ANORECTAL ENDOSCOPY AND SPECIFIC CONDITIONS

Proctoscopy

Proctoscopy enables one to view and biopsy the whole of the anal canal, but only a small part of the rectum is visible at its lower end. Good lighting is essential. It is helpful to obtain the patient’s confidence and cooperation. Talk to them throughout the examination. Explain the procedure and its purpose, emphasizing that it should cause only minor discomfort. Do not administer an enema unless the patient is constipated or unless sigmoidoscopy is also required.

Technique

1	Perform a preliminary digital examination. Then, with the patient in the same position, proceed to the proctoscopy to view any lesions that you have just felt. Lubricate and introduce the proctoscope, holding the handle with the fingers and pressing the thumb firmly on the head of the obturator (Figure 5.68). This grip will keep the two parts of the instrument assembled. Point the handle posteriorly.
	Figure 5.68
2	While you introduce the scope to its full length (Figure 5.69), instruct the patient to take deep breaths with the mouth open. Remove the obturator and direct the light into the scope (Figure 5.70). Remove any faecal material, mucus or blood. Align the scope so that the lumen of the gut just beyond is clearly visible. Slowly withdraw the instrument while maintaining its alignment in the gut so that you can view any mucosal lesions, including haemorrhoidal masses or polyps. Note the appearance of the mucosa and assess its integrity.
	Figure 5.69
	Figure 5.70
3	If reliable facilities for specimen examination exist, take a biopsy sample from any obviously or possibly abnormal area under direct vision, using special biopsy forceps. Remove the tissue sample through the proctoscope. Remember that taking a biopsy sample from the rectal mucosa causes some discomfort and that removal of tissue from the anal lining can produce severe pain. At this examination, do not take tissue from a haemorrhoidal mass or any other lesion that appears to be vascular.
4	Immediately after removal from the patient, fix the tissue sample by total immersion in formaldehyde saline: 10 ml of 37% formaldehyde solution + 90 ml of physiological saline; fixation takes about 48 hours. Alternatively, use a fixative as directed by your local pathologist.

Sigmoidoscopy
Sigmoidoscopy is indicated for patients who have symptomatic colorectal disease and have had an inconclusive proctoscopy. It is also indicated following an abnormal proctoscopy to detect additional lesions such as polyposis or rectal schistosomiasis. For amoebic colitis, sigmoidoscopy is useful in assessing the response of proctocolitis to treatment. It can also facilitate the introduction of a rectal tube to decompress and reduce sigmoid volvulus. This examination normally follows a rectal examination and a proctoscopy.

Technique

1	Ask the patient to evacuate the rectum. If they cannot do this spontaneously, give an enema. Check the equipment, particularly the light-head, the eyepiece fitting (window) and the inflation pump (bellows) to ensure that they fit together and that enough light reaches the end of the scope.
2	Lubricate the sigmoidoscope generously before you start and introduce it with the obturator in position. In its initial stages, sigmoidoscopy is similar to proctoscopy (Figure 5.71). Next, point the sigmoidoscope backwards and upwards as you advance it (Figures 5.72, 5.73). Hold the obturator firmly to prevent it being dislodged (Figure 5.74).
	Figure 5.71
	Figure 5.72
	Figure 5.73
	Figure 5.74
3	After introducing the sigmoidoscope about 10 cm, remove the obturator (Figure 5.75). If there is any obstruction before the sigmoidoscope has been inserted 10 cm, remove the obturator at this point. Then attach the eyepiece, which usually carries the light source and pump connections. To view the gut wall and the bowel lumen, introduce a little air and align the scope. Gently advance the instrument, keeping it accurately within the lumen of the bowel. Introduce air at intervals to open up the bowel lumen gradually beyond the scope. Should the view be obscured at any time by rectal contents, remove the eyepiece and evacuate the material using dental rolls held firmly with biopsy forceps.
	Figure 5.75
4	Progressively change the direction of the scope to keep within the lumen. Do not advance the scope unless the lumen of the bowel is in view. The rectosigmoid junction may be difficult to traverse, so do not rush the procedure. If there is much difficulty advancing the scope beyond this level, stop the procedure. Do not use force to introduce the scope or to take a biopsy specimen from the wall of the bowel. Injury or even perforation of the rectal wall can result. If the patient experiences discomfort during the examination, check for proper alignment of the sigmoidoscope, release air by removing the eyepiece or by disconnecting the pump tubing, then reassemble the instrument and continue the examination. If necessary, reintroduce the scope and repeat the examination. At the end of each examination, let out the air from the gut before withdrawing the scope.

Perianal haematoma

Perianal haematoma is usually associated with considerable pain. The inflamed area is tense, tender and easily visible upon inspection of the anal verge as a small, tender swelling about the size of a pea.

Management consists mainly of relieving the pain by local or oral administration of analgesics and by helping the patient to avoid constipation. The lesion will resolve slowly over several days or weeks. This can be expedited with hypertonic saline compresses. During this time, the haematoma may spontaneously rupture through the overlying skin, discharging blood clots and providing some pain relief. In the early stages of haematoma formation, surgical evacuation of the clot under local anaesthesia can rapidly relieve pain and discomfort. Drainage is not recommended in the sub-acute or chronic stages of perianal haematoma.

Anal fissure

An anal fissure is a tear in the mucosa of the lower anal canal. It is usually associated with intense pain, especially during and just after defecation. Hard stools precipitate and aggravate the condition.

The anus is tightly closed by spasm, so that the application of a local anaesthetic gel, or occasionally even general anaesthesia, is necessary to allow an adequate examination. The fissure may be acute or chronic, the latter having fibrotic margins.

Non-operative management is recommended, especially for an acute fissure. It should include prescription of a high-fibre diet and administration of a local anaesthetic ointment or suppository. A chronic fissure can be treated by manual dilatation of the anus.

Anal dilatation: technique

1	Before proceeding, empty the rectum by administering an enema. Give the patient a general anaesthetic without a muscle relaxant and use the tone in the anal sphincter to judge the extent to which the anal sphincter should be stretched. Perform a digital, and then proctoscopic, examination to confirm the presence of haemorrhoids (Figure 5.76, 5.77). The success of the treatment depends largely on adequate dilatation of the anus in the region of the “constricting bands”. This is achieved by applying pressure with the fingers but, to avoid over-dilatation and other complications, use no more than four fingers. Do not use any instruments.
	Figure 5.76
	Figure 5.77
2	First, insert the index and middle fingers of the left hand into the anus and press against the wall to assess the degree of constriction caused by the bands in the anal wall (Figure 5.78). Now, dilate the anus by inserting the right index finger and pressing it against the anal wall in the opposite direction to the other two fingers (Figure 5.79). Insert the middle finger of the right hand and repeat the procedure.
	Figure 5.78
	Figure 5.79
3	Finally, insert into the anus a sponge or gauze swab, soaked in a non-irritating antiseptic or saline and wrung out, or a piece of petrolatum gauze. Leave one end of the sponge or gauze protruding.
4	For aftercare, administer analgesics when indicated. Give the patient a mild laxative, such as liquid paraffin (mineral oil), to encourage the regular passing of soft, bulky stools. Instruct the patient to sit in warm water, preferably in which some salt has been dissolved, for about 15–30 minutes at least once a day for 14 days.

Complications can include haematoma formation, incontinence and mucosal prolapse. Provided that no more than four fingers are used for dilatation, no significant complications should arise.

Haemorrhoids

The main symptoms of haemorrhoids are bleeding on passing stools and prolapse of the varicose masses. Pain is not always a significant feature. Haemorrhoids are graded according to whether they prolapse and whether the prolapsed mass reduces spontaneously or must be replaced manually. Rectal examination, proctoscopy and sigmoidoscopy are necessary in diagnosing haemorrhoids and in checking for any associated conditions, in particular carcinoma of the rectum.
Complications of haemorrhoids are anaemia and thrombosis.

Treatment

Many patients benefit from a high-fibre diet which encourages regular, soft, bulky motions and the local application of an analgesic ointment or suppository. This non-operative management is sufficient for the majority of patients.

Patients whose haemorrhoids prolapse (and either return spontaneously or can be replaced) and patients in whom the above regimen has failed to give adequate relief can be treated by manual dilatation of the anus (see anal fissure). This is the only form of surgical treatment recommended for the non surgical specialist. Haemorrhoidectomy undertaken by the inexperienced can be complicated with anal stenosis. If haemorrhoidectomy is required, refer the patient to a qualified surgeon.

Never perform haemorrhoidectomy or anal dilatation on a pregnant or postpartum patient. Hypertonic saline compresses will temporize the discomfort and the haemorrhoids will improve dramatically several weeks after delivery.