Hypertrophied anal papillae are essentially skin tags that project up from the dentate line, or the junction between the skin and the epithelial lining of the anus They are often found as part of the classic triad of a chronic fissure, namely the fissure itself, hypertrophied papilla above and a skin tag below. They are also found in isolation, maybe firm and palpable on a digital examination of the anus. In this situation, they must be differentiated from polyps, hemorhoids, or other growths. Endoscopically they could be differentiated from an adenomatous polyp by their white appearance and their origin from the lower (squamous) aspect of the dentate line in the anal canal. They are usually a symptomatic but occasionally grow large enough to be felt by the patient or are likely to prolapse. Hypertrophied anal papilla should be included in the differential diagnosis of a smooth mass located near the anal verge, especially in a patient with a history of chronic anal irritation or infection
With passage of time, papillae continue to grow in size. A papilla is liable to acquire considerable fibrous thickening over a period of time when it gets a rounded expanded tip, which is known as a fibrous polyp. This is due to piling up and consolidation of chronic inflammatory tissues at the proximal part of the fissure at the dentate line. As many as 16% of the patients having chronic fissure in anus recorded the presence of papillae that turned into fibrous polyps. These papillae are presumed to be caused by edema and low-grade infection.
A fibrosed-hypertrophied papilla is also frequently found at the upper part of a chronic anal fissure or guarding the internal opening of fistula in anus. In the later case however, the symptoms may completely dominate and distort the clinical findings. Dilated veins, white areas, and a large hypertrophied anal papilla are often found in prolapsing types of hemorrhoids
In the past, these structures were not given any importance and were left untreated. Those patients, in whom, the fissure in anus was treated but the concomitant papillae or polyps were left untouched, continued to complain of pruritus, wetness, or an intermittent pricking sensation in the anus. Those with fibrous polyps felt incompletely treated due to a feeling of something projecting from the anus. Even a case of giant hypertrophied anal papilla complicated with a massive anal bleeding and prolapse was reported
This study was aimed to assess the impact and utility of attending to these two conditions concurrently while dealing with cases of fissure in ano
MATERIALS AND METHODS
This study was carried out at Gupta Nursing Home, Nagpur, India, between July 2000 and December 2001.
Two hundred patients suffering from chronic fissure in ano associated with hypertrophied anal papillae or fibrous polyps were selected for the study. All these patients had primarily reported symptoms and complaints of chronic anal fissure. The papillae and polyps were diagnosed preoperatively by using a pediatric anoscope to avoid discomfort during examination. The number of papillae ranged from two to four. However, the fibrous polyp was found to be single in all those patients who were having this pathology.
The procedure was carried out under a short general anesthesia with a muscle relaxant. A lateral subcutaneous sphincterotomy was performed to relieve the sphincter spasm. This was followed by insertion of the anoscope with a proximal illumination. The anal canal was cleaned off the collection. The papillae or polyps were located and were dealt with through a radio frequency surgical technique.
Radio frequency surgery aims at cutting or coagulation of tissues by using a high frequency alternate current. The radiofrequency device performs a simultaneous function of cutting and coagulating of the tissues. The effect of cutting, known as high frequency section, is executed without pressuring or crushing the tissue cells. This is due to the result of heat produced by the tissues' resistance to the passage of the high frequency wave set to motion by the equipment. The heat makes the intracellular water boil, thereby increasing the inner pressure of the cell to the point of breaking it from inside to outside (explosion). This phenomenon is called cellular volatilization.
In this procedure, we used the radio frequency generator known as Ellman Dual Frequency 4MHz by Ellman International, Hewlett, N.Y. This instrument produces an electromagnetic wave of a very high frequency that reaches 4 megahertz. The unit is supplied with a handle to which different inter-changeable electrodes could be attached to suit the exact requirement. In our study, we used the ball electrode for coagulation and a round loop electrode for shaving off the desired tissues.
The papillae were directly coagulated with a ball electrode with the radio frequency unit kept on coagulation mode, which resulted in shrinkage and disappearance of the papillae in no time.
For the fibrous anal polyp, we initially coagulated its base circumferentially by a ball electrode and then shaved off the mass by using the round loop electrode. The minor bleeding encountered in some cases was coagulated by touching the bleeding points with the ball electrode. The whole procedure took around 7-10 min to complete.
The patients were prescribed analgesics for one wk and a stool softener for a period of 1 mo.
The first follow up was made after 30 d. The fissures were healed and there was no sphincter spasm in any of the patients from either group. During examination of patients from group A, anoscopies showed total absence of the papillae. Patients who were treated for fibrous polyps did have some amount of edema and mild elevation at the site of destruction. However, patients had fewer complaints of pruritus, pricking, heaviness and a sense of incomplete evacuation as compared to patients from group B.
Anal papillae were found in almost 50-60% patients examined by us in regular practice. Usually, they were small, caused no symptoms, and could be regarded as normal structures. However, if it is a case of hypertrophy and the papillae start projecting in the anal canal, it not only requires attention but calls for a suitable treatment also. In such cases, there are chances of increase in the mucus leak resulting in increased anal moisture. These are liable to get traumatized and inflamed during the passage of stool. In addition, on being converted into a fibrous polyp, they tend to project at the anal orifice during defecation, often requiring to be digitally replaced. These polyps are considered as one of the differential diagnoses of rectal prolapse. The patients also reported symptoms like pruritus, a foreign body sensation, pricking, a nagging sense of incomplete evacuation and heaviness in the anal region.
As a routine practice, these pathologies were not given any importance. There is very brief reference to this entity in the standard textbooks and other references. Secondary goals of fissure surgery sometimes required the removal of hypertrophied papilla and skin tag as well as the removal of inflammatory and fibrotic tissues surrounding the fissure. Customarily, in the symptomatic papillae or polyps, their removal by crushing of the bases, excision after ligation or electrocautrization has been suggested. All these procedures are time consuming and are associated with complications at times. The use of radio frequency devices to deal with these pathologies has been found to be a quick, easy and significant complication free procedure The device can ablate the papillae instantly, while the fibrous polyps can be excised after coagulation of the bases and thereafter the pedicles. In the present study, we have specifically excluded those patients of chronic fissure in ano who had sentinel tags or piles, as they were known to cause few of the similar symptoms that were associated with hypertrophied papillae or fibrous anal polyps.
Hypertrophied anal papillae and fibrous anal polyps are important anal pathologies associated with chronic anal fissure and are responsible for symptoms like pruritus, a pricking sensation, heaviness, etc. Their removal should be made an essential part of treatment of chronic fissures in ano. Persistence of these structures leaves behind a sense of incomplete treatment and thereby reducing the overall satisfaction on the part of the patient. radio frequency procedures have been found useful in successfully eradicating these concomitant pathologies of chronic fissure in ano. This procedure should be given a fair chance to prove its utility and long-term efficacy.
World J Gastroenterol
Last edited by Medical Photos; 09-16-2015 at 06:37 PM.
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