ANAL AND PERIANAL DISORDERS MANAGEMENT

Transcription

1 Med. Surg. J. Rev. Med. Chir. Soc. Med. Nat., Iaşi 2018 vol. 122, no. 3 SURGERY ORIGINAL PAPERS ANAL AND PERIANAL DISORDERS MANAGEMENT M. V. Hînganu *, P. Salahoru, Delia Hînganu Grigore T. Popa University of Medicine and Pharmacy Iasi Faculty of Medicine Department of Morpho-Functional Sciences (I) * Corresponding author. hanganu.marius@yahoo.com ANAL AND PERIANAL DISORDERS MANAGEMENT(Abstract): Perianal disorders are the main cause of addressability to the family doctor and to the gastroenterologist. The study is conducted on the background of the increasing incidence of anal pathology in relation with the decrease in the age of appearance. Aim: to propose a protocol for management of patients with perianal disease. Material and methods: The study included a group of 2,000 patients, who were clinically and imagistic investigated. Results: The statistics show a much higher incidence of perianal pathology and an increasing prevalence of it in younger age. Conclusions: we propose a management plan for these patients that facilitates early diagnosis and determines the specific treatment required. The impact of this study is both medical and socio-economic as it shortens patient suffering and the time required for active social r e- integration. Keywords: PERIANAL DISORDERS, HEMORRHOIDS, MANAGEMENT, ANAL DISEASES. Perianal disorders are the main cause of addressability to the family doctor and to the gastroenterologist. The wide range of pathologies, from benign (hemorrhoids, anal fissures, fecal incontinence, fistulas and perianal abscesses, thrombosis) to malignant (rectal carcinoma), involves a clinical examination and a complete and correct anamnesis (1) Anal fissure is a linear or oval ulcer in the anal canal below the dentate line extending to the anus. The most frequent location is at the posterior median line, being explained by several theories with anatomical substrate: the elliptical shape of the external anal sphincter, which leads to low resistance of anal canal and relative ischemia of the posterior commissure, which compromises the blood circulation and increases anal sphincter tonus (2). Hemorrhoids are the increasing and/or distal movement of protrusions of the anal mucosa formed by smooth muscle and blood vessels, along with connective tissue, termed cushions. Hemorrhoids usually consists of three cushions in the left lateral, right anterior and right posterior positions (2). These anatomical structures are in the submucosal layer of fibrovascular tissue and due to lack of smooth muscle wall are considered as sinusoidal structures. Hemorrhoids are suspended in the anal canal due to Treitz's muscle, thus explaining the increase in the incidence of pathology with aging, because of the loss of the muscular tonus. When they increase their size become pathological, because of the venous stasis. This process can be accelerated by other pathologies such as high blood pres- 522

2 Anal and perianal disorders management sure, portal hypertension, and abdominal tumors. Anal cryptitis and papillitis are inflammatory proctologic illnesses with increased incidence. Papillitis is the inflammation of the anal papillae at the distal end of Morgagni's rectal columns. Cryptitis is the inflammation of an anal crypt and corresponding anal glands immediately above the dentate line. Initially, the inflammation occurs at the crypt of Morgagni, and then extends to the anal papilla. Inflammation of the papilla due to the cryptitis and its volumetric growth increase the likelihood that fecal material remains captive in the crypt and initiates inflammation, and if it forms the abscess, anal fissure and perianal fistula may occur. Cryptoglandular fistula is the most common cause of perianal infection and affects especially males. It represents the infection of the Hernmann and Desfosses glands from the intersphincteric space and their opening to the crypts of Morgagni (1, 2). Malignant pathology of the perianal region includes rectal cancer as a subtype of colorectal cancer (CCR) and anal cancer. In colorectal cancer, neovascularization is a critical event during tumor genesis, with an early peak in malignant process (3-8). Rectal cancer has a worse prognosis because it is characterized by an increased rate of local recurrence and a higher metastasis presence at the moment of diagnosis (9). MATERIAL AND METHODS This retrospective study was performed in a group of 2,000 patients, investigated at Medical ON Group, Iasi, between , with ages between years old, of which 63% were men and 37% women. Patients presented with various perianal pathologies: hemorrhoids, perianal abscesses fistula, condylomatosis, various anal and rectal tumors and anal polyps. Patients anamnesis was performed, following the clinical manifestations, methods of investigation and the therapeutic methods used in the past, followed by the clinical examination of the perianal region and the anal canal. This was done by rectal digital examination, video-anuscopy, and in some cases by rectoscopy to confirm or refute the presence of a colorectal tumor (up to 25 cm) or ulcerative colitis. A total of 2,050 minimally invasive interventions were performed, such as: rubber band ligation, infrared coagulation and resection with radiofrequency cautery. Using statistical methods, we calculated the prevalence of perianal affections according to the associated risk factors. RESULTS We calculated the proportion of each disease in total perianal pathology by reporting the total number of patients with certain pathology in total patients with perianal pathology (tab. I). TABLE I The distinctive variation of pathologies in total perianal pathologies Hemorrhoid Perianal abscesses Perianal fistula Anal polyps Anal papilloma Condylomatosis Squamous- Rectal cellular cancer cancer % 2.57% 1.28% 3.85% 0.51% 0.25% 0.25% 1.28% % 6.34% 2.11% 4.22% 0.21% 0.63% 0.42% 1.47% % 7.17% 1.18% 1.66% 0.16% 0.66% 0.50% 1.00% % 3.15% 4.26% 1.66% 0.37% 0.37% 0.18% 0.55% 523

3 M. V. Hînganu et al. Fig. 1. Distribution of patients according to their origin The environment from which the patient originates is also important. The emergence of an increasing number of sedentary persons in cities, correlated with the reduced addressability to doctors of the patients in the rural areas leads to significant statistical differences between the two situations (fig. 1). The distribution of patients by age and gender shows an increased prevalence of male perianal pathology and draws an alarm signal related to the early onset of age. The most affected age group oscillates between years old, with an apex of years (72%), as demonstrated in the literature, with respect to the group of years, where the incidence of pathologies is low (2 %). We observed that at the age at which the incidence of perianal pathology is increased (40-50 years old) men are 1.6 times more affected than women in the study group (fig. 2). Fig. 2. Distribution of patients by age and gender We have structured the types of studied pathologies as a percentage of the perianal disease and we observed that prevalence of hemorrhoidal disease is 88% with a total of 1,757 cases since 2,000 and the low prevalence of benign (70 cases) and malignant (28 cases) tumors between In the case of patients with hemorrhoids, the anuscopy revealed a small number of anatomical atypia, 10% presenting turgescent vascular bundle outside the three major bundles. As symptoms, lower digestive hemorrhage and proctalgia are the most frequent. From the analysis of the living and working conditions of the study group, we obtained data about the occupation and the time spent in the seating position (fig. 3). It was obvious that in the study group, patients with more than 5 hours per day in seating position had an increased risk for perianal diseases. There is an increased prevalence of hemorrhoidal disease compared to other pathologies, most of the cases being diagnosed in , most of them being men, from urban areas, aged years, the most common, in over 50% being hemorrhoidal disease, perianal abscess, perianal fistula and anorectal polyp and the physical activity rate being slightly low, 55% of them spending 5-10 hours in the sitting position. 524

4 Anal and perianal disorders management Fig. 3. Distribution of patients according to type of job and time spent sitting DISCUSSION Specific prevalence on pathologies over the period according to the formula Prevalence of period = total number of cases of illness / number of examined persons X 100, were 50% for hemorrhoidal pathology, 4% for perianal abscess, 1.8% for perianal fistula, 2.16% for perianal fissure, 2.16% for anorectal polyps, 0.24% for anal papilloma, 0.4% for condylomatosis, 0.28% for squamous cell cancer and 0.84% for rectal cancer. Particular attention should be paid to patients with chronic cardiovascular pathology, pacemaker carriers. At the same time, we noticed a special category of patients - vocal artists and those using wind instruments. In their case, the intraabdominal pressure raised during artistic act by contraction of the abdominal anterolateral muscles, correlated with a high vocal tract, can cause the hemorrhoidal disease in time (10-12). Following anamnesis, the dominant symptom was bleeding with red blood, small but repetitive abundance, conditions that led patients to see their doctor. Of these, 100 patients experienced pain, especially patients who had complicated hemorrhoids with thrombosis. The patient s reported swelling was 70% due to the hemorrhoid prolapse of Stage III-IV. Serum mucosal leakage was also reported in 35% triggering anal pruritus. The beginning of symptoms was acute, first-degree hemorrhoids patients presenting to their physician immediately, and those with a chronic evolution either did not take self-medication or used various unguents (13-17). The minimally invasive surgical interventions in the ambulatory (18-23) were grouped as follows: 71 patients under IRC (infrared coagulation), 1,686 for RBL (rubber band ligation), 100 incisions and drainage, 17 fistulectomies, 28 fistulotomies, 19 excisions, 2 curettage and 5 excisions and curettages. Following the study, we have proposed a protocol for ambulatory patient management: Patient s history: to insist on the symptoms, disease evolution, the debut, the medical history, the exposure to risk factors: sedentary, sitting position - for the benign pathologies and abuse of alcohol, smoking, HIV virus, sexually unprotected anal sex - for malignant pathology or condylomatosis. Clinical examination: inspection of the anal and perianal region may reveal external fistulae that secretes pus, the presence of lesions produced by laceration in the case of acute anal fissure, or the presence of the tegument impression at the distal end of the chronic fissure. In case of prolapsed internal hemorrhoids, the anal 525

5 M. V. Hînganu et al. mucosa appears together with the turgescent venous formation at the level of the anal ring and in the case of the superficial perianal abscess it can be observed an area showing signs of inflammation. Papilloma and prolapsed anal polyps are a perianal skin color formation at the anal orifice. Condylomatosis is white formation, in the anal or perianal orifice or perianal skin. In the case of malignant pathology, these formations may be elastic, mobile in the case of polyps or may be friable, stenotic, and harsh. Imagistic evaluation: video scanning, eventually fistulography and exploration of the fistula with a buttoned probe and in the case of suspicion of rectal cancer, anal cancer or acute and chronic complicated perianal suppuration, it is recommended to perform a CT, MRI or PET-CT. Preoperative evaluation with the anamnesis orientated to possible allergic reactions, the medication taken by the patient, the anesthetic-surgical history, possible postinterventional complications, stopping or passing the antiaggregant / anticoagulant therapy on fractional low molecular weight heparin. Treatment of hemorrhoidal disease is performed according to their degree and complications: in grade I - prophylactic treatment, local and general administrated drugs, minimally invasive - infrared coagulation; in grade II-III - prophylactic, local and general medical treatment, minimally invasive - infrared coagulation corroborated with Rubber Band Ligation; in grade IV - prophylactic, local and general medical treatment, minimally invasive - infrared coagulation, in conjunction with Rubber Band Ligation and classic surgical treatment in case of relapses. In: perianal abscess - incision, evacuation and drainage; perianal fistula - fistulotomy, fistulectomy; anorectal polyps, anal papillae - radiofrequency excision; acuminate condylomas - excision and curettage with radiofrequency (24, 25). CONCLUSIONS Under modern society, most patients do not have the time to hospitalize, this problem being solved by minimally invasive ambulatory treatment due to by lack of hospitalization, anesthesia, complications, minimal risks with efficiency, speed and safety, and reducing recovery days. In the last years there has been an increase in the incidence of hemorrhoidal disease (especially) among the young population (20-30 years), with direct socio-economic implications. This is due to the emphasis on sedentary life, especially in the urban areas, but also on labor migration to new areas such as IT. REFERENCES 1. Parsons CS, Scholefield JH. Other anorectal conditions: Haemorrhoids. Surgery 2006; 24(4): Eames TD, Scholefield. Fissures, pruritus ani and haemorrhoids. Surgery 2008; 26(8): Hînganu MV, Hînganu D, Frâncu LL. Microanatomic aspects of arterial blood supply in rectal carcinomas predictive models. Rom J Morphol Embryol 2013; 54 (3): Hînganu D, Eva I, Stan C, Hînganu MV. Morphological aspects of the rectal neovascularization in colorectal cancer-anatomical-surgical and imaging implications. Rom J Morphol Embryol 2016; 57(1):

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