Proctology
From Primary Surgery
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The general method for the anus and rectum
A patient's rectum and anus can cause him much disability and discomfort. In the tropics he can have most of the diseases which are seen elsewhere, but with a different frequency, and with a few extra ones. You should have little difficulty treating anorectal abscesses (5.13) and fistulae (22.2), piles (22.4), fissures (22.7),pilonidal sinuses (very rare in Africans, 22.8), prolapse of the rectum (22.9), juvenile polyps (22.10), lymphogranuloma venereum (22.10), and some cases of imperforate anus (28.6).
Although the anus is a particularly bacteria-laden area, so that any surgical wounds near it are sure to become infected, the infection seldom spreads, so that they readily heal - if you let them granulate from the bottom up. It is important that all your staff understand this. Don't attempt primary suture, and instead make wide, shallow saucer-like wounds. Don't let his subcutaneous tissues or his skin edges fall together and unite prematurely, before the bottom of his wound has healed. A shallow, open wound with trimmed edges heals better than one with much redundant skin and fat.
PHYSIOLOGY. The purpose of a patient's anus is to keep him continent. Its failure to do this is a social disaster. Continence is mostly maintained by his internal and external sphincters and his levator ani, especially its deep puborectalis part, which forms a sling at his anorectal line, in the angle between his anus and his rectum. The tone in his external sphincters is increased by reflex and voluntary contraction. His internal sphincter, which is under autonomic control, is less important, but helps to keep his anal canal closed and empty. In painful conditions, both his sphincters are in spasm. The lower part of his anal canal is sensitive enough to let him know what is in his rectum - nothing, gas, liquid, or solid. Receptors in the smooth muscle of his upper rectum and the voluntary muscle of his pelvic floor let him know when his rectum is dilated. (Goligher JC, 'Surgery of the anus, rectum and colon'. 4th ed. 1980, Balliere Tindall)
Equipment required
• PROCTOSCOPE, e.g. Gabriel, 64 x25 mm, one only. This is the standard instrument for examining the rectum. You will also find an ordinary Sims' speculum useful for examining the anal canal under general anaesthesia.
• SPECULUM, bivalve, Goligher pattern with detachable third blade, one only. Use this for doing minor rectal operations, such as division of the internal sphincter.
• SIGMOIDOSCOPE, e.g. Strauss, 330 mm, Luer fitting, in case with bellows,cord and standard endoscope bulb (35.1) complete with biopsy forceps,etc., one only. Keep sigmoidoscopes and proctoscopes in a case so that their various parts don't get lost.
• SPONGE HOLDER, for sigmoidoscope, 430 mm, one only.
• FORCEPS, for biopsy through sigmoidoscope, Officer pattern, one only. These are the most expensive part of the outfit. If necessary, you can use them to remove foreign bodies from the oesophagus, or even from the urethra.
• SUCTION TUBE FOR SIGMOIDOSCOPE, one only. You can make this from a piece of ordinary copper tube, 15 cm longer than the sigmoidoscope, with a right angle bend at one end.
• BELLOWS, spare for Strauss sigmoidoscope, Luer fitting, one only.
• BULBS, endoscope, standard (35.1), small fitting, ten only. Endoscope bulbs are very easily blown.
• BATTERY BOX, for endoscopes, holding D type dry cells, one only. This must be the same voltage as the standard endoscope bulbs, and have a lead which fits the endoscopes.
• PROBE, medium-sized, malleable silver, one only.
• DIRECTOR, probe-pointed, one only. This has a groove on it. Pass it through a fistula and then cut down on the groove.
THE PECTINATE LINE AND THE ANORECTAL LINE ARE LANDMARKS
THE GENERAL METHOD FOR THE ANUS AND RECTUM
EOUIPMENT. A rectal tray containing proctoscopes, finger cots or gloves, long cotton-tipped applicators, and testing materials for occult blood. If you are going to pass a sigmoidoscope, you may need a suction tube and a sucker.
PREPARATION, Put a drape over the patient and keep the instruments out of his sight. Tell him what you are going to do,and explain that you will not hurt him. If some pain is necessary,warn him. Be gentle, don't hurry, and use warm instruments.Lie him on his side with his buttocks extending well over the edge of the table, as in A Fig. 22-2. Flex his hips fully, but keep his knees at 90° so that they are out of your way. It is convenient to have his right upper hip and knee a little more flexed than his left.
DIGITAL EXAMINATION OF THE RECTUMDraw his buttocks apart and look at his anal region for skin tags, lumps and the openings of fistulae (B). Feel any abnormalities, such as the tracks or openings of fistulae, or tumours (C).Lubricate the end of your finger well. Insert it so that its larger broad dimension lies in the anteroposterior axis of his anal canal. When you touch the sphincter, it will contract. Wait, give it a few seconds to relax, and then press firmly and gently in the axis of his anal canal. Keep pressing, until you can feel your finger suddenly slip easily into his anus. Note the tone of the sphincter.
As you put your finger into his anus, feel for lesions below and above his anorectal line. Then palpate the entire circumference of his anus between your two fingers (E). In a man feel each of the two lobes of his prostate separated by a median furrow. In a woman, look to see if she has a rectocele, feel her cervix and uterus rectally, and feel for swellings in her rectovesical pouch.
Sweep your finger all round the patient's pelvis and examine his coccyx between two fingers (F). Finally, if you suspect an intraperitoneal mass, a bimanual recto-abdominal examination may be useful in a man (G), and a vagino-abdominal one in a woman.
PROCTOSCOPY. Examine his anus with your finger first. Lubricate the proctoscope and push it firmly in the direction of his umbilicus. Examine the lining of his anal canal as you withdraw it-slowly, and looking for piles as you do so.
SIGMOIDOSCOPYDo a sigmoidoscopy just after he has defaecated normally, or after he has had an enema. There is no need for a general anaesthetic, unless you fail without one and the examination is essential (as for carcinoma). If you are clumsy, you can perforate his gut, so: (1) Always do a digital examination first.(2)Never push a sigmoidoscope further in, if you cannot see the lumen in front of it. Follow the lumen at all times. (3) Never force it. If there is a pocket or a blind area in the way, withdraw it a little, and then advance it again. Your main aim while inserting it is to do so successfully. Do most of the examining as you withdraw it.
Ask him to breathe in and out while you gently insert it,lubricated and warmed with its inserter in place. You will feel the resistance of his anal sphincter suddenly diminish (B, in Fig. 22-3) as it enters his rectal ampulla.
While you look where it is going, direct it 90° posteriorly (C),as you gently manipulate it past the mucosal valves of his rectum.While you insert it, gently pump in enough air to distend the lumen in front of it. Don't blow his sigmoid up too much,or he will feel urgency and cramps.
The first 12 to 15 cm, as far as his rectosigmoid junction is usually easy. You will see his smooth rectal mucosa giving way to the concentric rugae of his sigmoid colon. At this point his gut passes over his sacral promontary, and may turn in any direction. Proceed anteriorly and to the left. You should be able to reach 25 or 30 cm, but don't force it. Be sure you can distend his gut with air, before you push the sigmoidoscope further in.
If you find much stool, send him to the lavatory; if that fails give him an enema, and try again later.
Rotate the sigmoidoscope as you withdraw it, so that you inspect every part of his mucosa. Be careful to examine the posterior wall of his rectal ampulla. This lies at 90° to his anal canal, and you can easily miss it. Remove some stool, and test it for occult blood.
PREOPERATIVE CARE FOR ANAL OPERATIONSDo a sigmoidoscopy before all anal operations to exclude coexisting tumours and inflammatory bowel disease. For this to be possible, his bowel must be empty, so give him a small enema or a glycerine suppository preoperatively.
POSTOPERATIVE CARE AFTER ANAL OPERATIONSDRESSINGS are important. Dress an open anal wound with flat pieces of gauze, soaked in hypochlorite ('Eusol' or 'Milton'15 ml to a litre of water), or some other antiseptic or salt solution. Cover the whole raw surface with a flat piece of gauze.Tuck an edge of the gauze into any flat crevices. Insert a corner of the gauze into any extension of the wound towards his anal canal. Use more gauze to fill out the hollow of the wound up to the level of the surrounding skin. Cover with further gauze and hold the whole dressing with a T-bandage.
BATHING is more convenient than irrigation. Sit him in a large bowl containing warmed salt solution equivalent to full strength or half-strength saline.
BOWEL ROUTINE. Give him a laxative (e.g. 15 ml of liquid paraffin) twice daily from the day of the operation. If he has not opened his bowels by the evening of the second postoperative day, counting the day of the operation, give a stronger laxative (e.g. cascara). If his bowels do not act the following morning, do a rectal examination to see what the problem is; his rectum may be empty. If his faeces are impacted give him 850-1000 ml of a soap and water enema, through a tube, a funnel, and a well-lubricated rubber catheter. Ask him to retain the enema as long as possible before using a bedpan. The dressing will probably come away with his bowel action. Give him a bath, and redress his wound.
Anorectal sinuses and fistulae
The anorectal abscesses in Section 5.13, and the sinuses and fistulae described here, are part of the same disease process. An abscess is the acute phase, and a sinus or fistula is a chronic condition which develops from an abscess. Both sinuses and fistulae are tracks lined by granulation tissue, which open on to the skin near the anus. The difference between them is that a sinus has no internal opening, whereas a fistula opens into the patient's anal canal, or occasionally into his rectum. Usually, there is only one internal opening, but he may have several external ones. These can either be insignificant little holes, or prominent little nodules of granulation tissue, which heal over temporarily. The treatment of sinuses and fistulae is similar.
Typically, a patient with a fistula starts by having an abscess, which either bursts and fails to heal, or is not drained properly (see Section 5.13), after which he complains of a chronic painless discharge which soils his clothes. His fistula is only painful when it becomes temporarily blocked, so that pus builds up inside it.
Fistulae can take any of the paths shown in Fig. 22-5; they can be subcutaneous (common), low anal, high anal, or intermuscular (rare).
One way to think about fistulas is the path they take in relation to the sphincter muscles. They can be classified as intersphincteric, trans sphincteric, suprasphincteric and extrasphincteric. A fistula seldom heals spontaneously, and almost always needs surgery. The surgery chosen balances the chance of it coming back compared to the chance of creating incontinence. If it is superficial then cut down on it, deroof it, expose it, and let the wound you have made heal from the bottom by granulation during several weeks. A fistula nearly always goes through the anal sphincters, so that in cutting down on it, you have to cut them. If you cut too much sphincter the patient will become incontinent. If it is an intersphincteric or low trans sphincteric fistula then usually there is enough sphincter to spare if the fistula is unroofed. If there is more muscles involved the incontinence caused will usually be permanent and difficult to fix. For these more difficult cases you may want to ask for some help from a surgeon who has a lot of experience with these types of fistulas.
You have a 50% chance of finding the internal opening quite easily, by passing a probe from the external opening towards his anal canal. One of the worst mistakes is to create an internal opening, where there was none before, in the process of looking for it, by forcing a probe through into his anal canal. This makes a sinus into an iatrogenic fistula, opens up healthy tissue to infection,and makes cure more difficult.
The key landmarks are his pectinate line, and his anorectal ring. If necessary, you can cut both his sphincters below his pectinate line. In doing so, you preserve his anorectal ring (formed by his puborectalis muscle), and he remains continent, although he may have some incontinence of watery stools. Cutting his anorectal ring makes him completely incontinent. Fortunately, fistulae which go deep to the anorectal line are rare. If you find he has one, and cannot refer him, all you can do is to lay open the superficial tracks, curette the deep ones and hope for the best. This is difficult surgery, so examine him carefully and only operate if he has an easier fistula; incontinence is worse than the intermittent discharge from a fistula!
Fistulae which have external openings in front of a transverse line across the anus enter directly into it by the shortest path. Fistulae behind this line usually curve round, so that they enter the anus posteriorly at 6 o'clock (Goodsall's rule, Aa, 22-6). In doing so they follow a horseshoe path, and are often bilateral, one side communicating with the other. There are exceptions, and very superficial fistulae behind the line may occasionally track directly into the anus.
You will find that the track of a horseshoe fistula hugs the puborectalis part of the levator ani muscle, as it forms a sling round the sides and back of the anorectal junction, external to the external sphincter. Fortunately, the internal opening of such a horseshoe fistula is usually at the pectinate line, although the fistula itself may go much deeper.
Provided you trim the wound edges well, the common straight superficial fistulae heal with only minimal postoperative care, but this is critical for deep ones. The wound must be laid open widely, and it must granulate from the bottom up. Marsupializing the wound can help. Usually once fistula tracts are unroofed, packing is not necessary. After surgery for a fistula is done the patient can be discharged home the same day usually. A prescription for some pain killers should be given.
PERIANAL ABSCESSES, SINUSES, AND FISTULAE ARE NOT HELPED BY ANTIBIOTICS
ANORECTAL FISTULAE
X-RAY. X-ray the patient's chest: his fistula may be tuberculous (uncommon). If it is tuberculous, surgery is usually unnecessary. He mayor may not have an obvious chest lesion.
EXAMINATION IN THE THEATRE. Prepare him for anaesthesia, if necessary. Before you start, warn him that you are going to examine him under anaesthesia to try to find where his fistula runs. Explain that if he has one of the easier fistulae, you are going to operate. Otherwise, you may have to leave it (unusual). Further indications are given below.
If the opening is less than 5 cm from his anus, his fistula is perianal, if it is more than 5 cm away, it is probably high. Multiple openings suggest a horseshoe fistula. Record the position of all external openings carefully on a copy of diagram A, in Fig. 22-4.
Feel for the thickened track which runs from the external opening(s) towards his anus. If a fistula is superficial, you can usually feel its firm, fibrous track quite easily. As you press it pus may exude from the external opening.
Put a finger into his anus and try to feel the internal opening: you may be able to feel an induration at its internal end. Feel the entire circumference of his rectum, as far as your finger can reach. Determine particularly where the fistula might be in relation to his anorectal ring and his pectinate line. Try to feel the track between your two fingers. Does it appear to come to an end low down, or high up in his anus? If you feel induration at the level of his puborectalis or above (rare), he has a complex high fistula.
PROCTOSCOPY. Examine his anal canal with a proctoscope. You may be able to see the internal opening of his fistula, usually at 6 o'clock on his pectineal line. Insert the proctoscope as far as it will go, withdraw the obturator, and then gradually withdraw the instrument itself. As soon as its end becomes obstructed and closed by his anorectal ring, stop. If you can still see the opening of the fistula, it is safely below the critical level of his anorectal ring.
You may be able to feel the track of a horseshoe fistula as a thick horizontal indurated rod, hugging his puborectalis sling.
In 50% of cases you will find the opening easily, in the other 50%, it will be present but tiny. A probe may show it, but if it does not, inject methylene blue (or boiled milk) into the external opening, and look for this flowing into his anus-finding the internal opening is the key to all fistula operations!
PROBING. Don't do this until you have finished your initial inspection. You may need to wait until he is anaesthetized. Decide where a track is probably going to go before you start probing. Pass the probe as far as possible towards his anal canal, and feel for its end in his anus. It may pass through into the lumen, or it may stop before getting there. If his fistula is superficial it will pass horizontally, if it is deep, the probe will pass almost vertically, parallel to his anus.
CAUTION! (1) If the probe passes vertically, and not towards his mid anal canal (even though there is an opening there), he probably has a high complex fistula or a deep sinus. (2) Only pass a probe into the rectum through a fistulous track-don't force it through normal tissues.
OEROOFING AN ANAL FISTULA
INDICATIONS. You should now know where the fistula runs. Only operate on the easier and more superficial fistulae. The main risk is incontinence. Refer him if: (1) His fistula has multiple openings, unless you have had some experience with the operation. (2) He has had previous unsuccessful operations. (3) The probe passes vertically upwards. (4) His fistula is palpable in his upper anal canal, or above his anorectal ring (rare). Also be careful of cutting sphincter muscles in females especially if the fistula is anteriorly based as the spincter is thinnest in this area - a primary fistulotomy in this area may lead to incontinence and if you are not comfortable in dealing with this then refer this patient.
Other factors which increase the risk of subsequent incontinence are: (1) The liability to attacks of diarrhoea, or a history of soiling, which might indicate reduction of his sphincter capability. (2) A female patient, particularly if she is old and also if she has a history of birthing injuries that could have affected her sphincter - ie a third or fourth degree tear during delivery
EOUIPMENT. This includes a medium-sized malleable silver probe, or a probe-pointed director.
ANAESTHESIA. (1) Ketamine. (2) Light general anaesthesia. Avoid relaxants and subarachnoid anaesthesia. You want to be able to feel the anorectal ring, so as not to cut it. Muscular relaxation makes feeling it more difficult, but does provide better exposure.
A SUBCUTANEOUS OR LOW ANAL FISTULA. Carefully confirm the findings you obtained before you anaesthetized him. If you thought that his fistula was blind at the inner end (a sinus), confirm this. Pass a probe or director through the track, from the external opening towards his anal canal, either completely through to its lumen, or as far as it will go. It may enter his anal canal, or it may stop before doing so.
If the probe enters his anus superficial to his pectinate line,cut down on all structures superficial to it, and lay the track open. If you are using a director, cut down to the groove in it.
Look at the velvety track of the opened fistula. If there is no such track, you have probably opened up a false passage. Look carefully for any side openings, and feel among the fatty tissue for nodules of induration, that might be offshoots of the fistula. As a general rule, all fistulous tracks communicate with one another. Using a sharp spoon, curette the tracks, so as to leave only healthy tissue, and trim away any overhanging skin.
Alternatively, make a narrow pear-shaped incision to include both the internal and external openings. Excise both of them, and the track of tissue that still clings to the probe.
If the probe enters his anus deep to his pectinate line, leave the fistula untreated, or refer him. Even experts find these fistulae difficult.
CAUTION! (1) Don't cut deep to his pectinate line, or you will cut too much sphincter. (2) When you cut down on to a probe or director, do so by the most direct route.
If the probe does not enter his anal canal, he has a sinus. Lay it open in the same way, but without opening into his anus.
With all sinuses and fistulae, look, feel, and probe for other track openings and areas of induration. If you find any, open them and curette them. Curette the granulation tissue.
Control bleeding with diathermy, or tie off bleeding vessels with 2/0 plain catgut. Excise the skin edges and bevel them,so as to leave a conical or pear-shaped concave raw area. Be sure that there will be no pockets or overhanging edges, when muscle tone returns. If a fistula is complex, you will have to make a deep, wide wound.
Always send tissue for histology to exclude tuberculosis. Apply flat squares of gauze soaked in hypochlorite, or salt solution,pad it with plenty of gauze, and hold it in place with a T-bandage. Avoid vaseline gauze because it may cause a foreign body granuloma ('paraffinoma').
If you are having trouble idenifying and internal opening it is important not to create a false internal opening. One method that can be used to help identify internal openings is by using some hydrogen peroxide and injecting a small amount through the external opening and seeing if bubbling can be seen coming from the internal opening.
ISCHIORECTAL (horseshoe) FISTULAE usually have two or more external openings. Pass a director into an opening, and lay open one side at a time.
Point the director forwards, make it project against his skin at the side of his anus, and cut down on it. The track will be deeply overhung by fat; trim this. Turn the director posteriorly, and see if you can follow the track across to the other side, and then forwards on that side.
Now see if you can find the opening into his anus posteriorIy. If you have seen a definite opening below his anorectal ring, encourage the director to follow it there, and lay the fistula open.
CAUTION! (1) Most of these fistulae have a posterior opening close to the pectinate line, and if you miss it and don't lay it open, the fistula will recur. If you don't find such an opening, make one. (2) Lay open all side tracks.
If oozing is a problem, apply pressure from adrenalin soaked gauze. Gutter, trim and dress the wound as above. If his fistula is complex and deep, feel it with your gloved finger each day, to keep the edge of the granulating wound smooth, and to make sure that no deep pockets are left, which would lead to recurrent infection. Lay a flat gauze square on it. If you are worried about the way it is healing, take him back to the theatre and further lay the wound open.
POSTOPERATIVE CARE is the same as for any granulating anal wound, with daily, or twice daily, salt baths (sitting in a bowl of saline), regular dressing changes, and measures to ensure soft stools. Warn him that a perianal fistula may take 2 weeks to heal, and an ischiorectal one 4 weeks. An extensive horseshoe fistula may take 12 weeks. If necessary, trim away any excess granulation tissue.
DIFFICULTIES WITH ANAL FISTULAEIf a FISTULA PASSES FORWARDS from his (or her) anus, it may be an URETHRAL FISTULA (23.8), or originate in Bartholin's glands (23.4).
If a FISTULA IS POSTERIOR, don't confuse it with a PILONDAL SINUS (22.8). If it is low and immediately behind his anus, it may have arisen in an anal fissure.
If the EXTERNAL OPENING IS SOME DISTANCE FROM HIS ANUS, look out for a long curved fistula, or a high one. Its thickened track will usually show you its course and destination. Probe it, but don't expect it to enter his anus.
If his FISTULA EXTENDS UP THROUGH A HOLE IN HIS LEVATOR ANI, and you cannot refer him, pass a haemostat through the hole and stretch it. Enlarge the opening to provide free drainage. If necessary, cut backwards, laterally or forwards, but not medially. Enlarge the external wound by wide trimming, especially posteriorly, to provide a wide gutter, extending backwards towards the side of his coccyx. Provided there is no internal opening above his levator ani, or chronic pelvic disease, such as regional ileitis, his prognosis is good.
CAUTION! Don't look for an opening in his rectum, there almost never is one, unless the cause of the fistula was a penetrating injury.
If you find a HIGH INTERMUSCULAR FISTULA (submucous fistula, unusual), leave it. If it really is submucous, it can be opened into his rectum, but if it happens to be outside his rectal wall, and you cut into it, this will be a disaster.
If he also has PILES, excise them, or they may thrombose and bleed postoperatively. Or, if they are first-degree, and leave his anus packed.
If he has RECURRENT DISCHARGE FROM THE TRACK, his wound has healed over externally, without healing from below. Operate again. It will not heal with antibiotics. Also consider the possibility of tuberculosis.
If he has ULCERATIVE COLITIS, or CROHN'S DISEASE (both uncommon in the developing world), he is a special case, so refer him.
If there is GREAT NODULAR THICKENING of his subcutaneous tissue, purplish discoloration (in a white skin), numerous sinuses which seldom discharge much pus, and no real cavity or track, suspect SUPPURATIVE HIDRADENITIS (rare).
If he, or more likely she, has MULTIPLE FISTULAE with much scarring and skin bridges between them, suspect LYMPHOGRANULOMA VENEREUM (22.10) or colloid carcinoma of the anus.
Rectal bleeding
A patient who bleeds severely from his stomach or duodenum, usually vomits the blood, if he bleeds fast. If he bleeds more slowly, it appears as black tarry melaena stools. The higher the source of the blood, the longer it takes to reach his rectum, and the more likely is it to be converted into melaena stools. Although a melaena stool is usually the result of bleeding from his stomach or his duodenum, it can follow bleeding from his small gut. Dark red 'burgundy-coloured' blood mixed with stool can come from the stomach, the duodenum, the small or the large gut, but fresh bright-red blood usually comes from the rectum or anus. Not all dark stools are the result of bleeding, so remember the possibility of iron medication (negative occult blood test), or nose bleeds (often positive for occult blood).
Bleeding from the upper gut is often severe, is usually more serious than it looks, and frequently threatens his life (11.3). Bleeding from the lower gut is often mild, and even a small quantity of bright blood can be alarming. He is usually not as ill as he seems, and you have more time to investigate him.
Rectal bleeding is common everywhere, but its causes differ geographically. In the developing world, where carcinoma is still comparatively unusual, you can treat most patients with rectal bleeding quite easily.
If he continues to bleed from his rectum, and you are not sure why, you will have to decide: (1) if you are going to operate, (2) when, and (3) what you are going to do when you get inside. In most areas, the commonest cause of massive rectal bleeding is a peptic or duodenal ulcer; but in some tropical areas it is bleeding from the terminal ileum, or ascending colon, due to typhoid or amoebiasis.
The major mistakes are: (1) To misjudge the severity of his bleeding. (2) To fail to use your finger, a proctoscope and a sigmoidoscope, to label him as having 'piles' without examining him properly, to fail to investigate him, and so to miss a carcinoma. (3) To miss the more treatable diseases, such as tuberculosis and amoebiasis, as the. following case shows.
POUL (53) had passed several bloody stools since the morning, but had no other gastrointestinal symptoms. He was neither anaemic nor hypotensive, but during the next few days he continued to bleed, and his haematocrit fell to 2 3 % Sigmoidoscopy showed friable, oedematous, reddish-yellow areas in his rectum, but no obvious ulcers. A smear from his rectal mucosa showed amoebae.'Metronidazole cured him dramatically. LESSONS (1) Amoebiasis is readily treatable-if you diagnose it. (2) A severe bleed in the absence of previous symptoms of amoebiasis is unusual.
THE GENERAL METHOD FOR RECTAL BLEEDING
See also Section 11.3.
COMMON CAUSES (other than piles 22.4). Peptic ulcer(11.3). Typhoid ulcers of the ileum (bleeding may be severe, 31.8). Amoebiasis (31.10). Schistosomiasis mansoni. Bacillary dysentery (diarrhoea with blood and mucus, 31.10). Anal fissures (which may bleed at defaecation, 22.7). Lymphogranuloma (22.10). Polyps, especially juvenile polyps (usually producing a little fresh blood, see below). Intussusception ('red currant jelly stools', 10.8). Also causes of high gastrointestinal bleeding (11.3).
UNCOMMON CAUSES. Carcinomas of the colon, rectum, or anal canal (32.27), tuberculous ulcers of the gut (29.5), nonspecific ulcers of the gut (see below), pigbel disease (31.9), Meckel's diverticulum (episodic massive bleeding in the young, 28.5), rectal prolapse (22.9).
RARE CAUSES. Ulcerative colitis, ischaemic colitis, diverticulitis, haemangiomas of the small gut, blood dyscrasias, villous adenomas of the rectum (bright blood with much watery mucus). A foreign body in the rectum.
EXAMINATION. (1) Assess the degree of the patient's hypovolaemia (53.2), and the severity of his anaemia. Does sitting him up in bed make him feel faint, or exercise make him breathless? Examine him for epigastric tenderness, distension, the signs of subacute gut obstruction (10.3), and abdominal masses.
Examine his rectum with your finger and a proctoscope, and don't forget to look at his stool.
CAUTION! Never forget to do a sigmoidoscopy if an adult presents with rectal bleeding. DIFFERENTIAL DIAGNOSIS. Bleeding related to defaecation? (an anal or rectal lesion). Blood mixed with stool? (some lesion higher than the rectum). Painful bleeding? (a lesion below the pectinate line; piles arise above this line and are painless, unless they prolapse or strangulate). A feeling of something prolapsing from the rectum? (piles, prolapse, or polyps). Dyspepsia, heartburn, etc.? (peptic ulceration, 11.1). High fever for a week or two? (typhoid fever, 31.8). Loss of weight, anorexia, night sweats, and fatigue? (abdominal tuberculosis; rectal bleeding is unusual 29.5). Vague lower abdominal pain followed by the passage of much dark blood? (non-specific ulceration of the gut, 22.10). Abdominal pain, diarrhoea, fever, prostration? (non-occlusive infarction of the gut, pigbel disease, 31.9).THE INDICATIONS FOR LAPAROTOMY. (1) Loss of >1500 ml of blood. If he is in extremis, surgery may be life saving. (2) The presence of a mass. The treatment of most causes of rectal bleeding is discussed elsewhere. Most colonic bleeding stops on its own, so don't operate too early. If possible, depending on the availability at your center, endoscopy can be used to localize and possibley treat the bleeding.
RESUSCITATION. Replace the blood he has lost, with due regard to the dangers of HIV (28a.2).
ANAESTH ESIA. General anaesthesia.
LAPAROTOMY. Enter his abdomen through a long midline incision. Exclude more common causes of bleeding, such as peptic ulceration, then examine his entire gut from his duodeno-jejunal junction down to his rectum. Note the colour of the contents of his gut. What is the highest site in his gut to show bleeding? Look for abnormal vessels going to the bleeding area, and feel for induration or an ulcer. If necessary, do a gastrotomy and enterotomies (open his gut, 9.3) to find the level of the bleeding. Make sure that a sigmoidoscopy and anoscopy is done in the operating room to ensure that you do not do a blind colectomy for bleeding piles.
If he is bleeding severely from his right colon, you don't find a lesion, and there is no bleeding more proximally, consider doing a 'blind' right hemicolectomy (66-20). This will not be easy, so don't do it lightly. Afterwards, open the specimen to see where the blood is coming from.
DIFFICULTIES WITH RECTAL BLEEDING
If a CHILD HAS INTERMITTENT CONTINUING RECTAL BLEEDING, he may have a JUVENILE POLYP. This is a friable, proliferative mass, which lies on his mucosa to begin with, and then develops a stalk. On rectal examination you can usually feel a soft, mobile, pedunculated mass, and see a strawberrylike lesion through a proctoscope or sigmoidoscope. If examination is difficult,You may have to anaesthetize him to examine it.
If a polyp is small, remove it through his anus, tie the stalk, and cut it off. If you cut the stalk without tying it first, it may bleed massively. Or, if tying it is impracticable, leave it to undergo spontaneous strangulation, necrosis, and sloughing.
If the cause of a patient's RECTAL BLEEDING IS NOT IMMEDIATELY OBVIOUS, consider the possibility of NONSPECIFIC ULCERATION OF THE GUT (uncommon). In the tropics patients sometimes bleed from small punched-out ulcers of unknown cause in the mucosa of their distal ileum and proximal colon. They are usually middle-aged adults of either sex, who present with lower abdominal pain and fever, followed by the passage of a quantity of dark blood rectally. He may be tender in his right iliac fossa; sigmoidoscopy is normal, except for blood coming from above. If bleeding does not stop and you are sufficiently skilled, a right hemicolectomy may save him, because the source of the bleeding is nearly always in his distal ileum, or proximal colon. In good hands he has a 10% chance of death.
His distal ileum and colon are likely to be discoloured by contained blood, and feel slightly oedematous and thickened. The ulcers in his mucosa are rarely palpable.
If you have established the source of the bleeding, and think you could remove it, do an extended right hemicolectomy, and take the last 20 cm of his ileum, his ascending colon, and his entire transverse colon up to his splenic flexure. Do an end to end ileo-transverse anastomosis in two layers.
Open the specimen, and you will find numerous punchedout ulcers in his terminal ileum and right colon, one of which may contain a bleeding artery. Histology shows non-specific changes only, with very little inflammation round the ulcers.
If he has RECTAL BLEEDING ACCOMPANIED BY SEVERE DIARRHOEA, PROSTRATION, vomiting, and fever, consider the possibility of pigbel disease, and see Section 31.9.
Piles
If the vascular lining of a patient's anal canal becomes swollen and starts to protrude, he has piles. These are common in the industrial world, but are less often seen in patients on high-residue traditional diets. They usually form in the 3, 7, and 11 o'clock positions (when he is in the lithotomy position), and although they usually cause no symptoms, they can bleed and make him severely anaemic; they can prolapse, and they can thrombose and become very painful. Untreated, they eventually shrink to form harmless skin tags.
He may complain of bleeding, of 'something coming down', of a mucus discharge, or of pruritus. If he has diagnosed himself, and says that he has piles, enquire how they affect him. Piles are the commonest cause of rectal bleeding, which is usually painless, bright red, and either streaks the stool, or follows after it. Carcinoma of the colon is the most important differential diagnosis, so exclude this by always sigmoidoscoping anyone with rectal bleeding, even in the developing world where carcinoma is uncommon; even if he has piles-he may have both!
Piles are reversible in their early stages, and will usually respond to a high-residue diet as long as there is adequate hydration as well. If they are very large and have been present for a long time, you will have to excise them. Never fail to examine him, and remember that ointments are seldom a sufficient treatment.
PILES
EXAMINATION. You can see piles through a proctoscope, but only the patient can tell you if they bleed, or prolapse on defecation,if they retract spontaneously, or if he has to replace them.There are 4 degrees of piles.
First degree piles usually only cause bleeding, and don't prolapse from his anus, so you cannot see them merely by looking at it.
Second degree piles prolapse on defecation, but return spontaneously afterwards. They form distinct swellings at the three main positions. If you pull gently, you may be able to draw them down.
Third degree piles prolapse on defecation, and don't return spontaneously, so that he has to push them back. They form large projecting lumps, their outer parts covered with skin, and their inner parts with purple anal mucosa, separated by a groove.
Fourth degree piles are prolapsed and can not be reduced manually - this will usually require an operative intervention.
DIGITAL EXAMINATION is not enough by itself for diagnosing piles, because you cannot usually feel them with your finger. If, however, a pile has been present for some time, you may feel it as a soft longitudinal projection, as you sweep your finger round his anus.
PROCTOSCOPY is the only satisfactory way to diagnose piles. They bulge into a proctoscope like grapes, as you withdraw it and ask him to bear down. Withdraw it just to his anus, and then ask him to continue straining. In addition, if an anoscope is available (especially side viewing), this will give you the best view of the piles as compared to the end viewing proctoscope.
If no red mucosa projects beyond his anal verge, his piles are first degree.
If they do project, they are second or third degree.
If they remain prolapsed when he stops straining, and you have to push them back, they are third degree.
SIGMOIDOSCOPY must be done routinely to look for carcinoma, especially if he is over forty and from the industrial world; it is desirable in the developing world. If he presented with bleeding, and you cannot see any piles, it is essential!!
INTERNAL PILESIf his symptoms are mild, or merely consist of bleeding, simple measures are usually enough. If he is not already on a high-residue diet, persuade him to eat one. Treat constipation with stool-softeners. If his piles have appeared in association with an attack of diarrhoea, they will probably go as his diarrhoea resolves. If necessary, treat it.
CAUTION! Don't treat piles, unless they cause symptoms (anaemia for example) that need treating. They often remain asymptomatic for many years. One patient may have classical third degree piles, but no symptoms. Another may collapse from hypovolaemic shock with only first degree piles.
If piles prolapse, the above measures are unlikely to be adequate, so see below for ligation and excision (22.6). The other measure that can be used if available prior to proceeding to surgery is to 'banding' of hemorrhoids. With banding equipment, a small rubber band is placed at the apex of the pile above the pectinate line (otherwise it would be too painful!). This causes an ulceration when it falls off and interrupts the blood supply to the pile and causes some scarring which will pexy the pile up a little and hopefully help with the symptoms.
If he has acutely painful, bluish, fixed swellings at his anus, which make sitting or defecation painful, his piles have probably been squeezed by his internal sphincter, so that they have thrombosed, ulcerated, strangulated, or become gangrenous. Digital examination is painful, and proctoscopy impossible. He may refer to his symptoms as 'an attack of piles'. One differential diagnosis is a 'thrombosed external pile', see below.
If the symptoms from his prolapsed piles are mild, give him a rubber glove and some analgesic ointment, and ask him to return them to his anus himself. This, combined with baths, may enable him to overcome his acute attack.
If the symptoms from his prolapsed piles are severe, bath him and wash the mass. A warm bath is remarkably soothing. Put him to bed, raise its foot steeply, and give him morphine. Apply a large moist gauze dressing to his anus, and hold it with firm pressure in aT-bandage. Some surgeons apply an ice pack. Don't worry about his bowels for a few days. Local anesthetic can also be infiltrated circumferentially around the anus and this will result in a good perianal block - this will help relax the sphincter muscles and may help the piles reduce.
Lord's anal stretch under anaesthesia is not a good procedure and is associated with a high rate of incontinence. Many surgeons across the world have abandoned this procedure because of this.
The mass will shrink over about a week. Thrombosis leading to fibrosis may cure his symptoms, so that he needs no further treatment. If it does not, excise his piles (22.6) when his oedema has settled.
CAUTION! Don't: (1) Try to incise thrombosed internal piles, or (2) try to excise them immediately.
If a thrombosed pile fibroses, it may present as a pedunculated fibrous polyp (unusual). Excise it.
If a thrombosed pile becomes infected, treat him with antibiotics, if necessary (rare). Tie and excise his piles as soon as the infection has subsided.
If he is admitted because of severely bleeding piles, exclude a bleeding diathesis (measure his bleeding and clotting time) or anticoagulant treatment. Put him to bed, give him morphine, and transfuse him. Many bleeding piles are cured by a high fiber diet with a good amount of oral fluid intake as well, if they are of first degree, or small second degree. The patients who bleed severely are usually the younger ones with tight anal sphincters.
EXTERNAL PILESIf he presents with a painful anus, and you find a small (0.5 to 1 cm), tense, black, acutely tender swelling just outside his anal verge, it is a thrombosed external pile. First, make sure it is an external pile, and not a thrombosed internal pile, which has prolapsed from higher up. It will probably resolve spontaneously in a week, and eventually become a skin tag.
If you see him within 36 hours, use a fine needle to infiltrate the skin around it with lignocaine, bisect it, squeeze out the clot, and excise it together with 1.25 cm of his adjacent skin. His pain will go immediately. Apply vaseline gauze, and let the pear-shaped wound granulate.
Lord's anal stretch
There should be very few indications for this procedure - it has been abandoned by many surgeons across the world because of its association with incontinence. Other methods such as banding of hemorrhoids are much more effective than the Lord's procedure for piles. Excision and ligation of hemorrhoids have a lower rate of incontinence compared to the Lord's procedure.
If a patient has second degree piles, you have the choice of trying a high residue/high fluid diet first as at times it will help. If banding is available this would be an ideal patient for it. Excision and ligation is a preferable option to the Lord's procedure as the Lord's procedure is associated with a high rate of incontinence. Piles are probably the result of an unduly tight anal sphincter, which may be associated with bands of rigid tissue in his anus. Lord's operation dilates his sphincter and breaks these bands. The indications for it, and for those tying and excising piles are important, and are given below, so follow them with the greatest care. They include the readiness of his piles to prolapse, his age, and the tightness of his anal sphincter. Lord's operation is one of the simplest in surgery. Anaesthetize him, put your fingers into his anus, gradually stretch it, and his piles will be cured. He need only be in hospital for a few hours, so that you can treat him as an outpatient. Tying and excising his piles will keep him in hospital for up to ten days.
WRD'S ANAL STRETCHINDICATIONS. (1) Piles which prolapse when a patient defecates, after which they either return spontaneously, or he has to push them back. The operation is particularly likely to be successful if he is under 50, and has a tight sphincter, and a history of painful defecation. (2) Acutely prolapsed and strangulated piles. (3) First or second degree piles which are bleeding heavily, especially if he has a tight sphincter. (4) Anal fissure, including an associated anal tag. (5) Constipation caused by a tight anal sphincter. (6) Always dilate his anus after you have have done a colostomy for obstruction, or a resection and anastomosis.
CONTRAINDICATIONS. (1) Piles which prolapse when he walks, sneezes, coughs, exercises vigorously, or passes wind. (2) Piles which are prolapsed most of the time (third degree). (3) A loose sphincter-never stretch his sphincter, unless you can feel some tightness in his anal canal-there is no point in doing so otherwise, and it may impair his continence. (4) Chronic diarrhoea.
The operation is less likely to be successful if he is over 50, and he is more likely to suffer from incontinence of wind, or occasionally faeces. Bleeding piles are not a contraindication.
ANAESTH ESIA. (1) General anaesthesia, preferably but not necessarily with relaxants is best. (2) Ketamine (A 8.2). (3) Caudal block (A 7.6).
POSITION. If you are using subarachnoid anaesthesia his position immediately after its injection is important-see A 7.6. As soon as the anaesthetic solution has been fixed (about 10 minutes), lay him on his back with his legs up in stirrups, and give the table a slight head-down tilt.
Alternatively, if your anaesthetist is more skilled, lay him on his left side.
SIGMOI DOSCOPY OR PROCTOSCOPY should always follow a careful digital examination. If you don't do this, you may fail to diagnose carcinoma of his rectum.
FEEL FOR THE CONSTRICTING BAND. First, do a digital examination with your right index finger. Insert two fingers of your left hand and pull upwards, and one finger of your right hand and pull downwards, if he is in the lateral position, as in A, Fig. 22-10. Feel for the constricting band, which is usually at the level of his anorectal line (22-1). If his anus feels tight, dilatation is likely to be successful. If it feels loose, proceed to haemorrhoidectomy (22.6).
01 LATATION must be gentle and controlled. Start by introducing the index fingers of each hand, then gradually insert more fingers as you overcome the constriction. Put the strain on the constricting bands in the right and left lateral positions, in the 3 and 9 o'clock positions. Try to avoid damaging his sphincter at 12 o'clock, and especially at 6 o'clock, where it is weaker. Stretch hard and then put four fingers in. Dilate his anus gradually over 3 or 4 minutes, so that the fibres of his sphincter are stretched, and not torn. Usually, you can insert six or eight of your fingers. The tighter his anus, the more you should stretch it. You may feel constrictions in his lower rectum, as high as your fingers can reach. Make these give way laterally. You should be able to see well up his rectum between your two hands. He may bleed a little, but he will not bleed severely.
CAUTION! (1) The necessary degree of dilatation varies, and it is better to dilate too little rather than too much. (2) The more severe degrees of dilatation are not indicated for anal fissures (22.7). For a fissure 'four fingers for four minutes' is enough.
Some surgeons put a pack in his anus to minimize haematoma formation, some give him a dilator, others do nothing. If his piles prolapse after the stretch, apply a pad and T-bandage to keep them in place.
Give him 20 ml of liquid paraffin daily for 10 days to soften his stools. There is no need for him to use a dilator. You can usually send him home on the same day.
If you have operated for piles, advise him to eat a high-residue diet.
DIFFICULTIES WITH LORD'S PROCEDUREIf he is INCONTINENT OF FLATUS, reassure him that this will pass off in for a few days to a few weeks.
If he FEELS UNSURE OF HIS SPHINCTER MECHANISM, reassure him. If his outlet was previously very tight, he will need to get used to its new condition. Encourage him, and ask him to do sphincter exercises for a few weeks.
If FAECES STAINED MUCUS escapes from his anus at the 6 o'clock position, causing soiling and soreness (keyhole deformity of the anus, rare), avoid producing it in future by making sure that the strain of dilatation is thrown on the lateral aspects of the anus.
If there is BRUISING, reassure him. It may be extensive.
If his PILES THROMBOSE postoperatively, with much swelling and soreness, reassure him. His symptoms will settle and the resu It wi II be excellent.
If his rectal mucosa or a LARGE PILE PROLAPSES postoperatively, and is troublesome, anaesthetize him, clamp the redundant mucosa, and cut it off distal to the clamp. Tape the clamp to his buttocks. Return him to the ward. Remove the clamp an hour later. Or, do nothing, except wait for a few weeks, and then do a haemorrhoidectomy if his piles are still troublesome.
If his PILES RECUR, excise them, do another maximal dilatation of his anus, and excise any skin tags. There is about a 25% chance of recurrence on the first occasion.
Tying and excising piles
If a patient has piles which prolapse while he walks, or during such activities as digging in his fields, and banding is not available then excision of the piles may be indicated. . Such patients are rare, and form only about 10% of those who present with piles. The alternatives are injection, which is only palliative, and difficult to do well; the application of rubber bands, which needs special equipment, or tying and excision. Tie and excise each of his three piles, together with a triangle of his perianal skin. This is not difficult, but be sure to leave bridges ofmucosa between each pile. Ifyou don't, a stricture may form.
MILLIGAN'S HAEMORRHOIDEClOMY
INDICATIONS. Piles which are unsuitable for Lord's procedure on the indications given in Section 22.5. These are: (1) Piles which prolapse while a patient is walking, sneezing, coughing, exercising vigorously, or passing wind. (2) Piles which are prolapsed most of the time, or are permanently prolapsed (third degree). (3) Patients with second degree piles, but with a loose sphincter, which makes them unsuitable for Lord's operation, particularly older patients.
CONTRAINDICATIONS. (1) Septic piles. (2) Acutely thrombosed piles, because it is easy to remove too much mucosa.
ANAESTH ESIA. (1) General anaesthesia, ether (A 11.3). Relaxation is useful. (2) Caudal block (A 7.6). (3) Ketamine may be adequate (A 8.2).
POSITION AND PREPARATION. Put him into the lithotomy position, with his buttocks well beyond the end of the table. A sandbag under his sacrum helps exposure. Clean his anal region, and arrange the instruments and towels as in Fig. 22-4.
Do a careful digital examination to make sure that he really does have no other pathology. Sigmoidoscope him if you have not already done so.
Some surgeons infiltrate the subcutaneous tissues round his anus with 1:100 000 adrenalin in saline or lignocaine (A, in Fig. 22-11). The adrenalin reduces bleeding, and the lignocaine reduces postoperative pain. Others prefer not to use it, saying that it increases the incidence of reactionary bleeding afterwards. It you decide to use it, insert the needle in the midline, and deposit 15-20 ml in the subcutaneous tissues on either side of his anus.
Push some dry gauze into his rectum, and slowly pull it out.His piles will prolapse with it.
Grasp the skin at the mucocutaneous junction of each pile with haemostats, and pull them outwards (B). This will make their mucosa covered parts protrude.
Take the purple mucosa covered part of each pile in other larger haemostats, and draw them downwards and outwards. This will bring all three piles well out of his anus, so that you see his pink rectal mucosa at their upper ends (C).
Pull on all three piles until you see the rectal mucosa, not only at the upper end of each pile, but also between them. The piles have now been drawn down as far as they will go, which will allow you to tie them at their upper poles, rather than around their middles.
The 3 o'clock or left lateral pile. Grasp the two haemostats attached to this pile in your left hand. Draw them down towards the opposite side, while your index finger rests in his anal canal, and presses downwards and outwards on the pile. Using blunt scissors in your right hand, make a V-shaped cut in his anal and perianal skin opposite this pile (D). The ends of the V should reach the mucocutaneous junction, but not extend into the mucosa beyond it. The point of the V should lie 2.5 to 3 cm from the junction.
If you press your index finger firmly against the end of the scissors as you cut, you will see the lower edge of his internal sphincter laid bare. This is a firm, whitish ring which should be clearly visible. If you hold the pile aside (E), you will see it quite clearly.
Make a slight nick in the mucosa above and below the narrow mucosal pedicle.
Transfix the pedicle of each pile using a 30 cm strand of No.16 braided silk. Alternatively, use No. 3 chromic catgut, but transfix the pile, because it will be more likely to slip off. As you tie the pile, remove the haemostat grasping its mucosa, and use it to hold the ends of the ligature. Hand both pairs of haemostats to your assistant, and ask him to retract them laterally (F).
Alternately, the dissection described above can be carried out using electrocautery if available. The pedicle can be tied as described above. Using the cautery can decrease the amount of oozing that is seen with the use of the scissors.
CAUTION! A slipped ligature can cause fearsome bleeding! The 7 o'clock or right posterior pile. Treat this in the same way. Hold the pile forceps with your right hand and make the scissor cuts with your left hand. When you make your cut, note the position of the cut you made for the 3 o'clock pile, and make sure you leave agood skin bridge and a bridge of intact mucosa running into his anal canal.
The 11 o'clock pile. Treat this similarly, being sure to preserve bridges of skin and mucosa between it and his other piles.
Excision. Now excise all three piles, leaving at least 1 cm of tissue beyond the ligatures (G). As you cut the ligatures short, the stumps of the piles will disappear inside his anal canal.
Pass your finger into his anus to assess the tightness of his anal canal. If it is tight, stretch it to four fingers, which may lessen postoperative pain.
Push some dry gauze into his anus, while you examine his skin wounds. Trim any loose edges with scissors, to leave three flat pear-shaped raw areas. The end result should look like a clover leaf ("If it looks like a dahlia it's a failure!") It is very important that when doing a hemorrhoidectomy that there are skin bridges between each of the piles that are excised. If there are no skin bridges, the patient will have a high rate of developing a stricture.
Pass a lubricated speculum and look at the ligatures. Control all bleeding, either with more ligatures, or with diathermy. Don't allow blood to pool in his rectum. Oozing will stop spontaneously, but all spurting vessels must be picked up and tied, however small.
Apply a hypochlorite or saline dressing, or vaseline gauze, to his anus, and cover this with plenty of dry gauze and cotton wool. Hold it in place with a T-bandage. Start salt baths (22.1) on the first or second day. Let him remove his own dressing in the bath.
If he has passed no stool by the third day, use some strong laxatives. If you are very concerned then do a rectal examination, and if he has faeces in his rectum, give him a glycerine suppository.
CAUTION! (1) Always leave skin and mucosal bridges between the excised piles. (2) Put the patient on a bowel regimen to avoid constipation and make sure he knows the importance of having regular bowel movements - some patients will try to avoid having a bowel movement and if they wait a week, a large constipated bowel movement may result in severe bleeding. In addition, having regular bulky bowel movements with a high residue/high fluid diet will ensure that the anal canal remains stretched and compliant and helps avoid the formation of strictures. The operation can be done as a day procedure but the patient will need a prescription for pain medication - a combination of an anti inflammatory as well as an opioid work well when used together. DIFFICULTIES WITH HAEMORRHOIDECTOMYIf he has has ACCESSORY PILES, only excise the main ones, so that that you only make three skin wounds (with skin bridges in between!).
CAUTION! Be careful not to take too much anal mucosa: it is better to leave secondary pi les alone.
If he has an associated ANAL FISSURE, treat it by gentle stretch although by using the operating anoscope while doing the hemorrhoidectomy will have resulted in some stretch already. ). There is no need to excise it. Large piles and fissures are seldom seen in the same patient.
If he has postoperative PAIN, give him pethidine. If severe pain follows defaecation, a hot bath will soothe it.
If he has DIFFICULTY PASSING URINE postoperatively, try giving him pethidine, or ask him to stand while he passes it. If this fails, give him subcutaneous carbachol 0.5 mg, and ask him to try again in 15 minutes. Only if his fails, catheterize him, and remove the catheter after 48 hours.
If he BLEEDS WITHIN 12 HOURS (reactionary haemorrhage), you may be able to secure the vessel with artery forceps in the ward. If this fails, return him to the theatre, reanaesthetize him, and tie it there.
If he BLEEDS BETWEEN 7 AND 10 DAYS (secondary haemorrhage), he may bleed into his rectum and pass clotted blood with his next stool. Bleeding may stop spontaneously; if it does not, try pushing a lubricated, adrenalin-soaked pack into his anus and lower rectum. If this is inadequate or impractical, insert a large Foley catheter, inflate it, tie a weight to it, and exert traction on the bleeding site. Maintain traction for 3 days. Thereafter, keep his stools soft. Return him to the theatre onIy as a last resort.
If you FORGOT TO LEAVE BRIDGES OF SKIN AND MUCOSA between his piles, so that his rectal mucosa has retracted up his anus, pull it down and suture it to his perianal skin. He will probably recover uneventfully, but watch for a stricture.
If he develops a STRICTURE (unusual), you probably did not leave adequate bridges of tissue between his excised piles. Provide him with an anal dilator. If you don't have one, he can use a banana, but he must use it with a lubricant.
Anal fissure
An anal fissure causes suffering out of all proportion to its size. It starts as a crack in the lower part of a patient's anal canal, which makes defaecation, and the time following it, acutely painful. Even the thought of a bowel movement may fill him with such fear that he ignores the urge, so that the hard constipated stools that he eventually passes make his fissure worse, and may occasionally make it bleed.
You will almost always find his fissure posteriorly in the 6 o'clock position, between his anal verge and his pectinate line, directly over the distal end of his internal sphincter. Typical fissures are found in the posterior midline 80% of this time, anterior midline 10% and can be in both positions about 5%. If fissures are seen laterally (and not in the anterior or posterior midline) then other causes should be suspected (infections, immunosuppressed states such as HIV, inflammatory bowel disease). A small oedematous skin tag commonly forms on his anal verge, just posterior to the fissure. This is the 'sentinel skin tag'. Later, his fissure may become indurated and infected, and may lead to a low perianal abscess (5.13), which may discharge through the fissure, and externally, to produce a low anal fistula. His internal sphincter lies directly under his fissure, and after several months of exposure this becomes fibrosed and spastic.
ANAL FISSUREDIAGNOSIS. A fissure is acutely painful, so don't do a rectal examination, or pass a proctoscope, until the patient is under general anaesthesia. Alternatively, and less satisfactorily, smear his anus with 10% amethocaine ointment for 10 minutes. Can you see a sentinel skin tag? Look for a triangular or pearshaped slit posteriorly, just inside his anus.
DIFFERENTIAL DIAGNOSIS Other obvious skin changes and cracks? (pruritus ani). Diarrhoea with multiple fistulae away from the midline? (the skin changes following some forms of colitis). More induration than in a fissure, a larger ulcer, and perhaps enlarged inguinal nodes? (carcinoma). Indurated margins, a symmetrical lesion on the opposite margin of his anal canal, and no pain? (primary chancre). The whole region is moist and pruritic, with flat, slightly-raised lesions, which are usually symmetrical on both sides? (secondary syphilis).
TREATMENT depends on how long he has had his fissure. Early presentation is unusual in the developing world.
If it is acute (less than 10 days old), only his epithelium is involved. The best treatment is a high fibre/high fluid diet. Sitz baths can also be used along with this. Education regarding what constitutes a high residue diet is important as a lot of patients will have no idea what this type of diet involves. Give the patient a 6-8 week period to try this before reassessment. Keeping the stools soft with liquid paraffin may help as well. When it has healed, warn him that it may return, if he allows himself to become constipated. He may have to continue this treatment indefinitely. Warn him that he must not keep his stools too loose, or they will never dilate his anus, so that it stenoses.
If you give him a local anaesthetic ointment (5% lignocaine), ask him to smear it over the sphincter inside his anus, not outside it.
If, his fissure fails to heal after you have kept his stools soft for 6-8 weeks, then a trial of an ointment such as nitroglycerine or a calcium channel blocker can be used (if available). These ointments are aimed at chemically lowering the sphincter tone. These should be used while a high residue diet is adhered to. Another very expensive method that is used in industrialized countries is Botulinum toxin injection. The ointments and Botulinum toxin have been shown in a Cochrane review to be better than placebo for healing. If his fissure is chronic (more than 10 days), fibrosed, has a sentinel skin tag, and especially if you can see the exposed fibres of his internal sphincter under it, it may not respond to non-operative treatment. A Cochrane review has been done that has looked at operative treatment for anal fissure comparing the lateral internal sphincterotomy to anal dilation. The lateral internal sphincterotomy was found to be the gold standard with a 95% success rate and the anal dilation is not recommended because of the issues associated with incontinence. Conservative therapy should be maximized prior to proceeding to a sphincterotomy because the rate of incontinence associated with it has been estimated to be between 2 and 20% although a lot of this is incontinence to flatus and not stool.
Pilonidal infections
The hairs from a patient's back sometimes work their way into the skin of his natal cleft and form a sinus or fistula, just behind his anus. These sinuses are very rare indeed in Indians and Africans.
He is usually a young man who presents with an abscess in his natal cleft. A history of "recurring abscesses at the base of his spine" is almost diagnostic. Incising his abscess may cure him, or he may get others.
Look also for one or more openings, sometimes with hairs coming out of them, exactly in the midline 5 cm behind his anus. Often, he has another sinus, 2-5 cm superiorly, and slightly to one or other side of the midline, with an indurated track joining it to the first one.
Look for hairs coming out of the sinuses. Don't mistake a pilonidal sinus for a subcutaneous or perianal fistula (22.2). If you are in doubt, remember: (1) In a pilonidal sinus there will be no induration between the lowest sinus and his anus. (2) There will be no fistulous opening inside his anus. (3) When you probe the lowest sinus, the probe will pass towards his sacrum, not his anus.
Aim to: (1) excise the sinus with a little surrounding tissue, (2) make sure that the wound heals properly, and (3) prevent hairs growing into it as it heals.
You have two choices: (1) You can do Lord's procedure (which is quite different from Lord's anal stretch). Lay open the main track, and excise the mouth of each sinus, together with a little cylinder of tissue, and then scrape, or preferably brush out, the hairs. If he will reattend regularly for postoperative care, this is probably the best method. (2) You can pass a probe through the sinus, cut down on it, and lay it open, as you would any other fistula. The most important part of the postoperative care, after either method, is to make sure that new hair does not grow into the granulating wound.
PIlONIDAL INFECTIONS
ACUTE INFECTION. Incise and drain the patient's abscess through a short incision, taking particular care to remove all hair and granulation tissue with a curette. Insert a drain. If necessary, treat his sinus later.
OPERATIVE TREATMENT FOR PILONIDAL SINUSESINDICATIONS. Two or more episodes of infection, and a persistent discharge. Be sure to operate at a time when his symptoms are quiescent.
ANAESTHESIA. You can operate on him while he is on his side, with his hips flexed, so there is no need to intubate him (A 16.12). (1) Ketamine (A 8.2). (2) As an outpatient, under local anaesthesia. Don't use subarachnoid or epidural anaesthesia-there is a septic lesion too close to the injection site.
METHOD. Shave the area around the sinus well. Put him in the left lateral position, with his buttocks over the edge of the table. Put a piece of gauze soaked in an antiseptic, such as chlorhexidine, over his anus, and towel him. Ask your asistant to stand at the other side of the table, and to retract his right buttock. The prone jacknife position using tape to distract the buttocks works better than the left lateral position for exposure.
Methylene blue injection makes the tracks much more visible, especially to a beginner. Most experts reckon it is unnecessary. Insert a cannula into the sinus, and tie a purse string suture round it. Inject methylene blue while your assistant tightens the purse string.
LORD'S PROCEDURE starts with probing any side-openings to find the direction they run in. Use a No. 11 scalpel to cut round them, and remove a little cylinder of tissue about 5 mm deep, with a 4 mm disc of skin.
Clean the track you have made, if possible with a very small brush (as made for electric razors), or a small curette. Treat all side openings in the same way. When you are sure that there are no more pockets that might contain hairs, apply a gauze dressing, and don't try to pack the cavity.
Postoperatively, regular salt baths (22.1) are important. Inspect the wound from time to time to make sure it is healing from the bottom up, without bridging or fistulae. Keep his back and buttocks shaved free of hairs while his wound heals, or his sinus will recur. Eventually, the scar will become strong enough to withstand them.
LAYING OPEN is done by passing a probe or fistula director into the primary opening, and letting it emerge through any secondary openings. Or, if a track is blind, bring it out to the skin. Incise the skin between the two openings, and lay the track widely open. Remove any hairs and curette the track. If necessary, trim the wound to encourage its edges to remain widely open. Pack it with a hypochlorite, or saline dressing, and treat it as for any other granulating wound in this region (22.1).
CAUTION! (1) Don't leave any sinuses behind. This is a disaster, and is why some surgeons excise a wedge of involved tissue down to the sacral periosteum.
Hold the raw margins of his wound apart until healing is complete. Let them heal from below, which is difficult, because of the anatomy of the natal cleft. If skin grows too soon, a residual cavity forms, into which hairs can fall or grow. Either pack the wound edges apart with a hypochlorite or saline dressing, or hold them apart by sewing a gauze roll in place. Ask him to run his finger up and down the wound itself each time he changes the dressings. This helps to keep the wound smooth and flat, removes debris, and is not painful. Give him some plastic or rubber surgeons's gloves, and some KY jelly. When he reattends, shave the edges of the wound carefully.
If he is fat, encourage him to lose weight. Ask him to separate the wound at least once a day with lateral traction. Warn him that his sinus might recur.
DIFFICULTIES WITH PILONIDAL SINUSESIf his wound BLEEDS postoperatively, give him some gauze, and ask him to sit on it.
If there is EXCESSIVE GRANULATION TISSUE, curette it. Remove loose hairs.
If his skin forms a BRIDGE ACROSS THE LESION, with a dead space underneath, his sinus will recur. This is the commonest cause of recurrence, and is the result of poor operative technique, or poor postoperative care; so try to get it right next time.
Rectal prolapse
Occasionally, the rectum prolapses out of the anus. It may prolapse incompletely, so that only a pink fold of mucosa shows, or it may prolapse completely, so that the whole thickness of the rectal wall is turned inside out (procidentia), and may ulcerate. At the same time the patient's anal sphincter may stretch and become patulous, so that he is incontinent. At first his rectum only prolapses with defaecation, later it does so on minimal coughing and straining; finally it is outside all the time.
Although the rectum can prolapse at any age, it commonly does so in children between the ages of 3 and 5 (usually incompletely), and occasionally does so in the aged (usually completely). The reasons are not clear..Prolapse is more common in malnourished children, perhaps because of poor tone and wasting of the anal sphincter mechanism. Prolapse is also associated with diarrhoea. If a child's malnutrition is treated, his prolapse is usually , cured also. A chronic cough, especially whooping cough, and worms, particularly Trichuris, may also play a part.
A child's rectal prolapse usually presents as his mother noticing that "Something red appears at his anus after defaecation". When she brings him to you, there is usually nothing to see. If there is, you can usually replace his rectum manually, but it is likely to return. If it remains prolapsed too long, it ulcerates. His prolapse will however correct itself as he grow older and his nutrition improves; some surgeons accept this, and don't usually do anything further. Somtimes the prolapse can be associated with constipation. Ensuring that the child is placed on a high residue/high fluid diet usually results in easy to pass, bulky stool that passes in one complete motion. This type of lifestyle modification should be attempted prior to thinking about the interventions discussed. You can strap his buttocks as described below. If this does not prevent it recurring, you can usually cure him quite easily with Thiersch's operation. Pass a suture around his anus subcutaneously, tie it just tight enough to prevent his rectum prolapsing, and just loose enough to let him pass his stools.
If you insert a non-absorbable suture, you will have to remove it later. Some surgeons also use gallows traction.
An adult's rectal prolapse is much more difficult to treat. Symptoms are due to the prolapse itself, and to a particular type of incontinence caused by difficulty in regulating bowel action. Try and refer this patient if possible. Starting the patient on a high residue/high fluid diet can sometimes help with the symptoms of the rectal prolapse. A rectopexy (hitching the rectum to the sacrum) is the optimal operation in terms of recurrence. The Thiersch operation can be very painful and result in erosion into the rectum. In industrialized countries it is usually reserved for patients who can not tolerate any type of operative intervention. If you cannot refer him, Thiersch's operation, preferably using wire, quite often succeeds. If it does not, you can hitch his rectum to his sacrum, in an operation which is similar to the ventrisuspension of a prolapsed uterus (20.10), but is more difficult. In patients over the age of 70 there are other perineal approaches that can be offered - Altmeier and Delorme procedures - but these should be done by surgeons who have experience with this technique.
RECTAL PROLAPSE
EXAMINATION. If a patient's prolapse is intermittent, he will give a history of "something coming down", but there will be nothing to see. If he is an adult, pass a proctoscope and ask him to strain down. His anal mucosa will prolapse into the hollow of the proctoscope, and extend beyond his anus as you withdraw it. If his prolapse is complete, the whole thickness of his rectum slides out all round, sometimes for several centimetres. When you do a rectal examination, his anal sphincter feels weak.
To find out if his prolapse is partial or complete, put you finger into his rectum, and feel the protruding ring of mucosa between your finger and thumb. If all you can feel is two layers of mucosa, it is incomplete; if you can feel more tissue than merely mucosa, it is complete. If it is a complete prolapse you will also be able to see concentric rings which are typical of a full thickness rectal prolapse.
If he is a child, distinguish a prolapse from a rectal polyp, or an intussusception. Examine him immediately after defaecation. Feel the outer aspect of the swelling, up to his anal orifice. In a prolape you cannot enter his anal canal at any point, but you can pass your finger between an intussusception, or a rectal polyp, and his anal wall.
If he is an adult, you will probably find that his prolapse is reduced when you examine him. Ask him to bear down to let you observe it. His anus may be large, and his sphincters abnormally lax. Assess their tone, because this is an important determinant of treatment and prognosis. Put your finger into his anus, and ask him to try to squeeze it. You may feel very little contraction. If it is very lax, he may allow you to put three or four fingers into it without discomfort.
CHILDREN WITH RECTAL PROLAPSEIf a child has diarrhoea, treat it. If his nutrition is poor, treat that first. These are the common causes of prolapse, and treatng them usually cures him and avoids an operation.
MANUAL REPLACEMENT AND STRAPPING. Using a glove and KY jelly, replace his prolapse manually. You may have to squeeze it for 15 minutes to do so.
Strap his buttocks securely together with a large gauze pad up against his anus. If this method is to work, the strapping must be adequate, painless, and easily applied. Apply a large square to each buttock. Join these with a 2.5 cm transverse strip, so as to close his buttocks, and leave this strip on during defaecation. Afterwards, remove it, clean his buttocks, and replace it with a fresh strip. Ask his parents to repeat this after each bowel movement, and give them some vaseline gauze, plain gauze, and strapping, with which to do it. After a time, his rectum will stay up where it belongs. Strapping is often all that is necessary.
If,after three or four reductions his prolapse soon recurs after defaecation, leave it out. Try again 3 or 4 days later, when it may stay in. After a week or two it will probably stay in. If it is not controlled after several weeks, and he is fit enough, do a temporary Thiersch's operation using No. 2 chromic catgut. If he is not fit enough, wait longer. Alternatively, consider gallows traction.
CAUTION! Too much trauma reducing a prolapse causes bleeding, which can be worse than leaving it outside covered by vaseli ne gauze.
GALLOWS TRACTION is controversial. Some surgeons don't use strapping and proceed immediately to gallows traction. Others consider it ineffective and messy. If you decide to use it, suspend him in the gallows position for a few days to two weeks (78.2). If this fails, consider a temporary Thiersch's operation.
ADULTS WITH RECTAL PROLAPSEIf an adult has an incomplete prolapse and the tone of his sphincter is normal, or only slightly relaxed, you can treat him in much the same was as if he had large third degree piles (22.6). Insert a bivalve proctoscope, and use haemostats to catch catch his redundant mucosa at the 3, 7, and 11 o'clock positions. Use scissors to divide the prolapse into three main portions, like primary piles, with narrow bridges of skin and mucosa between them. Tie and excise the bunches of mucosa, as if they were piles. These 'piles' are broad-based, so apply a transfixion ligature before you excise them. Preserving satisfactory mucocutaneous bridges may be difficult, but if one or even two are cut, the result may still be satisfactory.
If he has an incomplete prolapse and his sphincter is grossly relaxed, treatment is difficult, so refer him. If you cannot refer him, he may possibly benefit from Thiersch's operation (see below).
If he has a complete prolapse, refer him. If you cannot refer him: (1) If his prolapse is <15 cm and his sphincters are not too lax, try Thiersch's operation. (2) Otherwise, and if Thiersch's operation fails, try the operation described below for hitching up his rectum to his sacrum. If you can do a hysterectomy, you can do this, but it is not always successful.
THIERSCH'S OPERATION FOR RECTAL PROLAPSEINDICATIONS. (1) Children in whom strapping and/or gallows traction have failed. (2) Elderly debilitated adults whose life has been made miserable by rectal prolapse, particularly if you are inexperienced in abdominal surgery.
ANAESTHESIA. (1) Ketamine for children (A 8.2). (2) General anaesthesia.
SURGERY. Put the patient into the lithotomy position and replace his prolapsed rectum (A, in Fig. 22-13). Put your finger in his anus and feel his sphincter. It may be so loose that you can hardly feel it. Prepare and drape him.
Make short incisions in the 6 o'clock and 12 o'clock positions 2cm from his anus (B). Then, take a large curved round-bodied needle and thread it. For an adult use fine braided stainless 1 mm steel wire, or '2' braided silk. For a child use '1' or '2' chromic catgut.
Put the needle into his skin in the 12 o'clock position 1 cm from his anus. Pass it subcutaneously round his anus 1cm from it and out again at the 6 o'clock position (C). Pull the suture material through.
Put the needle back into the 6 o'clock hole from which it has just come. This time pass it round the other side of his anus and out at the 12 o'clock incision (D). Ask your assistant to put his little finger into the child's anus (E) (in an adult he should use his index). Tie the suture round his finger. Secure it with several knots, cut the ends 1 cm long and bury them. Close the two skin wounds with catgut.
CAUTION! (1) You must be able to get the tip of your little finger into a child's anus and your whole finger into an adult's anus. Getting the tension of the suture material right is difficult. If it is too tight, it will interfere with defaecation, and cause faecal impaction, or the wire may cut out. If it is too loose, it will not cure his prolapse. (2) Don't forget to make sure that he can pass stools normally before discharge.
The major complications are breakage of the suture, and difficulty in passing even a soft stool, if the suture is too tight. Advise an adult to eat his traditional high-fibre diet.
Alternatively pass an ordinary tubular hypodermic needle round his anus from the 12 o'clock to the 6 o'clock positions, and vice versa. Pass the suture material through this, and tie it as above.
POSTOPERATIVELY, an adult is usually old, so leave his nonabsorbable suture in.
STITCHING THE RECTUM TO THE SACRUMExpose the patient's pelvis through a lower midline incision, and pack away his gut. Mobilize his rectum down to his pelvic floor, laterally by incising his peritoneum, and posteriorly by finger dissection, keeping close to his rectal wall. If you don't there will be massive bleeding. Dissection is quite easy, because there is a bloodless plane between the rectum and the sacral fascia. Be careful not to go too far backwards, because there is a plexus of veins just anterior to the sacrum; if you damage this he may bleed severely. Bleeding gets worse with each attempt at ligation.
If you are unlucky and do injure this venous plexus, insert a gauze pack and wait 10 minutes. If bleeding continues, pack the area with ribbon gauze, leave the pack in place, and remove it under general anaesthesia after 48 hours. The prolapse may even be cured.
Divide the lateral ligaments (the sacrouterine ligaments in a woman, 20-17). These contain a few blood vessels, which may need transfixing.
Using non-absorbable '0' or '1' multifilament sutures, pull his rectum firmly upwards towards his sacral promontary, and place about 6 sutures between his pre-sacral fascia and the tissues around the back and sides of his rectum.
If you have an 'Ivalon sponge' or 'Marlex mesh', insert a broad strip of this between his rectum and his sacral periosteum.
CAUTION! (1) Don't penetrate the wall of his rectum. (2) Be sure to put all the sutures in first and then tie them later. (3) Make sure his rectum is pulled up well out of the hollow of his sacrum.
Other anorectal problems
Carcinoma of the rectum (32.27) is not uncommon in India, but is still unusual in Africa. Try to diagnose it and refer the patient. Here also are some other problems which you will meet occasionally.
OTHER ANORECTAL PROBLEMSLESIONS OF THE RECTUMIf a patient has an ULCERATIVE or PROLIFERATIVE LESION OF HIS RECTUM, it might be an amoebic granuloma, which an unusual compHcation of amoebic colitis (31.10). This can obstruct his colon or his rectum, but is more common in his caecum. An amoebic granuloma of the rectum is softer, and lacks the craggy hardness and friability of a carcinoma. Look for amoebic trophozooites in his stools, and biopsy the lesion. Don't do a colostomy. Metronidazole will usually make the lesion melt away.
CAUTION! If you think that any granulomatous mass in relation to the large gut might be an amoeboma, try metronidazole.
If he presents with CONSTIPATION, TENESMUS, and the passage of MUCUS, one possibility is a SOLITARY RECTAL ULCER (common in India in adults and older children). Sigmoidoscopy shows a solitary linear ulcer 8-10 cm from his anus. Digital evacuation is an important cause. Instead of asking "Do you put your finger into your rectum?", ask "How often do you put your finger into your rectum to remove the faecal matter?". Treat him with a hydrophilic colloid and the threat: "Although there is as yet no evidence of cancer, persistence with digital evacuation might produce it".
LESIONS AT THE ANUSIf he has a FIRM FUNGATING MASS at his anus, perhaps with enlarged inguinal lymph nodes, it may be a CARCINOMA OF HIS ANAL CANAL. Take a biopsy and refer him.
If you cannot refer him, there is little you can do for advanced lesions, but, if the lesion is small and near his anal margin, infiltrate it with local anaesthetic solution containing adrenalin. Ask your assistant to hold a speculum in position, while you excise the tumour widely.
If he has WARTY CAULIFLOWER-LIKE LESIONS in his perianal area, he probably has CONDYLOMATA ACUMINATA. These are of viral origin, and may extend inwards as far as his pectinate line, and become infected and ulcerated. They move on the underlying tissue (unlike a carcinoma), and the skin between them is normal. If in doubt, take a biopsy.
Infiltrate his perianal skin with dilute lignocaine with adrenalin (A 5.4). Then carefully remove the growths with scissors. Treat the raw areas that are left with hypochlorite or saline dressings, like any other perianal granulating lesion.
If he has a STRICTURE OF HIS RECTUM, which may partly obstruct it and cause alternating constipation and diarrhoea, with faecal incontinence, it is probably due to: (1) Lymphogranuloma venereum (much the most likely cause, see below). (2) Carcinoma. (3) Fibrosis following a corrosive traditional enema (usually a long stricture). (6) Schistosomiasis. (7) Amoebiasis (8) Unskilful haemorrhoidectomy (22.6). A stricture due to lymphogranuloma venereum is usually a localized shelflike lesion of hard fibrous tissue about 1cm deep, 5cm in from the anus, and lined by thin adherent anal skin. Sometimes there is a rectovaginal fistula below the stricture.
If you remove the stricture entirely, he may become more incontinent. Either: (1) Carefully dilate it with Hegar's dilators under general anaesthesia. Try not to tear it, or you will cause further inflammation and fibrosis. Or, (2) put the patient into the lithotomy position, and, preferably using diathermy, make four V-shaped incisions in the 12, 3, 6, and 9 o'clock positions to remove four triangular pieces of fibrous tissue. Or, (3) if obstruction is severe, consider referring him for an abdominoperineal resection and a permanent end colostomy.
If a woman has ULCERATIVE LESIONS ON HER GENITALIA, accompanied by acute inflammation and suppuration of her inguinal nodes, she probably has LYMPHOGRANULOMA VENEREUM. Most chronic cases are seen in women, in whom it causes thickened and oedematous perianal and vulval skin, with anorectal suppuration, fibrosis, fistulae, and a stricture (see above). Meanwhile, her perianal region discharges pus, blood, and mucus. Ultimately, her anus and lower rectum are destroyed, and replaced by a thick fibrotic tube. The demonstration with a probe of 'bridges of skin' virtually confirms the diagnosis. Amoebiasis is the important differential diagnosis. Early, tetracycline and chloramphenicol are effective. Later, they can do nothing, except control sepsis.
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