Anorectal Outlet Sources
Giuseppe Gagliardi, MDMario Pescatori, MD, FRCS
Coloproctology Unit, Rome Villa Flaminia
Acute bleeding:anorectal causes
More common Less common
Hemorrhoids Rectal varices
Post-surgical Angiodysplasya
Post-polypectomy* SRU
Radiation proctitis* Stercoral ulcer
Neoplasms Dieulafoy
IBD Aneurysms
Trauma*
Treatment of hemorrhoidal bleeding
Rubber band ligation vs excisional hemorrhoidectomy: no difference for bleeding symptoms
Cochrane 2005
Bleeding after RBL 25% patients taking warfarin7% NSAID2.9% patients taking neither
Iyier DCR 2004
Hemorrhoidectomy with Ligasure in anticoagulated patients
Lawes Colorectal Dis 2004
Treatment of hemorrhoidal bleeding
Morar Cardiovasc Intervent Radiol 2006
Bleeding after hemorrhoid treatmentReactionary: technical errors incidence 1%
PPH vs excisional hemorrhoidectomy (for PPH 1.8-44% reoperation 25-90%)
Secondary: after 6-11 days incidence 2.4-6%.
Treatment: Anal packing 15% rebleed
Hemostatic sponge
Rectal Foley
Adrenaline injections
Rectal irrigation 12% don’t stop Chen DCR 2002
Suturing required in 7%-40%
followed by late complications in 15%Mazier Semin Colon Rectal Surg 1990
? role of micronized flavonoids
Rectal Varices
Incidence in portal hypertension 44-90% > in viral cirrhosis Chawla Gut 1991
Bleed in 10%-37%, independent from Child’s classification
Treatment
Octreotide
Oversewing/stapling
Sclerotheraphy
TIPPS vs TIPPS + embolization 42 vs 28% rebleed Vangeli J Hepatology 2004
Venus shunts
Resective surgery contraindicated
Anorectal tumorsIs resection necessary for palliation?
Local recurrence
After surgery clinical improvement in 78%(curative) 40%(palliative), in the long term 63% and 88%% and develop symptoms Miner Ann Surg Oncol 2003
EXTR and re-XRTshort term palliation for non-metastatic, bleeding palliated
Mohiuddin Cancer 2002
EXRT+hyperthermia 72% immediate palliation Juffermans Cancer 2003
Brachytheraphy 60-90% response for bleeding Hoskins Radiother Oncol 2004
Metastatic disease EXRT 90% of patients with metastastic disease palliated until death
Crane Int J Radiat Oncol Biol Phys. 2001
Long term palliation in 75% with (repeated) APC Gevers Gastrointest Endosc
2000
Anorectal Tumors
Surgery indicated for palliation in patients with > 6 months life expectancyFazio J Gastrointest Surg 2004
Resection and anastomosis in patients with metastatic disease Moran Arch Surg 1987
Hartmann vs Abdominoperineal to avoid perineal wound sepsis and pain Heah DCR 1997
Local excision equivalent palliationChen J Gastrointest Surg 2001
Anorectal melanomaPresents with bleeding, beware of amelanotic lesionsTreatment is surgicalSurvival and recurrence not dependent on surgical strategy (LE=APR)
Yeh ASCRS 1995
Anorectal bleeding:IBDAcute Fulminant Colitis
In pre-pouch era 20% of acute bleedings underwent proctectomyIn emergency IRA for bleeding 18% rebleed from rectum but massive bleeding rare
Robert Am J Surg 1990
Emergency IPAA with low morbidity Ziv DCR 1994; Ham DCR 1994
Emergency IPAA higher septic and obstructive complications Penna DCR 1993
Medical theraphy, rectal foley, adrenaline, endoscopic, embolization* *Mallant-Hent Eur J Gastroenterol Hepatol 2003
Crohn’s
Bleeding from left colon ulcer
Medical 60% endoscopic 20% surgery 20% Balaiche AJG 1999
Rectal Ulcer
Dieulafoy, Acute hemorrhagic rectal ulcer, aspecific ulcerESRD, NSAID
Stercoral ulcer Frequency underestimated (1.7-5% in autopsy)Elderly, bedridden, constipatedPressure ulcer of necrosis, fecalomaSigmoid=perforation Rectum=bleedingAspecific chronic and acute inflammation
Solitary rectal ulcer
TreatmentSclerotheraphy1, clipping, cauterization, APC, suturing, embolization2, surgery
1 Matsushita Gastrointestinal Endoscopy 19982 Dobson Cardiovascular and Interventional Radiology 1999
Angiodysplasya
Klippel-Trenaunay
Rubber Bleb Nevus Syndrome
Hemangioma capillary
arterio-venous
cavernous
Treatment
Sclerotherphy, APC, endoscopic banding, EXRT
Surgery: LAR, mucosectomy and coloanal sleeve anastomosis
Londono-Schimmer BJS 1994
Conclusions
Rigid sigmoidoscopy and rectal washout should be part of the work-up of patients presenting with bright red blood per rectum
Some of the causes are rare and require specialist input in tertiary care centers
Most of anorectal acute bleedings can be controlled without laparotomy
Embolization of rectal arteries carries low morbidity