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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

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
slide4
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
slide5
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”
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
slide14
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
slide16
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
slide24
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
slide29
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
slide42
Cutting seton
  • Draining seton
  • Fistulotomy
  • Fistula plug
  • Advancement flap
slide43
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
slide44
Fistulotomy:
  • A surgical opening of a fistulous tract
  • Fistula plug:
  • Involves plugging the fistula with a device made from small intestinal submucosa
slide45
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
slide46
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
ad