Benign Anorektal Hastalıklar; Hemoroidler, Anal Fissür

Müslime  Kasa

doi:10.37609/akya.4154

Yazarlar

Müslime Kasa

https://orcid.org/0000-0002-1202-9471

DOI: https://doi.org/10.37609/akya.4154.c8260

Özet

Anorektal hastalıklar, anüs ve rektum bölgesinde ortaya çıkan, farklı etiyolojik nedenlere bağlı olarak gelişen rahatsızlıkları tanımlamaktadır. Bu hastalıklar benzer klinik semptomlarla seyretmekle birlikte, altta yatan nedenler ve tedavi yaklaşımları açısından farklılık göstermektedir. Hemoroidal hastalık ve anal fissür anorektal bölgenin en yaygın görülen hastalıkları arasında yer almaktadır. Hemoroidal hastalık (basur), anal kanal çevresindeki venöz pleksusların dilatasyonu sonucu gelişir, internal (iç) ve eksternal (dış) hemoroidler olarak sınıflandırılır. Dış hemoroidler anüs çevresinde ele gelen şişlikler şeklinde hissedilir ve genellikle ağrıya yol açar. İç hemoroidler ise anüs kanalının içinde yer alır; çoğu zaman ağrısızdır ancak kanama ile kendini gösterebilir. Anal fissür (makatta çatlak), anal kanal mukozasında meydana gelen lineer yırtıklar olarak tanımlanır. Çoğunlukla kronik kabızlık, zorlanmalı defekasyon veya tekrarlayan ishal atakları sonrasında gelişmektedir. Klinik olarak defekasyon sırasında veya sonrasında şiddetli ağrı ve parlak kırmızı renkte kanama ile karakterizedir. Anorektal hastalıkların klinik belirtileri arasında anal ağrı, rektal kanama, kaşıntı, irritasyon ve defekasyon güçlüğü yer almaktadır. Ağrı, özellikle anal fissür ve tromboze eksternal hemoroid olgularında belirgin olup defekasyonla ilişkili olarak artış gösterebilir. Rektal kanama genellikle defekasyon sırasında veya sonrasında ortaya çıkan parlak kırmızı kan şeklindedir. Anal bölgede kaşıntı ve tahriş, hemoroidal hastalık ve fissür varlığında sık gözlenmekte, hastaların yaşam kalitesini olumsuz yönde etkileyebilmektedir. Anorektal hastalıkların tedavisi; hastalığın türü, şiddeti ve klinik evresine göre planlanmaktadır. Erken evre olgularda konservatif tedavi yöntemleri ön planda olup, medikal tedavi ve yaşam tarzı düzenlemeleri ile semptom kontrolü sağlanabilmektedir. Bu amaçla topikal ajanlar, fitiller ve analjezikler sıklıkla kullanılmaktadır. Kabızlığın önlenmesi amacıyla liften zengin diyet, yeterli sıvı alımı ve gerektiğinde laksatif tedaviler önerilmektedir. İleri evre hemoroidal hastalık olgularında cerrahi veya minimal invaziv girişimler gündeme gelebilmektedir. Lazer tedavileri, skleroterapi ve benzeri girişimsel yöntemler günümüzde sıkça tercih edilen tedavi seçenekleri arasında yer almaktadır.

Anorectal diseases describe disorders occurring in the anus and rectum area, developing due to various etiological causes. While these diseases present with similar clinical symptoms, they differ in underlying causes and treatment approaches. Hemorrhoidal disease and anal fissures are among the most common diseases of the anorectal region. Hemorrhoidal disease (piles) develops as a result of dilation of the venous plexuses around the anal canal and is classified as internal and external hemorrhoids. External hemorrhoids are felt as palpable swellings around the anus and usually cause pain. Internal hemorrhoids are located inside the anal canal; they are often painless but may manifest with bleeding. Anal fissures (cracks in the anus) are defined as linear tears in the mucosa of the anal canal. They most often develop after chronic constipation, strained defecation, or recurrent episodes of diarrhea. Clinically, they are characterized by severe pain during or after defecation and bright red bleeding. Clinical manifestations of anorectal diseases include anal pain, rectal bleeding, itching, irritation, and difficulty defecating. Pain is particularly prominent in cases of anal fissures and thrombosed external hemorrhoids, and may increase with defecation. Rectal bleeding is usually in the form of bright red blood that appears during or after defecation. Itching and irritation in the anal region are frequently observed in the presence of hemorrhoidal disease and fissures, and can negatively affect the quality of life of patients. Treatment of anorectal diseases is planned according to the type, severity, and clinical stage of the disease. In early-stage cases, conservative treatment methods are prioritized, and symptom control can be achieved with medical treatment and lifestyle modifications. For this purpose, topical agents, suppositories, and analgesics are frequently used. To prevent constipation, a fiber-rich diet, adequate fluid intake, and laxative treatments when necessary are recommended. In advanced-stage hemorrhoidal disease cases, surgical or minimally invasive procedures may be considered. Laser treatments, sclerotherapy, and similar interventional methods are among the frequently preferred treatment options today.

Referanslar

Lohsiriwat V. Anorectal emergencies. World Journal of Gastroenterology. 2016;22(26):5867–5878. doi:10.3748/wjg.v22.i26.5867

Barleben A, Mills S. Anorectal anatomy and physiology. Surgical Clinics of North America. 2010;90(1):1–15. doi:10.1016/j.suc.2009.10.001

Cheung O, Wald A. The management of pelvic floor disorders. Alimentary Pharmacology & Therapeutics. 2004;19(5):481–495 doi:10.1111/j.1365-2036.2004.01875.x

Hawkins AT, Davis BR, Bhama AR, et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Diseases of the Colon and Rectum. 2024;67(5):614-623. doi:10.1097/DCR.0000000000003015.

Cengiz TB, Gorgun E. Hemorrhoids: A range of treatments. Cleveland Clinic Journal of Medicine. 2019;86(9):612–620. doi:10.3949/ccjm.86a.18029

Riss S, Weiser FA, Schwameis K, et al. The prevalence of hemorrhoids in adults. International Journal of Colorectal Disease. 2012;27(2):215–220. doi:10.1007/s00384-011-1346-4

Lohsiriwat V. Treatment of hemorrhoids: A coloproctologist's view. World Journal of Gastroenterology. 2015;21(31):9245–9252. doi:10.3748/wjg.v21.i31.9245

Hegde R, Trombold JM, Dominguez JM. Colorectal Surgery Review for Primary Care Providers. Missouri Medicine. 2020;117(2):154–158. doi:10.35772/001c.12625

Kalkdijk J, Broens P, ten Broek R, et al. Functional constipation in patients with hemorrhoids: a systematic review and meta-analysis. European Journal of Gastroenterology & Hepatology. 2022;34(8):813–822. doi:10.1097/MEG.0000000000002304

Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World Journal of Gastroenterology. 2012;18(17):2009–2017. doi:10.3748/wjg.v18.i17.2009

Mott T, Latimer K, Edwards C. Hemorrhoids: Diagnosis and Treatment Options. American Family Physician. 2018;97(3):172–179. doi:10.1016/j.amjmed.2017.11.034

Foxx-Orenstein AE, Umar SB, Crowell MD. Common anorectal disorders. Gastroenterology & Hepatology. 2014;10(5):294–301.

Pasha SF, Shergill A, Acosta RD, et al. The role of endoscopy in the patient with lower GI bleeding. Gastrointestinal Endoscopy. 2014;79(6):875–885. doi:10.1016/j.gie.2013.12.026

Salati SA. Anal Fissure - an extensive update. Polski Przegląd Chirurgiczny. 2021;93(4):46–56. doi:10.5604/01.3001.0014.3476

Yeo D, Tan KY. Hemorrhoidectomy - making sense of the surgical options. World Journal of Gastroenterology. 2014;20(45):16976–16983. doi:10.3748/wjg.v20.i45.16976

Kaidar-Person O, Person B, Wexner SD. Hemorrhoidal disease: a comprehensive review. Journal of the American College of Surgeons. 2007;204(1):102–117. doi:10.1016/j.jamcollsurg.2006.09.008

De Schepper H, Coremans G, Denis MA, et al. Belgian consensus guideline on the management of hemorrhoidal disease. Acta Gastroenterologica Belgica. 2021;84(1):101–120. doi:10.51821/agbel.2021.84.1

Gallo G, Martellucci J, Sturiale AE, et al. Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease. Techniques in Coloproctology. 2020;24(2):145–164. doi:10.1007/s10151-019-02097-4

Van Tol RR, Kleijnen J, Watson AJM, et al. European Society of ColoProctology: guideline for haemorrhoidal disease. Colorectal Disease: The Official Journal of the Association of Coloproctology of Great Britain and Ireland. 2020;22(6):650–662. doi:10.1111/codi.15079

Perera N, Liolitsa D, Iype S, et al. Phlebotonics for haemorrhoids. The Cochrane Database of Systematic Reviews. 2012;2012(8):CD004322. doi:10.1002/14651858.CD004322.pub3

Alonso-Coello P, Zhou Q, Martinez-Zapata M, et al. Meta-analysis of flavonoids for the treatment of haemorrhoids. British Journal of Surgery. 2006;93(8):909–920. doi:10.1002/bjs.5406

Čavčić J, Turčić J, Martinac P, et al.Comparison of topically applied 0.2% glyceryl trinitrate ointment, incision and excision in the treatment of perianal thrombosis. Digestive and Liver Disease. 2001;33(4):335–340. doi:10.1016/s1590-8658(01)80315-4

Alldinger I, Poschinski Z, Ganzera S, et al. Perianal thrombosis: no need for surgery. Langenbeck's Archives of Surgery. 2022;407(3):1251–1256. doi:10.1007/s00423-022-02495-3

Lehur PA, Didnée AS, Faucheron J-L, et al. Cost-effectiveness of new surgical treatments for hemorrhoidal disease: a multicentre randomized controlled trial comparing transanal Doppler-guided hemorrhoidal artery ligation with mucopexy and circular stapled hemorrhoidopexy. Annals of Surgery. 2016;264(5):710–716. doi:10.1097/SLA.0000000000001523

Porrett LJ, Porrett JK, Ho Y-H. Documented complications of staple hemorrhoidopexy: a systematic review. International Surgery. 2015;100(1):44–57. doi:10.9738/INTSURG-D-14-00139.1

Poskus T, Buzinskienė D, Drasutiene G, et al. Haemorrhoids and anal fissures during pregnancy and after childbirth: a prospective cohort study. BJOG: An International Journal of Obstetrics and Gynaecology. 2014;121(13):1666–1671. doi:10.1111/1471-0528.12811

Eglinton TW, Barclay ML, Gearry RB, et al. The spectrum of perianal Crohn's disease in a population-based cohort. Diseases of the Colon and Rectum. 2012;55(7):773–777. doi:10.1097/DCR.0b013e3182525d8b

Mapel DW, Schum M, Von Worley A. The epidemiology and treatment of anal fissures in a population-based cohort. BMC Gastroenterology. 2014;14:129. doi:10.1186/1471-230X-14-129

Newman M, Collie M. Anal fissure: diagnosis, management, and referral in primary care. The British Journal of General Practice. 2019;69(685):409–410. doi:10.3399/bjgp19X704957

Beaty JS, Shashidharan M. Anal Fissure. Clinics in Colon and Rectal Surgery. 2016;29(1):30–37. doi:10.1055/s-0035-1571073

Gardner IH, Siddharthan RV, Tsikitis VL. Benign anorectal disease: hemorrhoids, fissures, and fistulas. Annals of Gastroenterology. 2020;33(1):9–18. doi:10.20524/aog.2019.0460

Boland P, Kelly M, Donlon N, et al. Management options for chronic anal fissure: a systematic review of randomised controlled trials. International Journal of Colorectal Disease. 2020;35(10):1807–1815. doi:10.1007/s00384-020-03631-5

Perry WB, Dykes SL, Buie WD, et al. Practice parameters for the management of anal fissures (3rd revision). Diseases of the Colon and Rectum. 2010;53(8):1110–1115. doi:10.1007/DCR.0b013e3181e6a7bc

Lang DS, Tho PC, Ang EN. Effectiveness of the Sitz bath in managing adult patients with anorectal disorders. Japan Journal of Nursing Science. 2011;8(2):115–128. doi:10.1111/j.1742-7924.2010.00170.x

Nevins EJ, Kanakala V. Topical diltiazem and glyceryl-trinitrate for chronic anal fissure: A meta-analysis of randomised controlled trials. Turkish Journal of Surgery. 2020;36(4):347–352. doi:10.5578/turkjsurg.5840

Brisinda G, Chiarello MM, Crocco A, et al. Botulinum toxin injection for the treatment of chronic anal fissure: uni- and multivariate analysis of the factors that promote healing. International Journal of Colorectal Disease. 2022;37(3):693–700. doi:10.1007/s00384-021-04089-4

Davids JS, Hawkins AT, Bhama AR, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anal fissures. Diseases of the Colon and Rectum. 2023;66(2):190–199. doi:10.1097/DCR.0000000000002543

Renzi A, Brusciano L, Pescatori M, et al. Pneumatic balloon dilatation for chronic anal fissure: a prospective, clinical, endosonographic, and manometric study. Diseases of the Colon and Rectum. 2005;48(1):121–126. doi:10.1007/s10350-004-0673-3

Alawady M, Emile SH, Abdelnaby M, et al. Posterolateral versus lateral internal anal sphincterotomy in the treatment of chronic anal fissure: a randomized controlled trial. International Journal of Colorectal Disease. 2018;33(10):1461–1467. doi:10.1007/s00384-018-3092-3

Mirani S, Kumar D, Ahmad A. Comparison of outcome of lateral sphincterotomy with anal advancement flap in patients of anal fissure. Pakistan Journal of Medical & Health Sciences. 2021;15:368–369.

Zeitoun JD, Blanchard P, Fathallah N, et al. Long-term outcome of a fissurectomy: a prospective single-arm study of 50 operations out of 349 initial patients. Annals of Coloproctology. 2018;34(2):83–87. doi:10.3393/ac.2017.09.06

Agorria AA, del Casar Lizcano JM, Remis EB, et al. Treatment of a chronic anal fissure with a botulin toxin A injection and fissurectomy. Revista Española de Enfermedades Digestivas. 2019;111(9):672–677. doi:10.17235/reed.2019.6028/2019

D'Orazio B, Geraci G, Martorana G, et al. Fisurectomy and anoplasty with botulinum toxin injection in patients with chronic anal posterior fissure with hypertonia: a long-term evaluation. Updates in Surgery. 2021;73(4):1575–1581. doi:10.1007/s13304-021-01053-4

Yakovlev A, Karasev SA, Dolgich OY. Sacral nerve stimulation: a novel treatment of chronic anal fissure. Diseases of the Colon and Rectum. 2011;54(3):324–327. doi:10.1007/DCR.0b013e3182081792.

Andjelkov K, Sforza M, Barisic G, et al. A novel method for treatment of chronic anal fissure: adipose‐derived regenerative cells–a pilot study. Colorectal Disease. 2017;19(6):570–575. doi:10.1111/codi.13600

Aho Fält U, Lindsten M, Strandberg S, et al. Percutaneous tibial nerve stimulation (PTNS): an alternative treatment option for chronic therapy resistant anal fissure. Techniques in Coloproctology. 2019;23(4):361–365. doi:10.1007/s10151-019-01963-5