Internal sphincter and haemorrhoids: pathological study · JournalofClinicalPathology, 1978, 31,...

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Journal of Clinical Pathology, 1978, 31, 268-270 Internal sphincter and haemorrhoids: a pathological study M. T. HAQQANI' AND B. D. HANCOCK2 From the Departments of Pathology and Surgery, University Hospital of South Manchester, UK SUMMARY Histological examination of the lower margin of the internal sphincter has demonstrated an increased amount of fibrous tissue in patients with haemorrhoids compared with controls. This finding may be of relevance to the treatment of haemorrhoids by maximal anal dilatation. Interest in the internal sphincter in patients with haemorrhoids has been stimulated by the observa- tion that maximal anal dilatation will relieve symptoms. It seems possible that there is a degree of stenosis in the anal canal which is relieved by dila- tation. Recent studies (Hancock and Smith, 1975; Hancock, 1977) have demonstrated a motor ab- normality of the sphincter which was abolished by dilatation, but this was not present in every case so there may be other factors that produce a stenosis. Lord (1969), who popularized the dilatation treat- ment, suggested that there was a pecten band consisting of fibrous tissue in the anal submucosa that may be a primary cause of haemorrhoids. Since the first detailed description of the pecten band (Miles, 1919) its existence has been disputed and it is now generally accepted as a result of studies at operation that the pecten band is in fact the internal sphincter. Because there have been no pathological studies of the internal sphincter in patients with haemor- rhoids, we examined biopsies of the internal anal sphincter from presumed normal subjects and patients with haemorrhoids. Material and methods Specimens of internal sphincter were taken from 14 patients (11 males, 3 females) during the operation of haemorrhoidectomy. A small piece, about 3 mm3, was removed from the lower left lateral Present addresses: 'Department of Pathology, Walton Hospital, Liverpool, L9 1AE 2Department of Surgery, Wythenshawe Hospital, South Moor Road, Manchester, M23 9LT margin of the sphincter. Only large vascular haem- orrhoids were included in the study. A similar sized sample was taken in the same way from 'normal' internal sphincter obtained from 25 postmortem subjects (20 males, 5 females). The specimens were stained by haematoxylin and eosin, van Gieson, and Masson trichrome techniques and were classified into one of three grades according to the amount of fibrous tissue associated with the smooth muscle as follows: Grade I: Fibrous tissue either absent or present as thin strands running parallel to the muscle fibres (Fig. 1). Grade II: Fibrous septa abundant and more con- spicuous, occupying the entire interstitial spaces (Fig. 2). Grade III: Dense fibrous tissue in two planes, run- ning parallel to and intersecting groups of muscle fibres (Fig. 3). The mean age of the patients was 50 years and all had large prolapsing haemorrhoids. In 10 patients a preoperative anal pressure profile was measured (Hancock, 1976). The mean age of the controls was 62-5 years and it was not known if any of these subjects had suffered with haemorrhoids during life. Results Distribution offibrous tissue Grade I Grade II Grade III Controls (n = 25) 18 5 2 Haemorrhoids (n= 14) 2 4 8 Received for publication 19 September 1977 X2 = 14X6 p < 0-001 268 on January 7, 2021 by guest. Protected by copyright. http://jcp.bmj.com/ J Clin Pathol: first published as 10.1136/jcp.31.3.268 on 1 March 1978. Downloaded from

Transcript of Internal sphincter and haemorrhoids: pathological study · JournalofClinicalPathology, 1978, 31,...

Page 1: Internal sphincter and haemorrhoids: pathological study · JournalofClinicalPathology, 1978, 31, 268-270 Internal sphincter andhaemorrhoids: apathological study M. T. HAQQANI' ANDB.

Journal of Clinical Pathology, 1978, 31, 268-270

Internal sphincter and haemorrhoids: a pathologicalstudyM. T. HAQQANI' AND B. D. HANCOCK2

From the Departments ofPathology and Surgery, University Hospital of South Manchester, UK

SUMMARY Histological examination of the lower margin of the internal sphincter has demonstratedan increased amount of fibrous tissue in patients with haemorrhoids compared with controls. Thisfinding may be of relevance to the treatment of haemorrhoids by maximal anal dilatation.

Interest in the internal sphincter in patients withhaemorrhoids has been stimulated by the observa-tion that maximal anal dilatation will relievesymptoms. It seems possible that there is a degree ofstenosis in the anal canal which is relieved by dila-tation. Recent studies (Hancock and Smith, 1975;Hancock, 1977) have demonstrated a motor ab-normality of the sphincter which was abolished bydilatation, but this was not present in every case sothere may be other factors that produce a stenosis.Lord (1969), who popularized the dilatation treat-ment, suggested that there was a pecten bandconsisting of fibrous tissue in the anal submucosathat may be a primary cause of haemorrhoids.

Since the first detailed description of the pectenband (Miles, 1919) its existence has been disputedand it is now generally accepted as a result of studiesat operation that the pecten band is in fact theinternal sphincter.Because there have been no pathological studies

of the internal sphincter in patients with haemor-rhoids, we examined biopsies of the internal analsphincter from presumed normal subjects andpatients with haemorrhoids.

Material and methods

Specimens of internal sphincter were taken from14 patients (11 males, 3 females) during the operationof haemorrhoidectomy. A small piece, about3 mm3, was removed from the lower left lateral

Present addresses:'Department of Pathology, Walton Hospital, Liverpool,L9 1AE2Department of Surgery, Wythenshawe Hospital, SouthMoor Road, Manchester, M23 9LT

margin of the sphincter. Only large vascular haem-orrhoids were included in the study.A similar sized sample was taken in the same way

from 'normal' internal sphincter obtained from 25postmortem subjects (20 males, 5 females).The specimens were stained by haematoxylin and

eosin, van Gieson, and Masson trichrome techniquesand were classified into one of three grades accordingto the amount of fibrous tissue associated with thesmooth muscle as follows:Grade I: Fibrous tissue either absent or present asthin strands running parallel to the muscle fibres(Fig. 1).Grade II: Fibrous septa abundant and more con-spicuous, occupying the entire interstitial spaces(Fig. 2).Grade III: Dense fibrous tissue in two planes, run-ning parallel to and intersecting groups of musclefibres (Fig. 3).The mean age of the patients was 50 years and

all had large prolapsing haemorrhoids. In 10 patientsa preoperative anal pressure profile was measured(Hancock, 1976). The mean age of the controls was62-5 years and it was not known if any of thesesubjects had suffered with haemorrhoids duringlife.

Results

Distribution offibrous tissue

Grade I Grade II Grade III

Controls (n = 25) 18 5 2Haemorrhoids(n= 14) 2 4 8

Received for publication 19 September 1977 X2 = 14X6 p< 0-001268

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Page 2: Internal sphincter and haemorrhoids: pathological study · JournalofClinicalPathology, 1978, 31, 268-270 Internal sphincter andhaemorrhoids: apathological study M. T. HAQQANI' ANDB.

Internal sphincter and haemorrhoids: a pathological study

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Fig. 1 Empty interstitial spaces or thin strands offibrous tissue. (van Gieson x 55)

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Page 3: Internal sphincter and haemorrhoids: pathological study · JournalofClinicalPathology, 1978, 31, 268-270 Internal sphincter andhaemorrhoids: apathological study M. T. HAQQANI' ANDB.

270 M. T. Haqqani and B. D. Hancock

.........4.- .

Fig. 3 Dense widespread fibrous tissue in places replacing entire muscle bundles. (van Gieson x 55)

There was no apparent association between theamount of fibrous tissue and the size or duration ofhaemorrhoids nor with sphincter activity as esti-mated by measurement of the preoperative anal pres-sure.

Discussion

There appears to be an increased amount offibrous tissue in the internal sphincter of somepatients with haemorrhoids. This is unlikely to bedue to an ageing process because the mean age of thecontrols was greater than that of the patients withhaemorrhoids. A possible cause of fibrosis is long-standing vascular congestion, or it could be as aresult of repeated traction on the mucosal suspen-sory ligament which passes as fibromuscularbundles through the internal sphincter.

It might be thought that disruption of fibroustissue by anal sphincter stretching would lead toincreased fibrous tissue formation but the longerterm studies after dilatation do not suggest that thishappens (Hancock, 1977), so the motor abnor-mality of the sphincter may be the more important

cause of stenosis in some patients with haemor-rhoids. This finding of increased fibrous tissue in theinternal sphincter, however, does lend support to theidea of treating some patients by dilatation.

We thank all consultant surgeons for allowing us tostudy many of their patients, and the techniciansof the histopathology laboratory of the UniversityHospital of South Manchester for their help andco-operation.

References

Hancock, B. D. (1976). Measurement of anal pressureand mobility. Gut, 17, 645-651.

Hancock, B. D. (1977). Internal sphincter and the natureof haemorrhoids. Gut, 18, 651-655.

Hancock, B. D., and Smith, K. (1975). The internalsphincter and Lord's procedure for haemorrhoids.British Journal of Surgery, 62, 833-836.

Lord, P. H. (1969). A day-case procedure for the cure ofthird-degree haemorrhoids. British Journal of Surgery,56, 747-749.

Miles, W. E. (1919). Observations upon internal piles.Surgery, Gynaecology and Obstetrics, 29, 497-506.

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