Advanced Therapy in Gastroenterology and Liver Disease - part 7 pptx

Fecal Incontinence: Evaluation and Treatment / 515
recently reported excellent results; at a median of 2 years,
73% of previously incapacitated patients achieved full con-
tinence; symptoms markedly improved for the others.
Unlike the neosphincter procedures, SNS has been associ-
ated with minimal morbidity. This fact suggests that indi-
cations for the procedure might reasonably be broadened,
at least on an investigational basis, in the future.
R
adio
frequency Energy Delivery
S
ub
mucosal radiofre-
quency energy delivery to the anal canal (also known as the
Secca procedure) is a thermal technique currently under
investigation in a multicenter trial. The procedure consists
of anal insertion of a heat-controlled probe. The probe
then deploys electrodes that pierce the mucosa and heat
the muscularis, resulting in collagen contraction. However,
the exact mechanism of action using this technique is
unknown. Early results have shown modest improvement
in incontinence severity.
Anal Canal Bulking and Obstructing Agents In contrast
to stool bulking agents, anal canal bulking agents are made
of implanted natural or synthetic materials, such as colla-
g
en, silicone, or carbon coated beads, that are injected into
the intersphincteric space to bolster function of the inter-
nal anal sphincter. We do not perform this procedure,
although good outcomes in very small series have been

reported. Obstructing agents, such as pliable rubber bal-
loons, are placed in the anus; they can be removed by the
patient for controlled defecation (Norton and Kamm,
2001; Mortensen and Humphreys, 1991). Such an inter-
vention might be useful for patients who are at very poor
risk for surgery.
Stoma For patients with refractory incontinence, a
properly placed and well-constructed stoma offers
restoration of bowel control (if not true continence) with
minimal associated morbidity. Although the presence of
a st
o
ma admittedly distorts an individual’s body image,
this disadvantage is usually outweighed by the patient’s
enhanced ability to function normally (or nearly so) in
social, work, and sexual situations without fear of loss of
bowel control.
Summary
Fecal incontinence is a prevalent and frustrating problem
that has a profound impact on physical and psychological
well-being. Appropriate care relies on systematic evalua-
tion and application of a tailored treatment plan. Figure
88-3 presents a systematic algorithm for care of patients
with persistent fecal incontinence.Although we champion
the me
thodical approach, we frequently encourage a com-
bined treatment plan, such as medical optimization,
biofeedback, and sphincteroplasty, depending on the needs
and ab
ilities of individual patients. Broad adaptation of a

standardized pre- and postintervention evaluation system
will enhance the individual patient’s experience and our
und
erstanding of treatment effectiveness.
FIGURE 88-2 Radiograph of an implanted sacral nerve stimulator device. Courtesy of Robert D. Madoff, MD.
Fecal Incontinence: Evaluation and Treatment / 517
P
arker SC, Morris AM, Thorson AJ. New developments in anal
surgery: incontinence. Seminars in Colon & Rectal Surgery
2003;14:82–92.
Parker SC, Spencer MP, Madoff RD, et al. Artificial bowel
s
phincter: long-term experience at a single institution. Dis
C
olon Rectum 2003;46:722–9.
Rockwood TH, Church JM, Fleshman JW, et al. Fecal
Incontinence Quality of Life Scale: quality of life instrument
for patients with fecal incontinence. Dis Colon Rectum
2
000;43:9–16; discussion 16–7.
S
helton AA, Madoff RD. Defining anal incontinence: establishing
a uniform continence scale. Seminars in Colon & Rectal
Surgery 1997;8:54–60.
Whitehead WE, Norton NJ,Wald A. Introduction. Advancing the
t
reatment of fecal and urinary incontinence through research.
G
astroenterology. 2004;126(1 Suppl 1):S1–2.
Wong WD, Congilosi SM, Spencer MP, et al. The safety and

efficacy of the artificial bowel sphincter for fecal incontinence:
results from a multicenter cohort study. Dis Colon Rectum
2
002;45:1139–53.
518
CHAPTER 89
RECTAL PROLAPSE,RECTAL
INTUSSUSCEPTION, AND SOLITARY RECTAL
ULCER SYNDROME
ANDERS MELLGREN,MD,PHD, JOHAN POLLACK,MD,AND INKERI SCHULTZ,MD,PHD
Brodén and Snellman (1968) used defecography and
could demonstrate that rectal prolapse starts as an inter-
nal rectal intussusception. They demonstrated that rectal
prolapse starts as anorectal intussusception 6 to 8 cm up
in the rectum and as the patient strains, the intussuscep-
tion progresses and extends down through the rectum and
out through the anus.
The underlying mechanism for the rectum to prolapse
remains unclear.A mobile rectum, a weak pelvic floor, and
excessive straining at stool, all predispose for development
of rectal prolapse. Lack of rectal support is of etiological
importance, but rectal prolapse also develops in young men
and in nulliparous women with normal pelvic floor and
anal sphincter function.
Symptoms
Rectal prolapse is a full-thickness, circumferential intus-
susception of the entire rectal wall through the anal canal
and anus. The prolapsing bowel itself, mucosanguineous
discharge, bleeding, constipation and/or incontinence, and
a f

e
eling of incomplete evacuation, are the most frequent
complaints
. The incidence of preoperative incontinence
and constipation has only been reported prospectively in
a few studies and definitions vary. Allen-Mersh and col-
leagues (1990) studied 57 patients with rectal prolapse
prospectively and found fecal incontinence symptoms in
49% and constipation symptoms in 30% of the patients.
Madden and colleagues (1992) reported some degree of
anal incontinence in 17 of 23 patients (74%) and consti-
pation in 11 (48%) of their patients. In another prospec-
tive study, Huber and colleagues (1995) included 42
patients, 5 of whom had internal rectal intussusception.
They found fecal incontinence in 54% and some degree of
constipation in 44% of the patients.
T
he underlying mechanism for incontinence symptoms
in approximately 50% of patients with rectal prolapse is
not fully understood. Porter used needle electromyography
and not
ed excessive reflex inhibition in prolapse patients.
Recently, it has been demonstrated that patients with rec-
tal prolapse have a thickened internal anal sphincter at
Rectal Prolapse
The word prolapse comes from the Latin term ”prolapsus”
and means “falling down.” Rectal prolapse was described
in 1500 BC in the Ebers papyrus, and Mr. Frederick
Salmon, the founder of the famous St. Marks Hospital in
London, wrote his classic article “Practical observations on

prolapsus of the rectum” in 1831.
Rectal prolapse is a benign disorder that is frequently
associated with disturbed bowel function. Rectal prolapse
can be treated surgically by many different techniques and
results regarding recurrence rate and mortality are gener-
ally good. Unfortunately, anal incontinence and/or consti-
pation sometimes continue to bother the patients after
otherwise successful correction of the prolapse.
Epidemiology
Rectal prolapse is most commonly found in elderly and the
peak incidence is found after the fifth decade. Being female
is one of the highest risk factors for development of rectal
prolapse and women represent approximately 90% of the
patient population. Rectal prolapse in elderly women is fre-
quently accompanied with poor sphincter function and
fecal incontinence. In the rather few younger women with
rectal prolapse, continence function is frequently preserved.
A background history of lifelong straining is common in
these patients. Rectal prolapse is sometimes associated with
underlying psychiatric illness.
Etiology
There are two theories regarding development of rectal
prolapse. Moschowitz proposed in 1912 that rectal pro-
lapse is a sliding hernia that protrudes through a defect in
the pelvic floor. He found that patients with rectal prolapse
ha
ve a deep cul-de-sac, which he believed resulted from
herniation of the small intestine into the anterior wall of
the rectum. He suggested that the herniation pushed the
rectum down, resulting in rectal prolapse. This idea is sup-

ported by the finding of a deep cul-de-sac in many pro-
lapse patients.
Rectal Prolapse, Rectal Intussusception, and Solitary Rectal Ulcer Syndrome / 519
endo-anal ultrasound (Marshall et al, 2002). Several mech-
anisms have been proposed to explain prolapse-associated
incontinence. These include direct sphincter trauma caused
by repeated stretching by the intussuscepting rectum or
t
hat the intussuscepting rectum leads to chronic stimula-
tion of the rectoanal inhibitory reflex. Constipation,
defined either as abnormally few stools per week or
increased straining at stool may be explained by the pres-
ence of the intussuscepting bowel in the rectum, colonic
dysmotility or inappropriate puborectalis contraction.
Preoperative Evaluation
Verification of the rectal prolapse and differentiating it from
hemorrhoids and/or mucosal prolapse is usually the first
step in the examination of patients with a history sugges-
tive of rectal prolapse. Rectal prolapse is identified as a cir-
cular, full-thickness prolapse extending outside the anal
verge when the patient strains. Occasionally the patient is
unable to reproduce their prolapse at clinical examination
in the left lateral position. Examination in the sitting posi-
tion on a commode or diagnosis using defecography may
then be quite helpful (Mellgren et al, 1994).
The patient history should include preoperative con-
stipation and incontinence symptoms, bowel frequency,
obstetric history, and other associated pelvic floor disor-
ders, such as co-existing urinary incontinence or genital
prolapse. Patients with rectal prolapse are at an increased

risk for other concomitant pelvic floor abnormalities.
The clinical examination includes inspection of the per-
ineum. Digital examination will assess the resting and
squeeze tones of the anal sphincters. Proctoscopy or
endoscopy will frequently reveal an area of mild erythema
within the lower rectum. Sometimes a
solitary rectal ulcer
w
il
l be found in the mid-rectum. This may sometimes be
difficult to distinguish from a polyp or tumor, and biop-
sies may therefore be needed. Evaluation of the remain-
ing colon is encouraged, to exclude any coexisting
colorectal pathology, particularly cancer. Solitary rectal ulcer
syndrome (SRUS) is discussed later in this chapter.
Colon transit studies, anorectal manometry, pudendal
latencies and endo-anal ultrasound may also be used in the
examination of prolapse patients, but they are usually not
essential for the preoperative assessment.
Surgical Therapy
Rectal prolapse in children is generally treated conserva-
tively, whereas surgical repair is suggested for adults. In
1912, Moschcowitz presented his theory that rectal pro-
lapse is a sliding he
rnia and he suggested obliteration of
the deep cul-de-sac of Douglas as treatment, but this
method had a high recurrence rate.
Today both abdominal and perineal approaches are
used. Abdominal approaches include different types of
rectal suspension and fixation and they usually have low

recurrence rates (Table 89-1). Perineal approaches have
higher recurrence rates and they are usually reserved for
elderly patients or patients with concomitant health
p
roblems.
Abdominal Rectal Prolapse Repair
Most authors advocate complete posterior mobilization of
the rectum to the coccyx, and some recommend partial
anterior mobilization as well. The extent of lateral mobi-
lization has been debated and there is little data reported
in the literature. It has been found in patients undergoing
posterior mesh rectopexy for prolapse that division of lat-
eral ligaments may contribute to the development of onset
constipation. A marked increase of constipation has been
found in patients who had undergone Wells rectopexy with
division of lateral ligaments, when they were compared
TABLE 89-1. Recurrence Rates After Treatment of
Rectal Prolapse
Number Mean Follow- Recurrence
of Patients Up (years) (%)
Abdominal Procedures
Ripstein
Holmström 1986 82 6.9 5
Roberts 1988 130 3.4 10
Tjandra 1993 129 4.2 8
Winde 1993 35 4.2 0
Posterior rectopexy with mesh
Mann 1988 51 4.8 0
Yoshioka 1989 135 32
McCue 1991 53 3.1 2

Suture rectopexy
Ejerblad 1988 — 6.8 4
Blatchfor
d 1989
51
2.3 2
Graf 1996 135 5.3 9
Resection r
ectopexy
Madof
f 1992
5.4
6
Huber 1997
51 4.5 0
Anterior resection
Schlinkert 1985 53 7 9
Perineal Pr
ocedur
es
Perineal recto-sigmoidectomy 51 — —
Altemeier 1971 135 ? 3
W
illiams 1992
53
1
10
Delorme
Uhlig 1979 51 — 7
Monson 1986 135 — 7

Senapati 1994 53 2 22
Oliver 1994
— 3.9 13
Tsunoda 2003 31 3.3 13
Watkins 2003 52 5 6
520 / Advanced Therapy in Gastroenterology and Liver Disease
with patients who had undergone Ripstein’s operation with
the lateral ligaments preserved. Preservation of the lateral
ligaments may therefore be recommended.
R
ipstein Rectopexy
After mobilization, the rectum is usually suspended to the
sacrum, but the optimal technique for this suspension is
still debated. Ripstein (1965) described a repair based on
the theory that prolapse is caused by rectal attachment to
the sacrum. This repair has been used extensively in the
United States.
The rectopexy is performed by suturing an approxi-
mately 5 cm wide piece of mesh to the sacrum. The mesh
is wrapped around and sutured to the anterior wall of the
rectum. The wrap should be loose enough to avoid stric-
turing of the rectum.
The Ripstein rectopexy has sometimes been accused of
causing obstructed defecation, but early reports of post-
operative constipation following this procedure were not
controlled for preoperative symptoms. However, the tech-
nique includes a risk for infection and fistula formation
because of the circular mesh and the recurrence rate, and
functional outcome does not differ from other techniques.
Its popularity has therefore decreased.

Wells’ Rectopexy
The Ivalon sponge procedure is similar to the Ripstein pro-
cedure, but the mesh is placed partially around the bowel
instead of circumferentially. This technique was popular-
ized because of concerns over sling obstruction with a cir-
cumferential mesh.
The technique was described by Wells in 1959. Wells
based his procedure on the use of a polyvinyl alcohol
sponge (Ivalon) with its tendency to create a reactive
fibrotic response. It is, however, unclear whether this reac-
tive response is needed, as techniques such as suture rec-
topexy seem to offer the same low recurrence rates as the
Wells’ procedure.
Suture Rectopexy
Direct suture rectopexy was first advocated by Cutait in
1959. The suture rectopexy is used as a temporary sus-
pension of the rectum while adhesions form between the
rectum and the presacral fascia. This technique has gained
renewed interest after the introduction of laparoscopic
surgery (see below). After mobilization, the rectum is sus-
p
ended to the sacrum with 2 to 4 sutures that are anchored
in the mesorectum and the presacral fascia.
Suture rectopexy seems to offer similar recurrence and
complication rates as techniques involving mesh. Suture
rectopexy is therefore an attractive alternative and it may
also be used together with simultaneous sigmoid resection
(see below) because no foreign material is used.
Resection Rectopexy
Another topic of debate is whether the redundant sigmoid

colon should or should not be resected at suture rectopexy.
W
hen Frykman and Goldberg (1969) described resection
rectopexy, the original rationale of the resection was to sus-
pend the left colon from the splenic flexure to prevent
recurrence.
It is apparent today that this is not needed when the low
recurrence rates in most series evaluating abdominal pro-
lapse repair. On the other hand, the use of resection may
decrease the risk for postoperative constipation symptoms.
A higher rate of new or persisting constipation has been
reported in three additional trials in patients treated with
sling rectopexy alone versus those treated with suture rec-
topexy and sigmoid resection.
Sometimes patients are not relieved of preexisting con-
stipation despite a sigmoid resection at the time of rec-
topexy and on occasion subtotal colectomy with rectopexy
may be the appropriate surgical method for carefully
selected patients with severe slow transit constipation
(Madoff et al, 1992). The risk for postoperative fecal incon-
tinence may however be substantial, as many of these
patients will have loose stools postoperatively.
Anterior Resection
Schlinkert and colleagues (1985) have reported the Mayo
Clinic experience with anterior resection as therapy for rec-
tal prolapse and found an acceptable recurrence rate (9%).
They found that a low anastomosis increased morbidity
without significantly decreasing recurrence when com-
pared with high anterior resection. The effects of repair on
patient continence were unpredictable.

Laparoscopic Prolapse Repair
Laparoscopic abdominal repair represents a new develop-
ment in rectal prolapse surgery. Laparoscopy offers
improved patient comfort, better cosmetic result, and
decreased lengths of hospital stay and disability (Solomon
and Eyers, 1996; Kellokumpu et al, 2000) and most of the
procedures described above may be performed with this
t
e
c
hnique. In two recent studies (Heah et al, 2000; Zittel et
al, 2000), it was reported that functional outcome after
laparoscopic rectopexy was comparable with open surgery.
P
erin
eal Rect
al Prolapse Repair
Perineal prolapse repair is usually reserved for elderly
pat
ie
nts or patients with concomitant health problems,
because the recurrence rate is substantially higher.The recur-
rence rates in different series range from 5 to more than 50%
(Williams et al, 1992; Senapati et al, 1994; Tsunoda et al,
2003;
W
atkins e
t al,
2003; Frykman and Goldberg, 1969) and
the

re is a tendency that series with longer follow-up time
position. The submucosa above the dentate line is injected
with an epinephrine solution where after the rectal mucosa
on the external side of the prolapse is dissected free from
the underlying muscle. The rectal muscle is then vertically
p
licated in all four quadrants, usually by using eight pli-
cating sutures. As these sutures are tied, the muscle is pli-
cated, and the excess mucosa is then excised and the
mucosa is closed with a mucosa-to-mucosa closure.
Functional Outcome After Rectal
Prolapse Surgery
Several attempts have been made to predict postoperative
outcome with physiologic testing. Preoperative manome-
try results have generally not been predictive of the func-
tional outcome regarding continence, though patients with
very severe physiologic abnormalities may have a worse
prognosis (Williams et al, 1992; Yoshioka et al, 1989).
A majority of studies report that approximately 50% of
incontinent patients improve after surgery. Restoration of
internal anal sphincter function plays probably an impor-
tant role in this process, as improved continence after
surgery is often accompanied by increased resting pressures
(Schultz et al, 1996). The removal of the prolapsing may
also be an important reason, as the prolapse disturbs the
sphincter function by repetitive sphincter dilatation. Other
important factors may be postoperative improvements in
anal sphincter electomyogram and improved sensation
(Duthie, 1992).
The frequency of postoperative constipation varies

greatly between studies. Some studies report increased inci-
dence (Graf et al, 1996; Aitola et al, 1999), whereas others
report an unchanged (Tjandra et al, 1993), or decreased
(R
o
berts et al, 1988; Winde et al, 1993) incidence. Possible
reasons for postoperative constipation include colonic den-
ervation, rectal denervation by division of the lateral liga-
ments, or a redundant sigmoid that may contribute to
rectosigmoid kinking.
Rectal Intussusception
Internal rectal intussusception is sometimes labeled “occult
rectal prolapse” as the conditions are quite similar at
defecography, with the only difference that rectal intus-
susception does not extend beyond the anal verge.
Internal intussusception is associated with several dif-
ferent functional complaints. Johansson and colleagues
(1985) examined 190 patients with rectal intussusception
and found that 57% of patients experienced a sensation of
o
bstruction, 44% had fecal incontinence, 43% had painful
defecations, and 27% had anal bleeding. Mucous discharge
and diarrhea have also been reported.
T
he most common symptom associated with internal
intussusception is, thus, obstructed defecation. This can be
Rectal Prolapse, Rectal Intussusception, and Solitary Rectal Ulcer Syndrome / 521
have higher recurrence rates. In a recent study from our insti-
tution (Kim et al, 1999), perineal rectosigmoidectomy had
a recurrence rate of 16% compared with 5% after rectopexy.

Functional outcomes were similar following either opera-
t
ion. The results suggest that perineal rectosigmoidectomy
may not be the ideal operation for healthy patients due to
its relatively high recurrence rate.
Most authors currently favor either perineal rectosig-
moidectomy or Delorme’s operation and the choice
between these two types of procedures usually depends
upon individual surgeon training and preference. Series
comparing different perineal operations are rare.
Perineal procedures are well tolerated by most patients.
The postoperative course is usually benign and most
patients tolerate the procedure quite well and the postop-
erative stay is usually short.
Perineal Rectosigmoidectomy
Perineal rectosigmoidectomy was first described by
Mikulicz in 1889. Renewed interest in this procedure, par-
ticularly in the United States, can be attributed to W.A.
Altemeier, whose 1971 report claimed only 3 recurrences
in a series of 106 patients. A few series have recurrence rates
comparable to those seen after abdominal repairs, but sev-
eral reports have considerably higher recurrence rates. The
variability in results reported by different centers stands in
contrast to the marked uniformity and predictability of
success seen after abdominal repairs.
Perineal rectosigmoidectomy can be done under
regional or regional anesthesia in the lithotomy or prone
position. The rectum is externalized as far as possible, and
an incision is made approximately 1 to 2 cm from the den-
tate line. The incision is made full thickness through the

ou
t
er bowel wall, entering the space between the external
and internal bowel tubes of the prolapsed rectum. The rec-
tal and sigmoid mesenteric vessels are divided with liga-
tures or using a harmonic scalpel and the prolapsed
segment of rectum is folded down as far as possible.
Resection of 20 to 40 cm of rectum and sigmoid colon is
not uncommon. After mobilizing the maximum length of
bowel, the prolapsed segment is resected and an anasto-
mosis is sutured.
Addition of a levatoroplasty to the procedure might
influence recurrence rates by tightening the levator hiatus
and providing a new anorectal angle that contrasts with
the “straight” rectal contour typically seen in prolapse
patients (Williams et al, 1992; Agachan et al, 1997).
Delorme’s Operation
Delorme described an alternative perineal repair and the
method was popularized after the report of Uhlig and
Sullivan (1979). This procedure can also be done under
regional or regional anesthesia in the lithotomy or prone
522 / Advanced Therapy in Gastroenterology and Liver Disease
explained by several mechanisms. The intussusception,
sometimes together with a concomitant enterocele and/or
rectocele, may restrict emptying or produce a sensation
of rectal fullness. The intussuscepting bowel, present in the
r
ectum, may be experienced by the patient as fecal mater-
ial that cannot be expelled. Continued straining will then
increase the size of the intussusception and further worsen

symptoms.
The association between the internal rectal intussus-
ception and the above-mentioned symptoms remains
unclear. Surgical correction of the anatomical intussus-
ception does not always alleviate symptoms and rectal
intussusception is a frequent finding in patients with defe-
cation disorders. In an evaluation of 2,816 defecography
investigations, we found that 31% of the patients had a cir-
cumferential rectal intussusception (Mellgren et al, 1994).
Rectal intussusception has also been reported to be a fre-
quent finding in defecography studies of healthy volun-
teers (Shorvon et al, 1989; Goei, 1990).
Diagnosis
Rectal intussusception is usually diagnosed at defecography
as a circumferential infolding of the rectal wall that does
not pass beyond the anal verge. However, at rectal exami-
nation the intussusception may be palpated or inspected
with a proctoscope.A distal proctitis or a solitary ulcer may
also be seen.
Treatment
Patients with internal rectal intussusception have often a
long history of anorectal problems and they have consulted
several physicians. After establishing the diagnosis, man-
agement is usually conservative. Patients are informed
about the condition and they are advised to avoid strain-
ing at stool, as this may increase symptoms. Bulking agents
may be beneficial and, sometimes, small enemas may facil-
itate rectal emptying.
Indications for surgical treatment vary in different stud-
ies, as do the surgical results. Unfortunately most published

studies are retrospective and they include relatively small
numbers of patients. Fecal incontinence in patients with
rectal intussusception is an indication for surgical treat-
ment and most studies (Table 89-2) report improved post-
o
perative anal continence. Outlet obstruction is often
unchanged or may even deteriorate after surgery (see Table
89-2), and patients should be counseled regarding this
before surgical treatment. However the effect on outlet
obstruction is unpredictable and some patients improve
after rectopexy (Schultz et al, 1998).
As mentioned, rectal intussusception and rectal pro-
lapse are quite similar at defecography, with the only dif-
ference being that rectal intussusception does not extend
beyond the anal verge. Sometimes the risk for developing
rectal prolapse is used as a surgical indication in patients
with rectal intussusception. This risk seemed however to
be quite limited, when we followed rectal intussusception
patients over time (Mellgren et al, 1997).
SRUS
SRUS is a proctologic disease characterized by erythema
and/or one or several ulcerations of the rectal wall. It is a
benign condition with a characteristic histologic picture,
and patients usually have associated disordered defecation.
The ulcer is usually located anteriorly in the rectum, and
instead of an ulcer, the lesion may also be polypoid.
The histologic characteristics of the lesion were first
described by Madigan and Morson in 1969 and they
include a thickened muscularis mucosa, a lamina propria
expanded by fibroblasts, and smooth muscle cells arranged

to point towards the lumen. Colitis cystica profunda is a
form of the SRUS, with dilated displaced glands filled with
mucus and lined with normal colonic epithelium in the
submucosa. Frequently the lesion at SRUS can be difficult
to distinguish from adenomateus polyps or tumors, and
biopsies are therefore essential to verify the diagnosis.
T
he et
iology of SRUS remains obscure and patients fre-
quently have concomitant pelvic floor disorders. There is an
asso
ciation between SRUS, rectal prolapse, internal rectal
intussusception, paradoxical sphincter reaction (PSR), and
ou
tle
t o
bst
r
uction. The symptoms are similar and the con-
dit
io
ns so
metimes coexist, but the relationship between these
disorders is not fully understood, as all can exist alone.
T
ABLE 89-2. Treatment Results of Rectal Intussusception
Technique Number of Patients Mean Follow Up (years) Incontinence Constipation
Ihre 1975 Ripstein 36 2 to 13 Improved Worse
Johansson 1985 Ripstein 63 — Improved Worse
Lazorthes 1986 Post. Recopexy 14

> 0.5 Improved Improved
Berman 1990 Delorme 21
> 3 — Improved
McCue 1990 Wells 12 2.2 Improved Worse
Christiansen 1992 Wells + Orr 9 + 15 1 to 8 Improved 45% Improved
van Tets 1995 Post. Rectopexy 21 6 — Improved
Briel 1997
Sutur
e r
ectopexy
13 5.6 38% improved —
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innie NR, Papachrysostomou M, Clare N, Smith AN. Solitary
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Brodén B, Snellman B. Procidentia of the rectum studied with
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utait D. Sacro-promontory fixation of the rectum for complete
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elorme E. On the treatment of total prolapse of the rectum by
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M
adden MV, Kamm MA, Nicholls RJ, et al. Abdominal rectopexy
f
o
r complete prolapse: prospective study evaluating changes
in symptoms and anorectal function. Dis Colon Rectum
1992;35:48–55.

Madigan MR, Morson BC. Solitary ulcer of the rectum. Gut
1969;10:871–81.
Madoff RD, Williams JG, Wong WD, et al. Long-term
functional results of colon resection and rectopexy for overt
rectal prolapse. Am J Gastroenterol 1992;87:101–4.
M
archal F, Bresler L, Brunaud L, et al. Solitary rectal ulcer
syndrome: a series of 13 patients operated with a mean follow-
up o
f
4.5 y
ear
s. Int J Colorectal Dis 2001;16:228–33.
M
arshall M, Halligan S, Fotheringham T, et al. Predictive value
of internal anal sphincter thickness for diagnosis of rectal
intussusception in patients with solitary rectal ulcer syndrome.
Br J Surg 2002;89:1281–5.
Mellgren A, Bremmer S, Johansson C, et al. Defecography,results
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f
in
v
est
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ations in 2,816 patients. Dis Colon Rectum
1994;37:1133–41.
Mellgren A, Schultz I, Johansson C, Dolk A. Internal rectal
intussusception seldom develops into rectal prolapse. Dis
C

olo
n R
e
ctum 1997.[In press].
Excessive straining causing trauma and ischemia of the
p
rolapsed mucosa is probably one of the pathogenetic fac-
tors and self-digitation has also been discussed as a possi-
ble causative factor (Rutter and Riddell, 1975).
Symptoms
SRUS affects both men and women, usually with onset
before the age of 50 years. Typical symptoms include evac-
uation difficulties with prolonged straining at bowel move-
ments, passage of blood and mucous per rectum, tenesmus,
and, sometimes, anorectal pain. Digitation for evacuation
of feces is considered to be common. SRUS may, however,
also be found in asymptomatic patients.
Treatment
Nonsurgical options are usually preferred as initial treat-
ment (Vaizey et al, 1997). Retraining of bowel habits,
decrease of straining efforts, and a high fiber diet, is gen-
erally recommended. Biofeedback-training might be help-
ful, especially if the patient has PSR (Binnie et al, 1992).
Abdominal rectopexy offers long term symptom improve-
ment in approximately 50% of patients (Vaizey et al, 1998).
Rectal ulceration may persist after any treatment, even if
symptoms improve.
Surgery is frequently recommended when SRUS is
accompanied by rectal intussusception or rectal prolapse.
Reports on surgical outcome are, however, usually based

on small series with limited follow-up time. Successful out-
come has been reported after Ripstein rectopexy in 9 of 10
patients with concomitant rectal prolapse (Schweiger and
Alexander-Williams, 1977), after posterior rectopexy with
Marlex mesh in 5 of 6 patients with rectal prolapse
(Keighley and Shouler, 1984), and after Wells’ posterior rec-
topexy in 17 of 17 patients with concomitant internal rec-
tal intussusception. Other reports have not found the same
excellent results. Marchal and colleagues (2001) reviewed
13 patients operated on for SRUS with a mean FU of 57
months. The authors operated with various techniques and
they found a high failure rate after surgery. They there-
f
o
r
e r
e
c
ommend surgical therapy only in patients with total
rectal prolapse or intractable symptoms.
Editor’s Note: A complete 110-item bibliography is available at
<>.
Supplemental Reading
Agachan F, Reissman P, Pfeifer J, et al. Comparison of three
perineal procedures for the treatment of rectal prolapse. South
Med J 1997;90:925–32.
Aitola PT, Hiltunen KM, Matikainen MJ. Functional results of
operative treatment of rectal prolapse over an 11-year period:
emphasis on transabd
o

minal ap
proach. Dis Colon Rectum
1999;42:655–60.
Rectal Prolapse, Rectal Intussusception, and Solitary Rectal Ulcer Syndrome / 523
524 / Advanced Therapy in Gastroenterology and Liver Disease
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lusa SM, Charig JA, Balaji V, Watts A. Physiological changes after
Delorme’s procedure for full-thickness rectal prolapse. Br J
Surg 1995;82:1475–8.
Porter NH. A physiological study of the pelvic floor in rectal
p
rolapse. Ann R Coll Surg Engl 1962;31:379–404.
R
ipstein CB. Surgical care of massive rectal prolapse. Dis Colon
Rectum 1965;8:34–8.
Roberts PL, Schoetz DJ, Coller JA, Veidenheimer MC. Ripstein
procedure. Lahey Clinic experience: 1963–1985. Arch Surg
1
988;123:554–7.
Rutter KRP, Riddell RH. The solitary ulcer syndrome of the
rectum. Clin Gastroenterol 1975;4:505–30.
Schlinkert RT, Beart RW, Wolf BG, Pemberton JH. Anterior
resection for complete rectal prolapse. Dis Colon Rectum
1985;28:409–12.
Schultz I, Mellgren A, Johansson C, et al. Continence is improved
after the Ripstein rectopexy.Different mechanisms in patients
with rectal prolapse and rectal intussusception? Dis Colon
Rectum 1996;39:300–5.
Sc
hultz I, Mellgren A, Nilsson BY, et al. Preoperative

electrophysiologic assessment cannot predict continence after
rectopexy. Dis Colon Rectum 1998;41:1392–8.
Schweiger M, Alexander-Williams J. Solitary ulcer of the rectum.
Its association with occult rectal prolapse. Lancet
1977;1:170–1.
Senapati A, Nicholls RJ, Thomson JPS, Phillips RKS. Results of
Delorme’s procedure for rectal prolapse. Dis Colon Rectum
1994;37:456–60.
Shorvon PJ, McHugh S, Diamant NE, et al. Defecography in
normal volunteers: results and implications. Gut
1989;30:1737–49.
S
olomon MJ, Eyers AA. Laparoscopic rectopexy using mesh
fixation with a spiked chromium staple. Dis Colon Rectum
1996;39:279–84.
Tjandra JJ, Fazio VW, Church JM, et al. Ripstein procedure is an
e
ffective treatment for rectal prolapse without constipation.
D
is Colon Rectum 1993;36:501–7.
Tsunoda A, Yasuda N, Yokoyama N, et al. Delorme’s procedure
for rectal prolapse: clinical and physiological analysis. Dis
Colon Rectum 2003;46:1260–5.
U
hlig BE, Sullivan ES. The modified Delorme operation: its place
in surgical treatment for massive rectal prolapse. Dis Colon
Rectum 1979;22:513–21.
Vaizey CJ, Roy AJ, Kamm MA. Prospective evaluation of the
treatment of solitary rectal ulcer syndrome with biofeedback.
Gut 1997;41:817–20.

Vaizey CJ, van den Bogaerde JB, Emmanuel AV, et al. Solitary
rectal ulcer syndrome. Br J Surg 1998;85:1617–23.
Watkins BP, Landercasper J, Belzer GE, et al. Long-term follow-
up of the modified Delorme procedure for rectal prolapse.Arch
S
urg 2003;138:498–502; discussion 502–3.
Wells C. New operation for rectal prolapse. Proc R Soc Med
1959;52:602–3.
Williams JG, Rothenberger DA, Madoff RD, Goldberg SM.
Treatment of rectal prolapse in the elderly by perineal
rectosigmoidectomy. Dis Colon Rectum 1992;35:830–4.
Winde G, Reers B, Nottberg H, et al. Clinical and functional results
of abdominal rectopexy with absorbable mesh-graft for treatment
of complete rectal prolapse. Eur J Surg 1993;159:301–5.
Zittel TT, Manncke K, Haug S, et al. Functional results after
laparoscopic rectopexy for rectal prolapse. J Gastrointest Surg
2000;4:632–41.
525
CHAPTER 90
ILEOANAL POUCH:FREQUENT EVACUATION
L.J. EGAN,MD,AND S.F. PHILLIPS,MD
of the history is to determine precisely what it is about pouch
function that is unsatisfactory to the patient. A typical com-
plaint might be of having to “go all the time.” The physician
must then determine exactly what the patient means. Is the
patient having true watery diarrhea, or is the main complaint
urgency or leakage? Is an inability to completely empty the
pouch with consequent leakage of retained stool the real prob-
lem? Careful evaluation of the patient’s complaints, in con-
junction with knowledge of the likely causes of symptoms,

should point to the correct diagnosis. In practice, it is advan-
tageous to divide the clinical picture into those patients who
are distressed soon after surgery from those who present later.
Excessive or Uncontrolled Bowel
Movements with Newly Formed
Pouches
General Approach
Problems occurring soon after the operation (0 to 6 months)
present more often to surgeons, but gastroenterologists need
also to be aware of these issues (Table 90-1). It is helpful to
Proctocolectomy with ileal pouch-anal anastomosis (IPAA)
is the most popular surgical option when colonic resection
is necessary for the treatment of ulcerative colitis (UC) and
familial adenomatous polyposis. However,after IPAA, patients
will always defecate more frequently than do healthy people.
Thus, after proctocolectomy, whether surgical continuity is
restored with a terminal ileostomy or with a pouch, daily fecal
volumes will be 500 to 700 mL (Metcalf and Phillips, 1986).
In health, fecal volumes do not often exceed 200 mL.
Moreover, the reservoir of an ileoanal pouch is smaller than
that of a normal rectum. IPAA patients complaining of fre-
quent bowel movements must recognize their symptoms in
this context; they will never have only one or two solid stools
daily! Although patients who complain of frequent defecation
after IPAA may have no identifiable pathology, they can, nev-
ertheless, be helped to accept a new lifestyle by being taught
to understand the postoperative physiology (Dean and Dozois,
1997; Levitt and Kuan,1998).Moreover,simple antidiarrheal
therapy may significantly improve their lifestyle.
The majority of patients with normally functioning

IPAAs should evacuate between four and eight times per day,
and once or twice at night. After the initial postoperative
phase, IPAA patients should not have extreme fecal urgency
and should be able to distinguish between the urges of fla-
tus and feces. Approximately 10 to 20% of IPAA patients
experience minor leakage of stool, especially at night, when
they may need to wear a pad (Meagher et al, 1998). However,
they should be continent during the day. Passage of stools
should be painless, should not be accompanied by the need
to strain, and should feel complete. In taking the history, the
features of “diarrhea”need to be defined precisely; increased
fecal frequency needs to be distinguished from urgency,fecal
leakage, or gross incontinence.
Importance of an Adequate History
The key to helping IPAA patients who complain of exces-
sive bowel movements is to make an accurate diagnosis.
Disorders of the pouch outlet (the anal sphincter segment),
the pouch itself, or of the ileum proximal to the pouch may
be the cause of an increased stool frequency. In many patients,
a careful history will provide the astute clinician with a short
list of diagnostic possibilities. The most important element
TABLE 90-1. Approach to Patients After Ileal Pouch-
Anal Anastomosis With Excessive Bowel Movements in
the First 6 Months of Pouch Reanastomosis
Diagnostic
Cause Approaches Treatment
Unr
ealistic
Exclude pathology by
Education and

expectations physical examination; reassurance
± Endoscopy, Fiber supplements,
± Pouchogram antidiarrheals
Anastomotic leak
Endoscopy
Intestinal diversion, abscess
Pouchogram
drainage
Pouch revision (late decisions)
Defective sphincter
Physical Antidiarrheals, fiber
function and anal examination supplements
incontinence
Anal manometr
y
Biofeedback
Anastomotic Physical examination Dilatation
strictur
e
Endoscopy
Pouchitis Pouchoscopy and biopsy Antibiotics
Cuffitis Pouchoscopy and biopsy Mesalamine, steroids
526 / Advanced Therapy in Gastroenterology and Liver Disease
consider the time of onset of increased bowel frequency in
relation to the age of the pouch. The first few weeks after clo-
sure of the temporary ileostomy and restoration of the fecal
stream to the pouch are often marked by frequent loose stools,
t
o which the pouch and the patient must be helped to adapt.
The sensation of a full ileal pouch may be qualitatively dif-

ferent from that of a full rectum, and patients must learn to
recognize those sensations that indicate that they need to
empty the pouch.
Thus, some patients, if they have not received adequate
preoperative counseling, have unrealistic expectations about
the functional outcomes after “curative” IPAA surgery. They
need to be educated; they will always have a high fecal vol-
ume, and their stools will never be fully formed. Moreover,
it is important to reassure patients that a healthy pouch and
anal sphincter will
gradually adapt postoperatively and, con-
sequently, bowel function should be expected to improve.
In addition to reassurance and education, simple measures
can significantly help patients with a new IPAA to learn to
compensate. For example, fiber supplements, such as methyl-
cellulose or psyllium, of 1 g in a large glass of water once or
twice per day, will increase the consistency of stools.
Loperamide 2 to 4 mg taken 30 minutes before meals will
reduce postprandial urgency.Although many IPAA patients
find that certain foodstuffs increase stool, it is not particu-
larly helpful to counsel individual patients on the con-
sumption of specific items of food. One patient’s experience
is likely to differ so much from another’s. Rather, patients
should experiment, be moderate, and be guided by their
own experience in choosing a lifestyle that minimizes any
negative impacts of the pouch. It is important not to pro-
mote compulsivity in dietary or other habits.
Although many patients complaining of excessive bowel
frequency, diarrhea or leakage soon after IPAA will ulti-
mately be found not to have a structural/organic basis, one

must not overlook the possibility of a postoperative com-
plication.
Small bowel obstruction occurs in the first weeks
after pouch formation in 6 to 20% of patients. Though pain
is the expected symptom of obstruction, increased fecal
volumes can be the major complaint.
Anastomotic Leakage
Fortunately, leakage at the pouch-anus anastomosis is rare,
especially when the anastomosis is protected by a diverting
ileostomy. Most surgical series report this as less than 10%,
though some higher rates are reported. Anastomotic leak-
age typically causes pelvic pain and abscess. Pouch dysfunc-
t
ion is exemplified by painful, incomplete evacuation, and
excessive frequency. Demonstration of a leak with a retro-
grade barium contrast study (pouchogram) is usually diag-
nostic. Occasionally, a
p
ouch-vaginal
o
r
p
ouch-perineal fistula
may develop in association with anastomotic leakage; this
should always raise the question of unrecognized Crohn’s
disease (CD). However, further investigation should be
d
elayed until after the initial postoperative period. Treatment
is
surgical, and may require intestinal diversion, drainage of

an abscess if present, and possibly revision of the pouch.
Defective Sphincteric Continence
Innervation of the internal anal sphincter may be disrupted
during the perineal dissection and construction of the
pouch-anus anastomosis. Consequently, resting pressures
of the internal anal sphincter are usually reduced, at least
for 6 to 12 months postoperatively. After this, there is a
gradual return of basal anal tone; fortunately, function of
the external sphincter, which is usually preserved, helps
compensate for any lowering of internal sphincter pres-
sures. Exceptions may be seen in elderly patients and mul-
tiparous women whose anal pressures were low before
pouch construction. In this situation, defective anal conti-
nence can lead to leakage, which may be presented by the
patient as excessive bowel motions (“diarrhea”) after IPAA.
Indeed, even patients who will subsequently develop excel-
lent pouch function may experience soiling, incontinence,
and some degree of urgency soon after ileostomy closure.
Physical examination of the sphincter in these patients
reveals low resting tone and sometimes low squeeze pres-
sures, findings that can be confirmed by anal manometry
if necessary. Effective management involves the judicial use
of antidiarrheals such as
loperamide, 2 to 4 mg 30 minutes
before meals, and
fiber supplements to increase stool con-
sistency.
Biofeedback may be helpful later, for those patients
whose sphincter function returns only slowly or incom-
pletely; retraining of patients to use the external anal sphinc-

ter to greater advantage can be helpful. In a minority of
IPAA patients, incontinence due to poor sphincter tone per-
sists, and is occasionally sufficient to require
permanent
ileostomy
. This is one of the reasons for “pouch failure.”
Pouch Outlet Obstruction
In the early postoperative period, before takedown of the
diverting ileostomy, a thin web-like stricture often forms
at the ileal pouch-anal anastomotic line. After the fecal
stream into the pouch is restored, persistence of this stric-
ture obstructs the pouch outlet, leading to incomplete evac-
uation, somewhat analogous to bladder outlet obstruction
in prostatism. The patient will complain of diarrhea due
to incomplete emptying of the pouch, resulting in over-
flow leakage and fecal frequency. Digital examination of
the anus demonstrates a narrowing of the upper anal canal.
These strictures can usually be dilated easily with the fin-
ger or a rubber dilator.In some patients, anastomotic stric-
tures can progress to become chronic, recurrent and
fibrotic, and to require regular dilatation.
Ileoanal Pouch: Frequent Evacuation / 527
Residual Inflammatory Bowel Disease (“Cuffitis”)
M
odern pouch surgery leaves behind only a small cuff of
rectal mucosa, of 1 or 2 cm at the most, when a double-
stapled anastomosis is formed. No rectal mucosa should
remain when the anastomosis is hand sewn in conjunction
with a distal rectal mucosectomy. However, in some cases,
for example in obese patients when it is difficult to bring the

small bowel deep into the pelvis, the surgeon may need to
leave behind a more substantial cuff of rectal mucosa to
which the pouch is anastomosed. The term “
cuffitis” has been
used to describe persistent inflammatory bowel disease
(IBD) in the remnant of rectal mucosa. Most often it occurs
in patients who had active colitis before surgery. Symptoms
are proportional to the amount of rectal mucosa that
remains and to the severity of the inflammation. Patients
complain of fecal frequency and urgency and the motions
are commonly watery with mucous and blood. Urgency and
leakage occur, especially at night. Rarely, if several centime-
ters of rectum remain, systemic symptoms of malaise, low-
grade fever or weight loss may be experienced. Initial
treatment, with standard topical anti-inflammatory agents,
such as
mesalamine suppositories or hydrocortisone enemas,
may be sufficient. Patients who do not respond to locally
applied agents, and who require systemic steroids to control
cuffitis, will occasionally require a further operation, to
remove the inflamed rectal mucosa and to anastomose the
pouch to the upper anal canal, if technically feasible.
Acute Pouchitis
IBD of the pouch (pouchitis) is a syndrome defined by
clinical, endoscopic and histologic criteria that occurs in
UC-IPAA patients (Mahadevan and Sandborn, 2003), and
seldom, if ever, affects familial adenomatous polyposis-
IPAA patients. Patients complain of fecal frequency, and
the motions are commonly loose and watery and may con-
tain mucous and blood. Urgency and leakage, especially at

night, are common. In addition, depending on the sever-
ity of pouch inflammation, the presence of associated fis-
tulas, CD or concurrent pouch outlet obstruction, pelvic
pain may be present. Systemic symptoms of malaise, low-
grade fever or weight loss are often present in the more
severe cases of pouch inflammation. Physical examination
in patients with pouch inflammation is often normal.
However, individuals with marked inflammation of the
pouch from any cause may have the general features of
patients with IBD, with low-grade fever, weight loss, and
pallor. CD is suggested by signs of small bowel obstruction,
abdominal mass or tenderness, or perineal sepsis.
In most cases,
endoscopy and b
iopsy
o
f the pouch will be
diagnostic. We use flexible upper gut endoscopes to exam-
ine ileal pouches, because of their narrower caliber and
superior flexibility compared to sigmoidoscopes. It must
be recognized that even in a healthy pouch, the ileal mucosa
undergoes metaplasia to a more colonic type; accordingly,
normal ileum is not seen endoscopically or histologically.
The presence of edema, erythema, mucous exudates, and
ulceration suggest pouch inflammation. If endoscopic
c
hanges are confined to the pouch and do not extend into
the prepouch ileum, pouchitis is the likely diagnosis.
However, if aphthous or deep ulcerations and other
mucosal abnormalities extend proximal from the pouch,

or are seen solely in the prepouch ileum, CD is more likely.
Occasionally, a linear series of shallow ulcerations will be
observed extending along the divided pouch septum. This
appearance is suggestive of pouch ischemia, a complica-
tion that may occur if the mesenteric vessels have been
stretched too deeply into the pelvis (de Silva et al, 1991).
Severe microscopic inflammation can be found in a
pouch with a relatively normal endoscopic appearance.
Thus, biopsy and histological evaluation of the mucosa are
essential. An experienced pathologist should be able to dis-
tinguish between pouchitis, CD, and mucosal ischemia.
Pouchography detects pouch leaks, fistulas and strictures,
and thus can be helpful if these complications are sus-
pected, or if pouchitis needs to be differentiated from CD.
Almost all cases of acute pouchitis will promptly respond
to a course of antibiotics, such as metronidazole 250 to
500 mg 3 times daily or ciprofloxacin 500 mg twice daily
for 10 to 14 days. Rarely, cytomegalovirus can infect pouch
mucosa leading to chronic inflammation; the diagnosis is
suggested by the presence of viral inclusions on histology.
Treatment with ganciclovir is reported to be effective.
Excessive Bowel Frequency in Patients
with Established Pouches
General Approach
Several large series have reported excellent long term func-
tional outcomes of IPAA for UC; these have been summa-
rized and reviewed (Dean and Dozois, 1997). Ten years
after IPAA, incontinence had not occurred during the day
in 73% of patients, nor at night in 48% (Meagher et al,
1998). However, many IPAA patients, at some time after

construction of the pouch, experience increased bowel fre-
quency, urgency or incontinence, all symptoms that may
be presented as “diarrhea” (Table 90-2). Pouchitis is the
most common, but not the only, cause of these symptoms.
Disorders of the pouch other than pouchitis include dis-
orders of pouch emptying, diseases in the prepouch ileum,
and any of the causes of diarrhea that may occur in patients
w
ith an intact bowel. In the majority of cases, a correct
diagnosis should provide a management strategy that
brings about improvement. Ten years after IPAA surgery,
p
ouch failure requiring pouch excision or permanent
ileostomy occurs in less than 5% of patients.
Ileoanal Pouch: Frequent Evacuation / 529
CD
A
pproximately 5% of IPAA procedures are performed in
patients whose primary diagnosis is revised at some point
after surgery from UC to CD. Many had their original
colectomy for “fulminant colitis.” CD may be the cause of
chronic pouch and prepouch inflammation and perianal
fistulas. Once the diagnosis is confirmed, therapy is no dif-
ferent from that of pelvic and perianal CD in patients still
with a rectum. Infected cavities must be drained, obstruc-
tion must be excluded, and medical therapy with antibi-
otics such as metronidazole (250 to 500 mg 3 times daily)
or ciprofloxacin (500 mg twice daily) should be begun.* It
is our practice to start immunosuppressive therapy with
AZA (2 to 2.5 mg/kg/d) or 6-MP (1.5 mg/kg/d) in CD

patients whose conditions do not warrant immediate
pouch excision. Open-label experience with the tumor
necrosis factor alpha antibody (infliximab) for CD of
pouches has been published by Ricart and colleagues
(1999). A single infusion of infliximab (5 mg/kg) resulted
in a rapid and favorable response in most patients.
Despite the use of powerful immunosuppressive med-
ications in patients with pouchitis, CD of the pouch, or
cuffitis, a minority of patients will not respond. The result-
ing chronic inflammation leads to a scarred, noncompli-
ant pouch. In such patients, it may become futile to
continue attempts at medical therapy, because the quality
of life will clearly be much better after pouch excision and
permanent ileostomy.
Irritable Pouch Syndrome
A small minority of IPAA patients will experience symptoms
suggestive of pouchitis, but investigations reveal little inflam-
mation and the absence of pouch outlet or other problems.
These patients respond poorly to antibiotic therapy and are
best considered as having “irritable pouches”(Schmidt et al,
1995). Empiric use of antidiarrheals or antispasmidics and
fiber supplements is the most prudent approach.
†
Diarrhea Unrelated to the Pouch
A
fter IPAA, patients are not immune to any of the more
than 100 causes of diarrhea to which those with an intact
bowel are equally susceptible. However, local symptoms,
bleeding, incontinence and urgency tend to focus atten-
tion towards a local cause in the pouch. It must be recog-

nized though that increased fecal volumes, from any
generalized osmotic or secretory form of diarrhea, will, of
necessity, stress pouch function and focus attention on
pouch dysfunction, perhaps inappropriately.
Thus, any of the infectious diarrheas must always be
considered and excluded in patients with IPAA diarrhea.
Moreover, patients lacking a colon are more sensitive to the
fluid losses that accompany any common infectious diar-
rhea which increase fecal volumes. Thus, consideration
must always be given to small bowel diseases, such as celiac
sprue, lactase deficiency, CD of the proximal bowel, and
bacterial overgrowth. If a positive diagnosis of a pouch-
related cause cannot be made, etiologies outside the pouch
must be sought. Chapter 56,“Dietary-Induced Symptoms,”
has additional clues.
Supplemental Reading
Dean PA, Dozois RR. Surgical options—ileoanal pouch. In: Allan
RN, Rhodes JM, Hanauer SB, et al, editors. Inflammatory bowel
diseases, 3rd ed.London: Churchill Livingstone; 1997.p. 761–72.
de Silva HJ, Kettlewell MGW, Mortensen NJ, Jewell DP. Acute
inflammation in ileal pouches. Eur J Gastroenterol Hepatol
1991;3:343–9.
Levitt MD, Kuan M. The physiology of ileo-anal pouch function.
Am J Surg 1998;176:384–9.
Mahadevan U, Sandborn WJ. Diagnosis and management of
pouchitis. Gastroenterology 2003;124:1636–50.
Meagher AP, Farouk R, Dozois RR, et al. J ileal pouch-anal
anastomosis for chronic ulcerative colitis: complications and
long-term outcome in 1310 patients. Br J Surg 1998;85:800–3.
Metcalf AM, Phillips SF. Ileostomy diarrhea. In: Krejs GJ, editor.

Clinics in gastroenterology. London: WB Saunders Company;
1986. p. 705–22.
R
icar
t E,
P
ana
c
cione R, Loftus EV, et al. Successful management
of Crohn’s disease of the ileoanal pouch with infliximab.
Gastroenterology 1999;117:429–32.
Sc
hmidt CM, Horton KM, Sitzmann JV, et al. Simple radiographic
evaluation of ileo and pouch volume. Dis Colon Rectum
1995;38:203–8.
Stryker SJ, Kelly KA, Phillips SF, et al. Anal and neorectal function
after ileal pouch-anal anastomosis. Ann Surg 1986;203:55–61.
Thompson-Fawcett MW, Mortensen NJ, Warren BF. “Cuffitis”
and inflammat
o
r
y c
hang
es in the columnar cuff, anal
t
ransitional zone, and ileal reservoir after stapled pouch-
anal anastomosis. Dis Colon Rectum 1999;42:348–55.
*Edit
o
r’

s N
ot
e:
I
f
the d
ose of metronidazole is less than 1g/d,
peripheral neuropathy is rare.
†
Editor’s Note: Some patients give a history of classic irritable
b
o
w
e
l syndr
ome (IBS) as teenagers, years before the onset of UC. If
the
y ha
ve an IPAA, the ileum is as spastic as their colon had been as
a teenager. Their pouches hold only 90 cc; on average they are only
ab
le t
o e
xp
e
l half
o
f
the contents so they experience 10 to 20 bowel
movements per day. Some do better with decyclonine than with

loperamide, which contracts the pouch. I tend to urge against an
IPAA in a patient with severe preexisting IBS.
530530
Anal Fissure
Anal fissure can be acute or chronic and is usually located
in the midline of the anal canal, most commonly posteriorly.
When a fissure is situated off the midline, other conditions,
such as Crohn’s disease (CD), mucosal ulcerative colitis,
syphilis, tuberculosis, or leukemia, should be investigated.
The main goal of treatment is breaking the cycle of
hard stool, pain, and reflex spasm. This objective can usu-
ally be achieved by increasing dietary fiber using fiber sup-
plements, adequate liquid intake, and possibly stool
softeners. Warm baths and topical anesthetics are helpful
in providing symptomatic relief. The great majority of
patients with acute anal fissure will respond to medical
treatment. For patients with chronic anal fissure, several
recently developed nonsurgical methods, including nitric
oxide and botulinum toxin, are available (Utzig et al,
2003). Calcium channel blockers and
α-adrenoceptor
antagonists are still at the developmental stage.
Nitric oxide
ointment is used in a concentration of 0.2%, usually tol-
erable by patients, and applied in the anal canal 2 or 3
times daily for 8 weeks. Transient headache is a major side
effect of this treatment, more commonly seen at higher
c
o
ncentrations of the compound.

Botulinum toxin injection is indicated for patients who
are unresponsive to or have contraindications for nitric
oxide treatment. Two, 0.1 mL doses of diluted toxin are
injected beneath the anal fissure with a short, thin needle;
injections can be repeated if necessary. There is a risk for
minor incontinence, flatus, and soiling with this treatment.
Surgical lateral sphincterotomy is associated with a greater
risk of incontinence and is offered to patients who relapse
or fail these newer nonsurgical methods. Sphincterotomy
can be performed under local, regional, or general anes-
thesia as an open or closed procedure and is routinely per-
formed on an outpatient basis.
Anorectal Abscess
Anorectal abscess frequently results from a cryptoglandu-
lar infection. Extension may lead to perianal, ischiorectal,
intersphincteric, or supralevator abscess. A horseshoe
abscess originates from the deep postanal space commu-
nicating to the right and left ischiorectal spaces.
530
CHAPTER 91
ANORECTAL DISEASES
STEVEN D. WEXNER,MD,AND GIOVANNA DESILVA,MD
The treatment of an anorectal abscess is incision and
drainage. With the exception of simple perianal and ischiorec-
tal abscesses, the surgery is performed in the operating room
under adequate anesthesia. A cruciate incision is made and
the edges of the skin are excised to allow adequate drainage.
A horseshoe abscess is drained through an incision made
between the coccyx and the anus, exposing the deep postanal
space. An opening made in the posterior midline and the

lower part of the internal sphincter is divided to eradicate the
source of the infected gland. Counter incisions are made over
each ischiorectal fossa to allow drainage of the anterior exten-
sions of abscess
(Figure 91-1).
An intersphincteric abscess usually requires evaluation
under anesthesia for the diagnosis. Treatment involves
unroofing of the abscess cavity by partially dividing the
internal sphincter along the length of the abscess cavity. A
supralevator abscess most often results from a pelvic abscess,
but can also result from an upward extension of an inter-
sphincteric or ischiorectal abscess. It is important to deter-
mine the source of the abscess, as the surgical approach
differs in each case. If the origin is an intersphincteric
abscess, it is drained through the rectum in order to avoid
a suprasphincteric fistula, as would occur through the
ischiorectal fossa. In contrast, if the cause is an upward
extension of an ischiorectal abscess, drainage should be
through the ischiorectal fossa. Finally, if the abscess origi-
nates from the pelvis, drainage can be achieved either
through the rectal lumen or by laparotomy. It is our prac-
tice
not to perform a fistulotomy during drainage due to
the risk of incontinence as the tissue planes are inflamed
and distorted, precluding accurate assessment of sphinc-
ter involvement.
Fistula in Ano
Fistulas are classified as intersphincteric, transsphincteric,
e
xt

r
asphincteric, and suprasphincteric. Treatment is gen-
e
r
al
l
y s
urg
ical,
e
xcept in patients with CD with active prox-
imal intestinal disease. The goal of treatment is to cure the
fist
ula,
a
v
o
id recurrence, and preserve continence.
Therefore, identification of the primary opening and side
t
r
a
cts and division of the least amount of muscle are the
k
e
y fa
c
t
o
r

s for surgical success.
532 / Advanced Therapy in Gastroenterology and Liver Disease
the edge of the lesion and in all four quadrants of the per-
ineum. Biopsies are taken at the dentate line, anal verge,
and the perineum. In the absence of invasive cancer, a wide
local excision is performed. Small defects are primarily
c
losed, while large wounds are covered by split thickness
or rotational or advancement flaps or left to heal by sec-
ondary intention. In the presence of invasive carcinoma,
a more aggressive approach such as abdominoperineal
resection or combined chemoradiation therapy is indi-
cated. Microscopic disease serendipitously found in hem-
orrhoidectomy specimens is conservatively treated with
close follow up. Current controversy surrounds the treat-
ment of Bowen’s disease. Recent data suggest that areas of
anal intraepithelial neoplasia can usually be evaluated. If
this conservative approach is ultimately proven sufficient,
then the disfiguring excisional procedure will be avoided.
Paget’s Disease
Paget’s disease is a potentially malignant lesion consisting
of intraepithelial adenocarcinoma. Association with syn-
chronous visceral carcinomas is stronger for Paget’s than for
Bowen’s disease, and, therefore, appropriate evaluation to
exclude malignancies is recommended. Diagnosis and
management is similar to that for Bowen’s disease.Patients
are closely monitored and a biopsy of any suspicious lesion
is performed; local recurrence is treated with repeat wide
local excision.
Rectal Prolapse

Rectal prolapse is a full thickness protrusion of the rectum
through the anal sphincters. The treatment is surgical
repair; whether a perineal or a transabdominal repair is
indicated depends mainly on the patient’s medical condi-
tion (Figure 91-2). The laparoscopic technique consists
of mobilization of the rectum in the presacral space to the
levator ani and direct suture of the lateral rectal attach-
ments to the presacral fascia. Because division of the lat-
eral stalks decrease the recurrence rate but increase
postoperative constipation, we perform a full posterior and
anterior mobilization but only divide the upper half of the
lateral stalks. Other fixation procedures which use mesh to
fix the rectum to the presacral fascia have been advocated;
however, we prefer to avoid using foreign material in the
pelvis. The abdominal approach has lower recurrence rates
with slightly higher morbidity compared with the perineal
approach. Regarding the perineal techniques, in a previous
report from our institution comparing Delorme procedure
and p
erineal rectosigmoidectomy with and without leva-
torplasty, the recurrence rate was statistically significantly
different at 27.5%, 12.5% and 4%, respectively (Agachan
e
t al, 1997).
able to avoid more extensive surgery.
There are two chapters on perianal disease in CD (see
Chapter 82, “Perianal Disease in Inflammatory Bowel
Disease” and Chapter 83, “Dysplasia Surveillance
P
rogram”).

Anal Neoplasm
Evaluation including digital rectal examination, colonoscopy,
endorectal ultrasound, computed tomography, and exami-
nation of inguinal lymph nodes is performed to evaluate the
nodal and systemic spread of the disease. The great major-
ity of anal tumors consist of squamous cell carcinoma. Our
management consists of a modified version of Nigro’s pro-
tocol with
combined chemoradiation therapy (Beck and
Wexner, 1996) Radiation entails 30 to 48 Gy given over 4
weeks plus administration of IV 5- fluorouracil (1,000
mg/m
2
/d) on days 1 to 5 and days 31 to 35 and mitomycin
C (15 mg/m
2
) on day 1. After completion of chemoradia-
tion, patients are closely monitored with digital examina-
tion, proctoscopy, and biopsies of tissue from any
suspicious areas. Patients with persistent or recurrent dis-
ease may be recommended to undergo salvage chemother-
apy with cisplatin with or without radiation.However,
abdominoperineal resection is still occasionally indicated.
Adenocarcinoma of the anal canal may arise from a chronic
fistula. Because of the high recurrence rates despite radi-
cal surgery, we have also used combined modality ther-
apy for these tumors.
Anorectal melanoma is associated with a very poor prog-
nosis. The treatment is
surgical as these tumors are resis-

tant to chemoradiation therapy. The size and depth of the
tumor is the strongest determinant of outcome. If local con-
trol can be obtained, or in the case of advanced disease,
wide
local excision is performed. Abdominoperineal resection is
reserved for patients in whom local control is not possible
by wide local excision or for salvage local control in selected
patients with an isolated local recurrence. However, in the
vast majority of these patients local excision is the appro-
priate therapy as abdominoperineal resection does not
appear to confer any additional advantages related to recur-
rence or survival.
Bowen’s Disease
Bowen’s disease is a rare, potentially malignant intraep-
ithelial squamous cell carcinoma (carcinoma in situ). If the
lesion is visible, biopsy and histopathologic evaluation is
required to distinguish it from other perianal dermatoses.
Once the diagnosis is made, we perform “anal map
ping
,
”
to assess the extent of the disease and to ensure excision of
the lesion with negative microscopic margins. The “anal
mapping”technique consists of biopsies taken at 1 cm from
534 / Advanced Therapy in Gastroenterology and Liver Disease
the high penicillin resistance, a single dose of 250 mg intra-
muscular ceftriaxone (Rocephin) followed by 100 mg oral
doxycycline bid for 7 days may be used as a first choice.
Recurrence rates may be high (up to 35%), therefore, the
p

atient is instructed to return for follow-up for smears and
cultures to confirm remission. Because patients with gon-
orrhea may have associated chlamydial infection, treatment
for chlamydia is instituted as well.
Chlamydia trachomatis
Chlamydia infection is caused by Chlamydia trachomatis.
The organism can cause proctitis similar to that of CD.
Untreated disease may become ulcerated causing fistulas,
abscesses, or rectal stricture, which may be misdiagnosed as
adenocarcinoma. Diagnosis is usually made by serology.
Treatment consists of oral tetracycline or erythromycin, 500
mg 4 times a day for 3 weeks. Rectal strictures are primar-
ily treated medically; in case of failure, surgical resection
with coloanal anastomosis may be required.
Patients with moderate to severe stenosis are treated with
advancement flap procedures, which replace the fibrous
tissue with elastic compliant neoanoderm. We prefer to use
the house shape flap (Figure 91-3). The advantage of this
f
lap over other described flaps (V-Y, Y-V) is that it has a
broader base allowing advancement of maximal skin to the
stenosis without tension on the flap. This technique con-
sists of performing an incision in the stenotic area and
advancing the mobilized flap of skin in that area. The edges
of the flap are then sutured at the level of the stenosis.
Either the flap may be unilateral or bilateral.
For patients who may require excision of a large amount
of skin, such as patients with Bowen’s or Paget’s disease,
the S-plasty is a good option. The defect is covered by a
double rotational flap, outlined by a large “S” with the anal

canal in the center (Figure 91-4).
Sexually Transmitted Diseases
Gonorrhea
Gonorrhea is caused by Neisseria gonorrhea, affecting pri-
marily the rectum, leading to severe proctitis with a yellow
mucopurulent discharge. The diagnosis is confirmed by a
swab and culturing of the rectal discharge using
Thayer–Martin medium. The treatment is instituted
empirically with 4.8 million units of intramuscular aque-
ous procaine penicillin G and 1 g oral probenecid. Due to
FIGURE 91-3. House shape (advancement) flap: A, House shaped
flap is created;
B, the flap is advanced into the anal canal; and C, sutured
in place. Reprinted from Fundamentals of Anor
ectal Sur
gery, 2nd Edition,
Wexner et al, Fistula in ano and anal stenosis (Fig 14.12, page 221).
Reproduced with permission from Elsevier Ltd.
FIGURE 91-4: S-plasty
.
A, Perianal skin lesion r
equiring removal
of large skin area;
B, area of perianal skin excised, lateral curves incised
into buttocks;
C, curves of skin advanced into perianal defect and secured
laterally to produce S-shaped closure of rotated flaps. Reprinted from
Fundamentals of Anor
ectal Sur
ger

y, 2nd Edition, Wexner et al, Fistula
in ano and anal stenosis (Fig 14.13, page 221). Reproduced with per-
mission from Elsevier Ltd.
A
B
C
A
B
C
tum, systemic diseases, diarrheal states, and dermatologic
conditions, in which case appropriate therapy is instituted.
T
he majority of cases, however, are idiopathic and there
is no panacea treatment for this condition. First, it is
important to reassure these patients that they do not have
a cancer; avoidance of scratching is essential and is empha-
sized in order to break the scratch-itching-scratch cycle.
Clothing is discussed and tight fitting pants or undergar-
ments should be avoided, and all possible irritants to the
perianal area, such as harsh toilet papers, soaps, creams,
and ointments, should be discontinued. Foods and bever-
ages
such as tomatoes, spicy foods, nuts, coffee (regular or
decaffeinated), milk products, tea, beer, wine, and choco-
late can cause pruritus and the patient is instructed to
elim-
inate each of these products for a 1 week duration to help
determine if any are causative factors. It is extremely
important that the perianal skin be kept clean and dry.
Patients are instructed to clean the perianal area gently but

thoroughly after each bowel movement with water or a
nonalcoholic towelette and dry it with a hair dryer at a cool
setting or by dabbing with a soft cotton cloth. Bulking
agents are added to regulate bowel habits and minimize
incomplete evacuation and soiling. Warm sitz baths for 20
minutes may also provide some relief.
Short term hydro-
cortisone cream 0.5 to 1% can be used in resistant cases.
Supplemental Reading
Agachan F, Reissman P, Pfeifer J, et al. Comparison of three
perineal procedures for the treatment of rectal prolapse. South
Med J 1997;90:925–32.
Beck ED, Wexner SD. Anal neoplasms. In: Beck DE, Wexner SD,
editors. Fundamentals of anorectal surgery. 2nd ed. London:
WB Saunders; 1996. p. 261–77.
Fleshman JW. Fissure in ano and anal stenosis. In: Beck DE,
Wexner SD, editors. Fundamentals of anorectal surgery, 2nd
ed. London: WB Saunders; 1996. p. 221.
Mizrahi N, Wexner SD, Da Silva GM, et al. Endorectal
a
d
vancement flap: are there predictors of failure? Dis Colon
Rectum 2002;45:1616–21.
Utzig MJ, Kroesen AJ, Buhr HJ. Concepts in pathogenesis and
treatment of chronic anal fissure—a review of the literature.
Am J Gastroenterol 2003;98:968–74.
Vasilevsky CA. Fistula in ano and abscess. In: Beck DE, Wexner
SD,
e
dit

o
rs. Fundamentals of anorectal surgery, 2nd ed.
London: WB Saunders; 1996. p. 156.
Zmora O, Mizrahi N, Rotholtz N, et al. Fibrin glue sealing in the
t
reatment of perineal fistulas. Dis Colon Rectum
2003;46:584–9.
Herpes
H
erpetic infection is confirmed by
c
ulture
o
f suspicious
vesicles. Management of acute symptoms includes anal-
gesics, sitz baths, and stool softeners. Oral acyclovir
(Zocyrax), 200 to 400 mg 5 times a day for 10 days is pre-
scribed to shorten the duration of pain, viral shedding, and
systemic symptoms in primary herpes.
Syphilis
Primary anal syphilis can manifest as a painless fissure.If
left untreated it can progress to secondary syphilis mani-
fested in the perianal area as condyloma latum, multiple
raised warty lesions that coalesce.
Tertiary syphilis can occur
at more than 1 year following primary infection, mani-
festing as neurologic, cardiovascular, renal, hepatic,
mucosal, and ocular symptoms. Once the diagnosis is con-
sidered, a biopsy is performed on the suspicious ulcer and
the tissue is evaluated under

darkfield microscopy and with
serologic testing. Therapy consists of a 2.4 million units
intramuscular benzathine penicillin injection. In patients
allergic to penicillin, doxycycline may be used.
Condylomata Acuminata
The management of condylomata acuminata depends on
the extent and location of the lesions. Treatment options
include destructive therapy (podophyllin, trichloroacetic
acid, bichloroacetic acid, electrocautery, and laser surgery),
excisional therapy, and immunotherapy. We prefer
bichloroacetic acid 89 to 90%, a caustic agent that, unlike
podophyllin, can be used on the perineum and inside the
anal canal, has no systemic toxicity, and does not cause the
histological changes resembling carcinoma in situ, which
can o
c
cur after podophyllin application. Application can be
done at 7 to 10 day intervals.
Surgical excision has the imme-
diate advantage of reliably eliminating warts and allowing
tissue collection for histopathologic analysis. However, it is
associated with significant pain, potential stricture forma-
tion, and cost for the anesthesia. Thus, topical therapy is
preferred unless there is extensive condyloma. Immuno-
therapy is reserved for patients with recurrent warts.
Pruritus Ani
Pruritus ani is a difficult condition to treat. A careful his-
tory and physical examination should be performed to
exclude secondary causes, such as diseases of the anorec-
Anorectal Diseases / 535

536
CHAPTER 92
HEMORRHOIDS
NIR WASSERBERG,MD,AND HOWARD S. KAUFMAN,MD
rhoids are occluded veins induced by congestion and vas-
cular hyperplasia. However, the most widely accepted the-
ory suggests that pathologic slippage of the anal canal lining
is induced by attenuation of the muscular fibers anchoring
the vascular cushions caused by continued downward pres-
sure during defecation. This process results in sliding, con-
gestion, bleeding, and eventual prolapse of the hemorrhoids.
Contributing factors include chronic straining, aging,
increased intra-abdominal pressure, and absence of sinu-
soidal valves. Elevated anal resting pressures and ultraslow
waves are associated physiological changes; however, the
importance of these findings is unclear and may only rep-
resent secondary phenomena.
Diagnosis
The diagnosis of hemorrhoidal disease is based upon elu-
cidating a proper history and performing a physical exam-
ination. Patients usually complain of blood appearing on
the toilet tissue and/or in the toilet bowl after defecation. In
Hemorrhoidal disease is a very common medical distur-
bance, equally distributed among males and females.
Incidence peaks at middle age, and declines after the age of
65 years. Because many patients attribute anorectal symp-
toms to hemorrhoids, the precise occurrence of hemor-
rhoidal disease is difficult to compute. The probable
prevalence of this condition as estimated by questionnaires
is between 4 to 40%, with approximately 1,100 medical

office visits per 100,000 persons annually (Sardinha and
Corman, 2002).
Anatomy and Physiology
Hemorrhoids are cushions of vascular tissue that are pre-
sent from birth and are therefore considered normal
anatomy. Internal hemorrhoids arise from the superior
hemorrhoidal vascular plexus cephalad to the dentate line
and are covered by mucosa. External hemorrhoids are dila-
tions of the inferior hemorrhoidal plexus. Located below
the dentate line, they are covered with anoderm and peri-
anal skin. Because these plexuses communicate, a combi-
nation of external and internal hemorrhoid (mixed
hemorrhoids, Figure 92-1) is often seen.
There are three major hemorrhoidal cushions, which
appear in the left lateral, right anterior, and right posterior
positions; however, intervening minor hemorrhoidal com-
plexes may obscure this order. Although the exact role of
hemorrhoidal cushions has yet to be defined, it is gener-
ally accepted that these vascular cushions contribute to
continence by partially occluding the anus. Additionally,
they may protect the anal canal during defecation.
Pathophysiology
Many theories have been proposed to describe the mecha-
nism by which hemorrhoids protrude and become symp-
tomatic, causing bleeding, soiling, pruritus, difficulty with
h
ygiene, and occasional pain (Loder et al, 1994).
Hemorrhoids were once believed to be varicosities of the
hemorrhoidal veins induced by portal hypertension.
Although portal hypertension may contribute to the devel-

opment of anorectal varices, hemorrhoids may form inde-
pendently and distinctively to the degree of portal
hypertension. Another popular explanation is that hemor-
FIGURE 92-1. Patient in pr
one position with mixed hemor
r
hoids
(both internal and external components) in classic locations in the left
lateral, right posterior, and right anterior positions.
Hemorrhoids / 537
some patients, chronic hemorrhoidal bleeding may cause
asymptomatic or even symptomatic anemia. Patients may
complain of tissue protrusion, mucus discharge, itching,
perianal hygiene difficulties, and incomplete evacuation.
C
onstipation is common but not secondary to hemor-
rhoids. Pain is uncommon and is usually associated with
complicated thrombosed or ulcerated hemorrhoids. Other
anorectal pathologies such as anal fissures, fistulas, skin tags,
inflammatory bowel disease (IBD), tumor, and rectal pro-
lapse should be included in the differential diagnosis.
The patient should be thoroughly examined in the left
lateral decubitus position with a step-by-step explanation
provided to the patient of what will occur during the exam-
ination. Digital examination should be gently performed
after inspection and palpation of the perianal region for
masses and tenderness. Abnormalities should be anatomi-
cally described and recorded (ie, left lateral, right poste-
rior, etc) with particular attention to thrombosis, ulceration,
sites of drainage, and/or any signs of necrosis. The exami-

nation should be completed by anoscopy and by rigid or,
preferably,flexible sigmoidoscopy.Full colonoscopy is indi-
cated to rule out any other proximal pathology in patients
> 50 years of age or younger,if risk factors for colorectal car-
cinoma exist or if bleeding persists after treatment of hem-
orrhoids. Other anorectal physiology tests have no use, thus
far, in the diagnosis of hemorrhoidal disease.
Classification
Hemorrhoids are classified by location as internal, external
or mixed in relation to the dentate line, and by the degree
of
prolapse. External hemorrhoids are located below the
dentate line, are covered by squamous mucosa, and are
painful when thrombosis occurs.
Internal hemorrhoids are
lo
cat
ed above the dentate line and may prolapse, throm-
bose, or bleed. The degree of
prolapse is staged as follows:
1. Cushions bulge into the lumen and may bleed dur-
ing defecation but do not prolapse
2. Cushions prolapse during defecation or straining but
reduce spontaneously
3. Cushions prolapse outside the anal canal and may be
manually reduced
4 Irreducible piles
Treatment
Management of hemorrhoidal disease is dictated by symp-
toms, location (external versus internal versus mixed), the

d
egree of prolapse, and the length of time from presentation
(for thrombosed external hemorrhoids). Therapy should be
tailored appropriately to relieve symptoms and to uphold
remission (The Standards Task Force, 1993). Aside from
hemorrhoidectomy, most types of therapy can be performed
in a medical office setting.
Certain practical guidelines should be applied regard-
less of the hemorrhoidal type or stage. Patients should be
i
nstructed on proper bowel habits including quick response
to defecation urge and avoidance of unnecessary prolonged
toilet time. Proper perianal hygiene may reduce irritation
and itching. Patients should be instructed to use moistened
toilet paper (not recycled or perfumed) or wipes, and fre-
quent sitz baths are recommended, particularly following
a bowel movement.
Dietary high fiber supplements (20 to 30 g/d) with or
without additional bulking agents, such as psyllium, are
recommended to reduce the need to apply increasing
downward pressure during defecation. Fiber supplements
have been suggested to reduce bleeding and pain during
defecation, however, the data are inconsistent.
Prescription and nonprescription topical agents are plen-
tiful and include creams,suppositories, and ointments. These
products may contain astringents, analgesics, and steroidal
and nonsteroidal elements that function as anti-inflammatory,
local vasoconstrictors and anesthetic mediators to relieve
local symptoms.Allergic reactions to anesthetic preparations
have been reported. Other than the potential risk of devel-

oping contact dermatitis after long term use of topical
steroids, topical substances are generally considered safe.
Despite the widespread use of these products, there have
been no clinical trials to confirm their therapeutic value.
Management of External Hemorrhoids
Patients who present with acutely thrombosed external
hemorrhoids will typically complain of an intensely painful
anal mass. Inspection of the perianal skin reveals the diag-
nosis with a swollen, tense external hemorrhoid. If such a
lesion is not present, anal fissure or perianal abscess must
be ruled out.
Excision is recommended for a thrombosed hemorrhoid
manifested with intense pain if duration is within 48 hours
of onset, or if ulceration or rupture occurs. If pain is
improving, symptomatic therapy with sitz baths, bulking
agents, and analgesics is preferred. Excision may be per-
formed in the office using local anesthetic. The wound is
le
ft o
p
e
n t
o heal b
y secondary intention. Larger, more
broadly based thromboses may be managed by incision and
evacuation of the clot to avoid creation of a large skin defect.
Management of Internal and Mixed
Hemorrhoids
Nonsurgical Treatment
Most patients visiting a physician have already tried some

form of conservative therapy and come for medical attention
because of persistent symptoms. A variety of office-based
the
r
apies ar
e a
vailable, and common to these nonoperative
p
rocedures is the aim of abolishing the underlying patho-
538 / Advanced Therapy in Gastroenterology and Liver Disease
physiologic mechanism of advanced hemorrhoidal disease.
By promoting tissue fibrosis in various ways, the vascular
cushions become fixed to the underlying muscular tissue.
I
njection Sclerotherapy
Injection sclerotherapy has been used for hemorrhoidal dis-
ease treatment for over 100 years. Indicated to treat bleed-
ing first, second, or early third degree internal hemorrhoids,
a small amount of a sclerosing agent is injected above the
dentate line. Five percent
phenol in vegetable oil has been
traditionally used, but other agents such as
quinine, urea
hydrochloride
, and sodium morrhuate, are available. It is a
straightforward, quick, painless, and inexpensive method,
with success reported in up to 75% of patients. Although
complications of pelvic sepsis and perianal necrosis have
been reported, sloughing of the overlying mucosa, local
infections, and allergic reactions to the injected material are

more commonly described side effects.
R
UBBER BAND LIGATION
Rubber band ligation is probably the most commonly used
nonoperative modality to treat internal hemorrhoids. It
is generally a safe, simple and cost effective procedure indi-
cated for second or third degree hemorrhoidal disease. An
elastic rubber band is applied anoscopically or endoscop-
ically by means of a special introducer to the tissue just
above or at the base of a symptomatic pile. Care must be
taken to apply the band above the dentate line, otherwise
severe pain will ensue, and the band will need to be
removed. Rubber band ligation induces necrosis and
slough of the strangulated mucosa. Fibrosis occurs, and the
remaining cushion becomes fixed to the underlying tissue.
Patients should be informed to expect
delayed rectal bleed-
ing in about 7 to 10 days after the procedure.
Treatment of more than one hemorrhoidal group per ses-
sion is the subject of continued debate. Proponents of mul-
tiple banding at a single session cite a low completion rate
and quicker total treatment time with less office visits and
more rapid resolution of symptoms (Armstrong, 2003).
Alternatively, those who believe in banding only one group
per visit avoid multiple bands because of the potential for
increased discomfort, potential for obstruction, and an
increased risk of septic complications. Up to
80% of patients
will benefit from rubber band ligation. The recurrence rate is
between 15 to 20%, with

<
2% incidence of minor compli-
cations such as anal pain and bleeding. Rare cases of pelvic
sepsis have been reported.
THERMAL INJUR
Y
Alternative methods of treatment use different energy
sources to induce hemorrhoidal fixation by way of thermal
injury. These techniques include electrocoagulation, heater
probes, laser photocoagulation,
and infrared photocoagula-
tion (IRC). IRC uses an infrared source to generate high
temperature to induce submucosal tissue destruction. This
technique is uncomplicated, easy to perform, and mild with
good results and low morbidity. However, the expense of
t
his equipment for office-based therapy has diminished its
use. Cyrotherapy produces tissue destruction by a rapid cel-
lular freezing and thawing. Postprocedural pain, slow heal-
ing and risk for internal sphincter damage have led most
surgeons to abandon this method.
There are no good prospective randomized control stud-
ies that compare the various fixation modalities, and exist-
ing trials do not demonstrate superiority of any particular
method. In a meta-analysis comparing injection sclerother-
apy, IRC, and rubber band ligation, injection sclerotherapy
was found to be somewhat less efficient than the other forms
of therapy.
5
In the absence of randomized trials, and because

treatment methods appear equally effective, the technique
chosen for each patient should be customized to the prob-
lem and to the experience of the treating surgeon or physi-
cian. Regardless of the solution offered, patients should be
advised to continue following general recommendations,
such as avoiding straining and maintaining fiber use. Patient
follow-up should continue for treatment effectiveness and
to complete the colon evaluation as described above.
STRANGULATED PROLAPSED INTERNAL HEMORRHOIDS
Strangulated prolapsed internal hemorrhoids are often ede-
matous and thrombosed due to a compromised venous
return. Initial management is usually nonoperative. If the
piles are not gangrenous, a perineal field block may be per-
formed to aid in manual reduction. Application of
table
sugar (sucrose) to prolapsed hemorrhoids acts as a desic-
cant to absorb fluid and reduce hemorrhoidal edema. If
s
uc
cessful in reducing incarcerated piles, less morbid treat-
ment may then be performed more electively. Severe pain
accompanied by a foul smelling discharge usually implies
the presence of gangrene. Under these conditions, urgent
hemorrhoidectomy is indicated.
Special situations deserve mention.
Pregnant women
frequently endure hemorrhoidal disease. Conservative
treatment is recommended, because symptoms usually
subside after delivery. Nonsurgical treatment is also advised
for immunocompromised patients and/or in patients suf-

fering from IBD. Perianal procedures may result in infec-
tion and delayed wound healing in these patients.
Surgical Treatment
Indications for surgical hemorrhoidectomy include
advanced third or fourth degree piles, mixed hemorrhoids,
e
xtensive thrombosis, ulceration, and gangrene. The choice
of surgical procedure depends upon the patient’s condi-
tion, and surgeon and patient preferences. Similarly, anes-
the
tic choices include local anesthesia plus monitored
FIGURE 92-2. Four
th degr
ee (ir
r
educible) hemor
r
hoids befor
e (A)
and immediately after (B) procedure for prolaspe and hemorrhoids (PPH)
has been performed. Circumferential specimen of mucosa and submu-
cosa excised with the PPH stapler (C).
A
B
C
Hemorrhoids / 539
sedation, regional techniques, and general anesthesia.
Traditionally, regional training and culture have influenced
the choice of operation. Most surgeons in the United States
practice the closed technique,or Ferguson hemorrhoidec-

t
omy,
w
here following hemorrhoidal excision, the rectal
mucosa and anoderm are closed with an absorbable radial
suture line beginning at the apex of each hemorrhoidal
complex. Recurrence rates are < 2%. Scissors, electrocoutery,
laser, and scalpel may be used; however, none have been
proven to be superior over other means of excision.
Hemorrhoidectomy using advanced technologies such as
harmonic scalpel and ligasure have been reported to have
fewer complications and a quicker return to daily living,
however, further evaluations are indicated.
Alternatively, surgeons in the United Kingdom, Europe,
and many parts of Asia favor the
open hemorrhoidectomy
technique described by Milligan and Morgan. After exci-
sion of the hemorrhoidal complex(es) with overlying skin
and rectal mucosa and ligation of the base(s) of the pile(s),
surgical wounds are left open to heal by secondary inten-
tion. An open wound minimizes the risk for infection, but
a longer convalescence period and considerable discom-
fort may result (Senagore, 2002). This technique is advised
in the presence of gangrene where there is a greater risk for
infection, or when surgical judgment suggests that closure
may be too tight or promotes stricture formation.
Procedure for Prolase and Hemorroids
Recently, an alternative technique has been developed and
tested that is associated with markedly reduced postopera-
tive pain (Sutherland et al, 2002). The procedure for pro-

lapse and hemorrhoids (PPH), or
stapled hemorrhoidectomy,
employs a circular stapler with a hollow head to excise a cuff
of tissue at the most superior aspect of hemorrhoidal com-
plexes and create a superficial end-to-end anastomosis
(Figure 92-2). During this procedure, a submucosal purses-
tring is placed 4 cm above the dentate line and is secured to
the post of the anvil of the stapler. The excess tissue is pulled
into the hollow head of the stapler as the stapler is closed. As
the stapler is fired, a circumferential cuff of tissue is excised,
and the superficial anastomosis is created. In effect an
anopexy is performed which lifts the prolapsed tissue into
the anal canal. Randomized trials have reported significantly
lower pain scores when compared to conventional hemor-
rhoidectomy procedures. Although higher instrument costs
may deter widespread acceptance of the PPH, less pain, a
shorter convalescence, and earlier return to normal activity
should be considered in the choice of surgical therapy.
Conclusions
Hemorrhoids are a common condition with a variety of
presenting symptoms. Rectal bleeding should not be attrib-
540 / Advanced Therapy in Gastroenterology and Liver Disease
uted to hemorrhoids alone without proper investigations,
especially if symptoms persist following therapy. Most early
lesions may be treated in the office setting. Advances in
stapling devices offer less painful means of surgical man-
a
gement for advanced hemorrhoidal disease.
Supplemental Reading
A

rmstrong DN. Multiple hemorrhoidal ligation: a prospective,
randomized trial evaluating a new technique. Dis Colon
Rectum 2003;46:179–86.
Guy RJ, Seow-Choen F. Septic complications after treatment of
haemorrhoids. Br J Surg 2003;90:147–56.
Johanson JF. Nonsurgical treatment of hemorrhoids. J Gastrointest
Surg 2002;6:290–4.
J
ohanson JF, Rimm A. Optimal nonsurgical treatment of
hemorrhoids: a comparative analysis of infrared coagulation,
rubber band ligation, and injection sclerotherapy. Am J
Gastroenterol 1992;87:1600–6.
L
oder PB, Kamm MA, Nicholls RJ, Phillips RK. Hemorrhoids:
p
athology, pathophysiology and aetiology. Br J Surg
1994;81:946–54.
Sardinha TC, Corman ML. Hemorrhoids. Surg Clin North Am
2002;82:1153–67.
S
enagore AJ. Surgical management of hemorrhoids. J Gastrointest
Surg 2002;6:295–8.
Sutherland LM, Burchard AK, Matsuda K,et al.A systematic review
of stapled hemorrhoidectomy.Arch Surg 2002;137:1395–406.
The Standards Task Force American Society of Colon and
Rectal Surgeons. Practice parameters for the treatment of
hemorrhoids. Dis Colon Rectum 1993;36:1118–20.
541
CHAPTER 93
COLORECTAL POLYP AND

CANCER SCREENING
JOHN H. BOND,MD
Blood Screening Trial have demonstrated that when screen-
ing leads to resection of adenomas before they turn malig-
nant, not only is cancer death prevented, but the incidence
of colorectal cancer with its attendant morbidity and treat-
ment costs also is substantially reduced (Winawer et al,
1993; Mandel et al, 2000).
The Advanced Adenoma as the Primary Target of
Screening
The prevalence of small (≤ 1 cm) simple tubular adeno-
mas in adults over the age of 50 years exceeds 30%. These
common small adenomas, however, have a very low
malignant potential. Studies indicate that most remain
static or actually regress with time, whereas only a few
develop the additional acquired genetic changes that
make them grow, develop the advanced histologic changes
of villous architecture or high grade dysplasia, and turn
eventually to cancer.
Advanced adenomas as defined by
the National Polyp Study are those that are ≥ 1 cm in size
or contain villous tissue or high grade dysplasia
. These
advanced polyps are much less common, but much more
likely to progress to cancer if not detected by screening.
A larg
e b
ody of recent scientific data indicates that we
clinicians should shift our focus away from simply detect-
ing and removing large numbers of small tubular ade-

nomas, toward
strategies that reliably detect most advanced
adenomas. Long term postpolypectomy studies nicely
demonstrate the validity of this important concept (Bond,
2000). Follow-up studies from the Mayo Clinic and from
St. Mark’s Hospital in London show that patients with
resection of only one or two small tubular adenomas have
no measurable increased risk of developing subsequent
colorectal cancer compared with the average population.
In contrast, patients with large (≥ 1 cm) or multiple (≥ 3)
adenomas, or adenomas with villous changes or high
grade dysplasia have a risk of metachronous cancer that
is incr
eased 3- to 6-fold. Thus, the
o
bjectives of colorectal
cancer screening are to (1) detect cancers that have devel-
oped while they are still confined to the bowel and surgi-
cal cur
e is very likely or (2) to detect and resect
ad
vanced
adenomas thereby preventing cancer. The choice of a
screening option should be guided by how well it accom-
plishes these tw
o objectives.
Separate evidence-based guidelines developed and revised
during the past 8 years by the US Preventive Services Task
Force, a consortium of medical and surgical gastrointesti-
nal (GI) societies, and by the American Cancer Society, all

strongly recommend that physicians screen their patients
over the age of 50 years for colorectal cancer (Pigone et
al, 2002; Winawer et al, 2003; Smith et al, 2001). The guide-
lines also recommend that before beginning screening, each
patient first should be examined for any
special risks of col-
orectal cancer that might indicate the need for more intense
examination and surveillance, rather than the use of stan-
dard screening meant for asymptomatic, average-risk indi-
viduals. If a screening test is positive, appropriate diagnostic
evaluation and treatment of detected neoplasia is essential.
If screening is negative, repeat screening should be
arranged appropriately for the method used. This chapter
will include the advantages and disadvantages of current
screening options. I will also present my preferred meth-
ods to accomplish these objectives and discuss the reasons
for their selection from the menu of options contained in
the guidelines.
Objectives of Colorectal Cancer
Screening
There are two primary objectives of colorectal cancer
screening. The first is to detect cancers that have already
developed while they are still confined to the bowel and no
lymph node or distant metastases yet have occurred. Studies
indicate that the average surgical cure rate for such Dukes
A and B cancers (Stage I and II) exceeds 85% (Mandel et al,
1993). Because most of these early, favorable cancers are
asymptomatic, they must be detected by screening.
The second major objective of colorectal cancer screen-
ing is prevention. Studies now indicate that > 95% of col-

orectal cancers originate in benign adenomatous polyps
(a
denomas) that develop and grow very slowly in the colon
over many years before they turn cancerous (Bond, 2000).
Detection and resection of premalignant polyps therefore
prevent cancer, and this has become an objective of screen-
ing that is as important, or perhaps even more important,
than just detecting early cancers. Studies, such as the
National Polyp Study and the Minnesota Fecal Occult
542 / Advanced Therapy in Gastroenterology and Liver Disease
Risk Stratification for Colorectal Cancer
M
ost people are at average risk for colorectal cancer sim-
ply because they have reached the age when the prevalence
of cancer is sufficient to justify screening. Based on age-
incidence curves for this disease, guidelines recommend
that screening of the average-risk population (both men
and women) begin at the age of 50 years. Reported direct
screening colonoscopy experiences in people age 40 to 49
years confirm the very low prevalence of advanced neo-
plasia in average-risk people under age 50 years of age.
Patients with a
personal or family history of colorectal can-
cer
or adenomas, or those with long standing ulcerative col-
itis (UC) or Crohn’s colitis may have a higher risk of
colorectal cancer that often begins at an earlier age, and
these patients may benefit from special, more intensive
examination or screening. Screening recommendations for
these high risk groups are clearly outlined in the GI

Consortium Guideline (Winawer et al, 2003) and will not
be discussed further here. There is a separate chapter on
inflammatory bowel disease and cancer (see Chapter 83,
“Dysplasia Surveillance Programs”).
In order to determine whether a patient is average or
above average risk, I recommend taking a careful family
and personal history before initiating a screening option.
As spelled out in this guideline, risk stratification can
quickly be accomplished in just a few minutes by asking
each patient the following several questions well in advance
of the earliest potential initiation of screening:
1. Has the patient had colorectal cancer or resection of
a benign adenomatous polyp?
2. Does the patient have long standing chronic UC or
Crohn’s colitis that predisposes him or her to colorec-
tal cancer?
3.
H
as a family member had colorectal cancer or an ade-
nomtous polyp? If so, how many relatives were
affected, at what age was the cancer or polyp diag-
nosed, and were they first-degree relatives (parent, sib-
ling, or child)?
A positive response to any of these questions indicates
the need to do a more formal family history or more
detailed investigation of the patient’s past history to deter-
mine if more intense screening or screening at an earlier age
is justified according to the guidelines. There are separate
chapters on colonic neoplasia and genetic counseling (see
Chapter 94,“Colonic Neoplasia: Genetic Counselling”), and

colorectal polyps and polyposis syndrome (see Chapter 95,
“Colorectal Polyps and Polyposis Syndromes”).
Guideline Options for Screening
Unlike screening for other major malignancies (ie, breast,
cervix, and prostate) where a single screening test usually
is recommended, the colorectal cancer screening guidelines
present a menu of five different options, any one of which
is considered satisfactory. These options include the fol-
lowing:
1. Annual screening with fecal occult blood tests (FOBT)
2. Flexible sigmoidoscopy screening every 5 years
3. The combination of annual FOBTs and flexible sig-
moidoscopy every 5 years
4. Double-contrast barium enema (DCBE) every 5 years
5. Direct colonoscopy screening every 10 years
As discussed below, the guidelines emphasize that each
of these five options has advantages and limitations that
should be presented to the patient. Then, in a “shared deci-
sion process” the patient should be given an opportunity
to choose their own preference as to how they wish to be
screened. Proponents of screening stress that “the only
unacceptable option is to do no screening” and “the best
screening option may be the one that the patient actually
will agree to do.”
Advantages and Limitations of the
Five Screening Options
FOBT
The FOBT is the most intensively studied of the different
screening options and is the only method that has been
shown to be efficacious in randomized, controlled trials.

The Minnesota FOBT Trial demonstrated a reduction in col-
orectal cancer mortality of 33.4% and 21%, respectively, for
annual and biennial FOBT screening followed by
colonoscopy for anyone with a positive screening test
(Bond, 2002). When the data were analyzed just for those
who complied with all recommended screening, annual
FOBT screening resulted in
a 45% colorectal cancer mor-
tality reduction. This is an important number because it is
the benefit that clinicians can inform their patients to expect
if they comply with recommended screening. Further
follow-up in the Minnesota Trial also demonstrated a sig-
nificant reduction in colorectal cancer incidence in those
screened annually,presumably as the result of detection and
resection of advanced adenomatous polyps. Although
FOBT screening has been disparaged by many proponents
o
f alternative methods, it does have a number of proven
advantages. A program of
annual screening, using a rea-
sonably sensitive FOBT (ie, HemoccultSensa guaiac cards
[Beckman-Coulter, Palo Alto, CA] or one of the newer
immunochemical FOBTs) followed by colonoscopy for a
positive result, detects most colorectal cancers and many
advanced adenomas. Screening reduces both colorectal can-
c
er mortality and incidence and is feasible, widely available,
and generally acceptable to patients. Furthermore, this
o
p

t
io
n o
f
screening has a very low upfront cost.
Disadvantages of FOBT screening include low sensitivity
f
o
r polyps, especially smaller ones, and a relatively high
false-p
osit
i
v
it
y r
at
e for advanced neoplasia. In addition, to
b
e e
ff
e
c
t
i
v
e, relatively frequent screening is required.
Colorectal Polyp and Cancer Screening / 543
FLEXIBLE SIGMOIDOSCOPY
Flexible sigmoidoscopy screening also has a number of
important advantages. It detects most colorectal cancers

a
nd many advanced adenomas. An analysis from the
Veterans Affairs Multicenter Colonoscopy Screening Study
indicated that a single screening flexible sigmoidoscopy
would detect about 70 to 80% of all advanced colorectal
neoplasia, provided that those who have a left-sided neo-
plasm detected undergo subsequent full colonoscopy
(Lieberman and Weiss, 2001). Flexible sigmoidoscopy can
be performed by trained, experienced examiners accurately,
safely, and quickly following a simple bowel preparation.
The procedure is generally well tolerated by patients, and
has been shown in cohort and case-control studies to
reduce mortality from colorectal cancer within its reach by
60 to 80%. These studies also indicate that the protective
effect of a single examination lasts for 5 to 9 years; there-
fore, infrequent screening is possible.
C
OMBINATION FOBT PLUS FLEXIBLE SIGMOIDOSCOPY
The combination of annual FOBT screening plus flexible
sigmoidoscopy every 5 years largely corrects the limitations
of doing either method of screening alone. The FOBT
misses many polyps and has been shown to be relatively
insensitive for distal rectosigmoid cancers.When performed
annually, however, it will detect most colorectal cancers
before they become incurable. The flexible sigmoidoscopy
is highly accurate in the high risk left colon, but will
miss up
to 30% of proximal advanced neoplasia in patients who do
not have a synchronous distal polyp or cancer.
B

ARIUM ENEMA
Screening DCBE, although included in the menu of guide-
line options, is not used much for screening in the United
States and has not been directly studied for this purpose.
Furthermore, DCBE recently has been shown to be rela-
tively insensitive for detecting advanced neoplasia. A ret-
rospective study by Rex and colleagues (1997) showed that
about 15% of colorectal cancers are missed by barium
enema examination. The National Polyp Study performed
ba
c
k-t
o-bac
k DCBE and colonoscopy on 580 patients
undergoing postpolypectomy surveillance and showed that
the sensitivity of this method for detecting large polyps (≥
1 cm) was o
nly 48% (Winawer et al, 2000). For these rea-
sons, when this method is used for screening, the guide-
lines r
e
commend a
s
c
reening interval of 5 years
.
THREE-DIMENSION
AL
VIR
TUAL

COL
ONSCOPY
A recent New England Journal of Medicine editorial sug-
gested that three-dimensional computed tomography (CT)
scanning and reconstruction may be a consideration for
screening in the near future. The article by Pickhardt and
colleagues (2003) described 1233 asymptomatic adults who
underwent a new sophisticated 3-dimensional virtual
colonoscopy and same-day conventional colonoscopy.More
than 97% were at average risk for colorectal neoplasmia.
T
he sensitivity and specificity of virtual colonoscopy for
adenomatous polyps was comparable to standard
colonoscopy, 94% and 96% respectively for adenomatous
polyps > 10 mm on virtual colonoscopy.The sensitivity for
polyps at least 6 mm was 88.7%. Only two cancers were
found, both on virtual colonoscopy, and only one was found
on standard colonoscopy until results of the virtual
colonoscopy were revealed. Although this study should be
repeated to verify the results, its findings appear to be a
breakthrough in the use of virtual three-dimensional
colonoscopy.As the editorial asks: Is it ready for prime time?
C
OLONSCOPY SCREENING
Increasingly in the United States, direct colonoscopy screen-
ing has become the overwhelming preference of gastroen-
terologists and many others. In the broad area of preventive
screening, this option is somewhat of a perturbation of the
classic definition of a screening test. Instead of performing
a simple, acceptable, inexpensive and indirect test to iden-

tify those in the healthy at-risk population who might ben-
efit from further examination, we are substituting upfront
a highly definitive, complex, expensive and somewhat inva-
sive, diagnostic and therapeutic method. Direct screening
colonoscopy, however, is now being increasingly champi-
oned by physician and patient groups because it detects
almost all cancers and advanced adenomas, and it allows
for resection of most polyps during a single sitting. Thus
it is the most effective way of achieving both the major
goals of colorectal cancer screening—cancer prevention
thr
oug
h polypectomy and reduced mortality through the
detection of early cancers. Because of colonoscopy’s great
accuracy and the relatively long natural history of the
adenoma-carcinoma sequence,
infrequent screening (every
10 years) is possible. The VA Multicenter Colonoscopy
Screening Study demonstrated that, when performed by
well-trained experienced colonoscopists, colonoscopy
screening is feasible and very safe (Nelson et al, 2002).
Although there are no randomized controlled trials of
screening colonoscopy, compelling indirect evidence sug-
gests that this approach is very effective at reducing both
the incidence and mortality of colorectal cancer. For exam-
ple, colonoscopy and polypectomy in the National Polyp
Study cohort reduced colorectal cancer incidence by up to
90%;
there are a number of supportive case-control stud-
ies of both flexible sigmoidoscopy and colonoscopy, and

the FOBT trials effected their demonstrated reduction of
canc
er incidence and mortality by doing colonoscopy on
those with a positive screen. Limitations of direct screen-
ing colonoscopy that have not yet been satisfactorily
a
ddressed include questions of risk, cost, patient accept-