Home

helps physicians and healthcare professionals

Erectile Dysfunction

helps physicians and healthcare professionals

Doctor123.org

helps physicians and healthcare professionals

Anoscopy with or without Biopsy


Introduction


Anoscopy is a diagnostic and therapeutic technique for the anal canal. Anoscopy is performed in the office without sedation. Office evaluation of common anorectal complaints such as "hemorrhoids " ¯ will necessitate a thorough examination. This is best accomplished by performing an anoscopy. Frequently, examiners will substitute a rigid or flexible sigmoidoscopy to visualize the anal canal. This is a suboptimal examination because anal canal lesions may easily be missed, for example, as can occur when a lesion is hidden between the hemorrhoidal columns. Additionally, barium enema examination has been used to substitute a for thorough anorectal examination. This also has resulted in many missed anal lesions. Anoscopy provides the best means of examining the anal canal for hemorrhoids, fissures, fistulas, neoplasms, or other lesions. ‚  
Anoscopy is accomplished by using one of several different instruments. There are several different nondisposable anoscopes available. Anoscopes shown include the (A) Hirschman, available in three sizes: 9/16 inch (1.43 cm), 11/16 inch (1.75 cm), and 7/8 inch (2.2 cm), (B) Pennington, (C) Fansler-Ives, and (D) Chelsea Eaton. ‚  
View OriginalView Original
There is also a fiberoptic anoscope that has the convenience of a disposable sheath. It also allows the provider to work at a greater distance from the anus and often in a more comfortable position. ‚  
Biopsy can be performed by using rectal biopsy forceps. If a neoplastic lesion is identified, a biopsy may be performed. However, biopsy may not be necessary if surgical referral is planned. ‚  
No bowel preparation is needed for an anoscopic examination. A digital examination should precede an anoscopic examination to assess whether the patient will tolerate passage of an anoscope. Inspection and palpation alone can reveal the presence of some fissures, fistulas, perianal dermatitis, masses, thrombosed external hemorrhoids, condyloma, and other growths. ‚  

Equipment


Anoscopic Examination
  • Surgical water-soluble lubricant
  • Anoscope: disposable fiberoptic anoscope or metallic anoscopes
  • Illumination instrument

Biopsy Equipment
  • Biopsy forceps
  • Anorectal pure anesthetic cream or combination with steroid (optional)
  • 1% " ‚lidocaine with epinephrine
  • Silver nitrate
  • Cotton-tip applicators

Indications


  • Rectal symptoms: bleeding, itching, swelling, or pain
  • Anal lesion or mass

Figure 2 View Original Figure 2 View Original

Contraindications


  • Anal stricture or stenosis
  • Severe pain
  • Bleeding diathesis
  • Acute cardiovascular conditions (vasovagal reaction)
  • Acute abdominal conditions

Figure 2 View Original Figure 2 View Original

The Procedure


Anoscopic Examination
Step 1
Place the patient in the left lateral decubitus position. Inspect the perianal skin. A simple gooseneck lamp for illumination is ideal. Note the location of any lesions with respect to the patient 's anterior, posterior, left lateral, and right lateral positions. This is frequently designated by the use of "o 'clock " ¯ descriptions. With o 'clock description, the "12 o 'clock " ¯ position is the anterior midline of the anus (likewise, 3 o 'clock is left lateral, 6 o 'clock is posterior midline, and 9 o 'clock is right lateral). The patient shown has a posterior anal fissure (6 o 'clock) and a hypertrophic anal papilla on the right lateral aspect of anal canal (9 o 'clock). ‚  
  • PITFALL: Lesions such as an anal fissure may be too painful for anoscopy. Do not perform anoscopy in this setting.

Step 1 View Original Step 1 View Original
Step 2
Anoscopy is not necessary for diagnosis of an anal fissure. Simply stretching the perianal skin can expose and diagnose an anal fissure. If symptoms are consistent with an anal fissure, then a trial of medical treatment may be warranted. Of course, referral to a surgeon may be also made at this time. ‚  
Step 2 View Original Step 2 View Original
Step 3
Palpate the perianal region to identify lesions such as a perirectal abscess, fistula, or mass. Digital examination is gently performed with careful assessment of the degree of discomfort. ‚  
Step 3 View Original Step 3 View Original
Step 4
During digital examination, the anal canal should be palpated between the index finger and thumb, especially if an anal fistula or mass is suspected. If this can be accomplished without undue pain, then anoscopic examination can be performed. ‚  
  • PITFALL: Painful anal lesions such as fissures may not be adequately anesthetized with anal creams. Do not perform anoscopy in this setting.
  • Pearl: Some providers prefer a topical anesthetic such as 2.5% " ‚prilocaine and 2.5% " ‚lidocaine (EMLA) cream.

Step 4 View Original Step 4 View Original
Step 5
Gently insert the well-lubricated anoscope with obturator. ‚  
Step 5 View Original Step 5 View Original
Step 6
Remove the obturator to visualize the anal canal. Reinsert the obturator prior to rotating the anoscope to visualize another quadrant of the anal canal. ‚  
Step 6 View Original Step 6 View Original
Step 7
Examine the epithelium for lesions. Examples of lesions seen with the anoscope include (A) prominent internal and external hemorrhoid complex and (B) an anal fissure. ‚  
Step 7 View Original Step 7 View Original
Step 8
Other examples of lesions seen with the anoscope include (A) an anal fistula with the internal opening (marked by the probe) located at the posterior midline and dentate line and (B) an anal condyloma. ‚  
Step 8 View Original Step 8 View Original
Anoscopic Biopsy
Step 9
Anoscopic biopsy can be performed with relative ease and safety. Bleeding is rarely a problem, so unelectrified biopsy forceps may be used. The biopsy is done under direct vision. Note the location of the biopsy site relative to the o 'clock description and depth. The depth should be characterized by its distance from the dentate line (e.g., "3 mm distal to the dentate line " ¯). ‚  
Step 9 View Original Step 9 View Original
Step 10
Biopsy of anal canal lesions may be painful. A single biopsy is well tolerated; however, multiple biopsies may require injection of local anesthetic (1% " ‚lidocaine with epinephrine). ‚  
  • Pearl: Pathologic lesions such as an exophytic neoplasm are usually asensate, and thus a local anesthetic is usually unnecessary.

Step 10 View Original Step 10 View Original
Step 11
Bleeding is usually self-resolving and does not require further treatment. However, if the bleeding is pulsatile, then additional measures may be required. The biopsy site can be tamponaded with a cotton-tip applicator soaked with 1% " ‚lidocaine with epinephrine or cauterized using silver nitrate. Failed attempts to control bleeding mandate packing the anal canal with gauze and an immediate referral to surgery. ‚  
Step 11 View Original Step 11 View Original

Complications


  • Minor lacerations, abrasions, or tearing of hemorrhoids
  • Bleeding occasionally occurs after biopsy
  • Infection (rare)

Pediatric Considerations


These conditions are rarely encountered in the pediatric population. ‚  

Postprocedure Instructions


Instruct the patient to bathe in a warm tub as needed for spasms or pain. Have the patient report excessive rectal bleeding (especially blood clots), fever ≥101 ‚ °F, severe or worsening rectal pain, difficulties with urination, redness and swelling around the anus, or a yellow discharge from anus. ‚  

Coding Information and Supply Sources


‚  
View Large CPT Code Description 2008 AVERAGE 50th Percentile Fee Global Period 46600 Anoscopy $117.00 0 46606 Anoscopy with biopsy, single or multiple $244.00 0 CPT is a registered trademark of the American Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008 MMH-SI 's copyrighted Physicians ' Fees and Coding Guide.
Suppliers
The Ives slotted anoscope ($160) is available from Redfield Corporation, 336 West Passaic Street, Rochelle Park, NJ. Phone: 1-800-678-4472. Web site: http://www.redfieldcorp.com. ‚  
A suggested anesthesia tray that can be used for this procedure is described in Appendix F. ‚  

Bibliography


1
Corman ‚  ML.
Colon and Rectal Surgery
. 5th ed. Philadelphia: Lippincott;  2004:55 " “60. 2
Indinnimeo ‚  M, Cicchini ‚  C, Stazi ‚  A, et al. Analysis of a follow-up program for anal canal carcinoma.
J Exp Clin Cancer Res.
 2001;20:199 " “203. ‚  [View Abstract]
3
Kelly ‚  SM, Sanowski ‚  RA, Foutch ‚  PG, et al. A prospective comparison of anoscopy and fiber endoscopy in detecting anal lesions.
J Clin Gastroenterol.
 1986;8:658 " “660. ‚  [View Abstract]
4
Korkis ‚  AM, McDougall ‚  CJ. Rectal bleeding in patients less than 50 years of age.
Dig Dis Sci.
 1995;40:1520 " “1523. ‚  [View Abstract]
5
Lewis ‚  JD, Brown ‚  A, Localio ‚  AR, et al. Initial evaluation of rectal bleeding in young persons: a cost-effectiveness analysis.
Ann Intern Med.
 2002;136:99 " “110. ‚  [View Abstract]
6
2008 MAG Mutual Healthcare Solutions, Inc. 's
Physicians ' Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc.
2007.
Copyright © 2016 - 2017
Doctor123.org | Disclaimer