Perianal Disease

Introduction

Inflammatory Bowel Disease (IBD) is a chronic illness that causes the tissues in the digestive tract to become inflamed. The two main ailments are the following:

• Ulcerative colitis: Inflammation develops along the patient's colon and large intestine lining. 
• Perianal Crohn’s disease: This type of IBD also causes inflammation in the digestive tract's lining. The small intestine is specifically affected by Crohn's disease. However, it can occasionally impact the upper gastrointestinal system. 

The following are the main signs of both Crohn’s disease and ulcerative colitis: 

• Diarrhoea 
• Bodily bleeding 
• Continent pain 
• Fatigue loss 
• Weight loss

Grading and naming systems

Perianal diseases are classified into different groups. The main classified diseases are 

• Perianal Fistula
• Abscesses 
• Rectal strictures 
• Perianal ulcers
• Skin tags
• Perianal Fissures

Symptoms

Fistulas 

Anal fistulas occur when a tunnel forms between the anus and the lower portion of the bowel, then pus builds up in the tissue around an anus due to infection. 

The main signs of a perianal fistula are discomfort and skin irritability. Surgery is typically advised as a treatment because the condition doesn't go away on its own. 

Fistula symptoms include: 

• Constant discomfort whether you move, sit, or try to poo.
• Smell coming from the anal region. 
• Bleeding through poo. 
• Redness and swelling close to the anal region. 
• Abcess-area temperature is elevated. 
• Bowel movement issue.

Fistulas resemble a skin wound close to the anas, and an anal fistula typically develops after an abscess does. If an abscess is not adequately treated, it will eventually become a fistula. In most situations, surgery is advised.

Abscesses 

Abscesses are a condition in which pus builds up and causes swelling in the anal region, where pus is created as a result of the bacterial infection. When an infection developed inside the little gland of the anal canal, abscesses resulted. Abscesses create a passage between the skin surrounding the anal canal and the skin. 

Abscess slowly forms a heated, bloated, red mass around the anus. The patient experiences pain when standing or moving, and even a small press can be used as a treatment to get the pus out. A minor incision can be used to remove pus with the aid of a local anaesthetic to numb the area.

There are a few measures that can be taken to stop perianal abscesses, such as: 

• Keep up with your hygiene to prevent bacterial skin infections. 
• Never use another person's towel or clothing. 
• Smoking cessation and weight loss.

If abscesses are left untreated, cancer, diverticulitis, Crohn's disease, and sexually transmitted diseases can all occur. 

Rectal strictures

A digestive tract stricture is a constriction of a small portion, and a sphincter spasm is known as a rectal stricture. A stricture in the rectum may be brought on by the accumulation of fibrous tissue. Collagen and fibronectin are two distinct proteins that make up fibrous tissue, which are proteins that treat wounds that have been influenced by inflammation, abscesses, fistulas, or ulcerations. 

Symptoms of Perianal strictures are:

•  Frequent bowel motions,
•  Urgency and the impression that the bowels are not emptying.

One of the most successful treatments is balloon dilation.³ Sometimes, it's necessary to repeat the balloon dilatation. A more successful method that doesn't cause any complications is an incision combined with balloon dilation.

Ulcers 

Rectal ulcers are developed inside the rectum and give rise to a chronic condition. It takes several years to develop a rectal ulcer; however, various distinct disorders might cause these ulcers. For example, rectal ulcers can appear in people with an illness known as solitary rectal ulcer syndrome (SRUS). The rectum and intestines may potentially develop ulcers as a result of IBD, such as ulcerative colitis and Crohn's disease. Rectal ulcers can also form as a result of constipation and exerting too much force when having a bowel movement.

Symptoms of rectal ulcers are:

• Stool with blood. 
• Bleeding is caused by the anus. 
• Abdominal pain 
• Unpleasant bowel motions

Stress or physical damage (injury) to the rectum can lead to rectal ulcers. Trauma may be brought on by: 

• Severe or persistent constipation.
• Pushing or straining excessively when having a bowel movement (often because of constipation). 
• IBD, solitary rectal ulcer syndrome, or proctitis-related rectal inflammation (swelling and irritation,a condition that causes inflammation in the intestines). 
• Removing stools that have gotten caught in the rectum using your fingertips. 
• The rectum can herniate out of the anal orifice due to the condition known as rectal prolapse. 
• Anal sex or enemas, which are foreign items inserted into the rectum and anus. 
• STDs and STIs, like syphilis and herpes, are illnesses and infections spread through sexual contact.

Rectal ulcers can be diagnosed by performing a:

• Colonoscopy
• Sigmoidoscopy 
• Anoscopy
• Rectal ultrasound 
• Biopsy 

In many cases, a rectal ulcer can be cured by changing lifestyle, drinking plenty amount of water, and avoiding fast food and spicy food. 

Skin tags

Skin tags have a 37% risk of appearing in Crohn's disease patients. A growth that sticks out near the anal area is called a perianal skin tag. There are two basic forms of skin tags. 

• Large, bloated
• Painfully flat, soft 

The majority of skin tags are removed surgically with the aid of local anaesthetic. Several of the processes include 

• Cauterization: The removal of tags using heat. 
• Liquid nitrogen is used in cryosurgery to stop the growth of tags. 
• Skin tags can be removed by a doctor using electrocautery, which uses a specialised electric current. 
• Ligation: Removing skin tags by using surgical thread to stop the blood supply.

Fissures

An anal fissure is a tiny tear in the mucosa, a delicate, moist membrane that lines the anus. You could develop an anal fissure if you pass large or hard stools during a bowel movement. Anal fissures frequently result in pain and blood when bowel motions occur. Spasms in the muscular ring at the end of your anus are another possibility (anal sphincter). 

Although they can afflict anyone at any age, anal fissures are most common in early infants. Most anal fissures improve with straightforward therapies like increased fibre intake or sitz baths. Anal fissure sufferers may occasionally require surgery or prescription medication.

Symptoms of anal fissures are:

• Occasionally, severe discomfort occurs during bowel motions.
• After-bowel movement discomfort that may continue for several hours.
• After a bowel movement, bright crimson blood might be seen on the toilet paper or stool. 
• A skin break that is apparent around the anus.
• A skin tag (a tiny lump on the skin next to the anal fissure).

By taking steps to avoid constipation or diarrhoea, you may be able to prevent an anal fissure. Avoid needing to strain during bowel movements by eating high-fibre foods, staying hydrated, and engaging in regular exercise.

Diagnosis

Examination

Doctors or nurses perform rectal examinations primarily to detect perianal disease. A finger is put inside the rectum during the rectal exam. This process is quick and painless; however, sometimes, lubricant can be used to numb the area and eliminate any pain. 

The following conditions call for a rectal examination: 

• Regurgitation bleeding. 
• Pain around the rectum. 
• Constipation. 
• Inflammatory Bowel issues (IBS). 
• Men may occasionally need to get a rectal exam to look for any prostate-related issues.

The process includes the following:

• Patients lay on their left side and bring their knees up to their chests. 
• Putting on gloves, the doctor or nurse surveys the outside to look for any anomalies. 
• Gel lubricants are used to prevent pain. 
• To evaluate how the muscles are performing, patients are instructed to squeeze the area around the inserted finger.

Proctoscopy or rigid sigmoidoscopy

Patients with perianal Crohn’s disease, perianal fistulas, perianal abscesses, and complex perianal fistulas undergo proctoscopy or rigid sigmoidoscopy to detect tumours, inflammation, and bleeding within the rectum and anal region. 

A hollow tube called a proctoscope has a tiny light at the end. The patient's tissue is sampled via the proctoscope for a biopsy. 

The purpose of rigid sigmoidoscopy is to: 

• Discover the cause of anal bleeding.
• Find fistulas and perianal Crohn's illness.
• Determine inflammatory bowel disease origin.
• Detection of colon cancer

Proctoscopy is performed at medical facilities or in outpatient settings. Anaesthesia is not necessary for this surgery.

Throughout the process: 

• The doctor will inspect the exterior area while wearing lubricated gloves.
• Insert the tube slowly.
• To use a proctoscope and see properly inside the bowel, the air is inserted.
• Patients could experience a small amount of discomfort throughout this operation.

Flexible sigmoidoscopy and colonoscopy

A flexible tube with a tiny camera is put within the left side of the colon during a flexible sigmoidoscopy procedure to detect colitis and perianal Crohn's disease inside the anal canal. 

If a patient experiences symptoms like the following, a flexible sigmoidoscopy is advised: 

• Perianal bleeding
• Pain in the anal canal
• Inflammatory bowel disease

Occasionally, tumour-like formations called polyps are discovered while doing the surgery, and then a biopsy is requested for polyps. During the treatment, polyps in the anal canal are removed. Polyps could develop into cancer over a year. On the same day, patients can be sent home, and admission to a hospital is not necessary. 

However, this method does have a restriction. With flexible sigmoidoscopy, only the first half of the large bowel is examined, or even if the results are expected, there can still be a problem.

Treatment

There are several cutting-edge treatments available today for perianal fistula, perianal Crohn's disease, and complex perianal fistula. Surgery, immunosuppressive drugs, and antibiotics are all effective treatments for perianal illnesses. 

The primary objective of treating perianal illness is to prevent: 

• Inflammatory bowel disease 
• Sepsis 
• Surgery (needed to avoid inflammation) 

To stop any additional infection, the damaged area must be cleaned. A cream is also advised to protect the skin around the anus area. 

Antibiotics

An anal fistula is treated with antibiotics. After surgery or the evacuation of a perianal abscess, a combination of metronidazole and ciprofloxacin is taken for 7 to 10 days to prevent anal fistula.

Surgery

The anal canal's terminus is where a perianal abscess typically develops. It is quite painful. When a cyst or something resembling a tumour appears at the site of the abscess, surgery is necessary. When a tiny gland in the anus becomes infected, an abscess forms. The digestive system as a whole becomes inflamed with Crohn's disease. 

Treatment for a perianal abscess can be accomplished by draining the pus. 

During the procedure, general anaesthesia is employed. The abscess is examined by the surgeon, who then drains the pus to stop it from regrowing. 

A skin incision is used to alleviate pressure and remove diseased tissue.

Immunosuppressive agents

Effective treatment was necessary for complex perianal disease. Corticosteroids are inappropriate in the case of Chorn's disease. For a better result, antibiotics, immunosuppressive drugs, and anti-TNV are needed. After an MRI scan is done to provide a clear view of the pelvis, this therapy is carried out. 

Studies¹ have shown that using azathioprine for a prolonged period lowers the risk of perianal surgery. However, azathioprine and anti-TNV combination therapy is a more effective treatment for perianal Chorn's disease.

Complications

Major complications result if the digestive system is impacted. According to studies,² perianal fistulae are present in 12% of patients with ileal illness, 15% with ileocolonic disease, 41% with colon disease, and 91% of people with Chron's disease. Additionally, research indicates that when the small intestinal disease is the only cause of illness, Chron's disease alone results in a 52% completion rate. 

The intestine will become affected by Chron's disease if an anal lesion is one of the main symptoms. The intestinal symptoms of perianal Chron's disease take several months to years to develop.

Diet

Diet is a key factor in preventing perianal disease. To prevent perianal illness or treat someone who already has it, high-fibre foods and enough water consumption are essential. Here is a list of nutritious foods that are advised for people with perianal disease: 

• Cereals: They are high in fibre and simple to digest. It eases bowel movements. Pain and tension are, therefore, lessened. 
• Major pulses include chickpeas, soybeans, and lentils. They have added fibre and protein. They thereby aid in the clearing of the digestive tract.
• The importance of green leafy vegetables to the diet cannot be overstated. They include a lot of fibre, vitamins, and minerals. They are simple to digest and aid in gastrointestinal tract cleaning.
• Apples, bananas, and avocados are all excellent examples of fresh fruit. There is a lot of fibre in them. It aids in the alleviation of discomfort brought on by anal fistula-related inflammation. 
• Brown rice: It contains a significant amount of dietary fibre and lowers the risk of constipation. It is very beneficial for the patient who has an anal fistula. 
• Medium-chain fatty acids (MCFAs), which are saturated fatty acids, are present in coconut and are simple for people to digest. It promotes good digestion and aids in bowel movement.
• Yoghurt and skim milk are excellent food choices. Yoghurts contain probiotics that aid in restoring the beneficial bacteria in the gut. Therefore, it facilitates better digestion and bowel movements.
• High levels of Omega-3 are added to fish like salmon and tuna. Our bodies benefit greatly from omega-3 fatty acids, which also lubricate the digestive tract and aid in bowel movement.

On the other hand, there are some foods that should be avoided to prevent perianal disease.

• High-fat dairy product 
• Fast food
• Spicy food
• Fried food
• Salty food
• Red meat
• Alcohol
• Caffeinated beverage 
• Packaged food

Changes in lifestyle

Maintaining a healthy lifestyle is crucial to reversing perianal illness. For this health issue, it's crucial to drink lots of water, exercise regularly, and eat foods high in fibre, vitamins, and nutrition. It's also advised to get plenty of sleep and to exercise every day. Any person who has a high risk of developing perianal Chron's disease should have a flexible colonoscopy performed at least once a year. Contact your doctor as soon as any symptoms appear.

Summary

These days, perianal disorders are increasingly prevalent because of our bad eating and living habits. However, the majority of them can be cured thanks to modern medical procedures. Nothing to worry about. There are surgical, immunosuppressive, and antibiotic cures for them. However, it's crucial to have a healthy lifestyle in addition to eating well. Early disease detection will help all medications stop any future complications.