Page 176 - Medicine and Surgery

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172 Chapter 4: Gastrointestinal system

Management
Disorders of the rectum
Symptomatic treatment includes anti-diarrhoeal agents
and anus
such as loperamide or codeine phosphate. Anaemia is
supported with ferrous sulphate.
Acute exacerbations: Haemorrhoids (piles)
Induction of remission. Mild cases may be treated ini-

tiallywith5-aminosalicylicacid(5-ASA)drugssuchas Definition
Enlarged and engorged veins in or around the anus.
mesalazine. The next step is often antibiotics in ileitis
or colitis (usually ciprofloxacin and metronidazole)
– these may work by reducing inflammation due to Aetiology
infection, or transmigration of bacteria through the Associated with constipation and straining to pass stool
gut wall. Moderate or severe cases require corticos- or during labour. Suggested that low fibre Western diet
teroids which may be given as enemas in colonic dis- accounts for increased incidence.
ease or orally/parenterally, often in combination with
5-ASA drugs and antibiotics. Steroids are withdrawn
following induction of remission, but relapse may Pathophysiology
occur. It is thought that increased abdominal pressure causes
Maintenance of remission – apart from 5-ASA drugs,
dilatation of the internal haemorrhoidal plexus of blood
steroid-sparing agents such as azathioprine and 6- vessels. These drain to the portal system and contain no
mercaptopurine may be used to allow the reduction valves.
and withdrawal of steroid dose. Azathioprine requires First degree piles bulge into the lumen without pro-
careful monitoring as it may cause bone marrow sup- lapsing through the anus.
pression particularly in TPMT deficient patients (see Second degree piles prolapse on defecation but return
above) or abnormal liver function tests. spontaneously.
Infliximab (a monoclonal antibody directed against
Thirddegreepilesremainprolapsedbutcanbeactively
tumour necrosis factor alpha –TNFα)isusedinmod- returned.
erate to severe Crohn’s disease, particularly for fistulis- Fourth degree piles are those that can not be returned
ing Crohn’s. to the anal canal. The anal sphincter contracts around
Elemental and polymeric diets may be used, particu-
aprolapsed haemorrhoid causing venous congestion
larly in children. and a risk of thrombosis.
Surgical: 80–90% of patients will require some form of
surgical intervention during their lifetime. Surgery may
Clinical features
berequiredforcomplicationsorifthereisfailureofmed-
Patients normally present with rectal bleeding which is
ical treatment and severe symptoms. The procedure in-
typically a bright red streak on the toilet paper. Severe
volves resection of affected bowel; however, poor wound
bleeding may cause blood in the toilet. Prolapse may be
healing may lead to fistulas, so surgery is avoided if pos-
noted and cause a mucus discharge. Pain occurs with
sible.
strangulated or thrombosed piles.
Prognosis Investigations
The condition runs a course of relapses and remis- Proctoscopy visualises the piles, prolapse is demon-
sions. Virtually all patients will have a significant re- strated on straining. Flexible sigmoidoscopy is essential
lapse within 20 years. Mortality is twice that of the gen- in cases of rectal bleeding to exclude other pathology
eral population, operative mortality of 5%. The risk of and a barium enema or colonoscopy may be indicated
malignancy is 2–3% (slightly higher than the general depending on the index of suspicion of inflammatory
population). bowel disease or malignancy.