Expert: DANIL HAMMOUDI.MD - 7/1/2003

Question
Dr. Hammoudi,

This morning after a bowel movement I noticed that there was some bright red blood on the paper. I checked the stool and it was not discolored and looked normal.  I took a shower and went for my daily walk.  Later on this morning I noticed that there was a little spot of blood on my shorts.  If I pass gas and wipe myself there is a little blood on the paper.  This is the first time that this has happened to me and I am very concerned.  I had a sigmoidoscopy about two years ago and it was normal and I did not have any polyps.  He did tell me, however, that I had a small anal fissure.
I am wondering if the fissure is causing the bleeding.  It was a hard movement this morning.

Answer
FISSURE WITHOUT PAIN AND AFTER BOWEL MOVEMENT NO, IF PAIN DURING BOWEL MOVEMENT AND BLOOD MOST LIKELY
BUT I THINK AND THIS IS MOST LIKELY THAT YOU HAVE HEMORRHOID INTERNAL OR EXTERNAL OR BOTH.
YOU WILL NEED TO SEE A DOC FOR EXAMINATION AND ANURECTOSCOPY.
IF THEY ARE SEEN TREATMENT MEDICAL OR SURGICAL WILL RESOLVE THIS MATTER

The typical symptoms of an anal fissure are extreme pain during defecation and red blood streaking the stool. Patients may try to avoid defecation because of the pain.

The patient complains of painful rectal bleeding and perhaps constipation. The pain occurs with and immediately after defecation, and the patient is relatively comfortable between bowel movements. Bleeding with defecation is usually slight, only staining the toilet tissue. Mucus discharge may increase perineal moisture and cause itching. Examination of anus reveals a radial tear or ulceration of the posterior midline 95% of the time (the fissure is anterior in 10% of women but only 1% of men). If the condition becomes chronic, distal edema may produce a "sentinel pile."
WHAT CAUSES AN ANAL FISSURE?
A hard, dry bowel movement can cause a tear in the anal lining, resulting in a fissure. Other causes of a fissure include diarrhea and inflammation of the anorectal area.
Anal fissures may be acute (recent onset) or chronic (present for a long time or recurring frequently). An acute fissure is usually due to altered bowel habits while a chronic fissure may be either due to poor bowel habits, overly tight or spastic anal sphincter muscles, scarring or an underlying medical problem.

HOW CAN A FISSURE BE TREATED?
An acute fissure is managed with non-operative treatments and over 90% will heal without surgery. Bowel habits are improved with a high fiber diet, bulking agents (fiber supplements), stool softeners, and plenty of fluids to avoid constipation and promote the passage of soft stools. Warm baths for 10-20 minutes several times each day are soothing and promote relaxation of the anal muscles. Occasionally, special medicated creams may be recommended.
A chronic fissure (lasting greater than one month) may require additional treatment. Depending on the appearance of the fissure, other medical problems such as inflammatory bowel disease or infections may be considered and testing may be recommended. A manometry test may be performed to determine if anal sphincter pressures are high. An examination under anesthesia may be recommended to determine if a definite reason exists for lack of healing.

WHAT CAN BE DONE IF A FISSURE DOESN'T HEAL?
A fissure that fails to respond to treatment should be re-examined to determine if a definitive reason exists for lack of healing. Such reasons can include scarring or muscle spasm of the internal anal sphincter muscle. Those which continue to cause pain and/or bleeding can be corrected by surgery.
WHAT DOES SURGERY INVOLVE?
Surgery usual consists of a small operation to cut a portion of the internal anal sphincter muscle. This helps the fissure to heal by decreasing pain and spasm. Cutting this muscle rarely interferes with the ability to control bowel movements and can usually be performed without an overnight hospital stay.
HOW LONG DOES THE HEALING PROCESS TAKE AFTER SURGERY?
Complete healing occurs in a few weeks, although pain often disappears after a few days.
WILL THE PROBLEM RETURN?
More than 90% of patients who require surgery for this problem have no further trouble from fissures. If the problem returns without an obvious cause, the person may need further assessment including anal manometry testing or an exam under anesthesia.
CAN FISSURES LEAD TO COLON CANCER?
No! Persistent symptoms need careful evaluation, however, since conditions other than fissure can cause similar symptoms.
WHAT IS A COLORECTAL SURGEON?
Colon and rectal surgeons are experts in the surgical and non-surgical treatment of colon and rectal problems. They have completed advanced training in the treatment of colon and rectal problems in addition to full training in general surgery. Colon and rectal surgeons treat benign and malignant conditions, perform routine screening examinations and surgically treat problems when necessary.
The American Society of Colon and Rectal Surgeons is a professional association of 2,200 surgeons, many of whom specialize in the research, diagnosis and treatment of diseases of the colon and rectum.

Hemorrhoids are often asymptomatic but may cause bleeding, protrusion, and pain. Rectal bleeding should be attributed to hemorrhoids only after more serious conditions are excluded. Hemorrhoidal bleeding, which typically follows defecation and is noted on toilet tissue, rarely leads to anemia or severe hemorrhage. External and internal hemorrhoids can protrude; they may regress spontaneously or be reduced manually. Only thrombosed or ulcerated hemorrhoids are painful. A thrombosed hemorrhoid presents as a perianal protrusion with pain varying from nonexistent to severe. Ulcerated, edematous, or strangulated hemorrhoids (acute attack of piles) can cause severe pain. Less commonly, internal hemorrhoids cause mucus discharge and a sensation of incomplete evacuation, and external hemorrhoids cause difficulty in cleansing the anal region. Pruritus ani is usually not a symptom of hemorrhoids.

Thrombosed hemorrhoids and ulcerated edematous strangulated hemorrhoids can be readily diagnosed on inspection of the rectum. Examination after straining at stool or a phosphate enema often reveals the extent of the patient's hemorrhoidal pathology. Anoscopy is essential in evaluating painless hemorrhoids.

Treatment
Stool softeners or bulking agents (eg, psyllium) may correct constipation and straining, thus allowing hemorrhoids to resolve. Pain caused by a thrombosed hemorrhoid can be treated with reassurance, warm sitz baths, anesthetic ointments, or witch hazel (hamamelis) compresses. Bleeding hemorrhoids can be treated by injection sclerotherapy with 5% phenol in vegetable oil. Bleeding should cease at least temporarily.

Larger internal hemorrhoids or those that fail to respond to injection sclerotherapy are treated by rubber band ligation: A 1/4-inch diameter elastic band is dilated to about 3/8 inches; the internal hemorrhoid is grasped in an area that is insensible to pain and withdrawn through the band, which is then released to ligate the hemorrhoid, resulting in its necrosis and sloughing. One hemorrhoid is ligated q 2 wk; three to six treatments may be required. In certain circumstances, multiple hemorrhoids can be ligated at a single sitting. Infrared photocoagulation is useful for ablating small internal hemorrhoids, hemorrhoids that cannot be rubber band ligated because of pain sensitivity, or hemorrhoids that are not cured with rubber band ligation. Modalities of unproven efficacy include laser destruction and various types of electrodestruction. Hemorrhoidectomy is performed infrequently for bleeding hemorrhoids.

Protruding internal hemorrhoids are treated by rubber band ligation. With mixed internal and external hemorrhoids, only the internal component should be rubber band ligated. If there is no significant internal component, hemorrhoidectomy is required. Infrequently, simple incision and evacuation of the clot may relieve pain rapidly.

Ulcerated edematous strangulated hemorrhoids (acute attack of piles) can be managed conservatively because pain and swelling are likely to resolve rapidly; the thromboses are reabsorbed over 4 to 8 wk. Incapacitating pain that fails to resolve with analgesics, sitz baths, topical compresses, and other conservative measures may be treated by (1) injection of a local anesthetic containing hyaluronidase followed by rubber band ligation of the internal hemorrhoids and multiple thrombectomies or (2) hemorrhoidectomy.


THANKS
DAN