dr stephanie ulmer - gp cme north/sat_room4_1630_ulmer_bottoms.pdfanal fissure •management;...

Dr Stephanie UlmerGeneral Surgeon

Middlemore Hospital

Auckland

16:30 - 17:25 WS #168: Modern Treatment of Haemorrhoids

17:35 - 18:30 WS #180: Modern Treatment of Haemorrhoids (Repeated)

BOTTOMSScience and Art

Questions…

• What is the commonest symptom attributed to haemorrhoids?• A bleeding

• B painful lump

• C itch

• D all of the above

• What are other conditions that can be confused with haemorrhoids?• A anal cancer

• B rectal prolapse

• C anal fissure

• D all of the above

• Which symptom is generally not associated with external haemorrhoids?• A rectal bleeding

• B lump

• C itch

• D pain

The Who Dunnit…

Commonest Symptoms

• Lumps

• Pain

• Bleeding

• Itching

• Discharge

Commonest Conditions

• Haemorrhoids• Internal vs External

• Anal Fissure

• Anal Fistula

• Rectal Prolapse

• Rectal Cancer

• Proctitis

Key to Accurate diagnosis?

• History

• History

• History

• Examination

Haemorrhoids

Haemorrhoids• Internal Haemorrhoids

painless fresh rectal bleeding• Volume varies

intermittent or every BM

rarely between BMs

nothing to see or feel

• On Examination

mostly nil

• External Haemorrhoids

Swollen painful lump on anal verge

• Pain can be directed to the lump

Pain lasts 3-5 days

Indolent skin tags remain• Difficulty with hygiene

Episodic symptoms

Itchiness

Bleeding – nil or spot on toilet paper only

• On Examination

Skin tags only unless acute

Haemorrhoids

• Essential history• Bowel habit – detail

• Frequency

• Sits for long periods

• Prone to constipation

• Use of laxatives

• Blood

• Mucous

• Fibre intake/ Water intake

• Obstetric history:

• number, NVD vs C section, instrumentation, perineal suturing

• Symptoms associated with rectal prolapse:

• stress incontinence, urge incontinence, incomplete emptying, tenesmus, assisted evacuation

• Family history bowel conditions or cancer

• Previous colonoscopy

• Change in weight

• Anticoagulant use

Questions

• What are types of laxatives?• A softening

• B stimulant

• C probiotics

• D bulking

• What is not indicated for bleeding haemohhoids?• A Haemorrhoidectomy

• B Rubber band ligation

• C Phenol injections

Haemorrhoids

• Examination• Abdomen - ?mass

• Rectal – on inspection

- palpation - ?perianal tenderness

- DRE – NOT if pain ++ (fissure)

Haemorrhoids• Management:

• Optimise bowel habit – must be once a day

Lactulose (softener)

Kiwicrush (bulking)

Alpine Tea (stimulant)

• Titrate to needs

• Other options: Laxsol tablets, Movicol sachets, coloxyl and senna, Aloe juice, prunes or prune juice, LSA

• Ultraproct/ Proctosedyl Suppositories w KY Jelly

• bd for 2 weeks then stop for 2 weeks

• Much better than ointment

• Lignocaine Gel

• Salt baths/Ice

Thrombosed Haemorrhoid

• Symptoms; • more severe pain than normal

• Throbbing

• Management:• Same as for acute haemorrhoids

• Surgical excision if not responding

• Refer to ED

Ouch!!

Internal HaemorrhoidsStage 1:

• Little enlargement of hemorrhoidal mucosa but no prolapse. In this stage hemorrhoids often bleed.

Stage 2:

• Mucosa prolapsewhich reduces spontaneously.

Internal Haemorrhoids

Stage 3:

• Mucosa prolapsewhich has to be reduced manually.

Internal Haemorrhoids

Stage 4:

• Non-reducible mucosal prolapse

Internal Haemorrhoids

Internal Haemorrhoids

Treatment (Grade 1 or 2)

• ie If painless bleeding predominant symptom• Management:

Haemorrhoidal Rubber Band Ligation• In rooms – no anaesthetic

• Suction applicator puts rubber band onto apex of haemorrhoid, blocks it off, involutes, scars down and stops bleeding

• 95% success rate for bleeding

• Ongoing bleeding - ?other cause for bleeding (cancer/fissure)

• Colonoscopy

• If not, repeat banding

Internal Haemorrhoids

Other Treatments for Grade 1 or 2

• Sclerotherapy

• Infrared Light Therapy

• Lower resolution rates compared with rubber band ligation

External Haemorrhoids

Treatment

• ie predominant symptoms is painful lumps, itchiness, “I don’t like the lumps”• HAL-RAR

HAL-RAR Treatment Principles*’HAL’ part (Haemorrhoid Artery Ligation)

Doppler Sensor detects the hemorrhoidal arteries 5 - 7 arteries are being ligated

Step 1: HAL

• Pressure equalisation!

• Balances arterial inflow and venous outflow by ligating some (5 - 7) feeding arteries using HAL.

HAL- Hemorrhoidal Artery Ligation

• Reduced blood supply to the hemorrhoidal plexus

• Better balance between inflow and outflow of blood

• Hemorrhoidal cushions shrink back to normal within 6 to 8 weeks

RAR Step 2: Mucopexy

• Fixes the haemorroidal prolapse back to its original position by means of mucopexy (plastic surgery)

HAL-RAR Treatment Principles

HAL-RAR vs Traditional Haemorrhoidectomy

HAL-RAR

Advantages:

• Minimally-invasive ie no cutting

• Minimal necrosis

• No thermal tissue treatment

• Precise

• Every step under direct vision ie stay above the dentate line

• Short recovery period

• High patient acceptance

• Can combine with skin tagectomy

Traditional Haemorrhoidectomy

• Doesn’t address Internal haemorrhoids

• Cutting++

• Pain++

• Potential for serious complications ieincontinence, stenosis

• Likely lower risk of recurrence

Questions

• Which is the predominant symptom for Anal Fissure disease?• A bleeding

• B Pain

• C lump

• Which are red flags for Colorectal Cancer type bleeding?• A associated bowel changes

• B bright red blood

• C blood mixed with bowel motion

• What are symptoms associated with rectal prolapse?• A bleeding

• B frequency

• C tenesmus

• D incomplete emptying

Anal Fissure

• Classical History• “Hurts to have a poo” – “Is the pain like passing glass?”

• Severity – “How long does the pain last?”

• ‘Few secs’ to ‘most of the day’

• Bad enough to send people to bed

• Acute vs Chronic fissure

Anal Fissure

• Treatment

• Aim: Facilitate patients body to heal the cut

• Management - acute;

• Optimise bowel habit – must be once a day

Benefibre and Lactulose

• Rectogesic Oint – bd Top for 2 weeks

• Instructions – use gloved finger or cotton bud

• Insert tip of finger

• Should sting

• If headache; once a day just before going to bed

• 66% success rate

Anal Fissure

• Management;• Chronic fissure

• Rectogesic and Botox injection into Internal Anal Sphincter

• Relaxes smooth muscle sphincter

• Increased blood flow to the cut

• 75% success rate

• Ongoing/recurrent symptoms – repeat Botox Injection 6 weeks later

• 90% success rate after 2nd injection

• Lateral Sphincterotomy

• Almost obsolete

• NB not for young women

Rectal Prolapse

• History• Perineal pressure-type pain

• Deep to perineum ie can’t touch it

• Tenesmus, incomplete emptying, assisted defecation, circumferential lump

• Frequency or urgency

• Obstetric history

• Investigation• Defecating Proctogram

• Anterior rectocoele, intussusception, perineal descent/movement

• Treatment• Physio

• Surgery

Anal Fistula

• History;• Discharge through sinus adjacent to back passage

• May be bloody

• It is a result of chronic infection in the para-rectal space• Idiopathic, prev history trauma, inflammatory bowel disease, rectal cancer

• Investigation• MRI pelvis

• Treatment• Aim: optimise body to heal the hole ie Seton for drainage then laying open

• Advancement flap

• Glue

Take home messages…

• History, history, history

• Rectal bleeding always need investigation and treatment, or treatment and investigation…

• Which patients need referral?• Any rectal bleeding

• If the patient thinks there is a significant problem to them - refer

• Often discrepancy between history and examination