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Benign Colorectal

Conditions

UTC Department of Surgery

Eric C. Nelson, MD

June 11, 2014

Benign Anorectal Conditions

• otherwise known as the importance of

fiber…

Doc, I’ve got hemorrhoids

Outline

• Questions to ask

–Anal Pain

–Anal Protrusion

–Anal Itching

–Outlet Bleeding

Anal Pain DDx

• Anal Fissure

• Thrombosed External Hemorrhoid

• Perianal Abscess and Fistula

• Proctalgia Fugax

ANAL FISSURE

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Pathophysiology

• Traumatic Stooling

• Anal Spasm (internal anal sphincter)

• Anodermal Ischemia Nonhealing

• (Atypical Etiologies)

Presentation

• Cutting pain w defecation

• Outlet bleeding

Physical Findings

• Fissure

• Sentinel skin tag

• Hypertrophic papillae

Medical Treatment • High fiber diet (>30g)/Supplement

• Sitz Baths

• Ca++ Channel Blocker cream (nitrates)

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Plenty of Water Topical Treatments

Surgical Treatment

• Lateral Internal Sphincterotomy

• Botulism Toxin Injection

• Anoplasty

• Advancement Flap

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Thrombosed External

Hemorrhoid

Pathophysiology

• Stasis in Hemorrhoidal Varicosity

– Obesity

– Pregnancy

– Valsalva (constipation)

– Athletic Activities (squats)

Presentation

• Constant Pain

• Protrusion

• Bleeding

Physical Findings

• Tender Mass Protrusion

• Secondary Findings

– Skin Necrosis

–Prolapsed Internal Hemorrhoids

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Treatment

• Nonexcision

• Excision

• (Evacuation)

Excision vs Nonexcision

1 2 3 4 5 6 7 8 9 10 15 20 25

Perianal Abscess

and Fistula

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Pathophysiology

• Infected Anal Crypt Gland

• Crohn’s

• Post Surgical

Presentation

• Constant Pain

• Pressure

• Subacute Onset

• Fever/Malaise

Physical Findings

• Erythema

• Induration

• Swelling

• Drainage

Diagnostic Tests

• Need CT? MRI? Labs?

• NO!!

• Surgical Exam Under Anesthesia

Treatment • Incision and Drainage

• Antibiotics?

– Immunocompromised

– Diabetic

– Extensive Cellulitis

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Sequelae

• Cure 1/3

• Recurrence 1/3

• Fistula 1/3

Treatment • Fistulotomy

• Placement of Draining Seton

• Advancement Flap

• LIFT procedure

• Fibrin Glue/plug

• Remicade (Crohn’s)

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Fistula with Probe

Proctalgia Fugax

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Hemorrhoids

(Protrusion)

Pathophysiology

• Straining

• Hard Stools

• Stretching of hemorrhoidal

ligaments

Presentation

• Painless Protrusion

• Outlet Bleeding

• Thrombosis (dull ache)

• Seepage

Internal Hemorrhoids

• Grade I - prolapse into anal canal

• Grade II - prolapse outside of canal

• Grade III - requires manual reduction

• Grade IV - chronic prolapse, irreducible

Evaluation

• Inspection while straining

• Anoscopy

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Examination of the Anus Anoscopes

Treatment

• Fiber/(medications)

• Local Destruction

– Banding

– Heater Probe

– Injection

• Surgery

Surgical Options

• Ferguson Hemorrhoidectomy

• Procedure for Prolapse and Hemorrhoids

(PPH)

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Pruritis Ani

Pathophysiology

• Common…

– Excessive Anal Hygiene (soap, wiping, witch-

hazel, alcohol)

– Diet and Allergens

– Moisture

– Neoplasia

Physical Findings

• Thickened Perianal Skin

• Various Etiologic Factors

– Hemorrhoids

– Fissure

– Fistulae

– Condyloma

Treatment

• Initial

– Fiber, decrease wiping, stop soap/wipes, sitz

baths, calmoseptine, elimitation diet, time…

• Steroid Creams

– Short course

• Biopsy

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Rectal Bleeding

• Outlet Bleeding

– Small Amount

– Bright Red

– Separate from stool

• If >40, need CE

Benign Colorectal Complaints

• otherwise known as the importance of

fiber…

• Rectal Prolapse

• Fecal Incontinence

• Diverticulitis

Rectal Prolapse

• Intussusception due to straining

• Not enough fiber…

• More common in females

– Wide pelvis

– Childbirth

– Associated with other pelvic organ prolapse

Rectal Prolapse

• Evaluation

Rectal Prolapse

• Differentiate from Grade 4 int hemorrhoids

Rectal Prolapse

• Treatment: reduce and surgical referral

– Abdominal rectopexy

• Open, laparoscopic, robotic

• Resection vs no resection

• Mesh vs no mesh

– Perineal procedures

• Altemeier vs Delorme

• Levatorplasty vs not

• Theirsch procedure

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Fecal Incontinence

• Socially devastating condition with high

cost to society

• Definition

• Epidemiology

– 1-2% general population

– 7% postpartum women

– 50% nursing home residents

Evaluation

• Wexner score

Evaluation

• Wexner score

• Examination

• DDx is broad!

Treatment • Referral to multidisciplinary pelvic floor

center

– Workup includes DRE, endoscopy, TAUS,

EMG, Anal manometry, PNTML testing,

balloon expulsion testing, defecography,

dynamic MRI

– Options include fiber, medications, irrigation,

biofeedback, bulking injections,

sphincteroplasty, sacral neuromodulation,

artificial sphincter implantation, and (last

resort) colostomy

Fecal Incontinence

• Highly treatable disease

• Please screen patients, especially those at

high risk

Diverticulitis

• Diverticular dz common, Diverticulitis less so

• Pathophysiology

– “segmentation” of colon

– Risk factors: low fiber diet, age, males, opioid use,

– Worse dz: smoking, immunocompromised,

NSAID use

• S/Sx: f/c, LLQ abd pain/ttp

• W/u: CBC and CT scan

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Classification

• Simple vs Complicated

• Hinchey Classification

Treatment-acute

• Inpt vs outpt?

• Hinchey 1: NPO/IVF/(Abx)/?drainage

• Hinchey 2: IR drainage/(Abx)

• Hinchey 3/4: Operation

Treatment-elective

• After resolution of acute episode, what are

indications for elective resection?

– Clear

• Fistula, stricture, ongoing symptoms,

immunocompromised

– Unclear

• <50y/o, 2 or more attacks, needed IR drain

• NNT: 18

• Discussion with Colorectal surgeon

• www.fascrs.org for practice parameters

Surgery

• Typically laparoscopic, LOS 2-4d

• Resection of affected sigmoid colon down

to upper rectum

• Recurrence<10%

Summary of Benign Colorectal

• Rectal Prolapse requires surgery

• Fecal Incontinence is common and needs

referral to multidisciplinary clinic

• Diverticulitis can often be managed

nonoperatively but needs a surgical

assessment

Summary of Everything

Eat more fiber