Clinical features of rectal disease

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 occur in the middle-aged and elderly. But no age is exempt from any of the diseases, however young: ulcerative colitis has been reported in the newborn, and rectal cancer is not rare in young people. The common symptoms of rectal disease are the following.

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 into its lower end. A tumbler, mouth looking downwards, has been extracted by filling the interior with a wet plaster of Paris bandage, leaving the end of the bandage protruding, and allowing the plaster to set.

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.