Symptoms
Rectal diseases
are common and serious, and can occur at any age. The
symptoms of many of them overlap. In general, the inflammations affect younger
age groups, while the tumours
Bleeding
This demands at least digital examination at
any age.
Altered bowel habit
Early morning stool frequency (‘spurious
diarrhoea’) is a symptom of rectal carcinoma, while blood stained frequent
loose stools characterise the inflammatory diseases.
Discharge
Mucus and pus are associated with rectal
pathology.
Tenesmus
Often described by the patient as ‘I feel I
want to go but nothing happens’; this is normally an ominous symptom of rectal
cancer.
Prolapse
This usually indicates either mucosal
(partial) or full thickness (complete) rectal wall descent.
Pruritis
This may be secondary to a rectal discharge.
Loss of weight
This usually indicates serious or advanced
disease, e.g. hepatic metastases.
Main
symptoms of rectal disease
• Bleeding per rectum
• Altered bowel habit
• Mucus discharge
• Tenesmus
• Prolapse
Signs
Because the rectum is accessible via the anal
orifice these can be elicited by systematic examination. The patient is either
positioned in the left lateral (Sims) position or examined in the knee-elbow
position (Fig. 60.4).
Inspection
Visual examination of the anus precedes rectal
examination to exclude the presence of anal disease, e.g. fissure, haemorrhoids
or fistula.
Digital examination
The index finger used with gentleness and
precision remains the most valuable test for rectal disease (Fig.
60.5). Tumours
in the lower and middle thirds of the rectum can be felt and assessed; by asking
the patient to strain, even some tumours in the upper third can be tipped’
with the finger. After it is removed the finger should be examined for tell-tale
traces of mucus, pus or blood. It is always useful to note the normal as well as
the abnormal findings on digital examination, e.g. the prostate in the male.
Digital findings can he recorded as intraluminal (e.g. blood, pus), intramural
(e.g. tumours, granular areas, strictures) or extramural (e.g. enlarged
prostate, uterine fibroids).
Proctoscopy
This can be used to inspect the anus,
anorectal junction and the lower rectum (up to 10 cm) (Fig.
60.6). Biopsy can be
performed of any suspicious areas.
Sigmoidoscopy
The sigmoidoscope was in the past a rigid
stainless steel instrument of variable diameter and was normally 25 cm in length
(Fig. 60.6). This has in the main been replaced by a disposable Perspex
instrument which has major advantages when considering transmittable disease.
The rectum must be empty for proper inspection with a sigmoidoscope. Gentleness
and skill are required for its use, and perforations can occur if care is not
exercised.
Flexible sigmoidoscope
The ‘flexiscope’ can be used to supplement
or replace rigid sigmoidoscopy (Fig. 60.7). It requires special skill and
experience, and the lower bowel should be cleaned out with preliminary enemas.
In addition to the rectum, the whole sigmoid colon is within visual reach of
this instrument. The instrument is expensive and requires careful maintenance.
Injuries
The rectum or anal canal may he injured in a
number of ways, all uncommon.
•
By falling in a sitting posture on to a spiked or blunt pointed object.
The
upturned leg of a chair, handle of a broom, floor mop, pitchfork
or
a broken shooting stick have all resulted in rectal impalement.
•
By the fetal head during childbirth, especially forceps assisted.
Diagnosis.
When there is a history of rectal impalement, the first interrogation should
he, ‘Has the patient passed urine since the accident?’ The anus having been
inspected, the abdomen should be palpated. If rigidity or tenderness is present,
early laparotomy is imperative. Prior to the operation, a urethral catheter is
passed. If the urine is bloodstained and/or the quantity recovered is
unexpectedly small, it is wise to suspect ruptured bladder or urethra (see
Chapters 65 and 67).
Treatment.
After the patient has been anaesthetised, the rectum is examined with a finger
and a speculum, especial attention being directed to the anterior wall. A lower
laparotomy is then performed. If an intra peritoneal rupture of the rectum is
found, the perforation is closed with sutures. Should blood be present beneath
the pelvic peritoneum, it is necessary to mobilise the rectosigmoid, which
allows the rectum to be drawn upwards, thus permitting the perforation below the
pelvic diaphragm to be closed securely. A perforation in the bladder can also be
sutured via this avenue. After closing the laparotomy wound, a defunctioning
colostomy is constructed in the left iliac fossa. In cases where the bladder has
been injured, a self-retaining urethral catheter is placed in
position. If the rectal injury is below the
pelvic floor, wide drainage from below is indicated. A ‘protective’
colostomy is advisable. If the defect in the rectum is very large, resection may
have to be contemplated. In such circumstances, a Hartmann’s procedure is
indicated. Care must he taken to preserve sphincter function during the
debridemcnt of the perineal wounds. Antibiotic cover should be provided against
both aerobic and anaerobic organisms.
Foreign bodies
in the rectum
The variety of foreign bodies which have found
their way into the rectum is hardly less remarkable than the ingenuity displayed
in their removal (Fig. 60.8). A turnip has been delivered per
anum by the use of obstetric forceps. A stick firmly impacted has been
withdrawn by inserting a gimlet
If insurmountable difficulty is experienced in
grasping any foreign body in the rectum, a laparotomy is necessary, which allows
that object to be pushed from above into the assistant’s finger in the rectum.
If there is considerable laceration of the mucosa, a temporary colostomy is
advisable.