Hemorrhoids are dilated vessels in the submucosa of the lower rectum arising from the superior and inferior hemorrhoidal veins. Chronic fissures may expose the internal sphincter and be associated with a skin tag.
• Hemorrhoids are dilated vessels in the submucosa of the lower rectum arising from the superior and inferior hemorrhoidal veins. Vessels above the dentate line are referred to as internal, while those below the dentate line are referred to as external.
• Hemorrhoids occur as a result of conditions that increase the intrapelvic pressure such as pregnancy, pelvic tumors, prolonged standing or sitting, and chronic straining as a result of constipation.
• Symptoms of hemorrhoids include rectal bleeding (bright red blood coating the stool or noted while wiping), skin and anal irritation, and pain.
• Internal hemorrhoids are classified into four grades
Grade I: hemorrhoids remain above the dentate line
Grade II: hemorrhoids prolapse out of the anal canal but reduce spontaneously
Grade III: hemorrhoids prolapse out of the anal canal but require manual reduction
Grade IV: hemorrhoids are irreducible
• Grades I and II are treated conservatively with a high-fiber diet, analgesic creams, steroid suppositories, and sitz baths. Resistant hemorrhoids require more aggressive intervention such as endoscopic banding or hemorrhoidectomy. Hemorrhoidectomy is the more definitive treatment but carries a higher risk of complications (pain, hemorrhage, constipation, and urinary tract infection).
• Grades III and IV are usually treated with surgical hemorrhoidectomy.
• Thrombosed external hemorrhoids are treated with clot excision if presenting within 72 hours of occurrence, otherwise with conservative symptomatic management.
• A traumatic tear in the lining of the anal canal, mostly occurring in the posterior midline and caused by straining and chronic constipation. While usually selfhealing, many fissures progress to chronic fissuring because the associated internal sphincter spasm causes further widening of the fissure and a decrease in blood supply resulting in ulceration.
• Patients usually complain of severe pain associated with defecation and during rectal examination, and occasionally note blood on tissue paper.
• The diagnosis is made by observing a fresh tear in the anal mucosa. Chronic fissures may expose the internal sphincter and be associated with a skin tag.
• Treatment is straightforward and involves topical analgesics and sitz baths. The use of topical nitroglycerin or calcium channel blockers may help decrease the anal sphincter pressure and allow the fissure to heal. Refractory cases can be treated with Botox injection and ultimately surgically by lateral internal sphincterotomy. The surgical approach is associated with a risk of fecal incontinence.
Colonic Pseudo-Obstruction (Ogilvie Syndrome)
• Colonic pseudo-obstruction is characterized by severe adynamic dilatation of the colon (usually cecum, ascending, and transverse) in the absence of a mechanical obstruction.
• It usually occurs in hospitalized patients who are postoperative, critically ill, or using high-dose narcotics.
• After exclusion of mechanical obstruction, appropriate treatment includes intravenous hydration and discontinuation of the offending agents (narcotics).
• Severe resistant cases can be treated with careful endoscopic decompression of the colon or with the use of intravenous neostigmine with close patient monitoring.