(searched for: Diagnosis and Management of Internal Hemorrhoids: A Brief Review)
Current Problems in Surgery, Volume 54, pp 256-258; https://doi.org/10.1067/j.cpsurg.2017.02.005
The management, both surgical and medical, of perianal Crohnʼs disease represents a very specialized aspect of the treatment of inflammatory bowel disease and anal gastrointestinal disease in general. Perianal complications of Crohnʼs disease often bring patients to medical attention, often with the mistaken belief that they are suffering from hemorrhoidal symptoms. The consequences of misdiagnosis and inappropriate surgery can be immediate and severe or more chronic in nature. The lack of recognition of this entity and failure to appropriately triage patients remains a real problem for primary care providers, gastroenterologists, surgeons, and patients.This issue of Current Problems in Surgery focusses on the problem of perianal Crohnʼs disease and attempts to consider the various manifestations of the disease alongside their remedy in an accessible, evidence-based fashion. Perianal fissures, hemorrhoids, and skin tags should be considered individually with regard to surgery vs conservative management. It is pointed out that although surgical procedures are typically thought to result in unacceptable outcomes such as stricture and nonhealing anal wounds, there can be circumstances in which surgical intervention is an acceptable alternative. It is important to understand the specialized details of these exceptions and the data that support surgery and challenge more traditional notions of conservative management. It is clear from this examination of these data that more minimally invasive procedures that cause less tissue destruction like Doppler-guided hemorrhoidal ligation may actually be effective in treating some of the concurrent issues of hemorrhoidal prolapse and bleeding in patients in the setting of Crohnʼs disease. Likewise, the selective use of lateral internal sphincterotomy in patients with anal fissures has been a lightning rod of controversy since the concept was introduced. A balanced discussion of the data and a consideration of the very specialized circumstances where the technique deserves contemplation is welcome and provided.Experience with inflammatory bowel disease is essential to the treatment of Crohnʼs perianal fistulas but can be learned; treatment should be cautious. Drainage of abscesses that often herald the presence of a fistula is something that every surgeon should be able to perform safely and confidently. Options for the surgical treatment of Crohnʼs fistulas include techniques such as endorectal mucosal advancement flaps and ligation of the internal fistula tract procedure. It is indeed sobering to realize that long-term success rates with surgical repair of these fistulas is on par with medical therapy alone but helpful in counseling patients. Likewise, it is essential to understand that medical therapy is the cornerstone of treatment of fistulizing Crohnʼs disease and that surgical management of the tracts is often in the service of sepsis control.It is very clear from both clinical experience and literature review that surgical management, although important and necessary, particularly for control of sepsis, falls far short of the mark in actually curing perianal Crohnʼs disease. A spectrum of medical therapy is currently available and includes antibiotics, calcineurin inhibitors, thiopurines, anti-tumor necrosis factor agents, and the newer anti-integrin antibodies. As opposed to cryptoglandular fistulizing disease, Crohnʼs fistulas are actually quite responsive to medical management. The advent of infliximab in 2001 was revolutionizing for those with perineal disease. Initial data indicated that fistula closure rates as high as 50% to 70% were possible. Although initial success with anti-tumor necrosis factor therapy was quite good, recurrence rates remained unacceptably high, medication was not a solution in 30-50% of patients, and other avenues of relief were needed. There is very good evidence correlating highest success in controlling, healing, and resolving Crohnʼs fistulas with a combination of medical and surgical therapy.The detection and accurate treatment of perianal pathology (particularly abscesses and fistulas) is greatly aided by the use of imaging modalities that define and characterize the problem. The use of ultrasound technology for the evaluation of perianal pathology is an interesting and uncommon approach that can be thought of as highly specialized, but it is clear that it can be used in a complimentary fashion with magnetic resonance imaging (MRI) and it is also clear that there are situations that may require both modalities for accurate characterization. The Second European-Based Consensus on the Diagnosis and Management of Crohnʼs Disease recommends MRI as the imaging modality of choice, but patient-specific factors like claustrophobia and the inability to lie flat for lengthy periods make the flexibility of endoscopic ultrasound (EUS) a great advantage. Finding competent practitioners of this efficient and cost-effective technique, however, is increasingly difficult as MRI rapidly becomes integrated into the recommendations for practical purposes and ease of use, both for inflammatory bowel disease as well as for conditions like rectal cancer.Dealing with the Crohnʼs complications of patients with J-pouch reconstructions, typically in the context of an initial diagnosis of ulcerative colitis, is heartbreaking for both the patient and the surgeon. What was thought to be a durable “cure” is revealed as a major negative impact on quality of life, the very thing the patient thought to have gained by going through total proctocolectomy and J-pouch reconstruction. It is clear that following control of the septic focus, medical therapy is the mainstay of treatment. Surgical options like anal canal dilation for stricture or fistula surgery are reserved for those with disease that is well controlled and inflammation that is minimal or nonexistent. Diversion and pouch excision can be a necessary outcome of pouch-fistula or stricture complications and can be life-changing, resulting in weight gain, better nutrition, and much improved quality of life.Although excision of the J pouch or completion proctectomy can be a very difficult operation because of ongoing inflammation and its attendant complications, it is often the perineum itself that represents the most difficult problem. The severely affected Crohnʼs perineum represents one of the worst problems and challenges to quality of life for a patient with Crohnʼs disease. Fibrosis, ongoing, poorly controlled sepsis, excoriation, and severe pain can create an operative field that can defy good wound healing in spite of excellent surgical technique. The frequent use of steroids and other immunosuppressants can also have a detrimental effect on success of a reconstructive surgical procedure. It is often necessary in these most severe cases to beat a strategic retreat before proctectomy or pouchectomy and create a diverting ileostomy. This allows inflammation to resolve at least partially and helps augment control of sepsis greatly. Patients gain weight and resolve their malnutrition, which optimizes wound healing and allows the greatest chance of success with flap placement on the site as well as healing of the donor site. Knowledge of available flaps is key advising patients of their options. Working closely with a plastic surgeon can help inform patients, allay their fears, and involve them in the complicated considerations associated with perineal reconstruction.