Histopathological changes in haemorrhoid associated mucosa and submucosa

Histopathology of stapled haemorrhoidectomy specimens: a cautionary note

OBJECTIVE

Stapled haemorrhoidectomy is a new technique with encouraging early results. The aim of this study was to examine the tissue removed during stapled haemorrhoidectomy, in particular to check on the presence or absence of transitional or squamous anal canal mucosa and internal anal sphincter muscle.

METHODS

Twenty-six consecutive patients undergoing stapled haemorrhoidectomy were studied. Resected tissue was examined histologically according to a standardized histological protocol.

RESULTS

All 26 specimens contained columnar mucosa. Twelve specimens also contained anal transitional and stratified squamous epithelium. Two specimens contained columnar and transitional mucosa. Twenty-two of 26 specimens contained smooth muscle as well as mucosa (median maximum diameter 7.5 mm, range 2-20 mm). In 11 specimens this was circular muscle only; in 11 circular and longitudinal smooth muscle were present. In 10 specimens smooth muscle was seen to be lying beneath stratified squamous or transitional epithelium, suggesting that it was from the internal anal sphincter.

CONCLUSIONS

Stapled haemorrhoidectomy results in resection of stratified squamous mucosa or part of the internal anal sphincter in a significant proportion of patients. Surgeons should be aware that this technique may result in damage to the internal anal sphincter.

Pagetoid dyskeratosis is a frequent incidental finding in hemorrhoidal disease

BACKGROUND

Pagetoid dyskeratosis is considered a selective keratinocytic response in which a small part of the normal population of keratinocytes is induced to proliferate. Pagetoid dyskeratosis has been found incidentally in the squamous epithelium of the skin in various locations and in the ectocervix in uterine prolapse. In cases in which these pale cells are conspicuous, there is a hazard of overdiagnosis. It has been suggested that friction is the most probable inductor of the lesion. To the best of our knowledge, pagetoid cells have not been reported in surgically resected hemorrhoids.

OBJECTIVE AND DESIGN

We here describe the location of pagetoid dyskeratosis in the squamous epithelium of hemorrhoids and the incidence of this lesion in a group of 100 unselected patients surgically treated for hemorrhoidal disease. In addition to the conventional histologic method, special staining procedures and an immunohistochemical study of cytokeratins were performed in selected cases.

RESULTS

Pagetoid dyskeratosis was found in 68 cases (68%) and was a prominent finding in 22 cases (22%). The cells of pagetoid dyskeratosis were strongly positive for high-molecular weight cytokeratin. These cells showed an immunohistochemical profile that was different from that of the surrounding squamous cells and indicative of premature keratinization.

CONCLUSIONS

In hemorrhoidal disease, the cushions are susceptible to trauma as a result of prolapse. In this setting, friction may be the stimulus for the appearance of pagetoid dyskeratotic cells. These cells must be distinguished from the artifactual clear cells of the squamous epithelium, glycogen-rich cells, and koilocytes. The lesion must also be distinguished from extramammary Paget disease, pagetoid spread of carcinoma cells, pagetoid Bowen disease, and pagetoid melanoma. Pathologists should be familiar with the histologic features of pagetoid dyskeratosis in hemorrhoidectomy specimens to avoid misdiagnosis. Routine histologic study is usually adequate for recognizing this lesion.

Anal endosonography in haemorrhoidal disease: do anatomical changes have clinical implications?

OBJECTIVE

This study was designed to evaluate anal endosonographic findings in patients with internal haemorrhoids and to test whether endosonographic parameters can serve as prognostic factors for treatment outcome and recurrence.

PATIENTS AND METHODS

One hundred and twenty-nine patients (72 males, 57 females, mean age 48 years (range 19-82 years)) were treated for grade 1 to grade 3 internal haemorrhoids with either rubber band ligation (n = 62) or infrared photocoagulation (n = 67). Evaluation before and 1 month after the last treatment consisted of a symptom questionnaire, digital examination, proctoscopy and anal endosonography. The thickness of the submucosa (SMT) and internal (IST) and external anal sphincters (EST) was measured in four quadrants and averaged. Comparisons were made with 40 age- and sex-matched healthy controls. Follow up was 19.2 ± 7.8 months (mean ± s.d.). Multivariate analysis was performed to identify endosonographic factors for treatment outcome and recurrence.

RESULTS

Eighty-six patients had grade 1, 34 grade 2 and nine grade 3 haemorrhoids. At endosonography, most but not all haemorrhoids were recognized as anterior thickening of the submucosal layer with a partial hypoechoic appearance. Compared with healthy controls SMT (2.6 ± 0.8 mm vs 2.3 ± 0.5 mm, P < 0.03), IST (1.7 ± 0.5 mm vs 1.5 ± 0.5 mm, P < 0.03) and EST (8.7 ± 1.6 mm vs 7.7 ± 1.4 mm, P < 0.001) were increased. Submucosal thickness correlated with the degree of haemorrhoids (r = 0.19, P = 0.04). No difference in endosonographic appearance of anal morphology was found after treatment. With multivariate analysis no endosonographic factors could be identified which could predict treatment outcome or symptom recurrence.

CONCLUSION

Haemorrhoids are associated with endosono- graphic thickening of submucosal tissue, internal and external anal sphincter. Therefore, both sphincters as well as changes in the submucosa might be of pathophysiological importance. Endosonographic changes cannot predict treatment outcome or symptom recurrence.