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Chapter 8 ♦ Lower Gastrointestinal Disorders

Figure 8-44: Coronal section of the rectum and anal canal. A: Incomplete rectal (mucosal) prolapse. B: Complete rectal prolapse.

and resulting in rectal bleeding and no other causes of lower GI bleeding are discovered, surgery may be necessary. Many operative strategies are appropriate for rectal prolapse. ◆ ◆ Rectopexy , in which the rectum is fixed to the sacrum without removing a portion of the rectum ◆ ◆ A low anterior resection, which removes the upper and middle portions of the rectum, along with the redundant sigmoid colon (transabdominal rectosigmoid resection) ◆ ◆ A perineal approach, which removes the prolapsed rectum and sigmoid colon with the proximal sigmoid colon anastomosed to the transitional zone 1–2 cm above the dentate line Case 8.37 Perianal Problems A 30-year-old presents with rectal pain that is particularly severe during defecation. On examination, you note an ulcerated area in the anal canal that is very painful when touched. Q: What management is appropriate? A: Anal fissures involve tears in the anoderm, which is reputedly caused by trauma from pas- sage of hard stools but can also result from other diseases, such as IBD. They are associated with pain during bowel movements and tenderness on palpation. Blood is usually found on the toilet tissue after wiping. Anal fissures are almost always located in the posterior midline. A sentinel tag may be seen at the anal verge. Most anal fissures respond to conservative treatment , including bulk agents, stool soft- eners, and sitz baths. If the fissure is deep and chronic , lateral sphincterotomy , which di- vides a portion of the internal anal sphincter, may be necessary (Fig. 8-45). The hypothesis that reflex stimulation and spasm of the internal anal sphincter is important in pathogene- sis is the basis for this procedure. More than 90% of anal fissures heal after lateral sphincter- otomy. Biopsy of suspicious, chronic fissures to rule out anal cancer is warranted. SAMPLE