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H E M O R R H O I D S
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CHARLES N. HEADRICK
M I C H A E L J . S TA M O S
lthough disparate topics, these two different pathologic entities are commonly misdiagnosed by both
layperson and physician alike. The inclusion of both topics in a single chapter allows us to examine their similarities and emphasize their differences. In the process, we
hope to clarify common misconceptions regarding these
anal/rectal disorders. We think you will see there is no
one common profile particular to either diagnosis.
CASE 1
RECTAL PROLAPSE
A 33-year-old white female, who was gravida 0, para 0, presented with a chronic history of constipation and straining.
She also gave a history of bright red blood per rectum and
passage of mucus and tissue with each bowel movement.
She denied any rectal pain. The prolapsed tissue reduced
spontaneously at the completion of each bowel movement.
She described these symptoms as lasting for the previous 4
months. She gave no history of any anal intercourse,
trauma, or other significant past medical history. There had
been no previous anorectal or abdominal surgery and she
had no significant family history. Social history revealed that
she did not smoke and was unmarried. Questions regarding
her bowel habits revealed that she moved her bowels, at
best, every other day, and occasionally every 3 days. There
had been no history of laxative use in the past.
Physical examination revealed a healthy appearing
young female. Her abdominal examination revealed a thin,
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CASE 2
RECTAL PROLAPSE
IN AN ELDERLY PATIENT
A 79-year-old white female who was gravida 4, para 4, presented with a history of constipation, stating that her rectum falls out. She had a long history of taking laxative
products (senna, herbal tea, cascara, and magnesium
products). She was especially concerned because she
sometimes moved her bowels without warning and soiled
her undergarments. Other pertinent history revealed that
she had coronary artery disease and medically controlled
hypertension. She had previously undergone an abdominal hysterectomy and oophorectomy as well as an incidental appendectomy.
Physical examination revealed a moderately obese
white female with lower midline abdominal scars. Rectal
examination revealed both hemorrhoidal and rectal prolapse. The prolapse was easily reducible, but came back
out with a moderate increase in intra-abdominal pressure.
Digital examination revealed a diminished sphincter tone.
Some soilage of stool and mucus was noted on her undergarments. Preoperative workup included contrast enema
and flexible sigmoidoscopy. Anal manometry revealed a
low-resting sphincter pressure.
The patient was deemed to be at high risk of an abdominal operation, and a perineal approach was recommended. The patient subsequently underwent perineal
rectosigmoidectomy under spinal anesthesia. Postoperatively, the patient did well. Her prolapse was cured and
she had perceptible improvement in her continence.
CASE 3
HEMORRHOIDAL PROLAPSE
A 43-year-old Hispanic male with a history of straining and
constipation came in complaining of bright red blood per
rectum. He denied pain. He was found to have prolapse revealing radial folds (hemorrhoidal prolapse) and anemia of
8 g Hb. Preoperative workup included a colonoscopy, which
was normal, followed by surgical hemorrhoidectomy.
CASE 4
THROMBOSED EXTERNAL
HEMORRHOID
A 25-year-old male came in complaining of anal swelling
and a sudden onset of pain. The patient recently had severe gastroenteritis with diarrhea. Physical examination
revealed a thrombosed external hemorrhoid. Treatment
consisted of excision in the office under local anesthesia.
GENERAL CONSIDERATIONS
emorrhoidal disease is very common. The number of over-the-counter remedies available is proof
enough. Hemorrhoids are actually present in every person
and have a normal physiologic function. They cushion the
fecal bolus as it is expelled from the rectal reservoir and
contribute to normal continence. Poor diet and hygiene,
increases in intra-abdominal pressure, and family history
may contribute to the development of abnormal hemorrhoids, which usually manifest as enlargement and/or inflammation. Hemorrhoids are classified as internal or external, based on their relationship to the dentate line.
Distal to this junction of mucous membrane and anoderm
there is normal somatic sensation. Proximal to this line,
there is a transitional zone, measuring from 1 to 1.5 cm, in
which sensation is lessened as the somatic sensory apparatus is diminished. It is in this zone, proximal to the dentate
line, where internal hemorrhoids reside (Fig. 34.1). Symptomatic internal hemorrhoids may cause discomfort, prolapse, or even hemorrhage without pain to the individual
(painless bleeding). External hemorrhoids rarely bleed,
but may cause significant pain (Case 4) associated with
thrombosis. Hemorrhoids may also bridge this anatomic
boundary (mixed type) (Fig. 34.2).
Hemorrhoids have no sexual predilection, and span the
range of ages. Certain conditions may predispose toward
the formation of hemorrhoids: constipation, chronic diarrhea, and pregnancy. The most common causes of constipation are inadequate fluid intake, poor diet (low fiber intake), and infrequent exercise. There are also a number of
medications that can cause constipation (calcium channel
blockers, tricyclic antidepressants, diuretics).
Hemorrhoidal prolapse constitutes a special situation
in hemorrhoidal disease. The tissue has enlarged enough
to be partially expelled during defecation. A grading system is used to describe enlarged internal hemorrhoids: (1)
grade Ienlarged hemorrhoidal tissue, (2) grade II
hemorrhoidal tissue that prolapses with straining but
spontaneously reduces, (3) grade IIIhemorrhoidal prolapse that requires manual replacement, and (4) grade
IVunreducible prolapse. Anatomic orientation is also
helpful as one person may have coexisting grades of hemorrhoids. Left, right, anterior, posterior, and lateral are the
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DIAGNOSIS
digital examination to evaluate the canal for masses, tenderness, and sphincter tone, (3) anoscopy to examine the anal
canal visually, (4) flexible sigmoidoscopy to visually examine
the rectum and lower colon, and (5) when prolapse is suspected, visual examination of the anus and perineum during
straining, preferably while sitting or squatting.
External hemorrhoids are visible on simple inspection,
and in the noninflamed state simply may appear as fleshy
skin covered protrusions (tags). They may become inflamed and edematous or may thrombose. Thrombosis
(usually an acute event brought on by straining, constipation, or diarrhea), is typically very painful (Case 4). A firm
tender mass is palpated adjacent to the anal canal. The
mass may have a dark, bluish appearance. The overlying
skin is usually normal although central ulceration is not
uncommon due to pressure necrosis. The tenderness is localized to the thrombosis itself, unlike an abscess.
Internal hemorrhoids can only be appreciated adequately by visualization, either by inspection if prolapsed
or by anoscopy. Palpation is unreliable in the diagnosis of
internal hemorrhdoids.
Rectal prolapse can be difficult to diagnose. Even
though the patient may report frequent prolapse, reproducing the event in the doctors office may be difficult.
Frequently, the experience can be embarrassing for the
patient and even the physician. Often, the patient can only
produce the prolapse while squatting and straining. A
bathroom adjacent to the examination room is helpful for
this part of the examination. When the prolapse is reproduced, it may protrude 12 cm or up to 1520 cm. Rarely,
a patient will present with an incarcerated prolapse, which
should be treated as a surgical emergency.
Although flexible sigmoidoscopy is usually adequate, a
more thorough colonic examination (colonoscopy, air contrast enema) may be helpful. Rarely, a tumor can act as a
bedpost for intussusception or prolapse. Laboratory
studies are not helpful in making the diagnosis, although
the presence of anemia should mandate a full colonic
evaluation.
K E Y
P O I N T S
DIFFERENTIAL DIAGNOSIS
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FIGURE 34.3 True rectal prolapse. Note the circumferential mucosal folds and the sulcus outside the
prolapse (fixation of the dentate line).
TREATMENT
uccessful treatment of hemorrhoids requires an accurate diagnosis and elimination of other perianal disease
as the cause of the patients complaints. Since hemorrhoids are a normal part of human anatomy, they will invariably be present but may not be contributing to the patients problems. Indeed, other pathology (e.g., anal
fissures, proctitis) frequently will exacerbate existing hemorrhoids. Failure to appreciate and treat the primary disease process will likely lead to failure of therapy.
Internal hemorrhoids may be treated medically, with
office treatments, or with surgery. The decision rests on
the symptomatology and physical examination. For complaints of minor bleeding associated with bowel movements (outlet bleeding), dietary counseling and fiber
supplementation (psyllium) may be adequate, although
flexible sigmoidoscopy is mandatory to eliminate a distal
colon or rectal cancer as the possible cause of the bleeding. For prolapse, or bleeding associated with prolapse,
additional treatment is required. A variety of office treatments may be used, although sclerotherapy and rubber
band ligation are the most commonly employed. All of
these office based treatments are fixation techniques.
They work primarily by creating scar tissue locally that
fixes the mucosa overlying the hemorrhoid to the underlying internal sphincter muscle. Surgical treatment, including laser treatment, is reserved for more severe disease (Case 3) and for patients with associated external
hemorrhoids that are not amenable to office treatment.
Laser hemorrhoidectomy is identical to standard surgical
hemorrhoidectomy in every parameter studied. Its only
apparent advantage is in marketing. The disadvantage is
solely in cost.
External hemorrhoids may also be treated medically
or with surgery. Topically applied creams may help shrink
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FIGURE 34.4 Hemorrhoidal or mucosal prolapse. Note the radial folds and absence of rectal wall
(muscle) within the prolapse.
edematous and inflamed tissue, but office surgery is sometimes required to solve an acute painful process such as
thrombosis (Case 4). On rare occasions, circumferential
thrombosis is best treated in the operating room with
anesthetic blockade.
As a rule of thumb, it should be remembered that
most hemorrhoidal problems can be solved without surgical intervention.
Treatment for procidentia, unfortunately, does not
enjoy the same success rate as hemorrhoidectomy. Once
diagnosed, the solution is surgical, but the choices for repair are numerous. They fall into three basic categories:
(1) anal encirclement procedures (Thiersch), (2) perineal
approaches (Altmeier or Delorme), and (3) abdominal approaches.
Historically, the circlage, or Thiersch procedure, has
been around the longest. The prolapse is reduced and
maintained by reinforcing the external sphincter mechanism with a permanent material placed outside of the
sphincter mechanism and underneath the skin. The recurrence and infection rates are high. It is now reserved for
the very infirm.
Perineal solutions have enjoyed a resurgence in popularity, particularly among the elderly patient population,
since the operation is performed under regional anesthesia. It involves resection or plication of the redundant
bowel via the anal canal. Although this does not treat any
underlying cause of the problem, the recurrence rate is
somewhat lower than an encircling procedure and the operation is quite safe.
The abdominal approach has the lowest recurrence
rate but also the greatest morbidity. Evaluation of the
anatomy is more complete and the operation can be combined with a resection, rectopexy, or very low dissection.
Most versions include a very low dissection in order to
create a plane of scarring in the retrorectal space. The
risks are the same as for low anterior resection. Choice of
operation is based on an individuals activity, experience,
and preference of the surgeon.
It should be noted that the pathophysiology of procidentia is not completely understood. A weakening of the
pelvic floor leads to the intussusception or prolapse, but
the role of bowel function and motility is not fully appreciated as a precursor to this event.
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SUGGESTED READINGS
Successful treatment of hemorrhoids requires accurate diagnosis and elimination of other perianal disease as the cause of
patient complaint; since hemorrhoids are normal human
anatomy, will invariably be present, but may not be contributing to patients problem
Huber FT, Stein H, Siewert JR: Functional results after treatment of rectal prolapse with rectopexy and sigmoid resection. World Surg 19:138, 1995.
Simplified technical description of the most common technique used for internal hemorrhoid treatment.
Prospective study looking not just at anatomic but also functional results.
FOLLOW-UP
Loder KM, Kamm MA, Nicholls RJ, Phillips RKS: Hemorrhoids: pathology, pathophysiology and aetiology. Br J Surg
81:946, 1994
Comprehensive review focusing on pathophysiology.
Williams JG, Madoff RD: Perineal repair for rectal prolapse.
Prob Gen Surg 9:732, 1992
Outlines perineal approach and options.
QUESTIONS
1. Internal hemorrhoids?
A. Typically cause pain associated with bowel
movements.
B. Are universally present.
C. Are most appropriately treated with the laser.
D. Are readily diagnosed on digital examination.
2. Rectal prolapse?
A. Can be difficult to differentiate from internal
hemorrhoids.
B. Is best treated surgically.
C. Can lead to fecal incontinence.
D. May be treated via an abdominal approach.
E. All of the above.
(See p. 604 for answers.)