History of research of hemorrhoids is a history of one great mistake        

                         History of treatment of hemorrhoids is history of needless invasive treatment.

 Procedure for prolapsed hemorrhoids

Vindal A, Lal P, Chander J, Ramteke VK. Rectal perforation after injection sclerotherapy for hemorrhoids: Case report. Indian J Gastroenterol 2008;27:84-5

Injection sclerotherapy is a widely practised, effective, and generally safe method of treating first- and second-degree hemorrhoids. We describe possibly the first reported case of rectal perforation after injection sclerotherapy.

A 21-year-old man had symptoms of bleeding from hemorrhoids for 7 months for which he received injection sclerotherapy, using 5% phenol in almond oil from a private practitioner. Within the next 48 hours he developed pain in the perianal region, which increased on defecation, along with high-grade fever and vomiting. The perianal pain became progressively more severe over the next 5-6 days and from the 7th day onwards the patient also developed bleeding per rectum and foul-smelling discharge from the perianal area.

On general physical examination he was febrile, dehydrated, and had a pulse rate of 100/min. On local examination, there was blood at the anal opening and multiple pilonidal sinuses along the natal cleft which emitted a foul-smelling discharge. Digital rectal examination (DRE) revealed two irregular mucosal defects, one 3 cm × 3 cm at 9 o'clock position around 3 cm from the anal verge, and another 7 cm × 5 cm at 4 o'clock position, leading into the pararectal space around 3.5 cm from anal verge. On proctoscopy, the findings on DRE were confirmed.

Laboratory investigations showed hemoglobin 11.5 g/dL and WBC count 12 × 10 ³ /mL, with neutrophilia. Blood urea and blood sugar were within normal limits. X-ray of the soft tissue did not reveal any gas in the subcutaneous plane. An MRI of the pelvis (with gadolinium) revealed anorectal wall perforation at 5 o'clock position and a collection in the left ishiorectal fossa with an air-fluid level

The patient was given intravenous antibiotics (ceftriaxone 1 g q 12 hourly and metronidazole 500 mg q 8 hourly). At surgery, about 25-30 ml of purulent fluid was drained from the pararectal space. Intraoperative examination revealed rectal ulceration (3 cm × 3 cm) at 9 o'clock and perforation of the left lateral rectal wall (7 cm × 5 cm) at 3 o'clock position, which extended into the left pararectal space. The sigmoid colon and rectum were copiously lavaged with antibiotic solution and a proximal defunctioning sigmoid colostomy was done. The associated pilonidal sinuses were laid open.

The postoperative course was uneventful. Clinical examination and distal cologram revealed that at 16 weeks post surgery, rectal injuries had completely healed. The colostomy was closed 5 months after the initial surgery.

Many different substances have been used for injection sclerotherapy but the most popular sclerosant is 5% phenol in almond oil. Retroperitoneal and subcutaneous abscesses, injection ulcers, necrotizing fasciitis, anal stricture, prostatic abscess and fistula, and superficial necrosis following sclerotherapy have been described previously. In the present case, the patient developed severe reaction to the sclerosant in the form of fever and local sepsis, which caused necrosis of the wall possibly due to impairment of vascularity. To the best of our knowledge, no similar complication has been described before.

        

References

Ribbans WJ, Radcliffe AG. Retroperitoneal abscess following sclerotherapy for hemorrhoids. Dis Colon Rectum 1985;28:188-9.  

Kaman L, Aggarwal S, Kumar R, Behera A, Katariya RN. Necrotizing fasciitis after injection sclerotherapy for haemorrhoids: report of a case. Dis Colon Rectum 1999;42:419-20. 

Barwell J, Watkins RM, Lloyd-Davies E, Wilkins DC. Life-threatening retroperitoneal sepsis after hemorrhoid injection sclerotherapy: report of a case. Dis Colon Rectum 1999;42:421-3. 

Guy RJ, Seow-Choen F. Septic complications after treatment of hemorrhoids (Review). Br J Surg 2003;90:147-56. 

Hardy A, Chan CLH, Cohen CRG. The surgical management of haemorrhoids - a review. Dig Surg 2005;22:26-33.    

Comentes: Burkitt D. found in his epidemiological study that in third word countries including India hemorrhoids are rare, comparatively to Western countries. Burkitt hypothesized that the high fiber diet is responsible for this phenomenon(1), ignoring the fact that people in these  regions empty their bowels in a squatting posture. Nevertheless the hemorrhoids are still exists in third Word countries, using the squatting toilets but of low frequency. The explanation is that as 5% of people have inhereted immobile perineum and an adynamic recto anal angle(2), thus in this people the the recto anal outlet is not straitened in squatting defecation  posture explaining the potential for  developing of hemorrhoids(3).

1 Burkitt D. Hemorrhoid, varicose veins and deep vein thrombosis: epidemiological features and suggesive causative factors. The Canadian Journal of surgery 1975; 18:483-488

2 Connel A et all all. Variation of bowel habit in two population samples. Br Med J 1965; 2:1095-1099.

3 Sikirov D Comparoson of straining during defecation in Three positions. Digestive Diseases and Sciences 2003; 48:1201-1205