Dr, Mohammad Qudah Hemorrhoids & Anal Fissures 1

[Text written like this was mentioned in the slides but not by the doctor]

Around 40% of the population will someday suffer from one of these conditions – they’re

very common

Anatomy of the Anal Canal

The anal canal joins the rectum at the anorectal junction

(anorectal ring) which is 4 cm in length and is composed

of 2 parts divided by the dentate/pectinate line (a series

of anal valves). Distal to this line, the lower anal canal is

lined by specialized skin (squamous epithelium that’s

divided into appendages – this is called anoderm). You can

reach the lower part of the rectum by rectal examination.

Above the dentate line there’s a transitional zone and

above that the rectal mucosal line.

Pectinate: separates area insensitive to touch, cutting, etc above the pectinate line supplied

viscerally from the very highly sensitive area below the dentate line which is supplied by

somatic nerves

Average distances of the anal canal

- Petite female: 2-2.5 cm - Big male: 7-8 cm

- Internal and external (subcutaneous,

superficial and deep) sphincters

- Internal sphincter smooth muscles:

thickening of the circular smooth muscles of

the rectum

- External sphincter: subcutaneous, superficial

and deep (made of levator ani muscles

especially puborectalis)

- Internal hemorrhoidal plexus: between the

dentate line and the anorectal junction – in

the upper anal canal

- External hemorrhoidal plexus (plexus of veins): below the anoderm/perianal skin

The last two: totally different and separate

- Anal glands: the cause of most perianal abscesses and fistulae.

Dr, Mohammad Qudah Hemorrhoids & Anal Fissures 2

Hemorrhoids

- Hemorrhoids are not varicose veins

- Can be called anal cushions, composed of specialized vascular

tissue (erectile tissue)*, smooth muscle (Treitz’s muscle) and

elastic connective tissue in the submucosa

*The old name for hemorrhoidal plexus was corpus spongiosum

recti (not veins)

- They are located in the upper anal canal, from the dentate line up

to the anorectal ring/jnction

- Typically there are three cushions which lie in the following sites: left lateral (3), right

anterolateral (11) and right posterlateral (7) – these are the ones mostly operated on

*The numbers represent time on a clock, and are seen in the prone position

- Smaller secondary cushions may be present between the main cushions

- [The configuration is remarkably constant and apparently bears no relationship to

the terminal branching of the superior rectal artery]

Prevalence

Hemorrhoids have a prevalence rate of 4.4%, peaking in 60+ year olds as it’s a degenerative

disease (peak age between 45-65 years). Hemorrhoidectomies are more common in males

than in females. [1.3x more common in males]

Etiology and pathogenesis

Hemorrhoids are no more common in patients with portal hypertension than in normal

people as they are not varicose veins (the presence of a portosystemic anastomosis with

rectal veins doesn’t increase the likelihood of hemorrhoid development). The most accepted

theory is that hemorrhoids are degenerative in causation, due to the shearing force during

the act of defecation, especially if there’s constipation or if the sphincter is hypertonic. The

repeated shearing causes disruption of structures, mainly the smooth muscles, as well as

the elastic fibres, allowing the vascular channels to expand – NOT increased blood flow, but

instead the destruction of the supporting tissue. With time, the mucosa becomes elongated

and exaggerated and can prolapse outside the anal canal.

Contributing factors

- Age – most important, due to the deterioration of anal supporting tissues

- Constipation

Dr, Mohammad Qudah Hemorrhoids & Anal Fissures 3

- Prolonged straining

- Diarrhea

- Pregnancy

- Heredity

- Erect posture – animals (except apes) don’t develop hemorrhoids because of the

lower shearing force

- Increased intra-abdominal pressure

- Anything interfering with the elastic tissue structure

- [Absence of valves within the hemorrhoidal sinusoids]

- [Internal sphincter abnormalities].

Functions of anal cushions

Picture: the external hemorrhoids are totally different

below the dentate line. They compress to aid in the act of

defecation (compliant and comfortable plug). They account

for 20% of the resting pressure of the anal canal; they play

a minor role in incontinence. Anal sampling is sensation of

the contents of the anal canal to discriminate between

liquid, solid, and gas. Extensor hemorrhoidectomy may

cause minor incontinence without sphincter damage.

[Hemorrhoidectomy impairs continence to infused saline]

External hemorrhoids

They are venous, contain dark blood and are below the dentate line. They are covered by

squamous epithelium (anoderm/perianal skin). [They comprise the dilated vascular plexus]

Internal hemorrhoids

The symptomatic, exaggerated vascular tissue located above the dentate line [submucosal]

and covered by transitional and columnar epithelium.

Note External skin tags should be differentiated from hemorrhoids. They are commonly

congenital or acquired due to certain diseases. They are independent of any hemorrhoidal

problem.

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Grades (of internal hemorrhoids)

- Grade 1: symptoms occur while the hemorrhoidal tissue is totally inside the anus and

doesn’t come out. Might involve bleeding. [painless]

- Grade 2: prolapse but reduce spontaneously meaning the mucosa above them is

redundant

- Grade 3: partial anodermal prolapse where they come out spontaneously and they

have to be pushed back into the anal canal

- Grade 4: total anoderm prolapse where you’re unable to push it back – may be

complicated or not.

Uncomplicated grade 4: Classic sites seen in the prone position (can see

left lateral, right anterolateral, right posterolateral), you can also see the

dentate line which is also prolapsed.

Differential diagnosis

- Rectal prolapse (complete or mucosal)

- Hypertrophied anal papillae

- Rectal polyps

- Melanoma

- Carcinoma

- Fissure.

Major symptom: Bleeding

The content of these vascular channels is highly oxygenated blood like an artery but the

pressure is low. Bleeding occurs during the act of defecation due to trauma of the

hemorrhoidal tissue, or after defecation. The blood may squirt into the toilet or show up on

the toilet paper. It is red, painless, and always related to defecation. There are no clots, it’s

not mixed with the stool and is not dark. It’s rarely massive. The bleeding also may be

occult, resulting in anemia [or guaiac-positive stools].

Other symptoms

- Proplapse: determines the stage

- Pruritis ani

- Pain: absent unless complicated

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- Mucous and fecal leakage: may cause excoriation of the perianal skin in addition to

pruritis.

Examination

- Ask the patient to lie in a foetal position and ask them to strain, the hemorrhoids will

come out and become visible.

- Hemorrhoids are soft impalpable structures, so unless you see them you can’t

palpate them by digital examination. If you can palpate them, it’s either they’re

complicated by thrombosis or you’re not dealing with hemorrhoids (could be a polyp

or cancer)

- Anoscopy (small endoscope)

- Proctoscopy or flexible sigmoidoscopy

- Colonoscopy: sometimes needed especially if there’s deviation from the typical

hemorrhoidal bleeding.

*Anal bleeding is a common OSCE station.

**Hemorrhoidal disease is not static, sometimes it’s exaggerated and sometimes it

disappears according to the status of the patient (e.g. constipated)

Complicated grade 4 hemorrhoids

- Odemea

- Thrombosis

- Painful

- Sometimes the patient needs to be admitted to control it.

Treatment

- Medical: sufficient for 1st and 2nd degree hemorrhoids

- Minor procedures: for failed medical treatment for 1st and 2nd degree + for some 3rd

degree

- Surgery (hemorrhoidectomy): 3rd and 4th degree.

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Medical treatment: for 1st and 2nd degrees

- Warm sitz bath (Sitz in german means chair): the patient should sit in warm water to

relax the sphincter

- Diet (fibres) and bulk-forming agents in the feces

- Ointments, creams, gels, suppositories, foams and pads

- [Vasoconstrictors, protectants, astringents, antiseptics, keratolytics, analgesics,

corticosteroids]

- Traditional treatment sometimes has the best effect

- Careful when using corticosteroids as they can be absorbed systemically causing

increased blood sugars and hypertension, and locally can cause thrombin infection

- Oral agents are of no benefit (especially those acting on veins because hemorrhoids

are not actually veins)

Other procedures: not used for 4th, may be used for some 3rd as they have a high recurrence

rate (temporary measures)

- Sclerotherapy: injecting a sclerosing agent high above the dentate line

- Cryotherapy: using very low temperature – not used anymore

- Infrared coagulation

- Doppler guided hemorrhoidal artery ligation: the feeding vessel is detected by

Doppler and then a suture is applied to ligate it

- Anal stretch: anal dilatation: obsolete, may cause complete incontinence for the

patient with no way to treat it as it completely disrupts the sphincter’s mechanism.

Infrared coagulation Doppler-guided hemorrhoidal artery ligation

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Rubber band ligation

Hemorrhoidectomy: for 4th (and some 3rd) degrees

- Closed

- Open [excision and ligation]

- Laser: less pain than the open hemorrhoidectomy, can be used for coagulation

- Stapled: used in the past; no longer used due to high recurrence rate due to poor

fixation and some people develop permanent minor incontinence.

Stapled

Thrombosed External Hemorrhoids

It’s a different disease. It starts by the sudden appearance of a painful mass in the perianal

region. The pain peaks around 24 hours and disappears by 5 days (therefore it’s called the 5

day disease). If left alone, the thrombus will shrink and disappear. Most of the time we use

conservative treatment (avoidance of invasive measures), but many of these patients

experience minimal pain. It may result in a skin tag. It may ulcerate and cause bleeding.

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Early on, they can be incised, but for late thrombosed external hemorrhoids, local

anesthetics and warm Sitz baths are used.

Typical appearance Ulceration and bleeding

Anal Fissure

- Very common

- Occur in young adults and middle aged adults; may also occur in infants and children

due to dehydration

- Anterior fissures are more common in women than men

- Posterior fissures are more common than anterior fissures in both sexes.

- Pathology

Acute: a tear in the anoderm

Chronic: an ulcer in the anoderm (e.g. sentinel pile, hypertrophied anal papilla,

fibrous induration)

- Complications: abscess, fistula.

Predisposing factors

- Primary: due to hypertonic internal anal sphincter (IAS)

- Secondary (low pressure fissure)

Anatomic anal abnormality (e.g. postpartum)

Inflammatory bowel disease (IBS), ulcerative colitis, Crohn’s – most common

HIV

Other chronic infections, e.g. TB

Leukemia.

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Symptoms

- In contrast to hemorrhoids, the main presenting symptom is severe pain -due to

ischemia because of the hypertonic sphincter. Fissures occur in the anoderm which is

supplied by the somatic nerve index, therefore it’s painful. Pain is during and after

defecation

- Bleeding in the form of streaks on the surface of stools

- Constipation may cause a fissure (risk factor) or be a consequence of a fissure

(patient doesn’t like to go to the bathroom)

- Large sentinel pile

- Discharge, especially if it’s complicated by a fistula.

Sites

Most common is posterior followed by anterior. The causes of

lateral fissures are non-specific causes. If we find multiple

fissures on lateral, anterior and posterior we should suspect

non-specific causes (Crohn’s disease, UC, etc).

When is it chronic?

- History of more than 1 month

- Presence of

Sentinel pile

Hypertrophied anal papilla

Fibrosis

Submucous fistula.

{In the prone position}

- Acute: tear in the anoderm

- Chronic: ulcer with fibrosis; at the dentate

line we see hypertrophied anal papilla and at

the anal ridge outside there’s sentinel anal

pile/skin tag.

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Treatment: Acute fissure

- Conservative: most commonly used to break the cycle of pain, spasm and

constipation

Bulk-forming agents – decreases constipation

Local preparations (local anesthetics) – decreases pain

Warm Sitz baths – decreases spasm (relax sphincters)

- Pharmacologic sphincterotomy: use of agents to decrease sphincter tone

Glyceryl trinitrate – used in angina

Calcium channel antagonists – used locally to relax sphincter

Botulinum toxin – especially if the patient is not autoimmune, can work for about

6 months

- Sphincterotomy: the gold standard for hemorrhoidal surgery.

Treatment: Chronic fissure

- Conservative: same as acute

- Internal sphincterotomy: lateral partial sphincterotomy to prevent deformity of the

anus causing a thrombus – gold standard with excision of sentinel pile if present in

chronic; no recurrence

- Classic excision – high recurrence

- V-Y anoplasty

- Finger anal sphincter stretch: obsolete; shouldn’t be used

- Controlled intermittent anal dilatation: doesn’t give a long term result; could cause

anal incontinence.

Partial lateral internal sphincterotomy (open technique): we cut a small part of the internal

sphincter equal to the length of the fissure itself. The area is left to granulate or we can

perform V-Y anoplasty.

(1) (2)

(1) Partial lateral internal sphincterotomy (2) fissurectomy and VY anoplasty