ALEXANDRIA FACULTY OF MEDICINE – TROPICAL MEDICINE DEPARTMENT

Lower Gastrointestinal Tract Bleeding

Benign Anorectal Diseases
Haemorrhoids and Anal Fissures

By: Sarah Ahmed Gowil 551

Dr Mohamed Adel
 Haemorrhoids
Anatomy and Physiology

Hemorrhoids are highly vascular submucosal cushions that generally lie along
the anal canal in three columns—the left lateral, right anterior, and right
posterior positions. These vascular cushions are made up of elastic connective
tissue and smooth muscle, but because some do not contain muscular walls,
these cushions may be considered sinusoids instead of arteries or veins.
Clinically evident bleeding arises from the perisinusoidal arterioles and are
therefore arterial in nature. Hemorrhoids play a significant physiologic role in
protecting the anal sphincter muscles and augment closure of the anal canal
during moments of increased abdominal pressure (e.g., coughing, sneezing) to
prevent incontinence and contribute 15 to 20% of the resting anal canal
pressure. Increases in abdominal pressure increase the pressure in the
inferior vena cava that causes these vascular cushions to engorge and prevent
leakage. This tissue is also thought to help differentiate stool, liquid, and gas in
the anal canal.
Pathology

Hemorrhoids are therefore the pathological term to describe the abnormal

downward displacement of the anal cushions causing venous dilatation. There
are typically three major anal cushions, located in the right anterior, right
posterior and left lateral aspect of the anal canal, and various numbers of
minor cushions lying between them. The anal cushions of patients with
hemorrhoids show significant pathological changes. These changes include
abnormal venous dilatation, vascular thrombosis, degenerative process in the
collagen fibers and fibroelastic tissues, distortion and rupture of the anal
subepithelial muscle. In addition to the above findings, a severe inflammatory
reaction involving the vascular wall and surrounding connective tissue has
been demonstrated in hemorrhoidal specimens, with associated mucosal
ulceration, ischemia and thrombosis.
Classification

A hemorrhoid classification system is useful not only to help in choosing

between treatments, but also to allow the comparison of therapeutic
outcomes among them. Hemorrhoids are generally classified on the basis of
their location and degree of prolapse. Internal hemorrhoids originate from the
inferior hemorrhoidal venous plexus above the dentate line and are covered
by mucosa, while external hemorrhoids are dilated venules of this plexus
located below the dentate line and are covered with squamous epithelium.
Mixed (interno-external) hemorrhoids arise both above and below the
dentate line. For practical purposes, internal hemorrhoids are further graded
based on their appearance and degree of prolapse, known as Goligher’s
classification.
Clinical Manifestations

The most common manifestation of hemorrhoids is painless rectal bleeding

associated with bowel movement, described by patients as blood drips into
toilet bowl. The blood is typically bright red as hemorrhoidal tissue has direct
arteriovenous communication. Positive fecal occult blood or anemia should
not be attributed to hemorrhoids until the colon is adequately evaluated
especially when the bleeding is atypical for hemorrhoids, when no source of
bleeding is evident on anorectal examination, or when the patient has
significant risk factors for colorectal neoplasia.
Prolapsing hemorrhoids may cause perineal irritation or anal itching due to
mucous secretion or fecal soiling. A feeling of incomplete evacuation or rectal
fullness is also reported in patients with large hemorrhoids. Pain is not
usually caused by the hemorrhoids themselves unless thrombosis has
occurred, particularly in an external hemorrhoid or if a fourth-degree internal
hemorrhoid becomes strangulated. Anal fissure and perianal abscess are more
common causes of anal pain in hemorrhoidal patients.

Diagnosis

The definite diagnosis of hemorrhoidal disease is based on a precise patient

history and careful clinical examination. Assessment should include a digital
examination and anoscopy in the left lateral position. The perianal area should
be inspected for anal skin tags, external hemorrhoid, perianal dermatitis from
anal discharge or fecal soiling, fistula-in-ano and anal fissure. Some physicians
prefer patients sitting and straining in the squatting position to watch for the
prolapse. Although internal hemorrhoids cannot be palpated, digital
examination will detect abnormal anorectal mass, anal stenosis and scar,
evaluate anal sphincter tone, and determine the status of prostatic
hypertrophy which may be the reason for straining as this aggravates descent
of the anal cushions during micturition. Hemorrhoidal size, location, severity
of inflammation and bleeding should be noted during anoscopy. Intrarectal
retroflexion of the colonoscope or transparent anoscope with flexible
endoscope also allow excellent visualization of the anal canal and hemorrhoid,
and permit recording pictures
Treatment

 Dietary and Lifestyle Modification

 Medical Therapy
 Non-operative treatment
o Rubber Band Ligation
o Infrared Photocoagulation
o Sclerotherapy
o Anal Dilatation or Stretch
o Cryotherapy
o Radiofrequency ablation
 Operative treatment
o Plication
o DGHAL
o Hemorrhoidectomy
o Stapled hemorrhoidopexy
 Anal Fissures
Definition

An anal fissure, or fissure-in-ano, is an oval, ulcer-like, longitudinal tear in the

anal canal, distal to the dentate line. Although the exact incidence is unknown,
it is a common disorder, with equal gender distribution. Fissures can occur at
any age, but are usually seen in younger and middle-aged adults. In almost
90% of cases, fissures are identified in the posterior midline, but can be seen
in the anterior midline in up to 25% of affected women and 8% of affected
men. An additional 3% of patients have both anterior and posterior fissures.
Fissures occurring in lateral positions should raise suspicions for other
disease processes, such as Crohn’s disease, tuberculosis, syphilis, human
immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome
(AIDS), or anal carcinoma.

Early, or acute, fissures have the appearance of a simple tear in the anoderm,
whereas chronic fissures, defined by symptoms lasting more than 8–12
weeks, are further characterized by edema and fibrosis. Typical inflammatory
manifestations of chronic fissures include a sentinel pile, or skin tag, at the
distal fissure margin and a hypertrophied anal papilla proximal to the fissure
in the anal canal. In addition, fibers of the internal anal sphincter (IAS) are
often visible at the fissure base.
Etiology

The cause of anal fissure has been long debated. Trauma to the anal canal
secondary to the passage of a hard stool is believed to be a common initiating
factor. A history of constipation is not universally obtained, however, and
some patients report an episode of diarrhea before the onset of symptoms.
The persistence of a fissure after any initiating event is associated with
increased resting anal pressure—an observation first reported in the mid-
1970s. Physiologic studies using ambulatory manometry have confirmed the
presence of sustained resting hypertonia in fissure patients. Further
observations have delineated an inverse relationship between anal canal
pressure and perfusion of the anoderm. Ischemia was proposed as an
instigator of fissure persistence by Gibbons and Read4 in 1986.

Symptoms

The clinical hallmark of an anal fissure is pain during, and particularly after,
defecation. In acute fissures, pain may be short-lived, but it can last several
hours or even all day in the presence of a chronic fissure. The pain is
frequently described as passing razor blades or glass shards. Understandably,
patients with anal fissures may often fear bowel movements. Rectal bleeding,
although not uncommon, is usually limited to minimal bright red blood seen
on the toilet tissue.

Diagnosis

Diagnosis is suggested by patient history and

confirmed by physical examination. Most fissures
are readily visible by simply spreading the buttocks
with opposing traction of the thumbs. Once the
presence of a fissure is verified, further attempt to
examine the anal canal with insertion of a finger or
endoscopic instrumentation (anoscopy or
proctoscopy) is not appropriate. Most patients are
far too tender to justify such invasive evaluation,
which should be delayed or deferred until
symptoms have resolved.
Treatment

Initial treatment of anal fissures is medical. Frequent Sitz baths, analgesics,

stool softeners, and a high-fiber diet are recommended. Prevention of
recurrence is the primary goal. Adequate fluid intake is also helpful in
preventing the recurrence of anal fissures and is strongly encouraged. If
conservative management with dietary changes and laxatives fail, other
options can be used which include topical analgesics such as 2% lidocaine
jelly, topical nifedipine, topical nitroglycerin, or a combination of topical
nifedipine and lidocaine compounded by a pharmacy. Topical nifedipine
works by reducing anal sphincter tone, which promotes blood flow and faster
healing. Topical nitroglycerin acts as a vasodilator to encourage increased
blood flow to the area of the fissure, increasing the rate of healing. 
References
The ASCRS Textbook of Colon and Rectal Surgery

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3342598/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140328/

https://link.springer.com/referencework/10.1007/978-0-387-36374-5

https://www.researchgate.net/publication/282807716_Management_of_Hemorrhoids