).
Hemorrhoids are classified by location as internal, external or mixed in relation to the dentate line, and by the degree of prolapse. External hemorrhoids are located below the dentate line, are covered by squamous mucosa, and are painful when thrombosis occurs. Internal hemorrhoids are located above the dentate line and may prolapse, thrombose, or bleed. The degree of prolapse is staged as follows
Anorectal afflictions have troubled the human race for millennia, but remain somewhat of an enigma to a majority of both physicians and laypersons. First described formally in the Chester Beatty Medical Papyrus, written about 1250 bc and further defined by Hippocrates around 400 bc (19), the treatment of these disorders has progressively improved with the wider dissemination of knowledge regarding them and the development of an increasing number of physicians trained specifically in their care (two of the most common anorectal conditions seen in the clinician's office are anal fissure and hemorrhoids). They are not uncommonly confused with one another as both can present with rectal bleeding. Their proper differentiation is crucial to the selection of the appropriate treatment modalities.
Hemorrhoidal disease also is seen frequently. Factors predisposing to hemorrhoids may have predated the HIV infection. Severe diarrhea or proctitis may promote local thrombosis, ulceration, and secondary infection. Fleshy skin tags, resembling those seen in Crohn's disease, are also seen. Thrombosed hemorrhoids occur frequently, but it is unclear if the incidence is higher in AIDS patients than in a comparable population.
Diverticulosis is a common colonic condition in elderly patients of the Western world, with a prevalence of 37 to 45 . Although diverticula more commonly occur on the left side of the colon, bleeding usually originates from right-sided lesions. It is estimated that hemorrhage occurs in 3 to 5 of all patients with diverticulosis. Due to the high prevalence in the general population, and particularly the elderly, it is the most common cause of lower GI bleeding, accounting for over 30 of cases. Diverticular bleeding usually presents as painless, large-volume hematochezia of abrupt onset bleeding ceases spontaneously in up to 90 of patients. Rebleeding occurs 22 to 38 of the time, and the likelihood of a third bleeding episode in such Diverticulosis Angiodysplasia Cancer Polyps Inflammatory bowel disease Radiation proctocolitis Infectious colitis Ischemic colitis Anorectal disease Hemorrhoids Anal fissures Rectal ulcers Fistula in ano Rare Causes Portal hypertensive colopathy Small bowel...
Infectious colitis can present with frequent bloody, small volume stools, often associated with fever, abdominal cramps, tenesmus, and rectal urgency. Although the commonest infectious cause of bloody diarrhea in adults in the West is Campylobacter, pseudomembranous colitis, caused by Clostridium difficile, is one of the most common nosocomial infections it is usually seen during or following antibiotic administration. Its clinical presentation ranges from mild diarrhea to severe colitis and hematochezia. Patients infected with Shiga toxin-producing Escherichia coli (particularly serotype O157 H7) present with acute onset of bloody diarrhea, especially without fever, and with the hemolytic-uremic syndrome. In immunocompromised hosts, most episodes of lower GI bleeding are associated with opportunistic infection, such as cytomegalovirus colitis.
History (previous surgeries, the presence of adhesions, diverticula, and intestinal cancer in the family), and perform a thorough examination. Warning signs, which include weight loss, hematemesis, hematochezia, melena, obstipation, or rebound tenderness, warrant a more urgent workup and possible early surgical intervention.
Benign adenomatous polyps and adenocarcinoma of the colon and rectum are associated with chronic occult blood loss or intermittent hematochezia. Up to 10 of cases with severe lower GI bleeding in the elderly are related to benign or malignant neoplasia. These lesions often bleed from erosions or ulcers on the surface. Colonic bleeding can occur following endoscopic removal of polyps, with a reported incidence of 0.2 . Hemorrhage may be immediate, as a result of incomplete coagulation of the polyp stalk, or delayed up to 15 days, from sloughing of the eschar or erosion of a polypectomy ulcer. Elderly patients seem to be most prone to this complication. Although several studies have shown that endoscopic procedures can be performed safely in patients taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) without an increased risk of bleeding complications, some experts still recommend avoiding these medications for 7 days before and 7 to 10 days after polypectomy.
Selective mesenteric angiography should be reserved for patients with massive, ongoing lower GI bleeding when colonoscopy is not feasible, or with recurrent hematochezia when colonoscopy did not reveal a source. Angiography is able to detect small and large bowel bleeds at a rate greater than 0.5 mL min. In patients with severe lower GI bleeding,
There are two theories regarding development of rectal prolapse. Moschowitz proposed in 1912 that rectal prolapse is a sliding hernia that protrudes through a defect in the pelvic floor. He found that patients with rectal prolapse have a deep cul-de-sac, which he believed resulted from herniation of the small intestine into the anterior wall of the rectum. He suggested that the herniation pushed the rectum down, resulting in rectal prolapse. This idea is supported by the finding of a deep cul-de-sac in many prolapse patients. Brod n and Snellman (1968) used defecography and could demonstrate that rectal prolapse starts as an internal rectal intussusception. They demonstrated that rectal prolapse starts as anorectal intussusception 6 to 8 cm up in the rectum and as the patient strains, the intussusception progresses and extends down through the rectum and out through the anus. The underlying mechanism for the rectum to prolapse remains unclear. A mobile rectum, a weak pelvic floor, and...
Rectal prolapse in children is generally treated conservatively, whereas surgical repair is suggested for adults. In 1912, Moschcowitz presented his theory that rectal prolapse is a sliding hernia and he suggested obliteration of the deep cul-de-sac of Douglas as treatment, but this method had a high recurrence rate.
Rectal prolapse is a full-thickness, circumferential intussusception of the entire rectal wall through the anal canal and anus. The prolapsing bowel itself, mucosanguineous discharge, bleeding, constipation and or incontinence, and a feeling of incomplete evacuation, are the most frequent complaints. The incidence of preoperative incontinence and constipation has only been reported prospectively in a few studies and definitions vary. Allen-Mersh and colleagues (1990) studied 57 patients with rectal prolapse prospectively and found fecal incontinence symptoms in 49 and constipation symptoms in 30 of the patients. Madden and colleagues (1992) reported some degree of anal incontinence in 17 of 23 patients (74 ) and constipation in 11 (48 ) of their patients. In another prospective study, Huber and colleagues (1995) included 42 patients, 5 of whom had internal rectal intussusception. They found fecal incontinence in 54 and some degree of constipation in 44 of the patients. The underlying...
For patients considered a poor risk for abdominal surgery, a perineal approach to repair of rectal prolapse is indicated. Perineal rectosigmoidectomy, originally proposed by Altmeier (17) and modified by Prasad (18) is the procedure most often utilized. It is performed with the patient again in lithotomy position and either regional or general anesthesia can be utilized. Because it avoids laparotomy, hospital stay and postoperative
-AG, HG, IND, desmosis, absence of interstitial cells of Cajal Reduced fixation of the rectum in the small pelvis after pull-through disposition for rectal prolapse Hypoplastic and sometimes malpositioned muscle fibers Hemorrhoidal plexus on a higher level No longitudinal muscle fibers of the rectal muscle coat running through the external anal sphincter into the anal skin disposition for mucosal prolapse No anoderm reduced sensibility
When preparing the patient for a proctoscope examination, thorough explanation of the examination is needed during the consultation and consent must be obtained. The patient should be placed in the left lateral position, with their knees drawn in to the chest. The proctoscope should be well lubricated with a water-based gel and passed gently into the anus. The patient will feel pressure as the proctoscope comes into contact with the external sphincter ask the patient to relax and gently pass the proctoscope into the rectum. If there is resistance remove the instrument and allay the patient's fear. Note on inspection Faecal matter (if present), odour and consistency. Rectal discharge, threadworms, inflammation, mucosal ulceration, bleeding, haemorrhoids and any other abnormalities. Slowly withdrawing the proctoscope observe the haemorrhoidal cushions, the dentate line, and the anal epithelium.
Procedure for hemorrhoid ligation Under visualization with a proctoscope, suction is applied using a special applicator (Fig. 20.30) to an internal hemorrhoid localized above the dentate line. A rubber band is then placed around the base of the suctioned hemorrhoid pile, ligating it (Figs. 20.29, 20.31). The band falls off after a few days leaving a small ulceration. Complications include pain, rebleeding, or, in rare cases, abscess formation. After about three weeks, the ablation site has healed and the next session can proceed. Rubber band with ligated hemorrhoid pile Fig. 20.29 Schematic illustration of ligation of internal hemorrhoids. a Suction is applied to the internal hemorrhoid and a rubber band is placed over the hemorrhoid. b Hemorrhoid ligated with rubber band around its base. Rubber band with ligated hemorrhoid pile Fig. 20.29 Schematic illustration of ligation of internal hemorrhoids. a Suction is applied to the internal hemorrhoid and a rubber band is placed over the...
Since the classic paper published by Crohn and colleagues in 1932 describing the chronic inflammatory process of the bowel there have been multiple articles published on the complications of this illness. The description of perianal fistula was followed 6 years later with the incorrect concept that the inflammatory process extended from the bowel down to the perianal area. There are multiple problems that can affect the perianal area, including simple skin tags, fissures, hemorrhoids, high and low fistulas, strictures, rectovaginal fistulas, and, finally, neoplasia. Severe perianal skin excoriation can result in significant discomfort and impaired quality of life. The main purpose of this article is to review the perianal complications with a focus on management of fistulas.
Indications for surgical hemorrhoidectomy include advanced third or fourth degree piles, mixed hemorrhoids, extensive thrombosis, ulceration, and gangrene. The choice of surgical procedure depends upon the patient's condition, and surgeon and patient preferences. Similarly, anesthetic choices include local anesthesia plus monitored sedation, regional techniques, and general anesthesia. Traditionally, regional training and culture have influenced the choice of operation. Most surgeons in the United States practice the closed technique, or Ferguson hemorrhoidectomy, where following hemorrhoidal excision, the rectal mucosa and anoderm are closed with an absorbable radial suture line beginning at the apex of each hemorrhoidal complex. Recurrence rates are 2 . Scissors, electrocoutery, laser, and scalpel may be used however, none have been proven to be superior over other means of excision. Hemorrhoidectomy using advanced technologies such as harmonic scalpel and ligasure have been...
*A probable case was defined as onset of diarrhea (two or more loose stools during a 24-hour period) with either fever or bloody stools while at the resort or within 11 days of leaving the resort. A confirmed case additionally required Shigella sonnei isolated from stool. A total of 82 cases were identified, including 67 probable and 15 confirmed. *A probable case was defined as onset of diarrhea (two or more loose stools during a 24-hour period) with either fever or bloody stools while at the resort or within 11 days of leaving the resort. A confirmed case additionally required Shigella sonnei isolated from stool. A total of 82 cases were identified, including 67 probable and 15 confirmed.
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