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Benign Anorectal Conditions. Ahmed Badrek-Amoudi FRCS. Anorectal Anatomy. Nerve Supply Sympathetic: Superior hypogastric plexus Parasympathetic: S234 (nerviergentis Pudendal Nerve: Motor and sensory. Arterial Supply Inferior rectal A middle rectal A. Venous drainage

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Benign Anorectal Conditions


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benign anorectal conditions

Benign Anorectal Conditions

Ahmed Badrek-AmoudiFRCS

slide2

Anorectal Anatomy

Nerve Supply

Sympathetic: Superior hypogastric plexus

Parasympathetic:

S234 (nerviergentis

Pudendal Nerve:

Motor and sensory

Arterial Supply

Inferior rectal A middle rectal A

Venous drainage

Inferior rectal V middle rectal V

3 hemorrhoidal complexes

L lateral

R antero-lateral

R posterolateral

Anal canal

Lymphatic drainage

Above dentate: Inf. Mesenteric

Below dentate: internal iliac

Anal verge

haemorrhoids back ground
HaemorrhoidsBack Ground
  • They are part of the normal anoderm cushions
  • They are areas of vascular anastamosis in a supporting stroma of subepithelial smooth muscles.
  • The contribute 15-20% of the normal resting pressure and feed vital sensory information .
  • 3 main cushions are found
      • L lateral
      • R anterior
      • R posterior
  • But can be found anywhere in anus
  • Prevalence is 4%
  • Miss labelling by referring physicians and patients is common

This combination is only in 19%

slide4

HaemorrhoidsPathogensis

3 main processes: 1. Increased venous pressure

2. Weakness in supporting fibromuscular stroma

3. Increased internal sphincter tone

Risk Factors

slide7

HaemorrhoidsInvestigations:

  • Lab: CBC / Clotting profile/ Group and save
  • Proctography: if rectal prolpse is suspected
  • Colonoscopy: if higher colonic or sinister pathology is suspected
slide8

Complications

  • Ulceration
  • Thrombosis
  • Sepsis and abscess formation
  • Incontinence

Thrombosed internal haemorrhoids

Thrombosed external haemorrhoids

slide10

HaemorrhoidsExternal H. Treatment :

  • If presentation less than 72 hours:
      • Enucleate under LA or GA
      • Leave wound open to close by secondary intension
      • Apply pressure dressing for 24 hours post op
  • If more than 72 hours:
      • Conservative measures
perianal fistula and abscess
Perianal Fistula and Abscess

5%

60%

5%

Ischiorectal 20%

Intersphincteric

suprasphincteric

extrasphincteric

Trans-sphincteric

peri anal fistula clinical presentation
Peri-anal FistulaClinical presentation

Godsalls law

Anterior: drain straight

Posterior: drain curved to anorectal midline

  • Follow 40-60% of perianal abscess and cryptgland infections
  • Presentation:
    • External openings
    • Purulent discharge
    • Blood
    • Perianal pain
perianal abscess management
Perianal AbscessManagement

Aim: adequate drainage of abscess

preservation of sphincter function

* Preop: full lab evaluation

*Always perform Examination under GA ( EUA) and obtain a biopsy.

perianal fistula managment
Perianal fistulaManagment

Aim: Define anatomy

Eliminate tract

preservation of sphincter function

* Preop: full lab evaluation

*Always perform Examination under GA ( EUA) and obtain a biopsy.

anal fissure
Anal Fissure
  • Linear tears in the anal mucosa exposing the internal sphincter
  • 90% are posterior
  • Caused mainly by trauma ( hard Stool). Followed by increased sphincter tone and ischemia.
  • Other causes: IBD, Ca, Chronic infections
pilonidal sinus
Pilonidal Sinus

Pathogenesis:

A sinus tract at natal cleft resulting from:

  • Blockage of hair follicle
  • Folliculitis
  • Abscess followed by sinus formation.
  • Hair trapping
  • Foreign body reaction
  • The sinus tract is cephald

Associated with:

  • Caucasians
  • Hirsute
  • Sedentary occupations
  • Obese
  • Poor hygeine
presentation treatment
Presentation & Treatment
  • Also found: umbilicus, finger webs, perianal area