Common Anorectal Conditions lecture dated 8.11.2008

1. Common Anorectal Conditions lecture dated 8.11.2008

2. ANAL CANAL Anal canal has 2 sphincters : Internal anal sphincter,,,involuntary. External anal sphincter,,,voluntary. Lower half of anus�lined by sensitive stratified squamous epithelium. Lymphatic drainge from lower half goes to inguinal nodes.

3. Anal Fissure Anal fissure An elongated ulcer in the long axis of anal canal. Two locations�.common 90 percent midline posteriorly Next most common site Anterior.

4. Anal Fissure Etiology Constipation ..a hard mass of feces stretches the posterior wall more as it is unsupported Recently ischemia suggested as cause. Proved by doppler that blood flow to this area is low. Operation for hemmorhoids can cause Inflammatory bowel disease Sexually transmitted disease.

5. Anal Fissure Types acute or chronic Acute is a painful tear in the skin of anal canal with spasm with little indurations. In the chronic one inflammatory indurations with scarring, on inferior end there is a sentinel tag. There may be spasm

6. Anal Fissure Clinically it is seen in young especially women. Pain especially after defecation lasting almost an hour. Bleeding mild=streaks on stool Slight discharge.

7. Anal Fissure On exam General exam (may reveal a finding) followed by local (reveals a sentinel tag, with tight and puckered anus) Do not do DRE at this time as it is painful. May need a GA to examine.

8. Anal Fissure Investigations : When? How?

9. Anal Fissure Treatment Four finger dilatation-unpopular. Lateral sphincterotomy. Anal advancement flap. Local nitroglycerine oint. Local diltiazim oint.

10. Haemorrhoid Hemorrhoids are dilated veins in relation to anus. External or internal depending on whether below or above dentate line. External covered by skin. Internal by mucous membrane. Usually at three places 3,7 and 11 o�clock with the patient in lithiotomy position

11. Haemorrhoid Do not take lightly Can be due to:- chronic constipation. ca colon/rectum. straining at micturation. with pregnancy.

12. Hemorrhoid Symptoms Bleeding PR bright red blood(1st degree only bleed) during defecation, splash in pan Prolapse late symptom classification : First degree : Second degree : Third degree: Fourth degree :

13. Hemorrhoid Discharge,,,mucous discharge---pruritis? Pain is not a symptom of uncomplicated hemmorhoids. only if infected or thrombosed. look for a reason. Anaemia rarely due to bleeding piles look for another reason of anaemia.

14. Haemorrhoid On exam Inspection : DRE piles are not felt on DRE unless thrombosed. Proctoscopy�piles will bulge into the lumen of the scope. Sigmoidoscopy must be done.

15. Haemorrhoid Complications of piles Strangulation. Thrombosis. Ulceration . Gangrene. Fibrosis Suppration pylephlebitis

16. Haemorrhoid Treatment Treat the cause Symptomatic treatment for constipation etc Anal stretch Ligation =banding. Injection Cryosugery / photocoagulation

17. Hemorrhoid Surgery= hemmorhoidectomy 2 types ,open and closed Open= ,do not suture mucosa =miligan morgan technique Closed =suturing mucosa back Done in 3rd degree,or those 2nd degree which do not respond to treatment,fibrosed ENDOSTAPLING also done

18. Haemorrhoid External pile Can get thrombosed ..painful, it is a hematoma . 5 day painful self occuring lesion. If seen early treatment can be surgery.

19. AnoRectal Abscess Anorectal abscess 90 percent cases it starts as infection of anal gland. Other Causes crohns disease malignancy cutaneous boil foreign body like fish bone

20. AnoRectal Abscess Types perianal60 percent. ischiorectal 30percent. Submucous5percent. Pelvirectal. fissure abscess.

21. AnoRectal Abscess Treatment of abscess drainage Cruciate incision and deroof under GA. Antibiotics????? And treat the cause

22. Perianal Fistula Perianal fistula: Tract lined by granulation tissue connecting rectum or anal canal to skin outside. Usually after abscess.

23. Perianal Fistula Causes Abscess Crohns disease Malignancy Tuberculosis Bilharziasis Lymphogranuloma inguinale

24. Perianal Fistula Types (standard classification) Subcutaneous Submucous Low anal High anal pelvirectal

25. Perianal Fistula Parks classification Intersphincteric . Transsphincteric. Supralevator.

26. Perianal Fistula Symptoms Persistent discharge Perianal opening Sometimes abscess formation

27. Perianal Fistula On exam A perianl opening with granulation tissuepouting from mouth. A firm tract found on PR. Much indurations in the skin and subcutaneous tissue .

28. Perianal Fistula Investigation Proctoscopy . Probing of tract if needed by an experienced surgeon under GA carefully. Radiography. Endoluminal USG. MRI.

29. Perianal Fistula Goodsalls rule Anterior openings are usually straight tract and only one opening. Posterior ones have a curved tract with mutiple openings outside. Significance ?

30. Perianal Fistula Treatment Depending upon extent and cause. Simple laying open. Excision? Ligature�SETON. Sometimes colostomy needed. Always send a piece of tract for biopsy.

31. Perianal Fistula Traumatic fistula needs colostomy. In all cases of fistula treatment recurrence is common. So proper mapping of the tract before surgery is must. Patient to be explained before hand.

32. Pilonidal Sinus Pilonidal sinus A sinus in the area of sacral area. Containing hair Two theories of genesis 1..Congenital 2..acquired(mostly accepted) Mostly affects men rarely seen in persons who go for ablution or blondes or women.m;f=4;1

33. Pilonidal Sinus Usually in sacral area in midline. History of sinus or recurrent abscess. Hair seen in a sinus, which is branching, Foreign body type giant cells are common. Treatment of acute attack is lay open the track

34. Pilonidal Sinus For a chronic abscess excise the sinus with all the tracts. Or karyadakis= closure to one side. Buscom technique Excision with grafting Excision with flap

35. Thank you.

36. ANAL CANAL Abnormal Anatomy Congenital malformations Imperforate anus. covered anus ectopic anus Anorectal sgenesis Rectal atresia