Management of Benign Anorectal Disorders – ACG Clinical Guidelines
American College of Gastroenterology (ACG) Clinical Guideline: Management of Benign Anorectal Disorders
The American College of Gastroenterology has released new guidelines on the management of benign disorders of anorectal function and/or structure. These guidelines summarize the definitions, diagnostic criteria, differential diagnoses, and treatments of a group of benign disorders of anorectal function and / or structure. Disorders of function include defecation disorders, fecal incontinence, and proctalgia syndromes, whereas disorders of structure include anal fissure and hemorrhoids
Defecatory disorders
Diagnosis should be based on clinical history of chronic constipation, abnormal balloon expulsion test (BET) and anorectal manometry (ARM) results.
Digital rectal examination (DRE) should be the initial screening method, and barium- or MR defecography should be used to rule out obstructions.
Biofeedback is the preferred treatment for adult patients.
Chronic proctalgia
Diagnosis should be based on history of rectal pain episodes lasting 20 minutes or more, abnormal DRE results and exclusion of other causes of pain. Structural causes should be eliminated by imaging study or endoscopy.
BET and ARM can identify patients likely to respond to biofeedback therapy, the preferred treatment. Electrical stimulation and digital massage are among inferior treatments.
Proctalgia fugax
Diagnosis should be based on history of intermittent anorectal pain in episodes less than 20 minutes.
Structural causes of anorectal pain should be ruled out by imaging, endoscopy or other tests.
There are no evidence-supported treatments; patients should be assured the disorder is benign.
Fecal incontinence
Predisposing conditions should be identified. Patients should be asked directly and not relied upon for spontaneously reporting these symptoms.
Symptom severity and characteristics are best determined by the Bristol stool scale and bowel diaries, respectively.
Physical examinations should rule out causal diseases. Other diagnostics include digital anorectal exam and DRE. For patients who fail to respond to conservative therapies, ARM, BET, rectal sensation testing, pelvic floor and anal canal imaging and anal EMG are recommended.
Symptom management strategies include education, diet, skin care, pharmacologic agents, antidiarrheal agents and pelvic floor rehabilitation.
The only minimally invasive procedure is injectable anal bulking agents, but more evidence of its efficacy is needed. Surgical treatments include sacral nerve stimulation, anal sphincteroplasty, dynamic graciloplasty, artificial anal sphincter, and colostomy as a last resort.
Anal fissure
Treatments for acute fissure include sitz-baths, psyllium fiber and bulking agents.
Treatments for chronic fissure include calcium channel blockers, nitrates, local injections of botulinum toxin or surgical internal anal sphincterotomy.
Hemorrhoids
Diagnosis should be based on history, physical examination or endoscopy.
Thrombosed external hemorrhoids should typically be treated with excision.
Internal hemorrhoids should initially be treated with increased fiber and fluid intake.
First- to third- degree hemorrhoids that remain symptomatic should be treated with banding, sclerotherapy, infrared coagulation or ligation.
Surgical procedures include hemorrhoidectomy, stapled hemorrhoidopexy and Doppler-assisted hemorrhoidal artery ligation.
DEFECATORY DISORDERS (DD)
1. DDs are defined as difficulty in evacuating stool from the rectum in a patient with chronic or recurring symptoms of constipation.
2. Gastroenterologists and other providers should not make the diagnosis of DD on the basis of a single abnormal test because none is sufficiently specific. However, confidence in the diagnosis is increased if there is a combination of a clinical history of chronic constipation and two abnormal tests, i.e., impaired ability to evacuate a 50-ml water-filled balloon or abnormal defecography and evidence from pelvic floor EMG or ARM that the patient is unable to relax pelvic floor muscles or increase rectal pressure during simulated defecation.
3. Digital rectal examination is a useful first test to screen for DD, as it has good negative predictive value.
4. Barium or MR defecography can identify structural causes of outlet obstruction if one is expected. They may also confirm or exclude the diagnosis of DD when the clinical features suggest DD but the results of ARM and BET are equivocal.
5. Biofeedback is the preferred treatment for DD in adults.
The treatment protocols used in most RCTs include the following steps:
- Patient education – explain to patients that they unconsciously squeeze their anus when they are trying to defecate and this holds the stool in the rectum.
- Simulated defecation training – for patients who do not increase intraabdominal pressure during simulated defecation, the use of feedback on rectal balloon pressure teaches them to tighten their abdominal wall muscles and lower their diaphragm to push stool out.
- Training to relax pelvic floor muscles while simulating defecation — for patients who paradoxically contract their pelvic floor muscles during simulated defecation, provide visual feedback on anal canal pressure or averaged EMG activity from the anal canal to teach this skill.
- Practicing simulated defecation – patients practice defecation of a lubricated, inflated balloon while the therapist gently pulls on the catheter to assist them. Remind the patient to relax the pelvic floor muscles, increase abdominal pressure using abdominal wall muscles, and concentrate on the sensations produced by balloon passage.
PROCTALGIA SYNDROMES
1. Gastroenterologists and other providers should make a diagnosis of chronic proctalgia based on a history of recurring episodes of rectal pain, each lasting at least 20 minutes, a digital rectal examination showing tenderness to palpation of the levator ani muscles, and exclusion of other causes for rectal pain by history and diagnostic testing.
2. Gastroenterologists and other providers should obtain an imaging study or endoscopy to rule out structural causes of rectal pain.
3. Gastroenterologists and other providers should obtain a BET and ARM to identify patients with chronic proctalgia and levator muscle tenderness who are likely to respond to biofeedback.
4. Biofeedback to teach relaxation of pelvic floor muscles during simulated defecation is the preferred treatment.
5. Electrical stimulation is superior to digital massage but inferior to biofeedback.
6. Gastroenterologists and other providers should make a diagnosis of proctalgia fugax on the basis of a history of intermittent bouts of severe pain in the anal canal or lower rectum lasting less than 20 minutes.
7. Gastroenterologists and other providers should exclude structural causes of anorectal pain (e.g., anal fissure, hemorrhoids, cryptitis, malignancy) by imaging, endoscopy, or other appropriate tests.
8. Gastroenterologists and other providers should assure patients that the disorder is benign. The evidence for specific treatments is no better than anecdotal.
FECAL INCONTINENCE (FI)
1. Gastroenterologists and other providers should ask patients about the presence of FI directly rather than relying on spontaneous reporting.
2. Gastroenterologists and other providers should identify conditions that may predispose to FI i.e.:
- Anal sphincter weakness
- Traumatic: obstetric, surgical (e.g., fistulotomy, internal sphincterotomy)
- Nontraumatic: scleroderma, internal sphincter degeneration of unknown etiology
- Neuropathy: peripheral (e.g., pudendal) or generalized (e.g., diabetes mellitus)
- Disturbances of pelvic floor: rectal prolapse, descending perineum syndrome
- Inflammatory conditions: radiation proctitis, Crohn’s disease, ulcerative colitis
- Central nervous system disorders: dementia, stroke, brain tumors, multiple sclerosis, spinal cord lesions
- Diarrhea: irritable bowel syndrome, post-cholecystectomy diarrhea Other: fecal retention with overflow, behavioral disorders
3. Gastroenterologists and other providers should determine symptom severity by quantifying stool type using the Bristol stool scale, as well as characterizing the frequency, amount of leakage, and the presence of urgency.
4. Gastroenterologists and other providers should obtain bowel diaries because they are superior to self-reports for characterizing bowel habits and FI.
5. Gastroenterologists and other providers should perform a physical examination to eliminate diseases to which FI is secondary.
6. Gastroenterologists and other providers should perform a digital anorectal examination to identify rectal masses, gauge anal sphincter tone at rest, during voluntary contraction of the anal sphincter and pelvic floor muscles, and during simulated defecation.
7. Gastroenterologists and other providers should perform a digital rectal examination before making a referral for anorectal manometry.
8. ARM, BET, and rectal sensation should be evaluated in patients who fail to respond to conservative measures.
9. Pelvic floor and anal canal imaging, as well as anal EMG, should be considered for patients with reduced anal pressures who have failed conservative therapy, particularly if surgery is being considered.
10. Gastroenterologists and other providers should manage patients with FI using education, dietary modifications, skin care, and pharmacologic agents to modify stool delivery
and liquidity before diagnostic testing, particularly when symptoms are mild and not bothersome.
11. Gastroenterologists and other providers should prescribe antidiarrheal agents for FI in patients with diarrhea.
12. Pelvic floor rehabilitative techniques are effective and superior to pelvic floor exercises alone in patients with FI who do not respond to conservative measures.
13. Minimally invasive procedures such as injectable anal bulking agents may have a role in patients with FI who do not respond to conservative therapy.
14. There is insufficient evidence to recommend radiofrequency ablation treatment to the anal sphincter at this time.
15. Sacral nerve stimulation should be considered in patients with FI who do not respond to conservative therapy.
16. Anal sphincteroplasty should be considered in patients with FI who do not respond to conservative therapy and who have an anatomic sphincter defect.
17. Dynamic graciloplasty and artificial anal sphincter, where available, may possibly allow the occasional patient with FI to avoid colostomy.
18. Colostomy is a last resort procedure that can markedly improve the quality of life in a patient with severe or intractable FI.
ANAL FISSURE
1. Gastroenterologists and other providers should use nonoperative treatments such as sitz-baths, psyllium fiber, and bulking agents as the first step in therapy of acute fissure.
2. Gastroenterologists and other providers should treat chronic anal fissure with topical pharmacologic agents such as a calcium channel blockers or nitrates.
3. Gastroenterologists and other providers should refer patients who do not respond to conservative or pharmacologic treatment for local injections of botulinum toxin or surgical internal anal sphincterotomy.
HEMORRHOIDS
1. Gastroenterologists and other providers should diagnose hemorrhoids by history and physical examination. If there is bleeding, the source often requires confirmation by endoscopic studies.
2. Most patients who present urgently (within ~ 3 days of onset) with a thrombosed external hemorrhoid benefit from excision.
3. Gastroenterologists and other providers should treat patients with symptomatic hemorrhoids first with increased fiber intake and adequate fluids.
4. Gastroenterologists and other providers should consider patients with first- to third-degree hemorrhoids that remain symptomatic after dietary modifications for office procedures
such as banding, sclerotherapy, and infrared coagulation. Ligation is probably the most effective option.
5. Gastroenterologists and other providers should refer for surgical operations (hemorrhoidectomy, stapled hemorrhoidopexy, and Doppler-assisted hemorrhoidal artery ligation) those patients who are refractory to or cannot tolerate office procedures, who have large, symptomatic external tags along with their hemorrhoids, who have large third-degree hemorrhoids, or who have fourth-degree hemorrhoids.
The paper can be accessed and downloaded at http://gi.org/guideline/management-of-benign-anorectal-disorders/
Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis
The World Gastroenterology Organization (WGO) Global Guidelines published guidelines on Nonalcoholic Fatty Liver Disease and Nonalcoholic Steatohepatitis in the July issue of the Journal of Clinical Gastroenterology.
Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are the leading cause of liver disease in the western countries and NAFLD and NASH play an equally important role in the Middle East, Far East, Africa, the Caribbean, and Latin America. While NAFLD and NASH lack definitive etiology, effective therapy, or evidence-based clinical guidelines, the published WGO recommendations offer needed guidance for clinicians.
NAFLD is defined by excessive fat accumulation (steatosis) in the liver. NAFLD does not correlate with increased short-term morbidity or mortality.
NASH: A subgroup of NAFLD patients develop inflammation (steatohepatitis) which is histologically indistinguishable from alcoholic steatohepatitis. NASH dramatically increases the risks of cirrhosis, liver failure, and hepatocellular carcinoma.The exact cause of NASH has not been elucidated, although it is most closely related to insulin resistance, obesity, and the metabolic syndrome. Possible other risk factors include: hypertension, type 2 diabetes, sleep apnea, a positive family history, nonblack ethnicity, obesity, hyperlipidemia, and a sedentary lifestyle.
WGO Recommendations for NAFLD/NASH Diagnosis:
- Suspected NAFLD involves central obesity, diabetes mellitus, dyslipidemia, metabolic syndrome, abnormal liver function tests, and/or ultrasound changes consistent with fatty liver.
- Minimal assessment should include
- bilirubin
- alanine aminotransferase
- aspartate aminotransferase
- g-glutamyl transferase
- albumin
- fasting serum lipids
- complete blood count
- hepatitis C virus
- hepatitis B surface antigen
- antinuclear antibody
- fasting blood glucose
- oral glucose tolerance test if fasting blood glucose level of 5.6 mmol/L or higher
- height, weight, body mass index, waist circumference
- blood pressure
- abdominal ultrasound
- Optional tests include
- abdominal computed tomography if uninformative ultrasound
- liver biopsy if diagnostic uncertainty or for patients at risk for advanced hepatic fibrosis.
- Additional tests include tests for
- hereditary hemochromatosis
- Wilson’s disease
- alpha-1 antitrypsin deficiency
- polycystic ovary syndrome
- autoimmune liver diseases
WGO SUMMARY STATEMENT
- NAFLD and NASH represent a major global public health problem, which is pandemic and affects rich and poor countries alike.
- There is insufficient evidence to justify screening for NASH/advanced liver disease in the general population.
- The diagnosis should be sought in all patients who present with risk factors for NASH.
- Not all patients with risk factors will have NAFLD or NASH, and not all patients with NASH will have standard risk factors.
- Not every person with fatty liver needs aggressive therapy.
- Diet and exercise should be instituted for all patients.
- Liver biopsy should be reserved for those patients who have risk factors for NASH and/or other liver diseases.
- Patients with NASH or risk factors for NASH should first be treated with diet and exercise. Vitamin E or pentoxifylline may be added in these patients. Experimental therapy should be considered only in appropriate hands and only in patients who fail to achieve a 5% to 10% weight reduction over 6 months to 1 year of successful lifestyle changes.
- Bariatric surgery should be considered in patients in whom the above approaches fail, and it should be performed before the patient becomes cirrhotic.
- Liver transplantation is successful in patients who meet the criteria for liver failure; however, NASH may recur after transplantation and is likely to be denied to patients with morbid obesity.
- NAFLD and NASH are also becoming an increasingly serious problem in pediatric patients, including those under the age of 10.
Ultimately, NAFLD and NASH are diagnoses of exclusion and require careful consideration of other diagnoses. Just as the clinician cannot diagnose NASH on the basis of clinical data alone, the pathologist can document the histologic lesions of steatohepatitis, but cannot reliably distinguish those of nonalcoholic origin from those of alcoholic origin.
J Clin Gastroenterol. 2014;48:467-473.
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