Anal pain and discharge
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Anal Pain and Discharge. By: Mohammad Jamjoom Fahad Al- Sabhan Supervised by: Dr. Khayal Al- Khayal. Overview:. Anatomy of the anal canal Hemorrhoids Anal fissures Anal abscesses Anal fistulas. Anatomy of the anal canal:. The anal canal is 4 cm long

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Anal Pain and Discharge

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Anal pain and discharge

Anal Pain and Discharge

By: Mohammad Jamjoom

Fahad Al-Sabhan

Supervised by: Dr. Khayal Al-Khayal


Overview

Overview:

  • Anatomy of the anal canal

  • Hemorrhoids

  • Anal fissures

  • Anal abscesses

  • Anal fistulas


Anatomy of the anal canal

Anatomy of the anal canal:


Anal pain and discharge

  • The anal canal is 4 cm long

  • It extends from the anal verge to the anorectal junction

  • It is divided into upper and lower halves by the dentate (pectinate) line

  • Above Columnar epithelium

  • Below Squamous epithelium (anoderm)

  • Transitional zone Cuboidal epithelium


Anal pain and discharge

  • Internal (involuntary) and external (voluntary) sphincters

  • The internal sphincter is a thickened continuation of the circular smooth muscles of the rectum (autonomic nervous system)

  • It is responsible for anal continence

  • The external sphincter is a downward extension of the puborectalis muscle (internal pudendal nerve S2-S4)


Blood supply

Blood supply:

  • Arterial supply:

  • Upper half Superior rectal artery

  • Lower half Inferior rectal artery

  • Venous drainage:

  • Upper half Superior rectal vein Portal system

  • Lower half Inferior rectal vein Systemic circulation


Hemorrhoids

Hemorrhoids:

  • They are engorgement of the venous plexi of the rectum, anus or both; with protrusion of the mucosa, anal margin or both

  • Also known as “Piles”


Types

Types:


Sites

Sites:

  • Left lateral (3 o’clock)

  • Right posterior (7 o’clock)

  • Right anterior (11 o’clock)


Classification of internal hemorrhoids

Classification of internal hemorrhoids:

  • 1st degree: Do not prolapse

  • 2nd degree: Prolapse with straining, but are reduced spontaneously

  • 3rd degree: Prolapse with straining, but require manual reduction

  • 4th degree: Cannot be reduced


Etiology

Etiology:

  • Constipation or straining

  • Increased abdominal pressure

  • Pregnancy

  • Portal hypertension


Signs and symptoms

Signs and symptoms

  • Anal mass or prolapse

  • Bleeding

  • Pruritis

  • Pain or discomfort

  • Sensation of fullness

  • Mucoid discharge and soiling of underwear


Diagnosis

Diagnosis:

  • History

  • Rectal examination

  • Proctoscopy

  • Sigmoidoscopy or colonoscopy


Anal pain and discharge

DDx:

  • Anal polyps

  • Anal fissures

  • Peri-anal hematoma

  • Rectal prolapse

  • IBD

  • Dermatitis

  • Anorectal carcinoma


Management

Management:

  • Nonoperative (90%):

  • High fiber diet

  • Increase fluid intake

  • Laxatives

  • Avoid straining during defecation

  • Anal hygiene

  • Topical steroids

  • Sitz bath


Anal pain and discharge

  • Surgical (10%):

  • 1st degree:

  • Sclerotherapy

  • Infra-red photocoagulation

  • Liquid nitrogen cryotherapy

  • 2nd degree:

  • Rubber band ligation

  • 3rd and 4th degree:

  • Excisionalhemorrhoidectomy


Contraindications to surgery

Contraindications to surgery:

  • Anticoagulants

  • Portal hypertension and liver cirrhosis class C

  • Crohn's disease

  • Anorectal fissures

  • Anorectal infections

  • Anorectal tumors

  • Pregnancy

  • Rectal wall mucosal prolapse


Complications

Complications:

  • Exsanguination (bleeding may pool proximally in lumen of colon)

  • Pelvic infection (sepsis)

  • Urinary retention

  • Incontinence (sphincter injury)

  • Anal stricture

  • Abscess


Anal fissures

Anal Fissures:

  • They are tears in squamous epithelium of the anus (anoderm)

  • Most common cause of anal pain

  • Most common site is the posterior midline


Etiology1

Etiology:

  • Hard stool or constipation

  • Hyperactive sphincter

  • Disease process (Crohn’s disease)


Signs and symptoms1

Signs and symptoms:

  • Tearing pain with defecation

  • Rectal bleeding (blood streaks on toilet paper)

  • Painful rectal examination

  • Sentinel pile (tag)

  • Hypertrophic papilla


Diagnosis1

Diagnosis:

  • History

  • Rectal examination

  • Proctoscopy


Management1

Management:

  • Nonoperative (80%):

  • High fiber diet

  • Increase fluid intake

  • Laxatives

  • Avoid straining during defecation

  • Anal hygiene

  • Topical nifedipine

  • Sitz bath

  • Botox


Anal pain and discharge

  • Surgical (20%):

  • Chronic fissures refractory to conservative treatment

  • Lateral internal sphincterotomy (LIS)


Anal abscesses and fistulas

Anal Abscesses and Fistulas

  • They may present as acute or chronic manifestations of the same perirectal disease


Anal abscess

Anal Abscess:

  • It’s an infection of the soft tissues surrounding the anal canal, with formation of a discrete abscess cavity


Classification of anal abscesses

Classification of anal abscesses:

  • Perianal (60%)

  • Ischiorectal (20%)

  • Intersphincteric (5%)

  • Supralevator (pelvirectal) (4%) (is very difficult to diagnose clinically and is very rare and caused by inflammation or a disease in the pelvis)

  • Submucosal (1%)


Etiology2

Etiology:

  • Blockage of anal glands which permits the growth of bacteria leading to an abscess formation

  • Common organisms:

    - Escherichia coli

      - Enterococcus species

    - Bacteroides species

  • However, no specific bacterium has been identified as a unique cause of abscesses

  • Less common causes:Tuberculosis, squamous cell carcinoma, adenocarcinoma, actinomycosis, lymphogranulomavenereum, Crohn's disease, trauma, leukemia and lymphoma


Anal pain and discharge

Note:

  • most people have 8 to 10 glands , which are located circumferentially within the anal canal at the level of the dentate line, penetrate through the internal sphincter and end in the intersphincteric plane


Signs and symptoms2

Signs and symptoms:

  • Severe pain in the anal area (pain is constant and not necessarily associated with bowel movements)

  • Lump in the anal area

  • Lower abdominal pain (pelvirectal abscess)

  • Constitutional symptoms ( fever, malaise)

  • Drainage of pus


Management2

Management:

  • Early incision and surgical drainage of the purulent collection

  • Sitz bath

  • Anal hygiene

  • Laxatives

  • There is no role for antibiotics except for patients who are:

    - Immunocompromised

    - Diabetics

    - Diagnosed with valvular heart diseases

    - Diagnosed with cellulitis


Complications1

Complications:

  • A potential complication of anorectal abscess drainage is the formation of fistulous tracts within 6 months in 50% of cases


Anal fistulas

Anal Fistulas:

  • They are abnormal connections between the epithelialized surface of the anal canal and the perianal skin


Classification of anal fistulas

Classification of anal fistulas:

  • The 4 categories of fistulas according to Park’s classification, based on the relationship of fistula to sphincter muscles, are:

  • Intersphincteric

  • Transphincteric(most common)

  • Supra-sphincteric

  • Extra-sphincteric.


Etiology3

Etiology:

  • Opened perianal or ischiorectal abscesses, which drain spontaneously through these fistulous tracts

  • Fistulas can be found in patients with Inflammatory Bowel Disease (Crohn’s disease)

  • Diverticulitis, foreign body reactions, actinomycosis, chlamydia, lymphogranulomavenereum, syphilis, tuberculosis, radiation exposure and HIV


Signs and symptoms3

Signs and symptoms:

  • Recurrent malodorous perianal drainage

  • Pruritus

  • Recurrent abscesses

  • Fever

  • Perianal pain due to an occluded tract, may have pain during defecation


Physical examination

Physical examination:

  • Digital examination is usually all that is required, assessment of the anatomy of an anal fistula is very important

  • Digital examination in a patient with a fistula-in-ano may reveal an indurated tract or cord

  • Fistula can be identified by small circles of granulation tissue, which exudes pus when compressed if tissue is patent

  • A fistulous tract that opens internally can be visualized with aid of an anoscope

  • Inguinal lymph nodes may be enlarged and painful

  • In an acute fistulous abscess, cardinal signs of inflammation, (erythema, pain, increased temperature, edema) may be found


What to asses during physical examination

What to asses during physical examination:

  • Often done in the OR

  • External opening

  • Internal opening (Internal opening could be identified during fistula surgery, where we inject hydrogen peroxide (H2O2) & look for internal bubbling or inject methylene blue dye)

  • Course of the tract

  • Amount of sphincter muscle involved


Investigations

Investigations:

  • CBC (number of WBC in significant infection), blood culture

  • Fistulogram

  • Transanal US

  • MRI

  • CT


Goodsall s rule

Goodsall’s rule:

  • One of the most common used principles to assist in surgical management of fistulas

  • Fistulas originating anterior to a transverse line through the anus will course straight ahead and exit anteriorly

  • Whereas, fistulas exiting posteriorly have a curved tract


Management3

Management:

  • There are several stages to treating an anal fistula

  • Definitive treatment of a fistula aims to stop it from recurring

  • Treatment depends on where the fistula lies and which parts of the anal sphincter it crosses


Anal pain and discharge

  • Cutting seton

  • Draining seton

  • Fistulotomy

  • Fistula plug

  • Advancement flap


Anal pain and discharge

  • Cutting seton:

  • Is a thick suture placed through the fistula tract and staged pulling is done, so it will allow fibrosis and maintain continence

  • Draining seton:

  • A length of suture material looped through the fistula which keeps it open and allows pus to drain out

  • It only relieves symptoms, and can be used in patients with Crohn’s disease


Anal pain and discharge

  • Fistulotomy:

  • A surgical opening of a fistulous tract

  • Fistula plug:

  • Involves plugging the fistula with a device made from small intestinal submucosa


Anal pain and discharge

  • Advancement flap:

  • The internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. The flap is lifted to expose the fistula, which is then cleaned and the internal opening is sewn shut. After cutting the end of the flap on which the internal opening was, the flap is pulled down over the sewn internal opening and sutured in place


Anal pain and discharge

  • Intersphincteric fistulae: Primary fistulotomy

  • Low Transsphincteric fistulae: Primary fistulotomy

  • High transsphincteric or anterior fistulae: In female patients should be treated with a more conservative approach, for example a cutting seton or a fistula plug as to avoid fistulotomy incontinence

  • Suprasphincteric fistulae: Advancement flaps, sphincter reconstruction or cutting setons. Fistulotomy should not be performed, to avoid incontinence

  • Extrasphincteric fistulae: Endorectal advancement flap


Contraindications of fistulotomy

Contraindications of fistulotomy:

  • Anterior fistulas in females(perform a seton to avoid injuring the perineal body, due to it’s proximity)

  • A high level fistula

  • Patients diagnosed with Crohn’s disease


Anal pain and discharge

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