Società Italiana di Chirurgia ColoRettale www.siccr.org 2005; 3:18-25 Modern trends in ambulatory proctology ___________________________________________________________________ Tomáš Skřička ___________________________________________________________________ Bakeš Memorial Hospital, Brno, Czech Republic ___________________________________________________________________ Abstract Ambulatory proctology is till now very trombosis (personal experience with 382 anal underestimated discipline, which is out of tromboses) and anal fissures (personal interrest of „big surgeons“. But is is a very experience with 421 patients). We also important field due to incidence of proctological mention the other anal pathologies, which affections and severe social consequences of could be treated by means of modern their inappropriate diagnosis and treatment. proctology (hidrosadenitis analis, anal fistulas). We stress the conservative and semiinvasive Recently, more and more proctological treatment of hemorrhoids (personal experience diseases could by treated as the out patient with 5296 patients, to whome 13429 rubber department procedure. band ligations have been applicated), anal Key words: ambulatory proctology, hemorrhoids – semiinvasive therapy, anal fissure – dilatation Introduction Proctologic disease are as old as mankind good knowledge of the medical history helps itself and very „human“. And yet, most people delineate the clinical picture, although the final still fight shyness to talk about their signs and diagnosis cannot be made without symptoms in the anorectal region. Despite performance of a number of diagnostic tests recent effort to provide health education, the and procedures. Internal hemorroids, e.g., are anal region is still considered taboo. In the not readily palpable, but become evident only language of affiliated individual, the wide by means of anoscopy. Such systemic spectrum of proctologic complaints and examination procedure within the framework of manifestations associated with such a proctologic practice has unfortunately still not diseases is reduced to the almost stereotypic gained general acceptance. statement:“Doctor, I have hemorrhoids.“ A Haemorrhoidal disease Investigations revealed that about 70% of adult weeping or inflammation. For term population over 30 years of age suffer from „hemorroids“ is commonly used to designate a hemorroids (1). On the other hand it must be variety of anorectal diseases such as fissures, noted that many patients will not consult a rhagades, eczemas, abscesses, internal doctor until overt bleeding has occured. To the hemorroids and anal trombosis. layman, as a rule, all of the symptoms of the The anorectal diseases are generally anal region are hemorrhoids, whether they are associated with leadingsymptoms such as evidenced by pain, pruritus, bleeding, burning, bleeding, pain, and inflammation, which have www.siccr.org 18 Società Italiana di Chirurgia ColoRettale www.siccr.org 2005; 3:18-25 been a challenge to the medical profession rectal polyps, which could be also considered concerned with the art of wound treatment as „hemorroids“, without careful examination. from time immemorial. DO NOT TREAT Much more educational work will have to be WITHOUT PROPPER DIAGNOSIS !!!! Much done before patients learn to talk to their worse than above mentioned diseases are doctor early enough and without restraint about delayed diagnoses of rectal cancer, colitis, their anal discomfort. internal rectal prolapse, solitary rectal ulcer, Diagnosis Diagnosis of hemorrhoidal disease is the and can be seen at the exterior, only to synthesis of patient´s history, visual control disappear again immediately straining stops. before and during anoscopy and digital Third degree piles are cushions that descent examination, which serves only as a rough to the exterior on straining or defecation and orientation in the anal canal. It has been remain outside until the next bowel movement traditional to grade the hemorroids disease into or possibly the next act of straining. four degrees depending on the extent of „Fourth degree piles“ is the term sometimes prolaps: used to describe mucosal covered internal First degree piles are cushions that do not cushions that are permanently outside the anal descent below the dentate line on straining. By verge and at once inside when they are this strict definition everyone, even those replaced. Much more frequently this category without symptoms, fits into this category. The is used for the complicated third degree definition therefore has to be qualified to (trombosis, inflammation, exulceration). include only those individuals with symptoms, usually bleeding. Correct description of the localization of Second degree piles are cushions that hemorrhoids : 12 is anteriorly (in the direction protrude below the dentate line on straining to the pubis) , 6 posteriorly ( coccygis). Conservative treatment Step by step method should be the fist choice - regular bowel movements in the treatment of hemorroids. Taking a closer - diet high in dietary fibre look at the anorectal symptoms and the - ample fluid intake controversial views on the aethiology, it is - careful anal hygiene (but alcalic soap) understandable that a variety of therapeutic could cause anal mycosis and measures has come into widespread use. dermatitis!!) Every type of therapy, however, should - avoidance of laxatives (precise include the various general measures to be diagnosis of constipation, correction of tgaken by the patient himself: e.g. ventral rectocoele!!) Drug therapy Is important in most anortectal diseases. Therapy of bleeding Semiinvasive and surgical interventions are The main agents employed are adstringent generally not necessary until conservative metal compounds such as aluminium chloride treatment has failed. hydroxide, bismuth oxide and bismuth aubgallate. According to Mutschler (2), „it is www.siccr.org 19 Società Italiana di Chirurgia ColoRettale www.siccr.org 2005; 3:18-25 quite comprehensible that there is only a Antibiotics, antiseptics quantitative difference between adstringent Among the many agents used there are not effect and cauterisation“. only a variety of antiseptics (such a hexachlorophene) and antibiotisc(as e.g. Therapy of pain and irritation framycetine), but also phenylmercuric nitrate. First among theese substances are local Owing to the potential development of anaesthetics such as cinchocaine, lidocaine, resistance, antibiotisc should be avoided, benzocaine and polidocanol. Although fast end particularly in long-term therapy. When well acting, local anaesthetics, ultimately, have administered in high doses, phenylmercuric only symptomatic effects. Similar, but weaker nitrate can impair renal function. Its use in action are antihistaminics such as should, therefore, be discontinued. Agents diphenhydramine. As antiallergisc they have offering a broad antimicrobial spectrum, that is, good antipruritic action in allergically induced both, antibacterial and antimycotic action, eczema, e.g., but seldom relieve pain. On the shold be used by preference to guard against whole, these agents are of quastionable value local infection. in the treatment of pain and irritation. Recent drugs Anti-inflammatory agents Acute hemorrhoidal crisis is recently mostly Corticosteroids are still in widespread use as a and successfully treated by combined potent antiphlogistic agents, but leading remedies, e.g. Ginkor fort (containing extract coloproctologists are rather critical to the gingko bilobae, troxerutin and heptaminol employment of such agents (atrophy of anal hydrochloride). Detralex (micronized, purified mucosa and perineal skin and interference with flavonoidic fraction, diosmin, hesperidin). The the healing process). Candida infected perianal above mentioned drugs increase venous tone eczema is the frequent result of corticosteroid by improving venous wall noradrenalin activity, therapy (3). Lesions to the skin and mucosa they increase lymph draninage and they are to be expected already after a treatment protect the microcirculation by fighting period of 2 weeks. precapillary inflammnation, too (4,5,6). Semiinvasive therapy Sclerotherapy, cryotherapy, fotocoagulation, rubber-band ligation Sclerotherapy verge. The sclerotherapy is the first line of First attempts made by J. Morgan in 1869. treatment for minor degrees of hemorroids, Recently the gabriel syringe and needle is particularly causing bleeding without mucosal used (7). 5% phenol in almond or arachis oil is prolapse. One course of injection seems to be drawn up from individual 10ml phials to allow sufficient and probably upward of 70% of for about 3ml of injection into the base of each patients are satisfied with the results of the vascular cushion.. The result is the aseptic treatment. We used this method routinely till st nd inflammation and lately the mucosal fixation. In 1992 in the 1 and some 2 degrees of piles. the USA the phenol is forbidden and they use Now we prefere fotocoagulation and the 5% quinine and urea hydrochlorid in the same sclerotherapy is used very rarely. indication (Figure 2). The anoscope is passed into the anal canal and at the point where the Cryotherapy reddish mucosa changes to the purplish one, Cryodestruction of different lesions, using indicating engorged underlying vascular liquid carbon dioxide (CO2) or liquid nitrogen cushions, the sclerosant is injected (N2) is well known. The freezing of tissue immediately under the mucosa. The procedure bellow –22oC causes permanent destruction should