Anal Rectal Disease

Anal rectal diseases are common and involve the rectum, which is the lower part of your large intestine and the anus, which is the opening in the rectum through which stool passes from your body.

Patients with common anorectal problems are seen by the members of the Section of Colon and Rectal Surgery and by other colleagues in the Division of General and GI Surgery. The two most common problems seen in our office are patients with hemorrhoids and patients with anal fissures. It is important to realize, however, that common anorectal problems such as hemorrhoids and fissures are oftentimes associated with other problems of the colon and rectum. Besides evaluating the anus and distal rectum in the office, we often recommend followup flexible sigmoidoscopy or colonoscopy, particularly if an anorectal problem is associated with rectal bleeding.
One of the mainstays of therapy of many anorectal problems is a change in diet. Many patients do not take enough fiber in their diet. Fiber supplementation with products such as Metamucil, Citrucel, Konsyl, or Fibercon are recommended. High fiber breakfast cereals such as All Bran or Bran Flakes are also recommended if a patient has difficulty taking fiber supplementation on a regular basis. Fiber supplementation only works well if an individual patient takes enough water and fluids. Therefore, emphasis for the treatment of common anorectal problems will include increasing fluids over the course of a 24-hour period.
Two other common anorectal problems include pruritis ani (anal itching) and anorectal abscesses and fistulae. Anal itching is usually related to problems with diet and certain other maneuvers can be recommended to help this condition. If the condition persists after modification of the patient’s diet, then biopsy of the anal area is sometimes necessary. Anorectal abscesses and fistulae oftentimes develop suddenly and require drainage. Usually this infection can be drained during a small office procedure, although on occasion the patient must go to the operating room. Many anorectal infections result in a small fistula, or tunnel. Ultimate treatment of the fistula requires either one or two surgeries. Further workup with either a flexible sigmoidoscopy or a colonoscopy is sometimes recommended. On rare occasions, inflammatory conditions of the colon and rectum will be associated with an anorectal infection

Constipation

Constipation is defined as infrequent bowel movements, excessive straining at bowel movements or particularly hard stools. Although most people experience the symptoms of constipation at one time or another most people respond to simple dietary or behavioral manipulations to correct the problem. Persistent constipation should be brought to the attention of a physician and be evaluated, as any change in bowel habits would be. A small percentage of patients who have no anatomical explanation for their constipation and do not respond to the above measures are diagnosed with functional constipation. A very small subset of these patients can be evaluated for a potential surgical approach to their symptoms. The evaluation usually includes radiologic studies to evaluate the transit time of the larger intestine and/or internal abnormalities within the anorectal area. Anorectal manometry, a pressure study of the anus and rectum, is also used to rule out potential functional problems. If patients are diagnosed with a significant functional problem and fail all attempts at medical management, they may respond to surgical attempts to correct these problems.
Patients with severe constipation from "colonic inertia" will benefit from a total colectomy and anastomosis or "hookup" of the small intestine to the rectum. In properly selected patients, constipation is cured. However, this procedure is only reserved for patients with well documented and diagnosed colonic inertia for disorders of the colon.

Fecal Incontinence

Fecal incontinence or the inability to defer bowel movements to the proper time and place is a devastating and often embarrassing problem for patients. Because of this, fecal incontinence is often underreported to physicians. The symptoms can range from occasional seepage of stool to loss of control of full bowel movements. If an initial evaluation of this change in bowel habits is unrevealing, patients are often referred to a colon and rectal surgeon for further evaluation. This evaluation includes a careful history and physical examination. Further, more sophisticated testing includes a radiologic examination of the anal sphincters as well as an anorectal manometry, which measures pressure generated by the anal sphincters and potential injuries to the nerves that supply these sphincters. After this evaluation patients may be recommended to undergo changes in diet, medications, biofeedback exercises or a surgical repair of their anal sphincter. For those unfortunate few patients who do not respond to the above measure newer more aggressive treatments are being performed at a few centers in the United States, including the Brigham and Women's Hospital.

Anorectal Surgery

		Hemorrhoid Banding - rubberband ligation of internal hemorrhoids  This procedure is done in the office for patients with prolapsing internal hemorrhoids. It is usually very successful in patients with moderate symptoms. For patients with large or severe symptoms, surgery may be required. Click for larger image
		Closed Hemorrhoidectomy  Patients with large prolapsing hemorrhoids that have failed conservative therapy are best treated with removal of the hemorrhoids. Surgery usually requires a general anesthetic, but can be performed as an outpatient procedure. Click for larger image
		Lateral Internal Sphincterotomy - anal fissure surgery for patients with chronic symptoms  In this procedure, a small portion of the distal internal sphincter is divided in order to relieve chronic spasm. The procedure is very successful in curing a patient of chronic anal fissure. However, there are occasional changes in continence with this procedure so it is reserved only for patients who have failed conservative therapy. Click for larger image

Click here to read an article written by Dr. Bleday about hemorrhoids

For more information on hemorrhoids click here