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Training in the Endoscopic Management of Anorectal Disorders

Waqar Qureshi

Baylor College of Medicine, Houston, TX, USA

Introduction

The most common anorectal conditions seen in a gastroenterology clinic include hemorrhoids, fissures, acutely thrombosed hemorrhoids, and anal pruritus. Although hemorrhoids are a normal feature of anorectal anatomy, symptomatic hemorrhoids are relatively common with an estimated prevalence in the United States of 4.4% with a peak prevalence between the ages of 45 and 65 years [1]. It is thought that only a third of patients with symptomatic hemorrhoids seek help, making the true prevalence difficult to define [1]. It is estimated that over 23 million Americans suffer from hemorrhoid symptoms resulting in about 3.5 million visits to the doctor, resulting in over $500 million in health care costs [2, 3]. Many patients and even some physicians attribute symptoms in the anorectal area to hemorrhoid disease although this is not always the case. Training in treatment of anorectal disease has largely been left out of the training of gastroenterologists.

Procedures and equipment in diagnosis and management

Thorough examination of the anorectal area with inspection, digital rectal examination (DRE) and anoscopy are crucial to a successful outcome. Requirements in the office setting include:

Clinic examination bed.
Good light source.
Disposable gloves.
Anoscopes.
Banding and heat generating devices (infrared coagulation or the Hemorrhoid energy therapy HET).
Nitroglycerine ointment.
KY gel and lidocaine gel.
Injectable lidocaine.
Suture kit to include scalpel, clamps, scissors, gauze.

The photograph in Figure 32.1 of the examination room shows a clean and uncluttered room with a mobile electric bed and a bright light. Photograph in Figure 32.2 shows a beveled disposable anoscope with a built‐in light source. Photograph in Figure 32.3 shows an incision and drainage kit useful for draining an acutely thrombosed hemorrhoid.

Prerequisite cognitive and technical skills for trainees prior to learning DRE anoscopy and hemorrhoid treatment

Visual examination

In the office setting examination, this is usually done in the left lateral decubitus position with both the hips and knees bent. A good light source is required to inspect the peri‐anal area. Findings may include external hemorrhoids (Figure 32.4), external and prolapsed internal hemorrhoids (Figure 32.5), prolapsed internal hemorrhoids with mild external hemorrhoids (Figure 32.6), rectal prolapse (Figure 32.7), skin tags, sentinel tags, pilonidal disease, dermatitis, anal fissure, fistula‐in‐ano, warts, or malignancy. Malignancies are usually firm and ulcerated (Figure 32.8) while premalignant conditions such as Bowens or Pagets disease appear erythematous. A thrombosed external hemorrhoid has a bluish color from the clot underlying the anoderm (Figure 32.9). Prolapsed internal hemorrhoids are covered with pink mucosa while external hemorrhoids are covered with anoderm. If the patient complains of painful defecation, an anal fissure may be present, in which case gentle separation of the buttocks at the anal verge may cause pain or reveal a tear usually in the posterior aspect of the anal verge. A perianal abscess will likely require surgical drainage.

Photo depicts an ideal room with an adjustable bed and a good source of light to enable in a rectal exam and treatment. — **Figure 32.1** This photo shows an ideal room with an adjustable bed and a good source of light to enable in a rectal exam and treatment.

Photo depicts a beveled disposable anoscope with a built-in light makes examination easier for both the physician and the patient. — **Figure 32.2** A beveled disposable anoscope with a built‐in light makes examination easier for both the physician and the patient.

The digital rectal exam

A digital examination is an anal as well as a rectal examination. Pathology is frequently missed in the anal canal. In addition to looking for a fissure, tenderness, or mass, the tone of the anal sphincter is evaluated. A partially healed anal fissure may be felt as a roughness in the otherwise smooth anal canal and may not be visualized. Resting sphincter tone is assessed and a widened intersphincteric groove may indicate internal sphincter spasm. The puborectalis is felt posteriorly at the anorectal junction. The patient is asked to squeeze and strain to assess the symmetry and function of the sphincter.

Photo depicts a kit I keep in my office for emergent decompression of a thrombosed hemorrhoid. It consists of 1% lidocaine with syringe and needle, a scalpel, scissors tweezers, and gauze. — **Figure 32.3** This is a kit I keep in my office for emergent decompression of a thrombosed hemorrhoid. It consists of 1% lidocaine with syringe and needle, a scalpel, scissors tweezers, and gauze.

Photo depicts an external hemorrhoid. These commonly itch as a presenting symptom but may bleed intermittently. — **Figure 32.4** This is a photograph of an external hemorrhoid. These commonly itch as a presenting symptom but may bleed intermittently.

Anoscopy

This is the only tool that allows a thorough examination of the anal canal and distal rectum without any special preparation. There are several different types of anoscopes. I prefer a beveled anoscopy as opposed to a slotted one since it allows rotation without causing trauma. Disposable clear plastic anoscopes with built‐in lighting are cheap and convenient. A lubricated anoscope is inserted while the patient bears down to relax the anal canal. The anus in examined circumferentially and the hemorrhoid bundles noted in the right anterior, right posterior or left lateral positions. It is an extremely easy procedure to learn and quick to perform and yet essential for a complete examination of the anal canal and to assess the size of the internal hemorrhoids (Figure 32.10). Here, an ulcer is seen on a hemorrhoid from a recently placed band. This is what you expect to see to create fibrosis. Various banding devices exist in the market along with infrared and diathermy devices (Figures 32.11–32.13).