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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
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Incarcerated-prolapsed internal hemorrhoids (grade IV).
External hemorrhoids: most commonly no symptoms; pain (only if thrombosed); difficulty with hygiene (if very redundant);
psychological aversion; bleeding only if spontaneous rupture of acute thrombosis.
Differential Diagnosis
Rectal prolapse (concentric pattern).
Skin tags.
Anal fissure with sentinel skin tag ("painful hemorrhoid").
Condylomata.
Tumor (malignant, benign).
Hypertrophic anal papilla.
Abscess/fistula.
Proctitis (IBD, infectious, radiation etc).
Rectal varices.
Dieulafoy ulcer of the rectum.
Pathology
Enlarged hemorrhoidal plexus, focal areas of thrombosis. Internal hemorrhoids: proximal to dentate line, covered with
columnar/transitional epithelium. External hemorrhoids: distal to dentate line, covered with squamous-cell anoderm.
Evaluation
REQUIRED MINIMAL STANDARD
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History: description (presence/absence and extent of prolapse, need for reduction), pattern of occurrence, associated
symptoms (bleeding, pain, etc), daily bowel habits, constipation, preexisting incontinence?
Clinical examination: anal configuration (tags, etc)? Visible fissure or local skin pathology? Extent of prolapse (differentiation
from rectal prolapse). Axial location with regard to dentate line (internal, external, mixed). Radial location and number of
affected hemorrhoidal piles (1–3), presence/absence of complications (thrombosis, necrosis, ulceration, active bleeding).
Sphincter tone?
Anoscopy/proctoscopy: tumor, hemorrhoids, proctitis, etc.
Except in emergency: full/partial colonic evaluation as per general screening guidelines and prior to any planned intervention.
ADDITIONAL TESTS (OPTIONAL)
If other diagnoses more likely.
Classification
Internal hemorrhoid grading: descriptive clinical parameters for hemorrhoids (Table 4–1) should include patient-
reported extent of prolapse (grade I–IV), objective axial location with regard to the dentate line (internal, external,
mixed), objective radial location and extent in 1–3 of the hemorrhoidal piles, presence or absence of complications
such as thrombosis, necrosis/gangrene, ulceration, or active bleeding.
External hemorrhoid grading available only for thrombosis: ie, acute (< 72 hours post onset), subacute (> 72 hours,
still inflammatory changes).
Table 4–1. Grading and Treatment of Hemorrhoids.
Grade of
Hemorrhoids
Description (Covered with Mucosa) Symptoms Treatment Options
Internal grade
I
Bulging into anal canal Painless bleeding Diet
Local and general drugs
Rubber band ligation
Infrared coagulation
Sclerotherapy
Internal grade
II
Protrusion out of anal canal with bowel
movements; reduces spontaneously
Painless bleeding, swelling Rubber band ligation
Infrared coagulation
Sclerotherapy
(PPH/stapled hemorrhoidectomy)
Internal grade
III
Protrusion; requires manual reduction Above + possible strangulation Rubber band ligation PPH/stapled
hemorrhoidectomy
Excisional hemorrhoidectomy
Internal grade
IV
Constant protrusion; irreducible, or
instantaneous reprolapse
Above + high risk of
strangulation with pain,
necrosis, sepsis
Excisional hemorrhoidectomy
(PPH/stapled hemorrhoidectomy)
Mixed
hemorrhoids
Internal and external components According to the predominant
component
Treatment according to
predominant component:
Excisional hemorrhoidectomy
PPH/stapled hemorrhoidectomy
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External
hemorrhoids
Skin-covered "protrusions" Discomfort, itching Symptomatic conservative
treatment
Severe pain if thrombosed Incision and enucleation of
thrombus
Excisional hemorrhoidectomy
PPH, procedure for prolapse and hemorrhoids.
Nonoperative Treatment
Indicated for:
All grades of internal hemorrhoids, potentially sufficient for grades I/II, occasionally even grade III (and IV).
Thrombosed external hemorrhoid > 72 hours post onset (individualized exceptions from this rule).
Coagulopathy.
HIV infection with manifest AIDS.
Underlying IBD.
Pregnancy (relative contraindication for surgical intervention).
Dietary/lifestyle modification: fiber-rich diet, sufficient fluid intake, stool softener, decreased time spent on the toilet, Sitz
baths for acute symptoms.
Topical treatments: short-term (!) use of glycerin suppositories with/without topical steroids or local anesthetics, numerous
over-the-counter preparations with unproven effect.
Operative Treatment
INDICATION
General: lack of contraindications; in presence of risk factors (coagulopathy, portal hypertension, pregnancy, etc)
perioperative optimization, possible need for inpatient monitoring.
Internal hemorrhoids: symptomatic, failure of conservative management, complications (bleeding, anemia,
incarceration).
External hemorrhoid: Acute thrombosis (< 72 hours post onset).
OPERATIVE APPROACH
Office interventions: hemorrhoid banding, sclerosing, infrared coagulation of internal hemorrhoids;
excision/enucleation of thrombosed external hemorrhoid.
Surgical procedures: excisional hemorrhoidectomy (Ferguson, Milligan-Morgan, Whitehead), stapled
hemorrhoidectomy (PPH), doppler-guided hemorrhoid artery ligation.
Obsolete hemorrhoid procedures: cryoablation
foul-smelling discharge, uncontrolled tissue injury, incontinence.
Outcome
Conservative treatment and office management: 70% chance of success (depending on grade of symptoms).
Interventional/operative treatment: 90–95% chance of success. Recurrence rates with PPH unknown.
Complications of surgical management: delayed wound healing, pain, postoperative bleeding, urinary retention, fecal
impaction, infection/perineal sepsis, incontinence to stool/gas, stricture formation. Whitehead hemorrhoidectomy: important
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conventional tool for circumferential hemorrhoids, but risk of ectropion if done improperly.
Follow-Up
Recheck patient after 2–4 weeks of initiated or performed treatment. Once hemorrhoidal problem has resolved, no specific
follow-up is needed.
Cross-Reference
Colitis or proctitis (Ch. 1)
Lump or mass (Ch. 1)
Anal fissure (565.0) (Ch. 4)
Rectal prolapse (569.1) (Ch. 4)
Hemorrhoid office procedures (Banding, sclerosing, infrared coagulation) (Ch. 5)
Excisional hemorrhoidectomy (Ferguson, Milligan-Morgan) (Ch. 5)
Stapled hemorrhoidectomy/-opexy–PPH (Ch. 5)
PERIANAL/-RECTAL ABSCESS (566)
Overview
Perirectal abscess is a frequent, commonly not life-threatening but very annoying problem that is associated with pain, risk
of recurrence, and fear. Among various causes of an abscess in this area, the most common ones are cryptoglandular in
origin.
Pathogenesis of cryptoglandular abscess: 8–12 anal glands entering anal canal in anal crypts at the dentate line
plugging
of duct? retention/entry of bacteria amplification and expansion along anatomic perirectal spaces liquefaction (abscess
formation). No specific risk factors identified.
Etiologies:
Local origin: cryptoglandular, Crohn disease, Bartholin cyst, sebaceous glands, anastomotic leak (LAR, IPAA), status
post anorectal surgery, locally advanced cancer, tuberculosis, chronic form of LGV, trauma (impalement, foreign body,
etc).
Supralevator origin (very rare): diverticulitis, Crohn disease, malignancy.
Severity of perirectal abscess: varying size of localized abscess, horseshoe abscess (involving postanal space and both
ischioanal fossae; caveat: not to be mistaken for supralevator abscess), varying degrees of perifocal phlegmon, Fournier
gangrene.
Epidemiology
Population-based epidemiologic data are not available.
Symptoms
Worsening perianal/perirectal or deep rectal pain: constant, not related to bowel activity; increasing local pressure,
increasing perianal swelling (may be hidden in ischioanal abscess); positional aggravation (sitting, walking).
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Associated symptoms: possible fever, urinary retention; rarely sepsis (maximum: Fournier gangrene, Figure 4–3A).
Figure 4–3A.
Fournier gangrene.
Symptoms may be masked in immunocompromised patients (neutropenia, leukemia)
pain only, but no abscess formation.
Differential Diagnosis
Pain: anal fissure, thrombosed external hemorrhoid, incarcerated prolapsed internal hemorrhoids, levator ani spasm,
anismus, STDs (syphilis, herpes, etc).
Fever: other sources of infection—pelvic, extrapelvic.
Fistula system: hidradenitis suppurativa, Crohn disease, anorectal tuberculosis, actinomycosis, chronic LGV.
Pathology
Location within the perirectal spaces:
Perianal/subcutaneous: 40–65%.
Intersphincteric/submucosal: 15–25%.
Ischioanal and deep postanal: 20–35%.
High intramuscular: 5–10%.
Supralevator: 5%.
Evaluation
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REQUIRED MINIMAL STANDARD
History: gradual onset, absence of prolapse as primary symptom, bowel habits, preexisting incontinence, symptoms
suggestive of Crohn disease (abdominal pain, diarrhea, bleeding), previous abdominal/pelvic/anorectal surgeries?
Clinical examination:
External inspection: possible erythema/induration, possible fistula opening, absence of thrombosed external
hemorrhoid or fissure.
Digital rectal exam (only if diagnosis not already obvious): induration/tenderness of perirectal spaces, including
ischioanal fossae and/or deep postanal space? Caveat: even large abscesses may never show fluctuance!
ADDITIONAL TESTS (OPTIONAL)
Further tests typically are not indicated in emergency situations (unless patient is under anesthesia):
Anoscopy/proctoscopy: rule out tumor, proctitis, potential assessment for primary opening (eg, fissure), potential
intraluminal bulging of abscess (high intersphincteric/submucosal location).
Not indicated (unless for special reasons): blood work, imaging studies eg, CT (Figure 4–3B) or ERUS, cultures
(unless atypical circumstances/presentation).
Figure 4–3B.
Horseshoe abscess on CT scan.
Classification
Cryptoglandular abscess.
Secondary abscess (anastomotic leak, etc).
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Supralevator abscess.
Nonoperative Treatment
Not indicated.
Antibiotics only for special circumstances: immunosuppressed patient, severe phlegmonous component, valvular heart
disease.
Operative Treatment
INDICATION
Any perirectal abscess or suspected abscess (caveat: don't look or wait for "fluctuance").
OPERATIVE APPROACH
Office: incision and drainage of perirectal abscess in local anesthesia, no search for fistula.
OR: Larger abscess, inability to tolerate local procedure:
– Incision(s) and possible counter-incisions with placement of drain(s), possible mushroom catheter.
– Simultaneous evaluation and treatment for fistula (caveat: creation of iatrogenic fistula tract in altered tissue).
Fournier gangrene: aggressive debridement, possible second look operations, possible ostomy.
Outcome
Adequate drainage results in rapid improvement; ~50% probability of persistent fistula tract after first time I&D.
Follow-Up
Recheck patient after 1–2 weeks (resolution of acute inflammation?) and after 4–6 weeks (persistence of fistula?).
Planning of elective fistula surgery.
Full/partial colonic evaluation as per general screening guidelines.
Cross-Reference
Fistula (Ch. 1)
Lump or mass (Ch. 1)
Pain, perirectal (Ch. 1)
Endorectal ultrasound (ERUS) (Ch. 2)
Perianal/-rectal fistula (565.1) (Ch. 4)
Pilonidal disease (Cyst/Sinus/Fistula, 658.0/1) (Ch. 4)
Hidradenitis suppurativa (705.83) (Ch. 4)
Incision/drainage of perirectal abscess (simple) (Ch. 5)
Modified Hanley procedure for horseshow fistula/abscess (Ch. 5)
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PERIANAL/-RECTAL FISTULA (565.1)
Overview
Perirectal fistula is closely associated with perirectal abscesses. The fistula tract, which connects the primary opening(s) with
one or more secondary opening(s), becomes fully manifest upon spontaneous or surgical opening of a perirectal abscess. A
significant number of patients do not recall episode of an abscess. In an estimated 50% of drained abscesses (first episode),
the inflammatory process may obliterate the fistula tract. Blind-ending sinuses may complicate the picture and become the
source of recurrences.
Course of fistula may vary significantly, but some repetitive pattern (Goodsall rule):
Fistula opening anterior to transverse line and < 3 cm from anal verge straight radial course to dentate line.
Fistula opening posterior to transverse line curved course to the posterior midline.
Fistula opening anterior to transverse line and > 3 cm from anal verge curved course to posterior midline.
Epidemiology
Population-based epidemiologic data are limited; one Scandinavian study suggests prevalence of 6–12% per 100,000
people.
Symptoms
Cyclic symptoms: abscess with increasing pain rupture/surgery with drainage of pus cooling off with closure of skin
("healing") beginning of smoldering infection abscess...
Persistent symptoms: continued drainage, moisture, itching.
Differential Diagnosis
Cryptoglandular origin: overwhelming majority of fistulae.
Noncryptoglandular origin: Crohn disease, anastomotic leak (LAR, IPAA), status post anorectal surgery/trauma, locally
advanced neoplasm, tuberculosis, actinomycosis, chronic form of LGV, hidradenitis suppurativa.
Congenital fistulae.
Pathology
Location defined by anatomic perirectal spaces:
Subcutaneous/-mucosal fistula.
Intersphincteric fistula (45–60% of all fistulae): through distal internal sphincter intersphincteric space external
opening.
Transsphincteric fistula (25–30%): through both internal and external sphincters.
Suprasphincteric fistula (< 3%): originates in intersphincteric plane and tracks up and around entire external
sphincter complex.
Extrasphincteric fistula (< 3%): rectal wall above dentate line around both sphincters: most commonly seen in
trauma, Crohn disease, or PID.
Ischioanal (horseshoe) fistula (20–35%): primary defect most commonly in posterior midline deep postanal space
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and extends to bilateral ischioanal fossae with possible multiple secondary openings.
Evaluation
REQUIRED MINIMAL STANDARD
History: characterization of symptoms, bowel habits, preexisting incontinence, symptoms suggestive of Crohn disease
(abdominal pain, diarrhea, bleeding), previous abdominal/pelvic/anorectal surgeries?
Clinical examination:
External inspection: identification of possible fistula opening, possibly limited probing, but it is not relevant to
preoperatively identify exact course of fistula.
Anoscopy/proctoscopy: rule out tumor, hemorrhoids, proctitis, etc.
Full/partial colonic evaluation as per general screening guidelines.
ADDITIONAL TESTS (OPTIONAL)
Imaging studies: only for recurrent or more complex appearing fistula—conventional fistulogram, MRI fistulogram, endorectal
ultrasound with H
2
O
2
injection.
Classification
Park classification combinations possible:
– Intersphincteric fistula.
– Transsphincteric fistula.
– Suprasphincteric fistula.
– Extrasphincteric fistula.
Simple fistula vs complex fistula (eg, horseshoe fistula, branching fistula, multiple secondary openings etc; Figure 4–
4).
Figure 4–4.
Fistula-in-ano: simple (left panel) and horseshoe with inadequate drain (right panel).
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Nonoperative Treatment
Asymptomatic fistula.
Operative Treatment
INDICATION
Any symptomatic fistula.
OPERATIVE APPROACH
General: intraoperative evaluation: insertion of silver probe, injection of peroxide/dye, etc.
Selection of appropriate method based on location and extent of sphincter involvement:
Fistulotomy, fistulectomy: if < 10–20% of sphincter involvement.
Seton management: draining vs cutting seton—complex or recurrent fistulae.
Endorectal advancement flap with/without fistulectomy.
Plugging of fistula tract (fibrin glue, collagen plug): long, narrow tract, no active suppurations.
Rerouting of fistula tract.
External skin advancement flap.
Outcome
Recurrence of fistula: > 10–35% for all methods no perfect solution.
Risk of incontinence: 0–15% (stool), 0–25% (flatus); even higher in some series!
Follow-Up
Recheck patient every 2–4 weeks for outpatient management:
Open wound: check in regular intervals until healed by secondary intention.
Draining setons: unless they are intended for long-term use (eg Crohn disease), removal can be considered after 3–4
weeks if inflammation and drainage are decreased.
Cutting seton: tightening every 3–4 weeks until migrated through the involved muscle.
Collagen plug: check every 3–4 weeks until fistula opening is dried off.
Cross-Reference
Fistula (Ch. 1)
Endorectal ultrasound (ERUS) (Ch. 2)
Magnetic resonance imaging (MRI) (Ch. 2)
Pelvic fascial structures and spaces (Ch. 3)
Perianal/-rectal abscess (566) (Ch. 4)
Sexually Transmitted Diseases (STDs, 091, 098, 099) (Ch. 4)