TurkJMedSci 34(2004)285-293 ©TÜB‹TAK PERSPECTIVESINMEDICALSCIENCES CommonAnorectalConditions PravinJ.GUPTA ConsultingProctologistGuptaNursingHome,D/9,Laxminagar,NAGPUR-440022INDIA Received:July12,2004 Anorectaldisordersincludeadiversegroupof dentateorpectinatelinedividesthesquamousepithelium pathologicdisordersthatgeneratesignificantpatient fromthemucosalorcolumnarepithelium.Fourtoeight discomfortanddisability.Althoughthesearefrequently analglandsdrainintothecryptsofMorgagniatthelevel encounteredingeneralmedicalpractice,theyoften ofthedentateline.Mostrectalabscessesandfistulae receiveonlycasualattentionandtemporaryrelief . originateintheseglands.Thedentatelinealsodelineates Diseasesoftherectumandanusarecommon theareawheresensoryfibersend.Abovethedentate phenomena.Theirprevalenceinthegeneralpopulationis line,therectumissuppliedbystretchnervefibers,and probablymuchhigherthanthatseeninclinicalpractice, notpainnervefibers.Thisallowsmanysurgical sincemostpatientswithsymptomsreferabletothe procedurestobeperformedwithoutanesthesiaabovethe anorectumdonotseekmedicalattention. dentateline.Conversely,belowthedentateline,thereis extremesensitivity,andtheperianalareaisoneofthe Asdoctorsoffirstcontact,general(family) mostsensitiveareasofthebody.Theevacuationofbowel practitioners(GPs)frequentlyfacedifficultquestions contentsdependsonactionbythemusclesofboththe concerningtheoptimummanagementofanorectal involuntaryinternalsphincterandthevoluntaryexternal symptoms.Whiletheexaminationanddiagnosisof sphincter. certainanorectaldisorderscanbechallenging,itisa matterofconcernthatthephysicalexaminationofthe Symptomatologyoftheanorectallesions anorectumisofteninadequatelyperformedingeneral Thepresentationsofsymptomsinpatientswith clinicalpractice. anorectalpathologiesaremostlytypical,buttheymaybe Thediagnosisandmanagementofhemorrhoids, misleadingduetothepatient’sunderstatementor fissures,andpruritusani,accountonroughestimates, underplayingofsymptoms. formorethan81%ofthecomplaintscenteringaround Thecommonsymptomsdenotinganorectalpathology thispartofthehumananatomy. are-(intheorderoffrequency) Thisbrieftreatiseattemptstoofferasafeand practicalapproachtothemanagementofavarietyof Symptomatologyofanorectalpathologies anorectaldiseases. Briefdescriptionoftheanalcanal -Theanusisthe outlettothegastrointestinaltract,andtherectumisthe 1. Analpain lower10to15cmofthelargeintestine.Theanalcanal 2. Bleedingperrectum startsattheanorectaljunctionandendsattheanalverge. 3. Pusdischargefromandaroundanus Theaveragelengthoftheanalcanalis4cm.The midpointoftheanalcanaliscalledthedentateline.This 4. Prolapse 285 CommonAnorectalConditions 5. Analpruritus • Inflammatoryconditions[Proctitis,analcryptitisand 6. Presenceofswellingorlumpsinoraroundanus papillitis] 7. Passageofmucusperrectum • Inflammatoryboweldisorders[Ulcerativecolitisand Crohn’sdisease] 8. Constipationorfecalobstruction • Hypertrophiedanalpapillae. 9. Frequencyofstool Uncommon 10. Difficultyinpassingstool 11. Incontinencetoflatusorfeces. • Stricturesofanalcanalorrectum • Solitaryrectalulcer Asystematicapproachtopatientswithanorectal • Incontinence[Flatusorfeces] complaintsallowsforanaccurateandefficientdiagnosis oftheunderlyingproblem.Theprocesscanbedivided Investigatingacaseofanorectallesion- The intotheinterview,theexamination,andconveyanceof patient’shistory,andinspectionandpalpationofthe information.Throughoutthisprocess,thepatientmust anorectumremainthebasic,essentialfeaturesof bereassuredandmadeascomfortableaspossible. diagnosis.Asuccessfulinteractionwiththepatientleads Thekeytodiagnosisremainsthepatienthistory,with toadiagnosisandatreatmentplanthatisacceptableto confirmationbyvisualinspectionandanoscopy. boththephysicianandthepatient. Expensiveworkupsareusuallynotrequired.Basedonthe Anoscopy[proctoscopy]remainsthemainstayinthe symptomsandpossibledifferentialdiagnosis,further detectionofanalpathologies.Whenamoreproximal investigationmaybenecessary. lesionissuspected,asigmoidoscopyorcolonoscopyalong Themostcommonanorectallesionsencounteredin withbiopsyisneeded.Anorectalphysiologyandendoanal familypracticeare-(intheorderoffrequency) ultrasonographyarealsoregardedasessential investigativetechniquesinacolorectallaboratory.Anal manometryanddefecographyaremoreadvanced Commonanorectallesions investigativetoolsforcolorectalworkup. Commonest Fistulograms,magneticresonanceimaging,and • Hemorrhoids[Internalorexternal] tomographicscanningareotherinvestigationstobe • Analfissures[Acuteorchronic] mentioned. • Analfistula[Loworhigh] Treatmentofanorectaldiseases- • Abscesses[Perianal,ischio-rectal,submucus] Familyphysicianscantreatmostofthecommon • Polyps[Adenomatous,fibrousanal,juvenile] anorectaldisorderstheyseeingeneralpractice.Most casescanbetreatedbyconservativemedicaltreatment • RectalProlapse[Mucosalorcomplete] (e.g.,dietarychanges,sitzbaths,analgesics,antibiotics, • Analskintagsorsentinelpile stoolsofteners,hemorrhoidalcreamsandsuppositories) • Anorectalsepsis[Hyderadenitissuppuritiva,AIDS, ornonsurgicalprocedures. syphilis] Inrecentyears,greatinteresthasbeengeneratedin LessCommon thefieldofproctology.Theavailabilityofnewdiagnostic • Sacro-coccygealpilonidalsinusdisease andoperatingtoolsandarefinementintechnique, coupledwithnewtherapeuticmodalities,have • Neoplasm[Benignormalignant] contributedtointerestingresearchresultsinproviding • Condylomas reliefforpatientsneedingproctologicalintervention. • Connectivetissuemasseslikepapilloma,fibroma,and Anattempthasbeenmadeinthefollowing lipoma. paragraphstodescribeinbriefthetherapeuticmodalities • Antibioma[Organizedabscess] ofcommonanorectaldisorders. 286 P.J.GUPTA Analfissures- Chronicanalfissuresaremostlyfoundonthe Acuteanalfissuresaresuperficialandareusually posteriororanteriormidline.Theyareoftenassociated multiple.Theyrespondwelltoconservativetherapieslike withpathologieslikesentineltags,analpapillae,fibrous warmsitzbath,applicationofvarioushemorrhoidal polypsorhemorrhoids.Therapiesusefulforacute creams,analgesics,anddietarymodifications.Properanal fissuresmayonlyprovideshort-termreliefinsuch hygieneandcorrectionofchronicconstipationordiarrhea chronicforms.Inaddition,theyneedsomesortof areessentialtopreventrecurrenceoffissures. internalsphinctermanipulation.Suchmanipulationmay beeithersurgicalornonsurgical. Afewofthenon-surgicaltreatmentmodalitiesaresummarizedbelow(1). Method Advantages Disadvantages Costfactor Curerate Injbotox Easyofficeprocedure, Invasive,toxicity,infection. Costly 79% singleinjection. Oralnifedipine Oralortopicaladministration, Shortdurationofaction,side Economical 90-95% fasterhealingoffissure. effectslikeheadaches. Localapplicationof Easyapplication.Shortduration Headachein20-100%ofpatients. Economical 60-90% vasodilators[nitroglycerine] oftreatment,highhealingrates. Highrecurrencerate. Alpha-1adrenoceptorblockers. Oncedailydose. Recentlyintroducedstudy. Economical 70-80% Long-termeffectsnotknown. Chemicalcauterization Easyapplication,fasterhealing. Toxicityofdrugs,generalized Economical 60-70% poisoningandinfection. Despitetheinitialsuccesswiththesepharmacological rateisabove90%,asystematicreviewofrandomized agentsinthetreatmentofpatientswithchronicanal surgicaltrialsshowsthattheoverallriskofincontinence fissures,agrowingconcernisdevelopingabouttheiruse. isabout10%,whichisformidable(2). Increasesintheincidencesofadverseeffectsanda Treatmentofhemorrhoids- decreaseinlong-termefficacyhavebeenthemajor drawbacksofsuchnonsurgicaltherapies. Ithasbeenestimatedthat50%ofthepopulation developshemorrhoidsbytheageof50(3).Although Surgeryremainstheoptiontobeofferedtopatients patientsoftenconsidertheconditiontobeasinglesimple withrelapseortherapeuticfailureofpharmacological disease,itmaynotbeso.Hemorrhoidssharetheir treatmentalreadyundergone.Thereisaconsensusthata symptomswithawholeseriesofotherdiseasesanditis controlledlateralinternalsphincterotomyisthebest thislackofspecificitythatcallsforathorough surgicalprocedureforchronicanalfissure.Bothopenand examinationtoreachaprecisediagnosis. closedmethodsareequallyeffective.Althoughthecure Grades Symptoms Signs I Bleedinganddiscomfort Hemorrhoidsvisibleonanoscopy,whichmayprotrudeduringstraining. II Bleeding,discomfort,Discharge/pruritus Prolapsevisibleatanalvergeduringstrainingwithspontaneousreturnto normalcywhenstrainingends. III Bleeding,discomfort,discharge/pruritusand Prolapserequiringmanualreplacement. stainingofundergarments. IV Bleeding,discomfort,discharge/pruritusand Irreducibleprolapse. stainingofundergarmentsandpain. 287 CommonAnorectalConditions Thefollowingtableelaboratesthevarioustreatmentoptionsfordifferentgradesofhemorrhoids: Hemorrhoidgrade Treatmentoptions GradeI o Sclerotherapy o Infraredphotocoagulation o Bicap o Dopplerguidedhemorrhoidalarteryligation[DGHAL](4) o Radiofrequencyablation(5) GradeII oRubberbandligation o Infraredphotocoagulation o Heaterprobe o Ultroid[Directcurrentprobe] o DGHAL o Radiofrequencyablation GradeIII o Surgery[Conventional,diathermy,harmonicscalpel,laser] o Staplerhemorrhoidopexy(6)[PPH] GradeIV o Surgery o Staplerhemorrhoidopexy[PPH] Medicaltreatmentofhemorrhoids -Althoughnot Theinfectioncanpresentattheanalvergeasaperianal constitutinganetiologicaltreatmentofthedisease, abscess.Theseabscessescaneasilybedrainedinthe conservativetreatmentdoeshavearoleinrelievingthe officeunderlocalanesthesia. symptomsofhemorrhoidsandassociatedcomplaints(7). Bacterial,viral,andprotozoalinfectionscanbe transmittedtotheanorectumviaanoreceptive Medicaltreatmentofhemorrhoids intercourse.Anorectalsepsisisamedicalemergency requiringimmediatehospitalizationandtreatment, o Controlofconstipationusingbran,mucilage,lac-