Anorectal Outlet Sources

Giuseppe Gagliardi, MDMario Pescatori, MD, FRCS

Coloproctology Unit, Rome Villa Flaminia

Acute bleeding:anorectal causes

More common Less common

Hemorrhoids Rectal varices

Post-surgical Angiodysplasya

Post-polypectomy* SRU

Radiation proctitis* Stercoral ulcer

Neoplasms Dieulafoy

IBD Aneurysms

Trauma*

Treatment of hemorrhoidal bleeding

Rubber band ligation vs excisional hemorrhoidectomy: no difference for bleeding symptoms

Cochrane 2005

Bleeding after RBL 25% patients taking warfarin7% NSAID2.9% patients taking neither

Iyier DCR 2004

Hemorrhoidectomy with Ligasure in anticoagulated patients

Lawes Colorectal Dis 2004

Treatment of hemorrhoidal bleeding

Morar Cardiovasc Intervent Radiol 2006

Bleeding after hemorrhoid treatmentReactionary: technical errors incidence 1%

PPH vs excisional hemorrhoidectomy (for PPH 1.8-44% reoperation 25-90%)

Secondary: after 6-11 days incidence 2.4-6%.

Treatment: Anal packing 15% rebleed

Hemostatic sponge

Rectal Foley

Adrenaline injections

Rectal irrigation 12% don’t stop Chen DCR 2002

Suturing required in 7%-40%

followed by late complications in 15%Mazier Semin Colon Rectal Surg 1990

? role of micronized flavonoids

Rectal Varices

Incidence in portal hypertension 44-90% > in viral cirrhosis Chawla Gut 1991

Bleed in 10%-37%, independent from Child’s classification

Treatment

Octreotide

Oversewing/stapling

Sclerotheraphy

TIPPS vs TIPPS + embolization 42 vs 28% rebleed Vangeli J Hepatology 2004

Venus shunts

Resective surgery contraindicated

Anorectal tumorsIs resection necessary for palliation?

Local recurrence

After surgery clinical improvement in 78%(curative) 40%(palliative), in the long term 63% and 88%% and develop symptoms Miner Ann Surg Oncol 2003

EXTR and re-XRTshort term palliation for non-metastatic, bleeding palliated

Mohiuddin Cancer 2002

EXRT+hyperthermia 72% immediate palliation Juffermans Cancer 2003

Brachytheraphy 60-90% response for bleeding Hoskins Radiother Oncol 2004

Metastatic disease EXRT 90% of patients with metastastic disease palliated until death

Crane Int J Radiat Oncol Biol Phys. 2001

Long term palliation in 75% with (repeated) APC Gevers Gastrointest Endosc

2000

Anorectal Tumors

Surgery indicated for palliation in patients with > 6 months life expectancyFazio J Gastrointest Surg 2004

Resection and anastomosis in patients with metastatic disease Moran Arch Surg 1987

Hartmann vs Abdominoperineal to avoid perineal wound sepsis and pain Heah DCR 1997

Local excision equivalent palliationChen J Gastrointest Surg 2001

Anorectal melanomaPresents with bleeding, beware of amelanotic lesionsTreatment is surgicalSurvival and recurrence not dependent on surgical strategy (LE=APR)

Yeh ASCRS 1995

Anorectal bleeding:IBDAcute Fulminant Colitis

In pre-pouch era 20% of acute bleedings underwent proctectomyIn emergency IRA for bleeding 18% rebleed from rectum but massive bleeding rare

Robert Am J Surg 1990

Emergency IPAA with low morbidity Ziv DCR 1994; Ham DCR 1994

Emergency IPAA higher septic and obstructive complications Penna DCR 1993

Medical theraphy, rectal foley, adrenaline, endoscopic, embolization* *Mallant-Hent Eur J Gastroenterol Hepatol 2003

Crohn’s

Bleeding from left colon ulcer

Medical 60% endoscopic 20% surgery 20% Balaiche AJG 1999

Rectal Ulcer

Dieulafoy, Acute hemorrhagic rectal ulcer, aspecific ulcerESRD, NSAID

Stercoral ulcer Frequency underestimated (1.7-5% in autopsy)Elderly, bedridden, constipatedPressure ulcer of necrosis, fecalomaSigmoid=perforation Rectum=bleedingAspecific chronic and acute inflammation

Solitary rectal ulcer

TreatmentSclerotheraphy1, clipping, cauterization, APC, suturing, embolization2, surgery

1 Matsushita Gastrointestinal Endoscopy 19982 Dobson Cardiovascular and Interventional Radiology 1999

Angiodysplasya

Klippel-Trenaunay

Rubber Bleb Nevus Syndrome

Hemangioma capillary

arterio-venous

cavernous

Treatment

Sclerotherphy, APC, endoscopic banding, EXRT

Surgery: LAR, mucosectomy and coloanal sleeve anastomosis

Londono-Schimmer BJS 1994

Conclusions

Rigid sigmoidoscopy and rectal washout should be part of the work-up of patients presenting with bright red blood per rectum

Some of the causes are rare and require specialist input in tertiary care centers

Most of anorectal acute bleedings can be controlled without laparotomy

Embolization of rectal arteries carries low morbidity