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
examination.
hemorrhoids
by
history
and
physical
• 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
•
•
•
•
1st degree
2nd degree
3rd degree
4th 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.