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60
A. S. Kumar and J. Ayscue
Table 7.2 Evaluation of melena to rule out an upper gastrointestinal bleeding source
Evaluation Risk assessment Pathology (category) Specic diagnosis Treatment
EGD Benign Variceal
Colonoscopy Non-variceal
Enteroscopy Premalignant/
Malignant
[D]
[E]
[F]
1. Arterial
2. Arteriovenous
malformation (AVM);
Dieulafoy lesion
3. Venous
Mass
[G]
Esophageal varices
Gastric varices
Ulcers
• Duodenal
• Gastric
• Esophageal
Inammation
• Gastritis
• Esophagitis
Deep mucosal tears
(Mallory-Weiss tear)
Telangiectasias
Angioectasias
β-Blockade
Somatostatin
Endoscopic banding
TIPS
Sengstaken-Blakemore
Tube
Intravenous proton
pump inhibitor (PPI)
Treat H pylori
Endoscopic treatments
• Clips
• Bands
• Argon plasma
coagulation
• Heater probe
• Laser
photocoagulation
• Bipolar electrocautery
• Injection
– Epinephrine
– Thrombin
– Sclerosants
Excision, resection
Table 7.3 Hematochezia caused by anorectal bleeding (see also Table7.2)
Evaluation (in this order) Diagnosis Management
External exam (visual inspection) Pruritus
Digital Anorectal Exam Mass
Anoscopy Hemorrhoids
In-ofce proctoscopy (rigid/
exible)
All above negative, proceed with
endoscopy performed under
sedation
[H]
Anal Fissure
[I]
[J]
[K]
Proctitis
[L]
• Radiation
• Inammatory bowel
disease (IBD)
Colonoscopic
ndings
[M]
• Ischemia
• Prolapse
• AVM
• IBD
• Diverticulosis
• Neoplasm
Non-surgical Management/Medical Topical Therapy
Ofce-based intervention
Surgical procedures
Excision/biopsy
Topical therapies
Supportive therapies
Systemic therapies
Resection (if severe)
Refer to respective chapters on these topics
If these diagnoses are not encountered on endoscopy
but bleeding persists, follow algorithm for severe
hematochezia
7 Hematochezia andMelena
61
Either Intermittent +/++ 0/+ Mucous/urgency
During
Bright/dark? When? (during/after) Where? (toilet/TP) How often? How much? Pain? Other symptoms/signs?
Tumor Either Rectal-
Rectal prolapse Bright Either Either Intermittent +/++ + Mucous/prolapse
Infection/Ulcer Bright After TP Periodic + + Drainage?
Radiation Either During Toilet Intermittent +/+++ 0/+ Mucous/urgency
Pruritus ani Bright After TP Most ++ ++ Itching
Fistula Bright After TP Intermittent + 0/+ Clear to purulent drainage
Abscess Either After TP Periodic + ++ Pus
Fissure Bright After Either Intermittent ++ +++ Ta g
External hemorrhoids Either After TP Periodic + +++ Lump
Internal hemorrhoids Bright Either Either Intermittent +/+++ + to ++ Prolapse
Table 7.4 Anorectal and lower gastrointestinal bleeding guide for clinicians
Anal- either
Diverticulosis/AVM Either During Toilet Periodic +/+++ 0 None
62
A. S. Kumar and J. Ayscue
(e.g., sexually transmitted proctitides,
Clostridium difcile, etc.) or inammation
(ulcerative colitis, Crohn’s colitis). Damage
to the tissues from radiation or prior surgery
can also cause inamed rectal tissue, which
is prone to hemorrhage. Seek out these possibilities with a careful history.
M. Colonoscopic ndings
More proximal sources of bleeding
include prolapse, bleeding diverticular disease, inammatory bowel disease, arteriovenous malformation, neoplasia, and
ischemia. These topics are covered in more
detail in other chapters of this book.
Overall, 33–42% of lower GI bleeding is
due to diverticulosis. In 80% of patients,
the bleeding will cease spontaneously.
However, 5% of patients will have hemodynamically signicant bleeding. Although
75% of diverticulosis is usually on the left,
when diverticulosis bleeds, it can be from a
right-sided source in 50–90% of cases.
Risk factors for bleeding diverticulosis
includes: low ber diet, constipation,
advanced age, NSAID and/or aspirin use.
Refer toFig. 7.2
Severe Hematochezia Causing Hemodynamic Instability
N. Enteroscopy
Small bowel endoscopy, capsule endoscopy, enteroclysis, intraoperative endoscopy, and upper GI contrast studies are all
ways to evaluate the bowel lumen. For evaluation of the colon, air contrast barium or
gastrogran enema and CT colonography
are ways to image the colonic lumen, but
since they are not therapeutic, they are much
less favored in the work up of lower GI
bleeding. Elective exploration is usually
used as a last resort in the patient who is not
actively bleeding but who has had multiple
bleeding episodes without having a source
identied.
Contrast studies can nd a Meckel’s diverticulum. Meckel’s is a true diverticulum
located in the terminal ileum 45–90cm from
the ileocecal valve, which is a remnant of
omphalomesenteric duct present in about 2%
of the population. Of symptomatic diverticulae, 40% present as bleeding due to ulceration
caused by heterotopic gastric mucosa. The
treatment is resection.
O. Radionucleotide testing
Radionuclide scan can be done using
technetium- 99 m sulfur colloid or technetium- 99 m-labeled autologous red cells. A
bleeding rate of 0.1–0.5ml/min can be demonstrated. The accuracy of these scans varies
between 30–90%. With a positive scan it is
reasonable to continue with angiography
with the aim of therapeutically embolizing
the area and abdicating the role of surgery.
Another possible adjunct of the two modalities is also the most sensitive method to
detect slow bleeding: injection of technetium through a selectively positioned angiography catheter.
P. Angiography
Mesenteric angiography can be useful if
the bleeding rate is >0.5 ml/min, selective
angiography may slow the bleeding lesion.
The prerequisite for the positive angiography is active bleeding at the moment of the
contrast injection. If a lesion is found during
angiography, it may be amenable to embolization, thus making the both diagnostic and
therapeutic. The embolization must be as
peripheral as possible to prevent bowel wall
necrosis. If successful, embolization may
stop the bleeding. Even if unsuccessful, it
will facilitate the location of the bleeding
lesion to aid in preoperative planning.
Q. Surgery
In the patient with continued lower GI
bleeding without an obvious source, it is
advisable to proceed with a total abdominal
7 Hematochezia andMelena
63
colectomy. The operation avoids the complication of continued postoperative bleeding
after a lesser operation. However prior to
blind colectomy, intraoperative pan-endoscopy with transillumination can be performed. Localization of a segmented source
will allow segmental resection. If a total
abdominal colectomy is performed, an anastomosis should generally be avoided.
Alternatively, anastomosis with loop ileostomy may be acceptable.
Suggested Reading
Hoedema RE, Luchtefeld MA.The management of lower
gastrointestinal hemorrhage. Dis Colon Rectum.
2005;48(11):2010–24.
Moss AJ, Tuffaha H, Malik A. Lower GI bleeding: a
review of current management, controversies and
advances. Int J Color Dis. 2016;31(2):175–88.
Strate LL, Gralnek IM. ACG Clinical Guideline: man-
agement of patients with acute lower gastrointestinal
bleeding. Am J Gastroenterol. 2016;111(4):459–74.
Vernava AM III, Moore BA, Longo WE, et al. Lower
gastrointestinal bleeding. Dis Colon Rectum.
1997;40(7):846–58.
Anal Disease intheNeutropenic
Patient
MargauxN.Mustian andMelanieS.Morris
8
Refer to Algorithm in Fig.8.1
A. The prevalence of anal disease in oncology
patients is reportedly 2–32%, with recent
mortality rates ranging from 11–57% secondary to complications from perianal sepsis.
Neutropenia is dened as fewer than
1000 cells/mm3 granulocytes, while severe
neutropenia is fewer than 500 cells/mm3.
Patients undergoing systemic chemotherapy
with subsequent neutropenia lack the appropriate immune response necessary to overcome anorectal infections, which makes these
infections signicant and potentially lethal.
Neutropenia can be a result of chemotherapy
regimens, hematologic malignancies, HIV,
long term corticosteroid use, or other systemic illnesses. Mortality rates due to perianal sepsis in this patient population are
reportedly as high as 78%. The risk for sepsis
has been strongly correlated with degree of
neutropenia due to the role of neutrophils in
mounting an inammatory immune response
M. N. Mustian
Department ofSurgery, University ofAlabama at
Birmingham, Birmingham, AL, USA
M. S. Morris (*)
Department ofSurgery, University ofAlabama at
Birmingham, Birmingham, AL, USA
Birmingham VA Medical Center,
Birmingham, AL, USA
e-mail: msmorris@uabmc.edu
and formation of pus. Likewise, count recovery has been associated with improved outcomes. Debate still exists, however, regarding
the utility of the absolute neutrophil count in
determining treatment plans. Historically, the
absolute neutrophil count (ANC) has been
used as a tool for determining the role of surgical intervention, but the utility of this lab
value as a risk factor for surgical outcomes
remains controversial. Additionally, the role
for using colony-stimulating factors has been
described in the literature as an adjunctive
therapy to enhance patients’ abilities to mount
an immune response. In a retrospective analysis of 18 patients, Shaked etal. recommend
awaiting count recovery to above 1000cells/
mm3, prior to surgical intervention based on
their retrospective analysis of patients with
agranulocytosis. They found that attempts to
drain inammation for patients without purulence did not improve outcomes due to open
wounds with evidence of persistent spread of
infection. In contrast, based on data from 20
leukemic patients with perianal infections (14
with neutropenia), Buyukasik et al. found
poor outcomes for patients with severe neutropenia who were medically managed, so
they recommended surgical management for
patients without neutrophil recoveries.
Badgwell etal. retrospectively evaluated 100
cancer patients at MD Anderson with anorectal infections, of which 48 of whom had
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_8
65
66
Early wide
H. Necrotizing fasciitis
Medical
strangulation?
Thrombosis or
G. Hemorrhoids
Ye sNo
M. N. Mustian and M. S. Morris
debridement
empiric antimicrobial
therapy +/- colostomy
alone
therapy, fiber
Sitz baths, stool
softeners, topical
and hydration
management
Hemorrhoidectomy
patient
the neutropenic
A. Anal disease in
B. Symptoms
Pain, fever, fluctuance,
bleeding, drainage, pruritis
C. Evaluation
cultures
exam,anoscopy, EUA,
CT, MRI, US, lab work,
Inspection, digital rectal
F. Fissure
No
E. Fistula
surgical candidate?
Evident on exam and
otherwise appropriate
Ye s
No
on imaging
Fluctuance present
D. Abscess/Cellulitis
Medical
management
Medical
management
Fistulotomy
alone
Antimicrobial therapy,
Medical management
Consider
No resolution
Surgical
No resolution
No resolution
I & D
supportive care
sphincterotomy
management
Ye s
spectrum
antibiotics
I & D + broad
Fig. 8.1 Algorithm for anal disease in the neutropenic patient. I & D incision and drainage
8 Anal Disease intheNeutropenic Patient
67
ANC<1000 cells/ml. Sixty-seven percent of
these patients were non-operatively treated.
The authors stated that after accounting for
other factors, neutropenia was not a signicant determinant for the decision to pursue
operative intervention. As neutropenic
patients often have associated pancytopenia,
thrombocytopenia also affects surgical
decision- making. Concern for bleeding risk
due to thrombocytopenia is also a common
reason for delaying operative intervention.
Due to the complexity of this patient population, collaboration among multiple medical
teams is necessary in order to provide care for
the immunocompromised patient with anorectal disease, including surgeons, medical
oncologists and infectious disease specialists
for infectious etiologies. In many cases, conservative management with medical therapy
is appropriate rst line treatment in the
absence of discrete perianal abscess with
uid collection or failure to respond to nonoperative management. However, surgical
intervention for anorectal disease may be
necessary for select neutropenic patients with
no prohibitively increased risk of morbidity
or mortality given improvement in adjunctive
medical therapy and critical care in a multidisciplinary approach.
B. When evaluating neutropenic patients with
anorectal complaints, they may present with
symptoms such as perianal tenderness or
pain, uctuance, fever, or bleeding. Similar to
other populations, a wide array of physical
symptoms may be used to describe their anorectal complaints. In order to further diagnose
anorectal disease in the neutropenic patient,
detailed history regarding symptomatology is
key. Differential diagnoses should include
anal ssure, stula, hemorrhoids, abscesses,
condyloma, and malignancy.
C. Work up of neutropenic patients with perianal
symptoms begins as it would in the general
patient population. Thorough history and
physical exam direct the diagnosis, including
digital rectal exam and anoscopy. Exams
under anesthesia are often utilized due to
patient intolerance of bedside exam second-
ary to pain. Further imaging may be necessary with computed tomography (CT) or
magnetic resonance imaging (MRI), especially if there is a concern for abscess with no
discrete evidence on physical exam. Larger
abscesses can be visualized on CT scans but
MRI may be benecial for better evaluation
of stulous tracts or smaller uid collections.
The role for MRI is debated. Morcos et al.
found that in their single institution, MRI
results did not change clinical management
and do not recommend routine use except for
in the case of uncertain diagnosis.
Ultrasonography can also be used to evaluate
for uid collections without radiation
exposure.
D. Certainly, in the immunocompetent popula-
tion, management for perianal abscesses
necessitates an incision and drainage.
However, in this unique patient population,
the decision to proceed with an operation is
more complicated. These patients may have
an absence of classic signs of abscess formation such as purulent drainage or uctuance.
Instead, their main signs or symptoms may be
perianal pain and fever. On exam, they may
have areas of erythema or induration but
again may lack any appreciable areas of uctuance. As a result, a high index of suspicion
must be maintained for any neutropenic
patient who presents with fever and perianal
pain. These symptoms usually arise when
neutrophil counts nadir, around 1–2 weeks
after cytotoxic chemotherapy. An exam under
anesthesia is highly recommended in this
population to evaluate for and exclude occult
abscess. Blood and urine cultures should be
obtained at the time of presentation to evaluate for other sources of infection, after which
broad spectrum, empirical antimicrobial therapy with both gram positive and gram negative coverage should be initiated. If an abscess
is identied on physical exam or during an
exam under anesthesia, treatment with an
incision and drainage should be performed.
Surgical intervention should also be considered for those patients not responding to conservative medical therapy alone.
68
M. N. Mustian and M. S. Morris
Imaging with CT or ultrasound may also
be useful to identify uid collections not
appreciated on physical exam. Alternatively,
needle aspiration at the bedside may also be
utilized to determine treatment plan. A retrospective study from the National Cancer
Institute in 2002 examined anorectal
infections for patients undergoing chemotherapy found that over the course of 12years
over half the patients were treated with antimicrobial therapy alone, and 30/82 (37%) of
patients required surgical intervention. This
study also demonstrated the recent improvement in medical management and critical
care, with no deaths attributed to anorectal
infection during the study period (1984–
1993), as compared to the previous decade at
the same institution with mortality rate of
15.9%. As such, they advocated for selective
surgical intervention for patients with discrete abscesses, progression of soft tissue
infection or signs of necrosis.
E. Perianal stulas in neutropenic patient are
treated similarly to anorectal infections or
abscesses. Many patients require an exam
under anesthesia to conrm diagnosis. MRI
may also be benecial to identify stulous
tracts. Once the diagnosis is made, the decision for operative intervention is similar to
the outlined evaluation for perianal abscesses.
Conservative medical management should be
attempted, with select patients undergoing
surgical intervention. Antimicrobial therapy,
including metronidazole is often recommended for these patients. In immunocompetent patients, a randomized controlled trial
evaluating patients with stula identied
intraoperatively for perianal sepsis demonstrated lower recurrence rates (5%) for
patients randomized to drainage plus stula
treatment compared to drainage alone (29%).
The same principles can be applied to neutropenic patients. If they warrant surgical intervention based on exam or failure to respond
to medical therapy and undergo incision and
drainage of an abscess and are found to have
stulous disease, intervention for the stula
should also be performed.
F. Patients with anal ssures will typically
describe pain as their chief complaint, with
feelings as though they are “sitting on glass.”
These patients will not usually tolerate a
digital rectal exam or anoscopy, but external
examination will demonstrate small lesion
or tear to the anoderm usually in the posterior midline. Neutropenic patients with ssures should be treated non-operatively with
Sitz baths, pain control, stool softeners, high
ber diet and topical therapy. Surgical intervention is not recommended for this patient
population as the potential risks outweigh
the benets.
However, in the neutropenic population,
ssures may also occur in locations other
than the posterior midline and with no
response to medical therapy may require surgical intervention or biopsy of the atypical
ssure. In a retrospective analysis of 151 leukemics with benign anorectal disease, Grewal
etal. described a subgroup of 22 neutropenic
patients with anal ssures, 15 of which were
treated operatively with sphincterotomy.
There was no difference in outcomes and
mortality between their operative and nonoperative groups, which led them to conclude
that surgical intervention does not lead to
excessively poor outcomes in selected
patients when operative intervention is otherwise clinically indicated.
G. Patients with hemorrhoidal disease may pres-
ent with varying complaints, which include
bleeding, pain, perianal itching or identication of mass-like protrusion or edema.
Physical exam, including digital rectal exam
with anoscopy should be performed for further evaluation. As anorectal instrumentation
during neutrophil nadir may lead to higher
risk of perianal sepsis, most hemorrhoidal disease can be safely treated with medical management alone. Treatment regimen should
include high ber diet and supplementation
with adequate hydration, Sitz baths, stool softeners, and topical medications. However,
some patients may present with an acute hemorrhoidal crisis due to thrombosis of external
hemorrhoids, or incarceration or swelling of
8 Anal Disease intheNeutropenic Patient
69
prolapsed internal hemorrhoids, which leads
to severe pain and may cause bleeding or pressure necrosis of overlying skin. Surgery in the
neutropenic patient is typically only recommended for patients with acute hemorrhoidal
crises, and even for these patients count recovery is encouraged prior to surgical intervention. Data for surgical intervention for this
patient population is exceptionally sparse. In
the review of leukemia patients at MSKCC,
12 patients with hemorrhoidal disease were
identied. Operative management was performed for two patients and one mortality was
observed, while the non-operative group had
no mortalities. Additionally, North etal. found
that medical management alone for patients
with symptomatic internal or external hemorrhoidal disease did not lead to increased risk
of poor perioperative outcomes in their group
of 30 patients from 1982–1994. While there
are no established guidelines for this particular patient population, the general conclusions
that can be drawn from small case series in the
literature are that medical management does
not lead to poorer outcomes. However,
selected patients with strangulation or thrombosis may be safely managed safely with an
operation if indicated or after failure of medical therapy.
H. Patients presenting with signs or symptoms
of necrotizing infection should be managed
with early initiation of broad spectrum antimicrobial therapy and early surgical intervention. Neutropenic patients are treated in same
manner as their immunocompetent counterparts with early wide surgical debridement
for necrotizing soft tissue infections.
However, in the neutropenic patient, there is a
much higher risk of mortality associated with
this disease process. Therefore, a high index
of suspicion is necessary for neutropenic
patients with concern for necrotizing fasciitis
and a low threshold for operative interven-
tion. Once in the operating room, debriding
down to healthy tissue during the initial operation is also critical. Additional operations to
ensure thorough debridement of all necrotic
tissue may be needed. Additionally, many
patients will require diversion with an ostomy
to enhance recovery.
Acknowledgements Disclosures: None.
Suggested Reading
Badgwell BD, Chang GJ, Rodriguez-Bigas MA,
et al. Management and outcomes of anorectal
infection in the cancer patient. Ann Surg Oncol.
2009;15:2752–8.
Bohl JL, Saleeby RG, Herline AJ.Acute hemorrhoidal
crisis. Semin Colon Rectal Surg. 2007;18:197–201.
Buyukasik Y, Ozcebe OI, Sayinalp N, Haznedaroglu
IC, Altundag OO, Ozdemir O.Perianal infections in
patients with leukemia: importance of the course of
neutrophil count. Dis Colon Rectum. 1998;41:81–5.
Grewal H, Guillem JG, Quan SH, Enker WE, Cohen
AM. Anorectal disease in neutropenic leukemic
patients. Operative vs. nonoperative management. Dis
Colon Rectum. 1994;37:1095–9.
Lehrnbecher T, Marshall D, Gao C, Chanock SJ.A second
look at anorectal infections in cancer patients in a large
cancer institute: the success of early intervention with
antibiotics and surgery. Infection. 2002;30(5):272–6.
Morcos B, Amarin R, Abu Sba A, Al Ramahi R, Abu
Alrub Z, Salhab M. Contemporary management of
perianal conditions in febrile neutropenic patients. Eur
J Surg Oncol. 2013;39(4):404–7.
North JH, Weber TK, Rodriguez-Bigas MA, et al. The
management of infectious and noninfectious anorectal complications in patients with leukemia. J Am Coll
Surg. 1996;183:322–8.
Rizzo JA, Naig AL, Johnson EK. Anorectal abscess and
stula-in-ano: evidence-based management. Surg Clin
North Am. 2010;90(1):45–68.
Shaked AA, Shinar E, Freund H.Managing the granu-
locytopenic patient with acute perianal inammatory
disease. Am J Surg. 1986;152(5):510–2.
Sullivan PS, Moreno C, Shaib WL. Management of
anorectal and intra-abdominal infections in the neutropenic cancer patient. Curr Problems Cancer.
2015;39:274–86.
Evaluation andPerioperative:
AnalMass
Robert A. Malizia andBrianT.Valerian
9
Refer to Algorithm in Fig.9.1
A. Careful and detailed evaluation is warranted
when working up a patient with concern for
an anal mass. As with any thorough history
details regarding onset, location of the mass,
duration of symptoms, presence and characteristic of pain, aggravating or alleviating
factors, associated symptoms, and prior episodes, should be obtained. Additionally, discussion pertaining to bowel habits, character
of stool, constipation, diarrhea, pain with
bowel movement, bleeding per rectum, anal
discharge or leakage, uctuation in size of
mass, incontinence episodes, pruritus, difculties with hygiene maintenance, or constitutional symptoms should be discussed. A
detailed sexual history should be obtained
regarding sexual orientation, practices of
anoreceptive intercourse, prior history of
sexually transmitted diseases, barrier contraceptive use, HIV status or other immunocompromised states. Social habits including
smoking status and intravenous drug use
should also be discussed. Personal or family
history of inammatory bowel disease, such
as Crohn’s disease or ulcerative colitis, and
colorectal cancer should be elicited as well.
R. A. Malizia · B. T. Valerian (*)
Section of Colon and Rectal Surgery, Department of
Surgery, Albany Medical College, Albany, NY, USA
e-mail: Valerib@amc.edu
B. Much of the differential diagnosis may be
generated from appearance and palpation of
the anal mass on physical examination. The
patient should be properly gowned and
draped in a manner to preserve as much modesty as possible, as the examination may be
anxiety provoking. Prone jackknife positioning is preferred for adequate exposure, but
lateral decubitus may be an acceptable alternative. Once the patient is properly positioned in a well-lit room, careful visual
inspection and palpation of the perianal and
perineal region should be conducted.
According to the algorithm in Fig. 9.1, a
broad differential may be generated based on
the presence or absence of pain at the site of
the lesion. Further stratication may be
obtained based on the following features: the
presence of erythema, hematoma, ulceration,
exophytic, or draining lesions.
C. Better characterization of the mass may
occur with the aid of digital rectal examination. With the use of copious lubrication, the
index nger of the dominant hand may be
gently inserted into the anal canal.
Circumferential evaluation should occur with
particular attention to ndings of tenderness,
extension of an external mass, ulceration,
internal stulous openings, and internal hemorrhoids. If a mass is present, sphincter
involvement, distance from the anorectal
ring, rmness, and mobility of the lesion,
© Springer Nature Switzerland AG 2020
S. R. Steele etal. (eds.), Clinical Decision Making in Colorectal Surgery,
https://doi.org/10.1007/978-3-319-65942-8_9
71