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Benign Anal and Colonic Disorders. Bruce George John Radcliffe Hospital. 16-6-04. Anatomy revision. Factors contributing to normal bowel function. Colonic transit. CNS co-ordination. Sensation. Mechanical barrier. Ability to evacuate. Anal pain Bleeding Discharge Swelling Itching

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benign anal and colonic disorders

Benign Anal and Colonic Disorders

Bruce George

John Radcliffe Hospital

16-6-04

factors contributing to normal bowel function
Factors contributing to normal bowel function

Colonic transit

CNS co-ordination

Sensation

Mechanical barrier

Ability to evacuate

symptoms of anal pathology
Anal pain

Bleeding

Discharge

Swelling

Itching

Leakage

Urgency

Symptoms of anal pathology
slide5

Examination

General

Abdominal

Inspection

at rest soiling, excoriation, scars,

patulous, guttering

squeeze

straining perineal descent

Rectal examination

Proctoscopy and sigmoidoscopy

slide6

Investigations

Anal canal pressures

Sensation

Pudendal nerve latency

Endoanal ultrasound

Rarely:

MRI anorectum

MRI spine

ambulatory pressures

causes of anal pain
Causes of Anal Pain

PILES (thrombosed)

ABSCESS

FISSURE

anal fissure
Linear ulcer below dentate line

midline (if multiple/lateral think of Crohn’s disease)

Anal pain

During + after defaecation

Bleeding

Bright red/spotting

Anal fissure
management
Most acute fissures heal spontaneously

Assisted by bulking laxatives

Non-constipating analgaesica

?lignocaine gel

Chronic fissures associated with internal sphincter hypertonia

Above + reduction in IAS tone

Management
methods of reducing ias tone
Surgical

Anal stretch

Internal sphincterotomy

Pharmacological

GTN

botulinum

Methods of reducing IAS tone
natural history of perianal abscess
Natural history of perianal abscess
  • Drainage via anal gland
    • resolution
  • Drainage via abnormal route
    • Resolution of abscess
    • Creation of fistula
      • Intersphincteric
      • Trans-sphincteric
      • others
symptoms
Abscess severe anal pain

Fistula recurrent discharge

cycles of pain/discharge

Symptoms
slide26

piles

Swollen or fragile anal cushions

injection sclerotherapy
INJECTION SCLEROTHERAPY
  • First and Second Degree where bleeding is principle symptom.
  • Irritant sclerosant solution (phenol in oil) injected into submucosa proximal to each haemorrhoidal plexus
  • Simple, safe , painless
  • Complications related to incorrect application.
  • Long-term success rate - sparsely reported.
rubber band ligation
RUBBER BAND LIGATION
  • I / II Degree, some III degree
  • Barron ligator applies two bands to base of pile.
  • ? Number of bundles banded per session.
  • ? Success Rate: 33% relapse in 5 years
  • Complications
    • Pain
    • Bleeding
    • Postbanding Pelvic Sepsis
symptoms of colonic disease
Obviously GI

COBH, blood PR, distension, abdominal pain, tenesmus

Involvement of adjacent structures

Fistula to bladder, vagina, skin

Back, psoas irritation

Extra-colonic manifestations

Iritis, erythema nodosum, arthriris, sclerosing cholangitis

Symptoms of colonic disease
examination
Examination
  • General examination
  • Abdominal examination
  • Rectal examination
investigations
Proctoscopy and rigid sigmoidoscopy

Stool examination

Flexible sigmoidoscopy

Colonoscopy

Barium enema

CT colon

Investigations
who needs which investigations
Rectal bleeding

Change in bowel habit

The elderly/frail

Suspected diverticular disease

Suspected inflammatory bowel disease

Who needs which investigations?
slide35
25 year old BRRB, associated with straining

50 year old BRRB and mucus

75 year old DRRB

change in bowel habit
25 year old bloody diarrhoea for 3 months

50 year old constipation and bloating intermittently for 12 months

75 year old COBH and iron deficiency anaemia

Change in bowel habit
change of bowel habit
75 year old increased frequency of bowel movements and LIF pain for 3 months

80 year old change in bowel habit for 3 months

Change of bowel habit
summary
Everyone:

History and examination including PR

Proctoscopy and rigid sigmoidoscopy

Rectal bleeding:

Rigid/flexi/colonoscopy (safety margin)

Change in bowel habit:

Usually barium enema

Colonoscopy if suspected IBD or high index suspicion cancer

Top and tail if iron deficiency anaemia

CT colon if frail

Stool cultures if diarrhoea

Summary
diverticular disease
Diverticular disease

Disease of modern elderly Western population

Lack of dietary fibre

roller milling of wheat flour

geographical differences in fibre intake

Oxford vegetarian study

spectrum of diverticular disease
Spectrum of diverticular disease
  • Diverticulosis
    • Asymptomatic
    • symptomatic
  • Diverticulitis
    • Uncomplicated
    • Acute complicated (hinchey 1-4)
    • Fistulating
    • stricturing
  • Diverticular haemorrhage
treatment of diverticular disease
Diverticulosis

Make diagnosis accurately

High fibre diet

Treatment of Diverticular Disease
treatment of diverticulitis
Acute uncomplicated and Hinchey 1-2

Aim to avoid acute surgery

Intravenous fluids and antibiotics

Radiological drainage of contained abscess(es)

When acute episode settled:

Visualise colon (DCBE/colonoscopy)

Consider surgery

Treatment of diverticulitis
treatment of diverticulitis44
Hinchey 3-4

Resuscitation and emergency surgery

Fistula

Surgery soon

Stricture

Complete obstruction: urgent surgery

Partial obstruction: surgery soon

Treatment of diverticulitis
crohn s disease
Chronic inflammatory bowel disease

40% terminal ileum/caecum

30% small bowel

30% colonic

20-80% anal disease, especially in association with rectal or colonic inflammation

Crohn’s disease
crohn s disease47
Crohn’s disease

Skip lesions

Cobblestone appearance, fissures, ulceration

Transmural inflammation

treatment of crohn s disease
Medical

Steroids

5-ASA drugs

Immunosuppressants (azathioprine)

Nutritional

Enteral

TPN

Surgical

Treatment of Crohn’s disease
indications for surgery for crohn s colitis
Failure of medical therapy

Chronic complications

Abscess, fistula, obstruction

Dangerous acute complications

Perforation, dilatation, haemorrhage

Risk of developing malignancy

Indications for surgery for Crohn’s colitis
ulcerative colitis
Ulcerative Colitis
  • Chronic inflammatory condition of large bowel
  • Dentate line extending proximally in continuous fashion
  • Disease of mucosa only
treatment of ulcerative colitis
Medical therapy

5-ASA drugs

Steroids

Immunosuppressants (azathioprine)

Surgery

Treatment of Ulcerative Colitis
indications for surgery in uc
Acute attack

Failure of medical therapy

Risk of malignancy

Growth retardation in childhood

Indications for Surgery in UC
acute severe colitis
Acute Severe Colitis
  • Truelove and Witts criteria
    • Diarrhoea: over 6/day
    • Macroscopic blood in stool
    • Temperature over 37.5
    • Tachycardia over 90/min
    • Anaemia less than 10.5g/dl
    • ESR over 30mm/hour
predictors of outcome
Predictors of outcome
  • Bowel frequency
  • Pulse>100/min
  • Max temp >38
  • Albumin < 30g/l on day 4
  • Mucosal islands on AXR
  • Toxic dilatation
the standard operation
The standard Operation
  • Total colectomy
  • End ileostomy
  • Rectal stump
subsequent management
Histological confirmation of diagnosisSubsequent management

Completion proctectomy + pouch reconstruction

+/- covering stoma

Completion proctectomy + permanent ileostomy

Closure of ileostomy

summary64
Everyone:

History and examination including PR

Proctoscopy and rigid sigmoidoscopy

Rectal bleeding:

Rigid/flexi/colonoscopy (safety margin)

Change in bowel habit:

Usually barium enema

Colonoscopy if suspected IBD or high index suspicion cancer

Top and tail if iron deficiency anaemia

CT colon if frail

Stool cultures if diarrhoea

Summary