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Hemorrhoids, Anal Fistulas    

Hemorrhoids

Fistulas

Anal fissures

What causes an anal fissure?

Classification of fissures

Symptoms of an anal fissure

Making a diagnosis

Can anal fissures ever lead to colon cancer?

Anal fissures vs anal fistulas

Non-surgical treatment

Alternative Treatments

Surgery

Risks of surgery

Return of the fissure

 

Hemorrhoids  http://www.dekalbsurgical.com/pics/clearpixel.gif

Hemorrhoids, or piles, is a sometimes painful mass of distended (swollen) veins in the lining of the anus and rectum, resulting from the formation of varicose veins around the anus. Internal hemorrhoids occur at the junction of the anus and rectum and are covered with mucous membrane. External hemorrhoids occur just outside the anus and are covered with skin. On occasion an internal hemorrhoid may prolapse, or protrude, to the outside, cutting off the blood supply. A number of treatments are available for internal hemorrhoids. External hemorrhoids may be treated with local care to relieve pain; if they recur or remain symptomatic they may be surgically removed.

Hemorrhoids can occur at any age, often without apparent cause.  A typical scenario for developing hemorrhoids might be someone with a little chronic constipation, who sits for several minutes or more for each bowel movement, often reading a magazine or newspaper at the same time.  Repeated straining at stool, over time, causes the encircling dilated veins to gradually stretch and get pushed downward through the anus, ahead of the stool.  You might notice that you must wipe several times afterward, and you may be aware of some "extra tissue" protruding through the anus, or note a little trace of blood on the toilet paper.  Contributing factors may include severe constipation or diarrhea, pregnancy, liver disorders, rectal tumors, and the repeated long term use of laxatives. Hemorrhoids can cause itching and burning and may bleed during a bowel movement.

Hemorrhoids do not cause cancer nor do they become cancerous. But any rectal bleeding may be a sign of cancer of the colon or rectum and should be checked by a physician

Temporary relief from hemorrhoids may be obtained by applying a cold compress directly to the affected area until the pain subsides. This is most easily done if the patient lies face-down and another person applies the compress. Tepid water baths may also help. A person should eat a high-roughage diet to ensure regular defecation of large, soft stools. Ointments, creams, and suppositories containing corticosteroids may also ease the symptoms.  In addition to these measures, avoiding constipation is certainly key.  It is important to have an adequate amount of fiber in your daily diet.  So what do we mean by that?  Well, the short answer is to have some sort of bran cereal for breakfast, like All Bran (probably the highest fiber content of the options available), or Raisin Bran, then be sure to include salads and lots of fresh fruits and vegetables in your other meals.  You should also drink 6-8 glasses of water or juices per day.  Lots of fiber without enough fluids can make the situation worse, similar to the difference between a dry and a wet sponge.  The fiber (sponge) can absorb lots of liquid, but without the liquid, the stool will be hard to pass (like a dry sponge).

There's more detailed information about fiber in the next few paragraphs.  If you want to skip this detail, click here.

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Dietary fiber or roughage is defined as a  carbohydrate complex which comes from plants, and it does not get digested in the stomach and small intestine. Since it remains in this undigested state all the way to the colon (large intestine), the remaining fiber absorbs water into the stool, creating bulk and speeds the process by which waste is eliminated from the body.

There are two types of fiber:  

  • Insoluble fiber doesn’t dissolve in water, and it helps move food through the digestive tract. Whole wheat flour, cereals, pastas, seeds, nuts, green beans, cauliflower, tomatoes, flax seeds, and potato skins contain insoluble fiber.
  • Soluble fiber dissolves in water and forms a gelatinous-like material which lowers blood cholesterol and glucose levels. You can find soluble fiber in oats, barley, carrots, broccoli, artichokes, fruits, and berries.

 Although dietary fiber has little nutritional value, it has great health benefits.  Everyone should be aware how it can help you lead a healthier life:

  • Relieves and prevents constipation. Fiber shortens the transit time of material in the digestive system by absorbing water into the stool, which increases bulk and softens the waste helping it speed along. Constipation and the straining to have a bowel movement are often the causes of hemorrhoids.
  • Reduces cholesterol levels. Low-density lipoproteins (LDL), the bad cholesterol, are reduced by soluble fiber. This lowers your risk of developing cardiovascular diseases associated with heart attacks and strokes by preventing the build-up of plaque in the arteries.
  • Reduces the risk of digestive conditions. Hemorrhoids, Irritable Bowel Syndrome and Diverticulosis  (a disease where small pouches develop in the intestinal walls) are less likely to occur, because with fiber the intestinal contractions do not have to work as hard to move the stool along. It is interesting to note that diverticulosis is virtually unheard of in African countries, presumable because of the high fiber content of their diet.
  • Regulates blood sugar levels. The absorption of sugar is slowed by soluble fiber which helps prevent type 2 diabetes from forming, and it helps maintain more stable blood sugar levels in those that have diabetes.
  • Colorectal cancers may be reduced. Studies are inconclusive but some have shown a reduced number of colorectal cancers in people who eat a high-fiber diet.
  • A weight-loss aid. Fiber creates a sense of fullness because high-fiber food is chewed longer and creates more bulk in the stomach. It curbs the tendency to overeat at mealtime, and usually high-fiber food contains fewer calories.

 

Recommended daily amounts of fiber needed by adults according to the National Academy of Sciences’ Institute of Medicine:

 

   Age 50 and younger

     Age 51 and older

    Men

          38 grams

            30 grams

    Women

          25 grams

            21 grams

 Adding more dietary fiber to your meals is one of the nicest things you can do for yourself. If you have hemorrhoids, fiber can work to aid your digestive system in healing and eliminating  them.

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All cases of rectal bleeding should be examined by a physician to rule out cancer of the colon and rectum. If the diagnosis is hemorrhoids, the remedies mentioned above may solve the problem. However, persistent hemorrhoids may need to be removed, using one of several methods. The hemorrhoid may be frozen off during cryosurgery; hardened, using a sclerosing agent; tied off, using a rubber band at the base of the hemorrhoid; or removed surgically (hemorrhoidectomy).  At DeKalb Surgical, the preferred method for most symptomatic  hemorrhoids is the rubber band technique, which can be performed as an office procedure.

rubber band ligation surgery

Hemorrhoids are typically classified according to the amount of prolapse (sticking out) that occurs.  Those hemorrhoids which do not prolapse, or which spontaneously reduce (go back inside the anus) can usually be treated in the office setting.  At DeKalb Surgical Associates, rubber band ligation is most often used.  These small bands are placed over the hemorrhoid tissue, causing them to slowly strangulate and fall off.  This treatment can be repeated if necessary.  Though some patients experience moderate pain, in most cases, the procedure is tolerated with little discomfort.

If you have been diagnosed with symptomatic hemorrhoids and would like to be seen by Dr. Kennedy for possible band ligation treatment, call our office at 404-508-4320 to schedule an appointment.  If you have other questions you may email him directly at drkennedy@dekalbsurgical.com.

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Fistulas

A fistula is an abnormal channel from a hollow body cavity to the surface (for example, from the rectum to the skin) or from one cavity to another (for example, from the vagina to the bladder). A fistula may be congenital (bladder to navel), the result of a penetrating wound (skin to lung), or formed from an ulcer or an abscess (appendix abscess to vagina, or tooth socket to sinus).

The repeated filling of an abscess or a wound by the fluid contents of some body cavity prevents healing and encourages the formation of a fistula. An anal fistula, for example, begins with inflammation of the mucous lining of the rectum. The area becomes an abscess as it is constantly reinfected by feces; eventually a fistula breaks through to the skin near the anus. The usual treatment is an operation to open the fistula channel completely and drain any abscess so it does not recur.

Illustration of anal fissure and anal fistula

 

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Anal fissures  

                Anal fissures are small tears in the mucus lining of the anal canal.  They can occur as a result of passage of a large hard stool. Fissures can be quite painful, particularly with bowel movements.  Often, some bright red blood will be noticed on the stool, or on the toilet paper after wiping.

If you have ever had a painful papercut on your finger, you can understand all about anal fissures. The anus is the ring-like sphincter or valve at the end of your rectum. It relaxes and tightens at your will to allow a bowel movement when convenient. An anal fissure is a small tear in the rim of the anus - just like a tiny papercut.

One problem with a papercut is that every time you use your hands, you tend to break open the small wound, which delays healing, and causes more pain. The same holds true with an anal fissure. Every time you have a bowel movement, the anus is stretched and the fissure can possibly be reopened causing more symptoms. This makes some anal fissures chronic and difficult to heal. This problem is quite common and may cause considerable misery.

                Fissures will often heal on their own, if constipation is avoided.  There are some simple measures that can be used to hasten the healing, including the use of stool softeners, and ointments such as Preparation H.  Prescription medications may also be used, including a variety of analgesics, and steroid preparations.  A more recent treatment option is the use of nitroglycerin ointment, the same type of medication used for patients with angina (heart pain).  This medication relaxes the smooth muscle lining underneath the torn mucus layer of the anus.  By treating the spasm of this smooth muscle, the fissure will heal in about 85% of cases.  However, many patients have headaches as a result of using the nitroglycerin (because it relaxes smooth muscle cells in the arteries to the brain as well).

                If the fissure does not heal, a simple outpatient surgical technique can be used.  This procedure is called lateral internal sphincterotomy. 

Lateral Internal Sphincterotomy

The anal canal is anesthetized by injection with a small needle.  A small incision is made in the anal canal, and the ring of muscle under the fissure is cut. This relieves the muscle spasm, which in turn allows the fissure to heal.  Patients often experience immediate improvement in their symptoms, though in some cases, the improvement is slower.  Potential side effects or complications include temporary incontinence, bleeding, or persistent pain.  Incontinence as a complication is unusual, but there may be temporary difficulty in distinguishing between gas, liquid stool, or solid stool in the rectum.

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What causes an anal fissure?

The anal opening is only so big. To have a bowel movement the anal sphincter relaxes and open up as much as it can, but the stool must be still be soft enough to squeeze through the opening. If the stool is dry and hard, the anal sphincter is forced to open even wider than normal. This difficult passage can cause a tear in the rim of the anal opening, resulting in a fissure. Other causes of a fissure include severe diarrhea, inflammatory bowel disease, and sexually related trauma.

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Classification of fissures

Fissures are graded as superficial or deep. A superficial fissure does not extend full thickness through the skin; a deep fissure results in exposing underlying muscle fiber. Fissures are also graded as acute or chronic. An acute fissure is less than thirty days duration; a chronic fissure is present for greater than thirty days.

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Symptoms of an anal fissure

Once the skin is torn, each subsequent bowel movement can be painful. Just like a papercut, it doesn't take a very big tear to cause considerable misery. The pain is often quite severe. Patients often complain of a stinging pain during bowel movements. The pain often lasts for hours and gradually subsides. This occurs with each bowel movement. Many times there is also some bleeding on the toilet paper, which is usually of small quantity and generally bright red in color. The symptoms of an anal fissure are commonly mistaken for hemorrhoids, but hemorrhoids generally do not cause pain with bowel movements. In chronic cases, there may be the development of a localized swelling called a sentinel pile. This is commonly mistaken for a hemorrhoid.

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Making a diagnosis

An accurate diagnosis is the first step in treatment. Your doctor can perform special tests to be certain about the cause of your symptoms. This will include an examination of the anus and anal canal in the office. The tear of the skin is usually easy to visualize, although sometimes the pain precludes an adequate exam without anesthesia. Occasionally a small viewing instrument, called an anoscope, is used in the evaluation. To rule out other more serious possibilities, a flexible sigmoidoscopy or full colonoscopy examination may be recommended.

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Can anal fissures ever lead to colon cancer?

No! A fissure or a hemorrhoid can never turn into colon cancer. But, it is important to be sure that any rectal symptoms are thoroughly evaluated since conditions other than fissure can cause similar symptoms such as bleeding.

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Anal fissures vs anal fistulas

These two conditions are often confused. A fissure is a tear or crack in the anal lining. A fistula is a totally different problem but often occurs in the same anal area. A fistula is more like a tunnel between the rectum and other body parts - such as between the rectum and the vagina ( a recto-vaginal fistula), or between the anal canal and the nearby skin.

http://www.dekalbsurgical.com/hemorr1.jpg

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Non-surgical treatment

If you could just not use your anus for a few weeks, the fissure would probably heal faster, but, of course, you have to eat....and eliminate. Fortunately, over half of fissures heal either by themselves or with non-surgical treatment in a few weeks or months. Superficial fissures rarely require surgery; most are able to be treated with topical medications. Non-surgical treatments may include:

 

  • Apply 1/2 percent hydrocortisone cream to the anal area to help relieve irritation.
  • Apply a numbing ointment to the anal area to help relieve pain
  • Take oral pain-killers such as acetaminophen (Tylenol) for additional relief. Avoid constipating narcotic painkillers like codeine, Darvon, hydrocodone, or oxycodone.
  • A stool softener (Colace, Surfak) may help prevent constipation until the fissure heals.
  • Soak the anal area in plain warm water for 20 minutes, several times a day to reduce pain (Sitz bath)
  • Eat high-fiber foods (fruits, vegetables, bran, whole-wheat grains)
  • Take a high-fiber supplement daily such as Metamucil, Citrucel, Fibercon.
  • Drink 6 to 8 glasses (soda-can sized) of water to keep the stool from being too "dry",
  • Do not strain too hard during bowel movements, and don't sit on the commode for more than a minute or two.
  • Avoid anal sex.

Call your doctor if you have any severe bleeding or fever, or if the fissure becomes more painful or shows no improvement after 3 days of treatment.

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Alternative Treatments

Two new forms of treatment have recently been reported. One is the use of Nitroglycerine cream to the anal area to relax the anal muscle spasm. Though frequently effective, many patients experience headaches when using this ointment.  The other new treatment is the use of Botox (botulism toxin) injections to weaken the anal sphincter and allow the fissure to heal.  Experience with this novel technique is limited.

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Surgery

If a fissure continues to cause pain and bleeding and does not respond to conservative medical therapy, it is considered chronic and surgery may be required. Chronic fissures heal only 10% of the time without surgery. This may involve an operation that divides one of the circular anal muscles (internal lateral sphincterotomy). Surgery can usually be performed without an overnight hospital stay. The pain often disappears a few days after surgery, though full healing requires one to two months Most patients are back to normal activity within a week or two.

Risks of surgery

There is a risk of fecal incontinence (loss of the ability to control bowel movements) with this procedure, but the incidence of this is quite low. Infection and complications incident to anesthesia are also possible, but again the risks are low. If you have any questions about this, you should discuss them with your doctor.

Return of the fissure

More than 90% of patients who require surgery for this problem have no further trouble from fissures as long as they take measures to prevent constipation and straining with bowel movements.

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 If you have been diagnosed with one of the above conditions and would like to be seen by one of our surgeons, call our office at 404-508-4320 to schedule an appointment.

 

 

 

 




 

 

DeKalb Surgical Associates ©2012

DeKalb Surgical Associates
2665 North Decatur Road
Suite 730
Decatur, Georgia 30033 (a suburb of Atlanta)

980 Building, Suite 430
980 Johnson Ferry Road, NE,
Atlanta, Georgia 30342

Phone: (404) 508-4320
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