Fig. 31.1
Acute presentation of massive thrombosed external hemorrhoids. This patient was brought to the operating room for emergent hemorrhoidectomy
Internal hemorrhoids, on the other hand, rarely present with pain because of their location proximal to the dentate line. In the absence of an obvious thrombosed external hemorrhoid, a complaint of severe pain should alert the surgeon to search for another diagnosis. Patients with symptomatic internal hemorrhoids typically present with painless bleeding as the overlying mucosa becomes thin and friable. The bleeding associated with internal hemorrhoids typically occurs with defecation and is described by patients as bright red blood on the toilet paper. Occasionally, the blood will be noted to drip into the toilet bowl. Additionally, as a consequence of excessive straining and increased intra-abdominal pressure there is prolonged and increased engorgement of the internal hemorrhoidal plexus. Over time, the bulky hemorrhoids lose their attachment to the underlying anorectal wall, resulting in prolapse. The severity of internal hemorrhoids is graded according to severity of prolapse based on a classification system described below in Table 31.1.
Table 31.1
Grading of internal hemorrhoids
Grade I | Prominent hemorrhoidal tissue without prolapse |
Grade II | Prolapse on straining with spontaneous reduction |
Grade III | Prolapse on straining requiring manual reduction |
Grade IV | Prolapse is irreducible. Incarcerated and/or strangulated |
Patients with prolapse may experience mucous drainage causing irritation and inflammation of the perianal skin, and some patients may report the feeling of incomplete evacuation. It is only in the rare circumstance of strangulation that a patient will experience pain associated with an internal hemorrhoid.
Diagnosis
The completion of a full history is followed by a thorough rectal exam, starting with external inspection. Inspection should make note of any evidence of perianal skin irritation caused by anal discharge, skin tags, external hemorrhoids or evidence of an alternative diagnosis such as the external opening of a perianal fistula. During inspection, the surgeon may also ask the patient to “bear down” in order to demonstrate the prolapse of internal hemorrhoids with strain. Following visual inspection is the digital rectal exam; however, hemorrhoids are not easily palpated on DRE. Therefore, the clinician should proceed to anoscopy. Although anoscopy often reduces any prolapsed internal hemorrhoids, the physician will be able to visualize the redundancy of the engorged hemorrhoidal cushions.
For patients who present with bleeding, it is necessary to recommend a full colonoscopy, once their acute issues related to hemorrhoids have resolved, to rule out a more proximal source of bleeding as well as other potential diagnoses including inflammatory bowel disease and cancer. This colonoscopy can be done as an outpatient and should be done in patients older than 40 years of age, as well as in younger patients with other risk factors, such as family history, and in whom hemorrhoids are the not the obvious source of bleeding.
Treatment
Since hemorrhoids are a physiologic part of normal anatomy, the decision to treat should be based on the frequency and severity of symptoms. For thrombosed external hemorrhoids—the most common presentation of hemorrhoidal disease to an acute care surgeon—treatment options include excision or observation. For patients that present within the first 48 h from the onset of pain, current guidelines recommend surgical excision in order to provide the patient with the most rapid relief from pain. Excision can easily be performed in the emergency room under local anesthesia, or if desired in the operating room. Excision is preferable to simple unroofing and evacuation of clot due to higher rates of recurrence and re-thrombosis with the latter. Post-procedure the wound can be left open with or without packing (based on surgeon preference), with postoperative care focused on pain control and proper hygiene. Patients should be instructed to soak in warm sitz baths after each bowel movement to aid in cleanliness. Beyond 48 h, the clot begins to reabsorb, and patients will often report improvement in pain. Subsequently, supportive treatment with sitz baths, analgesics, and prevention of constipation with fiber supplements are usually effective without the need for excision. After treatment, patients should be advised of the risk of possible recurrence: 25% after supportive nonsurgical therapy and 6.5% after excision [11].
For internal hemorrhoids, the treatment options can be classified based on the degree of symptoms and grade of hemorrhoids. For Grade I and II internal hemorrhoids associated with minor symptoms such as bleeding and do not significantly interfere with daily activities, the initial treatment should begin with conservative therapy, which includes fiber supplements and a high-fiber diet. The rationale is to produce soft, bulky stools that decrease the need for straining. Patients should also be advised to avoid prolonged straining or attempts at defecation. The addition of sitz baths may provide symptomatic relief as well as over-the-counter topical therapies; however, there are no studies that demonstrate their efficacy. In contrast, conservative therapy has not demonstrated significant efficacy in Grade III or IV hemorrhoids with significant prolapse and therefore treatment should begin with more aggressive treatment modalities discussed as follows.
For hemorrhoids that do not respond to conservative management, as well as Grade III and IV hemorrhoids with significant prolapse, the first line of therapy is rubber band ligation, with other options including sclerotherapy and infrared photocoagulation. All of these therapies are techniques of fixation. By securing the hemorrhoids to the normal anatomic location, high in the anal canal, the incidence and degree of prolapse diminishes, the venous drainage of the hemorrhoids improves, and the size of the hemorrhoids ultimately diminishes. Sclerotherapy is the oldest treatment and similar to that used for esophageal varices. It works by injecting a sclerosing agent into the submucosa, resulting in fibrosis and fixation of the hemorrhoidal cushion. Infrared photocoagulation has been well studied, and alternatively causes tissue destruction by delivery of heat via an infrared light source. However, the most commonly used treatment for severely prolapsed or refractory internal hemorrhoids is rubber band ligation. In a recent meta-analysis reviewing over 18 prospective, randomized controlled trials comparing rubber band ligation to sclerotherapy and infrared photocoagulation, rubber band ligation was more effective, with a decreased recurrence rate; albeit with a higher incidence of post-procedure pain [12].
Rubber band ligation can be performed in the office, or emergency room, using a fenestrated anoscope. A circular rubber band is then placed around the base of the internal hemorrhoid resulting in an inflammatory response, which causes fixation to the sphincter. By constricting the blood supply, the tissue and the band will typically slough within 5–10 days, and the patient should be informed that this is normal. Typically, banding all three hemorrhoidal cushions at once is avoided due to increasing patient discomfort with increased banding. However, one or two hemorrhoids can be banded simultaneously, with further ligations done at 4-week intervals. During placement, it is imperative that placement of the band is proximal, and not including, the dentate line so as to avoid pain associated with somatic nerve fibers. A band that has slipped or is placed too distally should be suspected in patients who complain of immediate, severe pain. The band should be removed and replaced correctly. Rubber band ligation is not painless and even when the band is placed properly patients will experience some mild discomfort usually secondary to sphincter spasm. Post-procedure, patients should be advised to take sitz baths to reduce their pain as well as oral analgesics as needed. They should also be advised to increase their dietary fiber or add supplements to their diet. The success rate of rubber band ligation approaches 80% [13].
Excisional hemorrhoidectomy is the gold standard and most effective therapy for symptomatic hemorrhoids, and is recommended for those patients who have failed less invasive treatment options, those who have combined symptomatic external and internal hemorrhoids, as well as those with severe symptoms including incarcerated or strangulated Grade IV internal hemorrhoids. Surgical hemorrhoidectomy is performed in the operating room as a Ferguson closed hemorrhoidectomy. This procedure involves an elliptical incision starting at the anal margin with extension to the anorectal ring, making sure to include both the internal and external hemorrhoidal plexus. Dissection is carried out in the submucosal plane taking care to avoid injury to the sphincters. The wound is completely closed using running suture. The primary complaint postoperatively is significant pain, which is treated with analgesics, sitz baths, and bulk laxatives starting on postoperative day 1.
Although excisional hemorrhoidectomy is considered the “gold standard,” it is not without complications, including significant pain, urinary retention, and possible anal stenosis. As a less painful alternative to excisional hemorrhoidectomy, stapled hemorrhoidopexy, or the procedure for prolapsed hemorrhoids (PPH), was introduced [14]. In lieu of hemorrhoidal excision, this procedure makes use of a specially engineered circular stapler to divide the hemorrhoidal blood supply, excise the redundant submucosal tissue, and suspend the prolapsing internal hemorrhoids. The staple line lies entirely within the anal canal, proximal to the dentate line. This eliminates very painful external incisions. A recent Cochrane review compared PPH to conventional excisional hemorrhoidectomy, and concluded stapled hemorrhoidectomy is associated with decreased postoperative pain and hospital stay; however, it is associated with increased recurrence, increased prolapse, and an increased need for further procedures. Therefore excisional hemorrhoidectomy is still considered the “gold standard” of surgical care [15].
Complications
Complications for most procedures include bleeding, infection, urinary retention, and pain. After excision for external hemorrhoids, complications are rare but may include bleeding and perianal abscess and/or fistula [11]. After rubber band ligation, the most common complications include pain due to malpositioning of the band, as mentioned previously, as well as bleeding. For this reason, it is recommended that patients taking nonsteroidal anti-inflammatory drugs (NSAIDs) or anticoagulants stop therapy seven days prior to anticipated banding. For the rare instance when a patient presents post-banding with a triad of delayed pain, urinary retention, and fever, one must be suspicious of infection and/or perianal sepsis, which can be fatal if not immediately diagnosed and treated with antibiotics +/− drainage of associated infection/abscess. Due to this risk, albeit low, some surgeons avoid rubber band ligation in immunocompromised patients who are at increased risk of morbidity from this complication.
Complications of excisional hemorrhoidectomy include: bleeding (2–4%), urinary retention (2–32%), anal stenosis (0–6%), and infection (0–5%). Coagulopathic patients and immunocompromised patients pose a unique problem due to already high risk of bleeding and the morbidity of a potential non-healing with an open wound. Furthermore, for patients with portal hypertension, although the incidence of pathologic hemorrhoids does not increase, bleeding from hemorrhoids can be life-threatening and difficult to stop. In addition to correcting any abnormal coagulopathy, the recommended treatment is to suture ligate the bleeding hemorrhoid including the mucosa, submucosa, and underlying muscle in order to effectively stop bleeding. Excisional hemorrhoidectomy in these patients should be reserved for when suture ligation fails.
Follow-up
The follow-up for hemorrhoids is dependant on the treatment prescribed. For thrombosed external hemorrhoids that were treated with supportive management or internal hemorrhoids treated with conservative management, no follow-up is necessary unless they experience recurrent symptoms. However, patients who underwent excision for thrombosed external hemorrhoids should be reevaluated within 1–2 weeks to check for proper healing. After rubber band ligation, the patient should be seen in 4–6 weeks unless they develop signs of infection or sepsis. At this interval, further banding can be performed if necessary. After either conventional or stapled hemorrhoidectomy, the patient should be seen soon after surgery and then at 4–6 weeks to ensure proper healing. All suitable patients with bleeding should be considered for colonoscopy upon completion of treatment for hemorrhoids.
Anorectal Abscess
Epidemiology/Pathophysiology
The large majority of anorectal abscesses result from infection of the anal glands and crypts, called crypto-glandular infection, and are thought to be part of the same disease process as anorectal fistula, which is discussed later. The abscesses are the acute manifestation of disease and fistula represent the chronic stage. Anorectal abscesses can affect patients at all ages; however, they most often present during the third decade of life. They are more common in men than women and typically affect healthy individuals; however, there are some conditions that predispose patients to abscess and these include diabetes mellitus, trauma (i.e., foreign body or surgery), Crohn’s disease, malignancy, radiation, human immunodeficiency virus (HIV), or other immunosuppressed states that may leave the patient susceptible to opportunistic infection.
The pathogenesis of an anorectal abscess is thought to start with infection of one of the 6–10 anal glands that lie in the intersphincteric space and normally function to secrete mucous and lubricate stools. These glands traverse the internal anal sphincter and empty into the 10–15 anal crypts, which lie circumferentially around the dentate line. Therefore, infection of the anal gland or crypt, usually by blockage, follows the path of least resistance and spreads along one of several planes in the anorectal region to form a perianal or perirectal abscess. Indeed, anorectal abscesses are classified according to location (Table 31.2), which aids in diagnosis as well as treatment and requires the surgeon to be familiar with the anatomy of anorectal spaces.
Table 31.2
Classification of anorectal abscesses.
Perianal abscess | Most common. Lies beneath the anal verge and lateral to, without traversing, the external anal sphincter |
Intersphincteric abscess | Occurs between the internal and external anal sphincters, commonly posterior. Most commonly associated with fistula and likely to recur |
Ischiorectal (Ischioanal) abscess | A progression of the intersphincteric abscess that traverses the external sphincter and occupies the area bounded by the levators superiorly, the transverse perineal septum inferiorly, the external sphincter and anal canal medially and the ischial tuberosity laterally. May cross the midline posteriorly to form a horseshoe abscess |
Supralevator abscess | Occurs above the levator ani |
Clinical Presentation
The presentation of an anorectal abscess may depend on its location; however, the initial presentation of most abscesses, regardless of location, is anal pain. This pain is usually described as dull or achy and is often independent of defecation. However, patients may note that the pain worsens with straining, coughing, or even walking. In rare circumstances, patients may present with fever, chills, urinary retention, and signs of sepsis suggestive of systemic illness, which should raise the suspicion of a necrotizing soft tissue infection.
Diagnosis
Diagnosis starts with a complete history and physical eliciting pertinent past medical history including comorbidities and predisposing risk factors as listed previously, as well as a focus on prior abscesses or prior anorectal surgery. Physical exam should include a thorough abdominal and rectal exam, as well as a bimanual exam in women to rule out involvement of the vaginal wall. In the case of a perianal abscess, external inspection may reveal perianal swelling with associated erythema, cellulitis, and/or fluctuance. Intersphincteric abscess are usually without external signs, yet digital rectal exam will often elicit severe tenderness. Ischiorectal abscesses have the potential to be large and DRE may elicit lateral swelling and pain, however, with less obvious external findings. Supralevator abscess are the most difficult to diagnose since they may be the result of a cephalad progression of perianal infection or a manifestation of an intra-abdominal process such as diverticulitis. Therefore, computed tomography (CT) scan may be required to confirm the diagnosis. If there is ever a doubt as to the diagnosis or location of an anorectal abscess, an exam under anesthesia should be performed to allow for confirmation of the diagnosis as well as an opportunity for treatment.
Treatment
The treatment for an anorectal abscess is incision and drainage. Perianal abscesses are often superficial and the easiest to drain, and can be performed in the emergency room under local anesthesia. An elliptical or cruciate incision should be made over the most prominent, fluctuant part of the abscess, taking careful measures to avoid injury to the sphincter muscles. The incision should also be made large enough so as to prevent premature closure of the skin before complete drainage of the abscess has occurred, and should also be made close to the anal verge in order to limit the extent of any potential fistulas that may develop in the future. The abscess cavity should then be thoroughly irrigated and loculations broken by either the surgeon’s finger or a blunt hemostat. No packing is necessary if the incision is adequate; however, a superficial dressing is ideal to prevent drainage onto the patient’s clothing. An ischiorectal abscess can be drained by a similar method, but may require a larger incision with a more thorough evacuation of the abscess. In the case of a horseshoe abscess that spreads posteriorly to both ischiorectal fossas, drainage often necessitates regional or general anesthesia in the operating room. At that time, an incision is made either posterior to the anus or over each ischiorectal fossa with a Penrose placed to allow for adequate drainage of the postanal space. The surgical drainage for intersphincteric abscesses is slightly more complicated in that it requires an incision in the anal mucosa overlying the abscess, followed by a partial division of the internal anal sphincter in order to access and fully clear the abscess. Again, packing is not necessary after drainage. Finally, in the case of supralevator abscesses, the treatment requires accurate diagnosis and identification of location prior to drainage. If the cause originates from cephalad spread of an ischiorectal or intersphincteric abscess then the drainage should be performed as discussed previously via the ischiorectal fossa or the rectum, respectively. For those supralevator abscesses caused by an intra-abdominal source, drainage is performed via the most direct route and often requires CT-guided drainage. Post-procedurally, patients should be given analgesia and instructed to take sitz baths three to four times a day to keep the area clean.
If a fistula is identified at the time of draining the abscess, then a seton may be placed through the fistula tract. This will keep the fistula open at both the internal and external openings, and promote drainage. Suture material or silastic vessel loops may be used as the seton. The fistula will not heal while the draining seton is in place, but it will protect the patient from recurrent abscess. Subsequently, the seton must be removed, or the fistula treated operatively in order to heal.
The success of incision and drainage for an anorectal abscess averages 50% with approximately 20–30% developing a recurrent abscess or fistula [16]. Recurrence is thought to be more common with ischiorectal fossa abscesses, potentially secondary to inadequate primary drainage; however, recurrence should also prompt the surgeon to look for a possible underlying disease such as Crohn’s disease or malignancy. Historically, surgeons prescribed post-procedure antibiotics to decrease this relatively high recurrence of abscess or fistula; however, data from a recent randomized control trial demonstrate that adjuvant therapy with antibiotics does not decrease the incidence of fistula formation at 1 year [17]. Certain patient populations should, however, be given adjuvant antibiotics, and likely require hospitalization. These groups include those patients who are immunocompromised, patients with diabetes mellitus, those with prosthetic devices or valvular heart disease as well as those patients with extensive cellulitis or a necrotizing soft tissue infection [18].
Complications
The main complication with abscesses, as previously discussed, is abscess recurrence or development of a fistula at the time of diagnosis. The risk of abscess recurrence increases significantly if there is a concurrent anal fistula. Fittingly, the role of primary fistulotomy at the time of anorectal abscess drainage has been debated as a method to reduce recurrence. While initial studies looking at the success of a combined procedure concluded no difference in the rate of abscess recurrence in those patients treated with incision and drainage alone versus the addition of a fistulotomy, a recent Cochrane review demonstrates that simultaneous fistula treatment and incision and drainage of the anorectal abscess does indeed decrease the incidence of persistent or recurrent abscess as well as the need for repeat surgical procedures [19]. A small number of patients may experience incontinence after this combined procedure; however, it is often transient. In our experience, when a fistula is discovered at the same time of abscess drainage, it is best to avoid extensive exploration of the tract due to the risk of creating false passages, and instead we place a seton to identify the tract for future definitive therapy once the inflammation surrounding the abscess has resolved. With proper drainage of the abscess, the fistula may heal on its own without the need for any further procedures.
Follow-up
After definitive incision and drainage of an anorectal abscess, complete healing takes approximately 4–8 weeks. Postoperatively, patients should be evaluated soon after surgery, within 1–2 weeks, and then again closer to 8 weeks to ensure proper healing. Afterward, patients only need to be seen on an as-needed basis based on recurrence of symptoms. Follow-up in patients with underlying Crohn’s disease or those who are immunosuppressed should, however, be more aggressive with almost weekly office visits to ensure healing without signs of perianal sepsis.
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