Introduction
Assessment of the anal canal and perianal region is part of an adequate screening
for neoplasias and evaluation of intestinal bleeding sources [1]
[2]. Although colonoscopy is a recognized diagnostic and therapeutic method for investigation
of colorectal diseases, it presents limited visualization and evaluation of the anal
region. Some maneuvers may be used to improve evaluation of the lower rectum and anal
canal by colonoscopy, such as rectal retroflexion [3]
[4]. Even with use of this technique, lesions may go unnoticed and many disorders of
the anal canal may not be detected [5]
[6]
[7]
[8]
[9]
[10].
Anoscopy is the gold standard for anal canal evaluation, but is often neglected in
medical practice [2]
[9]. Standard anoscopy is the one performed with use of an anoscope and direct visualization
of the anal region, usually without sedation and without bowel preparation [11]. However, sometimes anoscopy without sedation can become an embarrassing, uncomfortable
and painful situation. It can be impossible if the patient has anal pain or improper
preparation. In addition, it has a more limited and distant view, with the face of
the operator exposed to the fecal spray.
In 1995 an examination technique called video anoscopy (VA) was described by Lazas
et al. [9]. Examination of the anal canal was performed with an anoscope and visualized by
video sigmoidoscope, without sedation. Performing VA during colonoscopy, with the
patient under sedation and with bowel preparation, may improve visualization of normal
and altered structures by way of high-quality images, thus increasing sensitivity
in detection of anal disorders ([Fig. 1]).
Fig. 1 Video anoscopy during colonoscopy.
Studies available in the literature on video anoscopy during colonoscopies in detection
of diseases of the anal canal are scarce. The purpose of our study was to access the
spectrum of diagnoses, prevalence of anal disorders, and importance of anal examination
made by VA in colonoscopies in evaluation of anal diseases.
Patients and methods
This is a single-center cross-sectional study of patients who were referred for routine
colonoscopy and were systematically evaluated with inclusion of anal examination by
video anoscopy. Data were retrospectively analyzed from consecutive patients who underwent
routine colonoscopy from October 25, 2006 to September 10, 2018. The study was approved
by the local Ethics Committee.
All patients in the study underwent bowel preparation. An admission record was filled
in with patient data and history of previous surgeries. The equipment used was a Pentax
standard videocoloscope (Pentax Corporation, Tokyo, Japan) or Fujinon (Fujifilm, Tokyo,
Japan) and the transparent disposable plastic anoscope (Plastic Way or Kolplast).
Patients were monitored throughout the procedure, with heart rate, blood pressure,
and oximetry parameters. After conscious sedation, they were submitted to VA and colonoscopy,
by the same professional.
Patients underwent a digital rectal examination and the colonoscope was inserted into
the rectum with aspiration of the liquid contents. An evaluation was performed with
straight withdrawal of the colonoscope, visualizing the rectum, dentate line and anal
canal. Afterwards, the anoscope was inserted, the anal canal and perianal region were
evaluated using the videocolonoscope and the results recorded. Biopsies and polypectomies
were performed if needed. After this evaluation, the colonoscopy was performed.
Reports of the exams and the images obtained were recorded and saved in a database
(OCRAM, SP system). This system was used to record VA images and compose the respective
reports during the study period. The colonoscopy report format with anal examination
described in a separate item allowed the search for pre-established patterns. The
results were grouped separately, dividing the male and female patients and classified
by 10-year age groups. Reports that presented non-standardized descriptions were analyzed
individually by the images, and then grouped.
Repeated exams on different dates on the same patient were excluded and thus remained
the single most relevant report. The resulting patients who were analyzed and evaluated
displayed the following diagnoses: normal examination; hemorrhoidal disease; thrombosed
hemorrhoids; anal fissure; perianal Crohnʼs Disease (pCD); perianal fistula; condyloma;
polyps; neoplasms; anal stenosis; bleeding ([Fig. 2]). The Goligher classification for hemorrhoids was used [12].
Fig. 2 a Internal hemorrhoids grade II. b Thrombosed hemorrhoids. c hemorrhoids with active bleeding. d Anal ulceration in Crohnʼs Disease. e Fissure. f, g Perianal Crohn's disease. h External orifice in perianal fistula. i Purulent discharge in perianal fistula. j Squamous cell carcinoma of the anal canal. k Adenocarcinoma of the anal canal. l Condyloma acuminata (HPV). m, n, o Polyps.
Results
We retrospectively analyzed findings from 16,132 exams in 12,151 consecutive patients.
A total of 12,151 VAs were analyzed. The minimum age was 4 years and the maximum age
was 94 years. The average age was 48.57 and the median was 49, being 7,196 female
(59 %), and 4,955 male (41 %), divided into 10-year age groups ([Fig. 3a – p]). From this, 2787 video anoscopies were normal and 9364 cases presented some alterations
([Table 1]).
Fig. 3 Graphs. Findings of the video anoscopies in female and male groups divided by gender
and classified by 10-year age groups. a VA divided by gender.
Fig. 3b Bar chart of the findings and number of cases of the video anoscopies.
Fig. 3c Pie chart of the findings and number of cases of the video anoscopies.
Fig. 3d Total of VA divided by gender and classified by 10-year age groups.
Fig. 3e Normal VA divided by gender and classified by 10-year age groups.
Fig. 3f Hemorrhoids divided by gender and classified by 10-year age groups.
Fig. 3g Anal fissure divided by gender and classified by 10-year age groups.
Fig. 3h Polyps divided by gender and classified by 10-year age groups.
Fig. 3i Perianal fistula divided by gender and classified by 10-year age groups.
Fig. 3j Thrombosed hemorrhois divided by gender and classified by 10-year age groups.
Fig. 3k Anal stenosis divided by gender and classified by 10-year age groups.
Fig. 3l Perianal Crohn’s Disease divided by gender and classified by 10-year age groups.
Fig. 3m Condylomas divided by gender and classified by 10-year age groups.
Fig. 3n Bleeding divided by gender and classified by 10-year age groups.
Fig. 3o Neoplasm divided by gender and classified by 10-year age groups.
Fig. 3p Other divided by gender and classified by 10-year age groups.
Table 1
Findings of the video anoscopies in female and male groups divided by gender and classified
by 10-year age groups.
|
Min. Age
|
4
|
Video anoscopies
|
|
Max. Age
|
94
|
2006 to 2018
|
|
Average
|
48,57
|
12151
|
|
Median
|
49
|
|
|
Mode
|
51
|
Male
|
|
Age group
|
[0 – 10]
|
[10 – 20]
|
[20 – 30]
|
[30 – 40]
|
[40 – 50]
|
[50 – 60]
|
[60 – 70]
|
> 70
|
TOTAL
|
|
Anal examination
|
6
|
92
|
463
|
863
|
1138
|
1236
|
775
|
382
|
4955
|
|
Normal
|
6
|
60
|
215
|
223
|
178
|
146
|
85
|
86
|
999
|
|
Hemorrhoids internal/total
|
0
|
13
|
165
|
522
|
843
|
997
|
635
|
273
|
3448
|
|
Hemorrhoids grade I
|
0
|
12
|
139
|
414
|
585
|
586
|
324
|
140
|
2200
|
|
Hemorrhoids grade II
|
0
|
1
|
26
|
104
|
252
|
403
|
302
|
128
|
1216
|
|
Hemorrhoids grade III
|
0
|
0
|
0
|
4
|
6
|
8
|
9
|
5
|
32
|
|
Hemorrhoids grade IV
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
|
Anal fissure
|
0
|
9
|
38
|
50
|
37
|
35
|
9
|
5
|
183
|
|
Polyps
|
0
|
0
|
4
|
7
|
8
|
5
|
9
|
4
|
37
|
|
Perianal fistula
|
0
|
0
|
7
|
9
|
9
|
6
|
2
|
0
|
33
|
|
Thrombosed hemorrhoids
|
0
|
5
|
8
|
20
|
15
|
8
|
2
|
1
|
59
|
|
Anal stenosis
|
0
|
0
|
0
|
1
|
4
|
2
|
3
|
1
|
11
|
|
Perianal Crohnʼs disease
|
0
|
1
|
5
|
8
|
4
|
1
|
3
|
0
|
22
|
|
Condyloma
|
0
|
1
|
9
|
1
|
1
|
0
|
0
|
0
|
12
|
|
Bleeding
|
0
|
2
|
3
|
9
|
7
|
8
|
0
|
2
|
31
|
|
Neoplasm
|
0
|
0
|
0
|
0
|
0
|
0
|
3
|
0
|
3
|
|
Other
|
0
|
1
|
12
|
16
|
26
|
29
|
23
|
10
|
117
|
|
Female
|
|
Age group
|
[0 – 10]
|
[10 – 20]
|
[20 – 30]
|
[30 – 40]
|
[40 – 50]
|
[50 – 60]
|
[60 – 70]
|
> 70
|
TOTAL
|
|
Anal examination
|
7
|
130
|
830
|
1329
|
1669
|
1722
|
1045
|
464
|
7196
|
|
Normal
|
5
|
89
|
435
|
441
|
338
|
248
|
142
|
90
|
1788
|
|
Hemorrhoids internal/total
|
0
|
24
|
279
|
753
|
1198
|
1366
|
855
|
350
|
4825
|
|
Hemorrhoids grade I
|
0
|
23
|
247
|
656
|
969
|
997
|
595
|
224
|
3711
|
|
Hemorrhoids grade II
|
0
|
1
|
31
|
95
|
216
|
353
|
250
|
117
|
1063
|
|
Hemorrhoids grade III
|
0
|
0
|
1
|
2
|
12
|
16
|
10
|
6
|
47
|
|
Hemorrhoids grade IV
|
0
|
0
|
0
|
0
|
1
|
0
|
0
|
3
|
4
|
|
Anal fissure
|
2
|
10
|
66
|
58
|
47
|
35
|
11
|
3
|
232
|
|
Polyps
|
0
|
0
|
3
|
4
|
6
|
5
|
6
|
1
|
25
|
|
Perianal fistula
|
0
|
0
|
2
|
0
|
4
|
2
|
0
|
1
|
9
|
|
Thrombosed hemorrhoids
|
0
|
0
|
10
|
20
|
15
|
11
|
4
|
1
|
61
|
|
Anal stenosis
|
0
|
0
|
2
|
3
|
1
|
4
|
4
|
5
|
19
|
|
Perianal Crohnʼs disease
|
0
|
0
|
6
|
3
|
0
|
0
|
1
|
2
|
12
|
|
Condyloma
|
0
|
1
|
2
|
1
|
2
|
0
|
0
|
0
|
6
|
|
Bleeding
|
0
|
0
|
4
|
4
|
7
|
5
|
4
|
1
|
25
|
|
Neoplasm
|
0
|
0
|
0
|
0
|
0
|
0
|
0
|
1
|
1
|
|
Other
|
0
|
6
|
23
|
42
|
43
|
45
|
23
|
11
|
193
|
Hemorrhoidal disease was found in 8,273 cases (68.08 %) and separated according to
the findings of hemorrhoids of I, II, III and IV degrees. Hemorrhoidal bleeding at
the time of examination was noticed in 56 cases (0.46 %) and thrombosed hemorrhoids
in 120 cases (0.99 %).
A total of 415 patients (3.42 %) were found to have fissures. Perianal Crohn’s disease
was noticed in 34 patients (0.28 % of 7.57 %), including fissures and ulcerated lesions
in the anal canal.
Forty-two cases of perianal fistula (0.35 %) were identified by the external orifice
and the mucus or purulent discharge at the time of video anoscopy. There was a predominance
of males (33 cases – 78.57 %) over the female group (9 cases – 21.43 %).
Thirty cases (0.25 %) of symptomatic anal stenosis were observed, of which 36.66 %
were male and 63.33 % were female.
We found 18 cases of condylomatous lesions (0,15 %). Males predominated with 12 cases
(66.66 %) found, and in the female group six cases (33.33 %).
There were 310 cases (2.55 %) with small changes of little clinical importance and
that were grouped as other perianal disorders. These findings correspond to cases
of skin tags, perianal dermatitis, mucosal prolapses and anal sphincteric hypotonia
in digital rectal examination.
In 62 patients, polyps were found in the anal canal, of which 58 were fibroepithelial,
one telangiectatic granuloma, two cases were hyperplastic polyps, and one polyp was
tubulovillous adenoma with high grade dysplasia. The rate of detection of neoplasms
with the anal exam in the study was 0.03 % (4 cases), two cases of squamous cell carcinoma
and two cases of adenocarcinoma.
Discussion
Many examiners evaluate the anal region by performing straight withdrawal (SW) of
the colonoscope and rectal retroflexion (RR). However, evaluation of the degree of
hemorrhoidal disease is facilitated with use of the anoscope. The SW does not accurately
visualize the hemorrhoidal columns nor its prolapse. In the rectal retroflex maneuver
there is a need for complete air insufflation and this leads to hemorrhoidal venous
plexus collapse, impairing evaluation ([Video 1]). For visualization of anal fissures, it is also essential to use the anoscope,
which sometimes becomes impossible without sedation. A prospective, multicenter, blinded
study by Tellez-Ávilla et al. showed that RR during colonoscopy has limited effect
and little impact on diagnosis and therapy [13]. Two prospective studies have shown that anoscopy was superior to RR in detection
of hemorrhoids [1]
[2]
[14]. Kelly [2] showed that the SW had a disease detection rate of 54 %, RR of 78 % and VA 99 %
[2]. Harish [1] showed that VA detected significantly more hemorrhoids than RR.
Video 1 Video anoscopy during colonoscopy.
Rectal bleeding is always a symptom of alarm and countless exams are done for fear
of a serious condition going undetected [15]. Patients with hemorrhoids and painless bleeding are referred for colonoscopy to
exclude other causes of bleeding such as neoplasia. Hemorrhoids are by far the commonest
cause of rectal bleeding [16]
[17]. An appropriate examination of the anal canal is mandatory in evaluation of each
patient with a history of rectal bleeding to avoid misdiagnosis, unnecessary exams,
and inadequate treatment [1]. Rectal retroflexion (RR) is often used to evaluate hemorrhoids, but this technique
has little sensitivity [1]
[5]. One study demonstrated that the gain related to the finding of lesions identified
with RR was from 2 % to 8 % [13]. VA can determine the cause of bleeding if it is of anal origin. In this study,
it was observed that in 56 cases, the origin of anal bleeding was identified at the
time of colonoscopy, thanks to anal examination with VA and to visualization of the
exact site of active bleeding. There were 123 cases (0.76 %) that included cases of
internal and external thrombosed hemorrhoids.
Anal fissures are the most common causes of anal pain and typical symptoms include
pain and bleeding [18]. Some patients may experience severe discomfort during the examination and anoscopies
are not always well tolerated. The VA made during the colonoscopy, with the patient
sedated, greatly facilitates diagnosis of anal fissure. [Video 1] shows the difference in anal fissure viewing by SW, RR and VA. If anal fissure develops
in atypical sites, other diseases, such as Crohn's Disease (CD), ulcerative colitis,
syphilis, tuberculosis, leukemia, HIV-associated lesions, and anal canal neoplasms
should be considered. Visualization of the anal fissure is greatly facilitated by
use of the transparent anoscope in conjunction with the colonoscope, as well as sedation
with propofol, which allows adequate and painless examination, making the diagnosis
possible in all cases. Patients with Crohn's disease have complex perianal lesions
that need to be evaluated during colonoscopy because they require specific treatment.
Primary lesions include Crohn’s fissures and cavitating perianal ulcers. Secondary
lesions include deep abscesses fistulas and strictures [19]. The lowest 1 cm of rectal mucosa may be affected by localized caviting ulceration
and stricture, both of which are very characteristic of pCD [20]. Presence of proctitis, ulceration, fistula or stricture of the anal canal is an
important component to determine an optimal management strategy [21].
Anal abscesses and fistulas are, respectively, the acute and chronic manifestations
of the same process [18]. Symptoms of the perianal fistula are drainage of secretion in the perianal region,
pain, local swelling and presence of an orifice in the skin near the anal border,
from where the secretion exits [15]. Perianal fistulas are the most common manifestation of fistulizing CD, developing
in 20 % of Crohn’s patients and recurring in approximately 30 % of cases [21]. Exam under anesthesia remains the standard for diagnosis and classification of
perianal fistula with an accuracy of up to 90 % when diagnosing pCD [22]. Visualization of the external orifice and the purulent secretion discharge is facilitated
by use of the anoscope, which compresses the anal canal and promotes its drainage.
Malignant tumors of the anus and anal canal are rare, with carcinoma of the anal canal
being three times more common than that of the perianal skin. Both are uncommon entities
and represent less than 2 % of all colon, rectum, and anus carcinomas [23]
[24]
[25]. Although anal cancer is relatively uncommon, incidence rates are increasing in
certain risk populations, such as those with human papillomavirus or AIDS (HIV) [26]
[27]. The diagnosis of precursor lesion and anal cancer requires an adequate examination
[25]
[26].
It is important to identify tumors that grow in the anal canal of those of the perianal
skin, due to the peculiar biological behaviors and different therapeutics [18]. Squamous cell carcinoma of the anal canal is usually an ulcerated or fissured lesion
with raised or hardened edges. Proctological examination may reveal a hardened, ulcerated
hemorrhagic mass in the anal canal and lower rectum [23]
[28]. Any suspicious lesion around the anus should be biopsied. The concomitance of anal
canal neoplasia with benign diseases is common and some lesions are easily confused
with these conditions. Its clinical manifestations are uncharacteristic and often
attributed to hemorrhoidal disease, thus delaying correct diagnosis.
Anal cancer usually presents pain, anal mass, and bleeding; however, in 20 % of cases
there are no symptoms [29]. Careful anal examination allows these tumors to be diagnosed early, even with small
dimensions, allowing better prognosis [30]. The most common aspect is the fissure or ulcerated lesion with raised edges, irregular,
granular, hard, painful, and bleeding. Differential diagnosis with chronic anal fissure
can be performed due to absence of post-evacuation pain (typical of the fissure) and
the atypical location of the ulceration, since in 90 % of the cases the anal fissure
is posterior and the neoplasm can occur in any position.
Although uncommon, undiagnosed anal canal cancers and the missed chance of an early
diagnosis during a routine colonoscopy can be disastrous for the patient and could
also bring a malpractice lawsuit to the practitioner who fails to diagnose an initial
malignant lesion. The rate of detection of neoplasms with the anal exam in our study
was 0.03 % (4 cases), two cases of squamous cell carcinoma and two cases of adenocarcinoma.
In 62 patients, polyps were found in the anal canal , but only one polyp was neoplastic.
We found 18 cases of condylomatous lesions (HPV), with male predominance of 12 cases
(66.66 %), and in the female group six cases (33.33 %). The fragments for analysis
were collected by biopsy or with application of local anesthetic and removal with
surgical scissors.
During colonoscopy VA becomes easier, with high-quality images that improve visualization
of normal and altered structures, resulting in improved sensitivity over the standard
anoscopy in detection of anal disorders. In addition, it is a practice that interferes
little in the dynamics of the examination, is performed in a few seconds, reduces
exposure of fecal residues to the operator, and has a low cost. With the increased
number of colonoscopies performed due to the routine indication for prevention of
colorectal cancer, patients with few or even no complaints could have earlier diagnoses
of anal lesions.
An analysis with this significant number of cases may help to understand the importance
of anal canal evaluation during colonoscopy and correct identification of the anal
diseases and then referral of cases for appropriate specialized treatment. With proper
training, it is possible to make a good evaluation of the anal region and to include
this information in the reports.
Conclusion
The association of routine video anoscopy during colonoscopy improved the diagnosis
of the neoplastic anal lesions, allowed correct classification of the degree of hemorrhoidal
disease, helped to confirm the bleeding site and detected other anal pathologies.
The main findings were hemorrhoidal diseases, fissures and perianal fistulas. The
study suggests that VA should be used in all colonoscopies.
