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CHAPTER 11 Colorectal surgery
412
Haemorrhoids
Key facts
Broad term, often incorrectly used to refer any perianal excess tissue.
True haemorrhoids are excessive amounts of the normal endoanal cushions that comprise anorectal mucosa, submucosal tissue, and submucosal
blood vessels (small arterioles and veins). Commonest age of onset is
in young adulthood. Associated with constipation, chronic straining, obesity, and previous childbirth. May become ulcerated and infl amed if recurrently prolapsing.
• If confi ned to the tissue of the upper anal canal, they are referred to
as ‘internal’.
• If extend to the tissues of the lower anal canal, they are referred to
as ‘external’.
• Typically occur in the same location as the main anal blood vessel
pedicles (described as 3, 7, and 11 o’clock positions as seen in the
supine position).
Clinical features
• Features of irritation. Pruritus ani, mucus discharge, and perianal
discomfort.
• Features of damage to mucosal lining. Recurrent post-defecatory
bleeding—bright red, not mixed with stools, on paper or splashing in
the toilet pan.
• Features of prolapse. Intermittent lump appearing at anal margin,
usually after defecation, may spontaneously reduce or require manual
reduction.
Diagnosis and investigations
• Diagnosis is usually by rigid sigmoidoscopy and proctoscopy.
• Flexible sigmoidoscopy or colonoscopy may be appropriate if there
is concern about the cause of symptoms; remember—haemorrhoids
rarely start over the age of 55y and it is often best to assume another
cause until proven otherwise in these cases.
Treatment
Medical treatment Avoidance of constipation and straining; bulking or
softener laxatives.
Surgical treatment
• Banding or excessive tissue. Best for prolapse symptoms (not possible
for external components due to excellent nerve supply of lower anal
canal).
• Dilute phenol injections (5% in almond oil). Best for bleeding
symptoms.
• Haemorrhoidal devascularization procedures (e.g. arterial ligation
‘HALO’ either Doppler ultrasound-guided or blind). For failed topical
treatments and surgery not indicated/desired.
• Stapled anopexy (also called PPH). Sometimes used for circumferential
prolapsing haemorrhoids.
HAEMORRHOIDS
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• Haemorrhoidectomy for large external haemorrhoids or haemorrhoids
failing to respond to conservative treatment. Associated with a small
risk of impaired continence and anal stenosis.
Key revision points—anatomy of the anus
• Lower third of the anal canal is somatic tissue in origin—stratifi ed
squamous epithelium; very sensitive (pudendal and distal sacral
nerves); relatively poor blood supply and healing.
• Upper third of the canal is visceral tissue in origin—columnar
epithelium; insensitive; excellent blood supply and healing.
413
CHAPTER 11 Colorectal surgery
414414
Acute anorectal pain
Causes and features
Fissure-in-ano Acute severe, localized, ‘knife-like’ pain in the anus during defecation. Often associated with deep throbbing pain for minutes
or hours afterwards due to pelvic fl oor spasm. Blood on the paper when
wiping (small volume, red-pink streaks or spots).
Haemorrhoids Usually acutely prolapsed and infl amed with associated perianal lump, soreness, and irritation. May bleed, often profuse, bright red.
Perianal abscess Gradual onset, constant localized perianal pain. Associated
swelling with tenderness and possible discharge. May have associated systemic features of fever, malaise, anorexia.
Perianal haematoma Usually sudden onset; acutely painful with associated
perianal swelling (dark red coloured).
Rectal prolapse Acute full thickness rectal prolapse, occasionally causes
pain. Obvious large perineal lump, dark red blue with surface mucus and
occasionally some surface ulceration.
Emergency management
Establish a diagnosis
• Good inspection and careful digital rectal examination is usually all that
is required.
• Rigid sigmoidoscopy may be painful and is often unnecessary.
• Flexible sigmoidoscopy is rarely indicated.
Early treatment
• Give adequate analgesia; opiates may be necessary.
• Topical treatment is highly effective; cool pads, topical local
anaesthetic gels.
Defi nitive management
Fissure-in-ano Mainstay of acute treatment is analgesia and anal sphincter
muscle relaxants, e.g. topical GTN 0.2% ointment, diltiazem 2% ointment.
Local anaesthetics are helpful early in treatment.
Haemorrhoids May require bed rest with continued topical treatment
until swelling resolves and spontaneous reduction begins. Acute haemorrhoidectomy is almost always best avoided due to the risk of over-excision
of anal tissue. Minimal anal dilatation under GA is rarely necessary.
Perianal abscess Incision and drainage is a surgical emergency, particularly
if the patient is diabetic or immunosuppressed.
Perianal haematoma Incision to allow decompression of acute haematoma
may be necessary, often done under topical LA.
Rectal prolapse Swelling may be reduced by cool packs, elevation, and
sometimes icing sugar applied to the swollen mucosa as a dessicant! Very
rarely requires emergency surgery.
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CHAPTER 11 Colorectal surgery
416416
Acute rectal bleeding
Causes and features
Acute rectal bleeding is broadly divided into regions of the colon from
which it comes and the blood is typically different according to the origin.
Anorectal
Bright red blood, on the surface of the stool and paper, after defecation.
• Haemorrhoids.
• Acute anal fi ssure.
• Distal proctitis.
• Rectal prolapse.
Rectosigmoid
Darker red blood, with clots, in surface of stool and mixed.
• Rectal tumours (benign or malignant).
• Proctocolitis.
• Diverticular disease.
Proximal colonic
Dark red blood mixed into stool or altered blood.
• Colonic tumours (benign or malignant).
• Colitis.
• Angiodysplasia.
• NSAID-induced ulceration.
Upper GI bleeding occasionally produces dark red rectal bleeding, but it
is usually associated with signifi cant haemodynamic instability when
suffi ciently large.
Features (signs)
• Tachycardia and hypotension suggests substantial loss.
• LIF tenderness suggests diverticular infl ammation with bleeding.
Emergency management
Resuscitation
• Establish large calibre IV access; give crystalloid fl uid up to 1000mL
if tachycardic or hypotensive.
• Catheterize and place on a fl uid balance chart if hypotensive.
• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (albumin), group
and save, clotting.
Establish a diagnosis
• Rigid proctosigmoidoscopy should be performed in all cases to
exclude a simple anorectal cause.
• Urgent fl exible sigmoidoscopy and colonoscopy may be undertaken. It
is higher risk than elective endoscopy, but may confi rm an origin and
may allow therapeutic intervention (adrenaline injection, heater probe
coagulation, argon plasma coagulation (APC)).
• Urgent selective mesenteric arteriography for obscure or persistent
bleeding; needs active bleeding of 0.5mL/min.
ACUTE RECTAL BLEEDING
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• Urgent gastroscopy should be used to exclude massive upper GI
bleeding if suspected.
Early treatment Consider blood transfusion if major bleed (persisting
haemodynamic instability despite resuscitation, Hb <8g/dL).
Defi nitive management
Anorectal causes Most can be controlled by local measures, such as
injection, coagulation, or packing.
Acute colitis
• IV or PO metronidazole if thought to be infective until organism
identifi ed.
• IV hydrocortisone 100mg qds if thought to be ulcerative or Crohn’s
colitis.
• Surgery may be necessary whatever the aetiology if bleeding persists
(subtotal colectomy and ileostomy formation).
Diverticular disease
• IV antibiotics (cefuroxime 750mg tds + metronidazole 500mg tds).
• Angiographic embolization if bleeding fails to stop and patient not
critically unstable for time in radiology.
• Surgery is high risk, but may be unavoidable. If the location is known,
a directed hemicolectomy may be performed (on-table colonoscopy
may be used). If not, a subtotal colectomy is safest.
Angiodysplasia
• Colonoscopic therapy (injection, heater probe, APC) is ideal.
• Angiographic embolization may be possible.
• Right hemicolectomy is occasionally unavoidable.
Undiagnosed source
Rarely, the patient remains unstable with active bleeding and no cause can
be reliably confi rmed. Surgical options to deal with this include:
• On-table colonoscopy with washout via colostomy to locate bleeding
source.
• Formation of mid-transverse loop colostomy and subsequent targeted
hemicolectomy.
• ‘Blind’ hemicolectomy (left if signifi cant diverticular disease present;
right if no other cause obvious and angiodysplasia is likely).
417417
CHAPTER 11 Colorectal surgery
418418
Acute severe colitis
Causes and features
Any cause of colitis may progress to acute severity. Common causes
include:
• Severe ulcerative colitis (UC; usually pancolitis); occasionally, acute
severe colitis is the presentation of UC with no prior history;
• Acute infective colitis (e.g. Salmonella, C. diffi cile, amoebae, parasites);
• Neutropenic colitis;
• Pseudomembranous colitis (C. diffi cile-related);
• Progressive Crohn’s colitis (usually with a clear prior history).
Symptoms
• Diarrhoea (usually bloody with urgency and frequency). ‘Constipation’
may be an ominous feature, suggesting acute colonic dilatation.
• Abdominal pain (generalized).
• Malaise, anorexia, and fever (systemic infl ammatory features).
Signs
• Fever, tachycardia, possible hypotension.
• Abdominal tenderness; peritonism suggests perforation.
Complications
Any acute severe colitis may develop any of these complications.
• Haemorrhage.
• Hypokalaemia.
• Hypoalbuminaemia;.
• Perforation (localized or generalized).
‘Toxic dilatation’ is a term used to describe the situation of acute severe
colitis with colonic dilatation usually associated with reduced bowel frequency and impending perforation.
Fulminant severe colitis is defi ned as: tachycardia >120bpm or stool fre-
quency >10 times/24h or albumin <25g/dL.
Emergency management
Resuscitation
• Establish large calibre IV access; give crystalloid fl uid up to 1000mL if
tachycardic or hypotensive.
• Catheterize and place on a fl uid balance chart if hypotensive.
• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (albumin), group
and save, clotting.
Establish a diagnosis
• Send ‘hot’ stools for M,C,&S as well as microscopy for C,P,&O. Even
known colitics may catch acute infective colitis.
• Plain AXR (looking for colonic dilatation) and erect CXR (looking for
free gas).
• Rigid sigmoidoscopy and biopsy only if not unstable.
• Flexible endoscopy may be indicated, but carries a risk of perforation.
ACUTE SEVERE COLITIS
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Early treatment
• Give IV hydrocortisone if the diagnosis of UC is likely; if infective colitis
is suspected, consider withholding steroids until the M,C,&S results are
back.
• Blood transfusion if anaemic.
• Surgery if peritonitis or free gas on CXR (the operation for any
acute colitis is usually total abdominal colectomy and end ileostomy
formation).
Defi nitive management
Acute ulcerative colitis
• IV hydrocortisone 100mg qds, converted to oral prednisolone if
responding to treatment.
• IV cyclosporin if fulminant/not responding to IV steroids.
• Surgery for failure to respond to medical treatment or acute
complications of haemorrhage or perforation.
• Regular blood investigations and plain abdominal radiography to
monitor treatment.
Infective colitis
• IV or PO metronidazole until organism identifi ed.
• Salmonella, C. diffi cile—metronidazole.
• Surgery for failure to respond to medical treatment or acute
complications of haemorrhage or perforation.
Neutropenic colitis
• IV antibiotics.
• Bone marrow support.
• Surgery for failure to respond to medical treatment or acute
complications of haemorrhage or perforation.
419419
CHAPTER 11 Colorectal surgery
420
Post-operative anastomotic leakage
Causes and features
Any intra-abdominal anastomosis may leak. Highest risk of leak occurs
with oesophageal and rectal anastomosis and lowest with small bowel
anastomosis (see Table 11.1).
Anastomotic leakage may present as one of several clinical pictures.
3 Peritonitis
Acute severe generalized abdominal pain with generalized guarding and
rigidity. Fever, tachycardia, and tachypnoea are common. Diagnosis is usually clinical, but may require CT scanning if unsure.
Intra-abdominal abscess (see b p. 308)
Swinging fever and tachycardia, commonly around 5–7 days post-operatively. Localized tenderness related to the anastomosis may be present.
Diagnosis should be sought by CT scanning.
Enteric fi stula
A fi stula between the anastomosis and the wound or another organ may
occur. Usually occurs as a result of a subclinical leak and abscess formation that discharges through a pathway of low resistance. Often presents
late as an apparent wound infection that discharges with enteric content.
Diagnosis made by CT scanning or occasionally, fi stulography if presents
very late.
2 Cardiovascular complications
Sepsis originating from an initially subclinical leak may present with
apparent cardiovascular complications, e.g. AF, SVT, chest pain, and sinus
tachycardia. A wise precautionary rule is, ‘Any acute post-operative disturbance of physiology in a patient with an intra-abdominal anastomosis is
due to leak until proven otherwise.’
Emergency management
Resuscitation
• Establish large calibre IV access; give crystalloid fl uid up to 1000mL if
tachycardic or hypotensive.
• Catheterize and place on a fl uid balance chart if hypotensive.
• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (albumin), group
and save, clotting.
• Give appropriate analgesia if not on an epidural or PCA.
Establish a diagnosis
• Acute peritonitis needs no diagnostic investigation. Emergency re-look
laparotomy should be organized immediately.
• CT scanning with IV and PO contrast is the investigation of choice for
all other suspected leaks.
• For rectal anastomoses, a water-soluble contrast study may delineate a
leak.
POST-OPERATIVE ANASTOMOTIC LEAKAGE
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Table 11.1 Risk factors associated with increased risk of leak
Patient factors Disease factors Operative factors
Chronic malnutrition
Immunosuppression
High dose steroid use
Diabetes mellitus
Unprepared bowel, e.g.
obstruction
Local or generalized sepsis
Metastatic malignancy
Poor blood supply or
bowel ends
Tension on bowel ends
Early treatment
• Give IV antibiotics (e.g. IV cefuroxime 750mg tds + metronidazole
500mg tds).
• Monitor fl uid balance hourly.
Defi nitive management
3 Peritonitis
Always requires surgical intervention unless the patient is deemed unfi t.
Prepare for theatre. Ensure blood results from resuscitation are avail-
able. Stoma care review is not always necessary and often not practical
or useful.
Once the leak has been identifi ed, options for management include:
• Dividing the anastomosis, closing the distal end, and forming the
proximal end into a stoma;
• Emptying the bowel (lavage) and forming a proximal defunctioning
stoma;
• Re-forming or repairing the anastomosis (only suitable for fi t patients
with minimal contamination and an otherwise healthy anastomosis);
• Placing a large drain(s) next to the anastomosis.
Intra-abdominal abscess
• Radiologically guided drainage and antibiotics, provided patient does
not become peritonitic or show signs of secondary complications.
• Open surgical drainage if inaccessible or unresponsive to radiological
drainage.
Enteric fi stula
• Usually managed by antibiotics. May close spontaneously; if fails to
close, surgical repair may be required.
• Treat as for abscess or peritonitis if either develops.
421
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