Diseases of the rectum and anus

Fecal Impaction. Fecal impaction is the for­mation of a hard bolus of digestive residues which cannot be expelled. This occurs frequently in patients who are bedridden and particularly in the aged. It occurs in states of dehydration where the colon has extracted and absorbed prac­tically all of the water from the intestinal stream, leaving only a hard caked mass in the rectum. Such a mass may be too large to pass the anal opening. An excess of undigestible food residues in the diet may also cause a rectal fecal impac­tion. This condition obstructs the intestinal tract and if not corrected may lead to serious illness.

Another more common cause for impaction is a weakness in the rectal muscular wall so that it lacks the strength to expel its contents by nor­mal defecation. This occurs occasionally post- operatively after the rectal muscles have been stunned by anesthesia. It also occurs frequently in persons who habitually use and are addicted to cathartics, purgatives, and enemas.

The treatment of this condition simply in­volves removal of the rectal impaction. This is accomplished by manually breaking up the mass so that it may pass the anal opening, or by enemas or by instrumentation through a procto­scope. In some cases this may be a difficult pro­cedure and occasionally even an anesthetic is necessary.

Proctitis. The lining of the rectum is subject to inflammatory disease as are all other tissues. This may be by bacterial infections, parasitic infestations, mechanical irritations (harsh debris in the food residues), and rarely chemical. Proctitis may be acute or chronic. It is often confined entirely to the rectum but may be associated with sigmoiditis or higher colitis. Treatment is largely by diet, oral medi­cations, and medications applied through the rectum in the form of solutions and supposi­tories.

Cryptitis is a localized area of inflammation of the “pockets” between the folds of the anal lining. These depressions are called crypts and may become clogged with fecal material which remains and initiates inflammation. Treatment usually demands surgical correction so that the crypts will freely empty. Cryptitis is often associated with other rectal abnormalities.

Papillitis is inflammation of tags of the anal lining which project from the folded surfaces. Treatment is by their surgical removal.

Fissures are linear cracks in the anal lining which occur from stretching of the surface by passing of large or impacted stool, or even with prolonged forceful sneezing and coughing. With constant irritation and contamination healing is often delayed. Infection and ulceration may en­sue to form an anal ulcer. Such lesions are prone to very difficult healing. Treatment rests with local drugs and diet, but often operation is necessary, especially if associated with other anal diseases.

Abscesses about the rectum and anus are common since the area is subject to many sur­face lesions which may extend deeper into the adjacent tissues. The skin around the anus is more subject to the same hair follicle inflamma­tions as occur on other hairy regions. Once the surface has been broken in this highly contaminated area, the germs may readily enter to extend the infection into the deeper structures. As the process progresses, an abscess is formed. These anal and rectal abscesses may reach any size. They may lie on any surface about the rectum or just un­der the skin about the anus. Rarely will these subside spontaneously. They may disrupt to the nearest surface into the rectum or onto the skin spontaneously, but more often they have to be incised (cut into) to allow the infected contents to drain out. Medications and local drugs and diet must augment the treatment by drainage. The abscess cavity then scars closed as the in­fection subsides.

Sinuses. When an abscess disrupts to the sur­face, a rectal sinus or anal sinus is formed if the cavity fails to seal by scarring. This leaves a cavity or tract beneath the surface which is open at one end. Repeated infections ensue. Treatment is by operation to remove the infected channel. Occasionally one draining to the skin surface may be treated by electrical or chemical cautery of its lining to promote its sealing by scarring.

Fistula. When an abscess discharges its con­tents through both the rectal lining and the skin adjacent to the anus, an infected tract is left which is open on either end. This is called a fistula. Germs continually enter and infection remains. Treatment requires re­moval of the infected canal by operation.

Hemorrhoids. Hemorrhoids is the most common disease of the rectum. Hemorrhoids, or “piles,” are actually varicose veins involving the hemor­rhoidal veins. Several of these veins lie normally just beneath the anal covering. As these become distended and enlarged, they give rise to various symptoms and the diagnosis of hemorrhoids be­comes apparent. Hemorrhoids are of two main types: external hemorrhoids are those outside the level of the muscular sphincter and are cov­ered with skin; internal hemorrhoids are those inside the anal sphincter level and are covered with the same mucous lining which lines the rectum. Most frequently these two types oc­cur together; i.e., internal and external hemorrhoids. The internal variety may become so distended that they protrude through the anus even though their origin is internal.

The cause of hemorrhoids is in many cases remote, but often there is an obvious cause. The hemorrhoidal veins drain blood back to the heart and any pressure on the veins which im­pedes the flow produces “back congestion” which causes the veins to distend. This is com­moner in cases of chronic constipation, which is usual in persons with the cathartic habit. They may be initiated during pregnancy from the in­creased pressure within the lower abdomen from the enlarging womb. They are more prone to develop in certain occupational groups, more commonly in the sedentary and hard laborers. Hemorrhoids may appear as a tumor or inflam­matory mass develops higher in the abdomen, with consequent pressure on the vein channels.

The symptoms of hemorrhoids are those of pain, itching, protrusion, and painful bowel movements. Bleeding may be a prominent symp­tom since there is such a thin covering over the veins and this is easily injured by hard fecal passages. Bleeding may be scanty and only with bowel movements, but occasionally it is profuse. When bleeding occurs it is important to determine absolutely that the hemorrhoids are the source, as other serious diseases of the in­testinal tract may also give rise to bleeding. For this reason study of the intestinal tract by sigmoidoscopy, abdominal examination, and colon x-ray pictures is usually indicated.

The blood within the distended hemorrhoids may become stagnant and become clotted. This is called a thrombosed hemorrhoid. Such may occur in only one or more of these diseased veins. This condition is usually quite painful and necessitates small incision over the hard mass to express the clotted blood.

Hemorrhoids are frequently associated with cryptitis, in which case there is usually much itching and burning pain. Other anal and rectal afflictions are also occasionally associated with hemorrhoids.

The diagnosis of hemorrhoids is usually easily established, particularly when they are external or with protruding internal masses. But in every case digital (finger) examination, and direct visual inspection of the anus and rectum by speculum or proctoscopic examinations, is neces­sary to determine the extent of the hemor­rhoidal veins’ involvement. Further search of the lower abdomen and pelvic organs must be made to determine any underlying cause for the venous distention.

Treatment of hemorrhoids has been attempted by numerous methods, but some have proved only of temporary relief and some even harm­ful. Definitive and lasting treatment is accom­plished only by operative approach. Temporary measures which may give relief of the symptoms, which tend to occur in “attacks,” may be at­tained by the use of topical anesthetic ointments, heat, and dietary measures to prevent hard fecal boluses. These measures may be employed when there is no profuse bleeding, when they have been well evaluated to assure no major concur­rent causative disease, when the symptoms are so minor that operation is not warranted, or for relief of symptoms until operation is accom­plished. The anesthetic ointments relieve much of the surface pain and burning and itching. The use of heat relieves the deep severe pain caused by the always associated muscle sphincter spasm. Temporarily oil cathartics may be used to render the stool soft and lubricated to allevi­ate the severely painful bowel movements. Oc­casionally pain-relieving drugs may be used temporarily.

Operative treatment consists essentially of tying off the upper end of each vein and dissect­ing away the distended diseased portion at each hemorrhoid. There are several methods of ac­complishing this, so the exact details of any pro­cedure are beyond the scope of this book. Pre­operative preparation consists of the palliative measures given above, enemas until the lower bowel is free of any fecal residue, and the pre­paratory measures for operation. The anesthetic of choice may be local infiltration, nerve block, low spinal block, or intratracheal inhalation. The choice will depend in large on the position to be employed on the operating table. Postoperative care includes the above pain-relieving measures of ointments, heat, pain-relieving drugs, and dietary regimen.

Stricture. Stricture of the anus or lower rec­tum is a narrowing of the passageway with an inability to dilate for adequate evacuation of the bowels. This may be of congenital origin, chronic infections or ulcerations of the region with resultant scarring, certain chronic infectious (often venereal) diseases, ill-advised methods of hemorrhoidal treatment, and rarely by injury. When the stricture is not extreme, instrumental dilatation (stretching) of the canal may be curative. More often, operative correction of the defect is necessary.

Prolapse. Prolapse of the rectum or anus is a falling-down and protrusion of the lining layer of the canal. The muscular layer may also be involved in many cases. There are actually several varieties and degrees of pro­lapse. The causes are many: straining at stool or work, fecal impactions, progressive untreated hemorrhoids, excessive coughing or sneezing, diarrhea, injury of the pelvic muscles by child­birth, and congenital muscular weaknesses. Treatment for the initial prolapse may be by simple replacement and correction of the under­lying cause. Most cases, however, are recur­rent and progressive and demand surgical cor­rection.

Tumors. Tumors of the rectum and anus may be either benign or malignant. The benign growths more commonly are sebaceous cysts, polyps, granulations from chronic infections, fatty tumors, and surface warts. The smaller of some of these may be treated by the application of caustic drugs, but most will require surgical removal.

Malignant (cancerous) growths of this region require radical surgical removal. Cancer of the sigmoid colon and rectum are relatively com­mon sites for this treacherous disease. If the growth is within the upper sigmoidal area, fre­quently the continuity of the lower digestive tract can be re-established after removal of the growth. However, when the disease involves the lower sigmoid, rectum, or anus, these portions have to be sacrificed, and artificial terminal opening of the tract through the abdominal wall (colostomy) must be constructed.