EXPLAINED SERIES Anal and rectal diseases explained Eli D Ehrenpreis Anal and rectal diseases explained Eli D Ehrenpreis Perianal and rectal complaints are among the most common seen by primary care physicians, surgeons, and gastroenterologists. However, the wide variety of disorders associated with these complaints are, in general, poorly understood. Illustrated throughout with color images and exquisitely detailed line diagrams, Anal and Rectal Diseases Explained provides a practical introduction to the presentation, diagnosis, and management of a broad range of anal and rectal diseases. " What a great idea! This book will be a wonderful resource for clinicians. Every physician should have a copy on their shelf!” Dr Sunanda Kane, Department of Medicine, Gastroenterology Division, University of Chicago About the author Eli D Ehrenpreis, MD, is Assistant Professor of Medicine at Rush Presbyterian St Luke's Medical Center in Chicago, Illinois, and a practicing gastroenterologist at Adult Care Specialists, Arlington Heights, Illinois. Dr Ehrenpreis is the former director of the training fellowship program in gastroenterology at the University of Chicago and has also served as a staff physician at Cleveland Clinic, Florida. He is the author of more than 60 clinical research papers in the fields of gastroenterology and clinical pharmacology and has authored a number of chapters in gastroenterology, colorectal surgery, and critical care medicine textbooks. Dr Ehrenpreis is married with three children, and lives in Skokie, Illinois. 9 781901 346671 ISBN 1-901346-67-6 P469 Anus Cover 3/26/04 1:52 PM Page 1 This is trial version www.adultpdf.com Anal and rectal diseases explained This is trial version www.adultpdf.com Remedica Explained series ISSN 1472-4138 Also available Cardiology explained Interventional radiology explained Forthcoming Common spinal disorders explained Nuclear medicine explained While every effort is made by the publishers to see that no inaccurate or misleading data, opinions, or statements appear in this book, they wish to make it clear that the material contained in the publication represents a summary of the independent evaluations and opinions of the authors and contributors. As a consequence, the authors, publisher, and any sponsoring company accept no responsibility for the consequences of any inaccurate or misleading data or statements. Neither do they endorse the content of the publication or the use of any drug or device in a way that lies outside its current licensed application in any territory. Published by the Remedica Group Remedica Publishing, 32–38 Osnaburgh Street, London, NW1 3ND, UK Remedica Inc, Tri-State International Center, Building 25, Suite 150, Lincolnshire, IL 60069, USA Email: books@remedica.com www.remedica.com Publisher: Andrew Ward In-house editor: Tamsin White © October 2003 Remedica Publishing All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher. ISBN 1 901346 67 6 British Library Cataloguing in-Publication Data A catalogue record for this book is available from the British Library This is trial version www.adultpdf.com Anal and rectal diseases explained Eli D Ehrenpreis, MD Assistant Professor of Medicine Rush Presbyterian St. Luke's Medical Center Adult Care Specialists 1538 N Arlington Heights Rd Arlington Heights, Illinois 60004 USA This is trial version www.adultpdf.com Acknowledgements I would like to thank the following people for their assistance with this book: Avrum Epstein, MD, for assistance with radiographic images. Alessandro Fichera, MD, for manuscript review and additions from a surgical perspective. Arunas Gasparitus, MD, for providing many interesting and unusual radiographs for the book. Charles Dye, MD, for providing endoscopic ultrasound images. Sunanda V Kane, MD, for providing endoscopic photos for the Crohn’s disease section. Andrew Ward for encouraging me to write the book and providing publication support. Tamsin White for editorial assistance. This is trial version www.adultpdf.com Foreword This book gives a clear and detailed overview of some of the different anorectal and colonic pathologies. Although some of these conditions are very common in our patient population, our knowledge and our experience in managing these conditions is sometimes lacking. The aim of this book is to provide clinicians with a tool for rapid consultation and a source of information in order to properly answer the patient’s questions. Each section clearly describes the condition with up-to-date management guidelines and some very precious clinical pearls. Each topic is outlined in a multidisciplinary fashion with the medical, surgical, and pathological aspects clearly detailed in each section. Such a succinct overview has long been needed. The format is very clear and certainly this will be a book to have on a ward, in the doctor’s office, or on the shelves at home. Alessandro Fichera, MD Assistant Professor of Surgery University of Chicago Chicago, Illinois This is trial version www.adultpdf.com This is trial version www.adultpdf.com Contents 1. General information 1.1 Anal and rectal anatomy 3 1.2 The normal process of defecation 9 2. Diagnostic procedures 2.1 Anorectal manometry 15 2.2 Anoscopy and proctoscopy 19 2.3 Barium enema 21 2.4 Biofeedback therapy 25 2.5 Colonoscopy 27 2.6 Dynamic proctography 31 2.7 Electromyography 35 2.8 Flexible sigmoidoscopy 37 2.9 Pudendal nerve terminal motor latency 41 2.10 Quantitative stool collection 43 2.11 Transanal ultrasound 45 3. Benign anorectal disorders 3.1 Anal fissure 49 3.2 Anal stenosis 53 3.3 Anorectal abscess 55 3.4 Constipation 59 3.5 Fecal incontinence 65 3.6 Hemorrhoids 69 3.7 Hidradenitis suppurativa 75 3.8 Nonrelaxing puborectalis syndrome 77 3.9 Perianal Crohn’s disease 79 3.10 Perianal fistula 83 3.11 Proctalgia fugax 87 3.12 Pruritus ani 89 3.13 Radiation proctopathy 93 3.14 Rectal prolapse 97 3.15 Rectovaginal fistula 101 3.16 Solitary rectal ulcer syndrome 103 3.17 Ulcerative proctitis 105 4. Neoplasms of the anus 4.1 Anal carcinoma 111 4.2 Other anal malignancies 115 This is trial version www.adultpdf.com 5. Neoplasms of the rectum 5.1 Rectal carcinoma 121 5.2 Staging of rectal cancer 125 5.3 Surgery for rectal cancer 129 5.4 Medical therapy for rectal cancer 131 5.5 Other rectal malignancies 133 6. Infectious disorders of the anus and rectum 6.1 Chlamydia and lymphogranuloma venereum 139 6.2 Gonorrhea 141 6.3 Herpes simplex 143 6.4 HIV-associated anorectal disease 145 6.5 Syphilis 147 6.6 Venereal warts (condylomata acuminata) 149 7. Miscellaneous anorectal conditions 7.1 Diarrhea 155 7.2 Fecal impaction 159 7.3 Ileoanal pouch anastomosis 161 7.4 Pilonidal sinuses 167 7.5 Rectal foreign bodies 169 8. Patient information 8.1 Anal fissure 173 8.2 Fecal incontinence 175 8.3 Hemorrhoids 177 8.4 Kegel exercises 179 8.5 Nonrelaxing puborectalis syndrome 181 8.6 Perianal Crohn’s disease 185 8.7 Pruritus ani 189 8.8 Radiation proctopathy 191 8.9 Rectal prolapse 193 8.10 Solitary rectal ulcer syndrome 195 8.11 Ulcerative proctitis 197 8.12 Venereal warts 199 Abbreviations 203 Further reading 204 Index 205 This is trial version www.adultpdf.com 1.1 Anal and rectal anatomy 3 1.2 The normal process of defecation 9 General information Chapter 1 This is trial version www.adultpdf.com [...]... rectum, the puborectalis and anal sphincters relax; the levator ani, rectus muscles, and diaphragm contract (C) With defecation, the external anal sphincter relaxes; there is a rectal contraction This is trial version www.adultpdf.com 11 12 This is trial version www.adultpdf.com Chapter 2 Diagnostic procedures 2 .1 Anorectal manometry 15 2.2 Anoscopy and proctoscopy 19 2.3 Barium enema 21 2.4 Biofeedback... pelvic plexus (L1, L2, and L3), and the parasympathetic nervous system via the nervi erigentes (S2, S3, and S4) 4 This is trial version www.adultpdf.com Anal and rectal anatomy Puborectalis muscle Column of Morgagni Internal hemorrhoidal plexus Dentate line Internal anal sphincter Anal crypt External anal sphincter External hemorrhoidal plexus Anal gland Anoderm Figure 2 Anatomy of the anal region Fascia... version www.adultpdf.com Chapter 1. 1 Anal and rectal anatomy Anal canal The anal canal is the terminal portion of the gastrointestinal tract It is the short tubular segment, distal to the rectum, which is lined internally by squamous and transitional epithelium The anal canal begins where the distal rectum penetrates the muscular floor of the pelvic cavity It is surrounded by the anal sphincter muscle... is from the superior and inferior rectal arteries This is trial version www.adultpdf.com 7 Chapter 1 Inferior mesenteric vein Sigmoid veins Superior rectal vein Rectosigmoid vein Tributaries of left and right superior rectal veins Perimuscular rectal venous plexus Left middle rectal vein Left internal pudendal vein in pudendal canal (Alcock) External rectal venous plexus Figure 6 Rectal venous anatomy... rectum and separates it from the anal canal (see Figure 2) It also separates two types of epithelia, the simple columnar epithelium of the rectum and the stratified epithelium of the anal canal (anoderm) The dentate line has multiple folds called the columns of Morgagni The anal crypts and glands are located at the base of the columns of Morgagni These glands may be the site of perianal abscess and fistula... anal sphincter Internal anal sphincter Figure 1 The pull of the puborectalis anteriorly towards the pubis muscle contributes to the angulation between the rectum and anal canal termed the anorectal angle (dashed line) This is trial version www.adultpdf.com 9 Chapter 1 A B Figure 2 Normal dynamic proctogram (A) at rest and (B) straining demonstrating straightening of the anorectal angle When stool enters... valves of Houston Musculature Internal anal sphincter The internal anal sphincter is a thick ring of fibers from the circular smooth muscle of the colon at the proximal portion of the anal canal (see Figure 3) External anal sphincter The external anal sphincter surrounds the anal canal at the pelvic diaphragm, distal to the anal orifice (see Figure 3) The external anal sphincter is a ring of skeletal... puborectalis muscle remains tonically contracted at rest to form the anorectal angle, a sharp angulation (normally approximately 90°), which blocks stool from exiting out of the rectum (see Figures 1 and 2) The anal sphincters further function to provide a barrier for the passage of air, fluid, or solid stool to exit out of the anal canal External anal sphincter External anal sphincter Internal anal. .. muscle of rectum Rectal fascia Longitudinal muscle of rectum Muscularis mucosal of rectum Internal rectal venous plexus External anal sphincter muscle Internal anal sphincter muscle Intersphincteric groove (anocutaneous line) Subcutaneous part of external anal sphincter muscle External rectal venous plexus This is trial version www.adultpdf.com Figure 3 Anal muscular anatomy 5 Chapter 1 S2 S3 S4 Sacrospinous... sensation of stool within the anal canal and voluntary defecation has not been initiated 10 This is trial version www.adultpdf.com The normal process of defecation A Sacrum Fecal bolus Pubic arch Exernal anal sphincter Puborectalis muscle B Diaphragm Rectus muscles Levator ani muscle C Rectum Internal anal sphincter Figure 3 The process of defecation (A) Puborectalis and external sphincter are contracted . fistula 10 1 3 .16 Solitary rectal ulcer syndrome 10 3 3 .17 Ulcerative proctitis 10 5 4. Neoplasms of the anus 4 .1 Anal carcinoma 11 1 4.2 Other anal malignancies 11 5 This is trial version www.adultpdf.com 5 EXPLAINED SERIES Anal and rectal diseases explained Eli D Ehrenpreis Anal and rectal diseases explained Eli D Ehrenpreis Perianal and rectal complaints are among the. Page 1 This is trial version www.adultpdf.com Anal and rectal diseases explained This is trial version www.adultpdf.com Remedica Explained series ISSN 14 7 2-4 13 8 Also available Cardiology explained Interventional