Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (56 page)
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Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
Although per rectal bleeding is a common reason for acute surgical referral, major haemorrhage from an anorectal source is very rare. A series of lower gastrointestinal bleeds in an elderly North American population published in 1979 demonstrated an anorectal cause for massive blood loss in just four out of 98 patients.
54
Bleeding generally comes from a colonic source but rectal cancer, haemorrhoids, proctitis, rectal varices, anal fissures and solitary rectal ulcer syndrome have all been implicated in massive lower gastrointestinal bleeds. The increased use of nicorandil for the treatment of ischaemic heart disease has led to an increased awareness of the rectal ulcers that this drug can cause as a side-effect and a recent case report has been published of a life-threatening bleed secondary to this.
55
Worldwide the most common cause of anorectal trauma is childbirth, with 0.4% of all vaginal births complicated by a third-degree (into the external sphincter) or fourth-degree (into the rectal wall) tear.
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One prospective study using endoanal ultrasound to evaluate post-childbirth sphincter function has suggested that as many as 35% of women demonstrate damaged external or internal sphincters following vaginal delivery.
57
These tears are often repaired in the labour suite with interrupted sutures to approximate the sphincters but results from this are poor, with significant levels of faecal urgency and incontinence persisting (up to 50% in one study).
58
In an attempt to improve outcome, a recent randomised controlled study from Norway of 119 women with third- and fourth-degree tears compared this end-to-end approximation with an overlap technique for sphincter repair.
59
Unfortunately, they found no significant difference between the two techniques for reported faecal incontinence at 12 months or on anal manometry.
Anorectal trauma can also occur as a result of penetrating injury, iatrogenic damage or secondary to foreign objects inserted into the anal canal. Injury sustained to the intraperitoneal rectum can sometimes be primarily repaired but if there is significant contamination, large injuries, devascularisation or nearby open fractures, resection and formation of a stoma should be preferred.
60
Damage to the extraperitoneal rectum can also often be repaired primarily but proximal diversion may again be needed if the injuries are extensive.
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Sigmoidoscopy should always be performed if blood is seen in the rectal lumen or if an extraperitoneal haematoma is seen adjacent to the rectum at laparotomy.
Rectally inserted foreign objects and the innovative techniques used to remove them safely are extensively reported in anecdotal case reports in the world literature. These objects are most commonly inserted for sexual gratification and in most circumstances the patient has made an unsuccessful attempt to remove them before presentation. A review of these case reports suggests that in the majority of instances removal is possible under conscious sedation, either digitally for low objects or bimanually for those above the rectosigmoid junction.
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When this fails, endoscopic extraction with or without fluoroscopic guidance is worth attempting. Some authors have reported success with various obstetric instruments and in one reported case of an irretrievable metallic ball, an electromagnet was employed.
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If all of these measures fail, or there is radiographic evidence of perforation, laparotomy is usually inevitable. In a series reported from San Diego, this was necessary in five of 64 patients presenting with impacted foreign bodies.
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It is recommended that all patients undergo sigmoidoscopy after extraction to ensure no damage to the rectal mucosa has been sustained.
Key points
Anorectal sepsis should be managed by prompt drainage following sound anatomical principles.
Synchronous fistulotomy can be undertaken with care in low, uncomplicated posterior fistulas but should be avoided in those at high risk of incontinence or when a tract is not easily distinguished.
Acute pilonidal abscesses should be treated with simple incision and drainage alone.
Abscess cavities should not be packed following drainage.
Anal fissures should be managed pharmacologically, with surgery reserved for those that fail to heal.
Acute thrombosed haemorrhoids should be managed non-operatively. Emergency haemorrhoidectomy is only recommended if carried out within 72 hours of symptom onset by an appropriately skilled surgeon.
Management of anorectal trauma and retained foreign bodies should be determined by the site of injury and the anorectum should always be re-examined by sigmoidoscopy following removal.
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