Management of Benign Anorectal disorders ACG Clinical Guideline

Management of Benign Ano-rectal disorders: ACG Clinical Guideline Authors: Arnold Wald, Adil E. Bharucha, Bard C. Cosman and William E. Whitehead Published in the American Journal of Gastroenterology Volume: 109, Issue: 08 Aug 2014, Page: 1141 -1157.

Management of Benign Ano-rectal disorders: ACG Clinical Guideline • Guidelines summarize definitions, diagnostic criteria, D/Ds and treatment of a group of benign disorders of anorectal structure and/or functions. • Disorder of structures include anal fissure and hemorrhoids. • Disorders of function include defecation disorders, fecal incontinence and proctalgia syndromes.

Anatomy of Rectum and Anal canal

Anal Fissure • Ulcer-like, longitudinal tear in midline in distal anal canal. • 90% cases located in posterior midline. • Can occur in anterior midline. • Fissures in lateral positions should raise suspicion for others diseases.

Anal Fissure • Acute fissure looks like a simple tear in anoderm.

• Chronic fissure: • Lasting more than 8 to 12 weeks • Edema and fibrosis. • Sentinel pile (Skin tag) at distal fissure margin • Hypertrophied anal papilla in proximal to fissure.

• Chronic anal fissure maintained as a non healing ulcer by sphincter spasm and consequent ischemia. • Treatment typically directed toward relieving spasm. • Predominantly medical condition, surgery reserved for medically refractory cases.

Recommendation for treatment of acute anal fissure • Gastroenterologists and other providers should use non-operative treatments such as • • • sitz baths psyllium fiber bulking agents as the first step therapy of acute fissure (strong recommendation, moderate quality of evidence). About 50% acute anal fissure heal with supportive measures with or without addition of topical anesthetics or anti inflammatory ointments

Recommendation for treatment of chronic anal fissure • Topical pharmacologic agents such as calcium channel blocker or nitrates. (strong recommendation, moderate quality of evidence) • Local injection of botulinum toxin. • Surgical internal anal sphincterotomy. (strong recommendation, high quality of evidence)

Hemorrhoids • Most common problems encountered in industrialized world. • Anal cushions are renamed internal hemorrhoids when they bleed and/or protrude.

• Cardinal signs are • Painless bleeding with bowel movements • Intermittent, reducible protrusion. • Thrombosed external hemorrhoid involves a clot in a vein under anoderm.

Recommendation for diagnostic assessment • Should diagnose hemorrhoids by history and physical examination. • If there is bleeding, the source often requires confirmation by endoscopic studies. (strong recommendation, moderate quality of evidence).

Diagnostic assessment • Physical examination includes visual inspection of anus- in rest and straining. • Digital examination to exclude other pathology.

Diagnostic assessment Grades of internal hemorrhoids based on history • • 1 st degree 2 nd degree 3 rd degree 4 th degree : Bleeds only. : Prolapse but self-reduce. : Require manual reduction. : Can’t be reduced. Permanently prolapsed.

Recommendation for treatment of thrombosed external hemorrhoid Most patients who present urgently (within- 3 days of onset) with a thrombosed external hemorrhoid benefit from excision. (strong recommendation, low quality of evidence)

Recommendation for treatment of internal hemorrhoid • First with increased fiber intake and adequate fluids. (strong recommendation, moderate quality of evidence) • First to third degree hemorrhoids that remain symptomatic after dietary modification – • Banding • Sclerotherapy • Infrared coagulation (strong recommendation, moderate quality of evidence)

• Ligation is probably the most effective option.

• Surgical operations • hemorrhoidectomy, • Stapled hemorrhoidopexy • Doppler-assisted hemorrhoidal artery ligation • Indications: • Refractory to or can’t tolerate office procedures • Large symptomatic external tags along with their hemorrhoids • Large third degree hemorrhoids or fourth degree hemorrhoids (strong recommendation, moderate quality of evidence)

Treatment of internal hemorrhoid • Increased fiber intake reduces both Prolapse and bleeding. • To avoid straining and limit time spent on commode, as both associated with higher rates of symptomatic hemorrhoids. • Topical treatments for hemorrhoids are of unclear value.

Proctalgia syndromes • Chronic proctalgia, other names- levator ani syndrome, levator spasm, puborectalis syndrome, pyriformis syndrome, and pelvic tension mayalgia. • Defined by recurring episodes of rectal pain or aching, with each episode lasting 20 min or greater. • Stress and anxiety are often through to contribute to chronic proctalgia, but there is little evidence for this.

Recommendation for diagnostic assessment • Diagnosis of chronic proctalgia based on • A history of recurring episodes of rectal pain, each lasting at least 20 minutes. • Digital rectal examination showing tenderness to palpation of the levator ani muscles. • Exclusion of other causes for rectal pain by history and diagnostic testing.

• Obtain an imaging study or endoscopy to rule out structural cause of rectal pain. • Obtain a BET and ARM to identify patients with chronic proctalgia and levator muscle tenderness likely to respond to bio -feedback.

Recommendation for Treatment • Biofeedback to teach relaxation of pelvic floor muscles during simulated defecation is the preferred treatment. • Electric Stimulation is superior to digital massage but inferior to biofeedback.

Proctalgia Fugax • Characterized by intense sensations of rectal or anal canal pain lasting only a few seconds to minutes. • Pathophysiology is unknown. • Thickening of internal anal sphincter and elevated resting pressure in anal canal have been reported.

Recommendations for Diagnostic assessment • History of intermittent bouts of severe pain in the anal canal or lower rectum lasting less than 20 minutes. • Exclude structural causes of anorectal pain (eg. Anal fissure, hemorrhoids, cryptitis, malignancy) by imaging, endoscopy, or other appropriate tests.

Recommendation for treatment Assure the patient that disorder is benign. The evidence for specific treatment is no better than anecdotal.

Defecatory Disorders • A defecatory disorder refers to difficulty in evacuating stool from the rectum in a patient with chronic recurring symptoms of constipation. • D/D may be caused by functional or structural anorectal disturbances. • Functional disturbances include • dyssynergia, • failure to relax pelvic floor muscles • Inadequate defecatory propulsion.

Diagnostic assessment • Confidence in the diagnosis is increased if there is a combination of a clinical history of chronic constipation and two abnormal test • • Impaired ability to evacuate a 50 ml water-fluid balloon abnormal defecography Abnormal pelvic floor EMG Abnormal ARM

Recommendation for diagnostic assessment • Digital rectal examination is a useful first test to screen for DD, as it has good negative predictive value. • Barium or MR defecography can identify structural cause of outlet obstruction. They may also confirm or exclude the diagnosis of DD when the clinical features suggest DD but the result of ARM and BET are equivocal.

Recommendations for treatment • Patient education • Simulated defecation training • Training to relax pelvic floor muscles while defecation • Practicing simulated defecation

Fecal Incontinence • Fecal incontinence is the involuntary loss of solid or liquid feces. The more general term, anal incontinence, also includes involuntary loss of flatus

Recommendation for Diagnosis assessment • Should ask patients about the presence of FI directly rather than relying on spontaneous reporting. • Should identify conditions that may predispose to FI.

• To identify symptom severity by qualifying stool type using the Bristol stool scale, as well as characterizing the frequency, amount of leakage and the presence of urgency. • To obtain bowel diaries because they are superior to self-reports for characterizing bowel habits and FI.

Causes of Fecal Incontinence • Anal sphincter weakness • Traumatic: obstetric, surgical • Non-traumatic: scleroderma • • • Neuropathy Disturbance of pelvic floor : rectal prolapse, descending perineum Inflammatory condition : IBD, radiation proctitis Central nervous system disorder : stroke, cord lesions Diarrhoea • IBS • Post cholecystectomy diarrhoea • Fecal retention with overflow, behavioral disorder

Recommendation for physical examination • Exclude diseases to which FI is secondary. • Digital exam to identify rectal mass, anal tone during rest and contraction.

Recommendation for Diagnosis Testing • ARM, BET and rectal sensation should be evaluated in patient who fail to respond to conservative measures. • Pelvic floor, anal canal imaging, as well as anal EMG, should be considered for patient with reduce anal pressure who have failed conservative therapy, particularly if surgery considered.

Recommendation for non surgical treatment • • Education, Dietary modifications, Skin care, and Pharmacologic agent to modify stool delivery and liquidity before diagnostic testing, particularly when symptoms are mild and non bothersome. • Should prescribe antidiarrhoeal agent for FI in patients with diarrhoea.

Recommendation for surgical treatment • Sacral nerve stimulation. • Anal sphincteroplasty. • Colostomy is a last resort procedure.