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ACG updates guidelines for management of benign anorectal disorders
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The American College of Gastroenterology has released new guidelines on the management of benign disorders of anorectal function and/or structure, updated with research data through 2013.
“The newest ACG guidelines provide an update of the evaluation and management of benign anorectal disorders, which involve either disorders of function such as defecation disorders, fecal incontinence and proctalgia syndromes, or structural diseases such as hemorrhoids and anal fissures,” Arnold Wald, MD, MACG, division of gastroenterology and hepatology, University of Wisconsin School of Medicine and Public Health, and one of the researchers, told Healio.com/Gastroenterology. “As with all ACG guidelines, the authors have assessed the literature to make recommendations which are graded on the basis of quality of the available evidence.
“We hope these guidelines will assist health care providers in gastroenterology to manage patients with these disorders, in whom there remain sizable unmet needs.”
Arnold Wald
A summary of the recommendations are:
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 on for spontaneous reporting of 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.
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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.
– by Adam Leitenberger
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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Gina Sam, MD, MPH
One major point of these guidelines is really nicely outlined in the algorithm for evaluation and management of defecatory disorders (DD). It basically says to document DD with anorectal manometry plus balloon expulsion test (BET), and at that point if patients undergo biofeedback and show improvement you can just follow them clinically.
Biofeedback, usually done over 3 months with a nurse, physician or physical therapist, entails exercises to train the abdominal muscles and retrain/reconnect the receptors from the brain to the anal sphincter, because there are a lot of connections between the brain and the gut. If patients do not respond to biofeedback they may have rectoceles or some type of obstruction and should be sent for defecography or MRI proctogram. If there is an abnormality, then those are the ones you should consider for surgery.
Some patients just have a clinical rectocele and may be sent for surgery due to their constipation. If they have DD due to inability to relax the anal sphincter during defecation, these patients will have recurrence of the rectocele after you repair it if you have not corrected their DD. If they do have persistent DD and the MRI does not show a rectocele or rectal prolapse, then you might want to send them for biofeedback again.
If the patient undergoes biofeedback, changes their diet and does not have any improvement, and you have repeated the BET and it is normal, these may be a subset of patients with slow transit constipation, where the colon is actually moving or contracting slower. There are quite a few medicines that you can treat that with, including Amitiza (lubiprostone, Sucampo Pharmaceuticals), which works on the calcium channels of the colon to help secrete liquid out of the colon, and another medicine we also use for IBS or slow transit constipation is Linzess (linaclotide, Ironwood Pharmaceuticals).
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