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The upper half of the anal canal has the following important anatomical
features:
- it is lined by columnar epithelium
- it is thrown into vertical folds called anal columns which are joined together at
their lower ends by small semilunar folds called anal valves. At the base of each
valve are small anal sinuses into which open 4-8 anal glands.
Some of these glands are racemose and reach the intersphincteric layer.
The function of these glands is obscure and their importance lies in the fact that
they may be the route of infections into the submucous and intersphincteric
spaces and lead to abscess formation.
The nerve supply is the same as that for the rectal mucosa and is derived from
the autonomic hypogastric plexuses. It is sensitive only to stretch.
The arterial supply is provided by the superior rectal artery, a branch of inferior
mesenteric artery.
The venous drainage is mainly by the superior rectal vein a tributary of the
inferior mesenteric vein.
2.
The lymphatic drainage is mainly upward along the superior rectal artery and
then eventually to the inferior mesenteric nodes.
The lower half of the anal canal has the following important features:
- it is lined by stratified squamous epithelium which gradually merges at the anus
with the perianal epidermis.
- there are no anal columns
- the nerve supply is from the somatic inferior rectal nerve; it is sensitive to pain,
temperature, touch and pressure.
The arterial supply is the inferior rectal artery a branch of the internal pudental
artery. The venous drainage is by the inferior rectal vein, a tributary of the
internal pudental vein which drains into the internal iliac vein.
The lymph drainage is downward to the medial group of superficial inguinal
nodes.
The anal sphincter mechanism has three constituents, the internal sphincter,
external sphincter and puborectalis muscle.
The internal sphincter represents a downward but thickened continuation of the
rectal wall smooth muscles. This is the involuntary internal sphincter.
The encircling external sphincter and the puborectalis sling (which is a part of
levator ani) arise from the pelvic floor.
The external sphincter may be divided into three parts: subcutaneous, superficial
and a deep part.
The puborectalis fibers cause the rectum to join the anus at an acute angle.
Hemorrhoids
They represent vascular swellings involving the internal or external venous
plexuses. Hemorrhoids (piles) are extremely common, affecting nearly half of
the population at some stage in their lives.
Lack of fiber in the modern “civilised” diet is probably the most important
etiological factor; hemorrhoids are almost unknown in underdeveloped
countries.
Pathogenesis
Hemorrhoids represent excessive enlargement of the venous plexuses at the
lower ends of the anal mucosa columns. Hemorrhoids are usually located in the
three, seven and eleven o'clock positions. These correspond to the anatomical
positions of the three most prominent anal columns.
Piles are caused by straining to pass small hard stools. Increased intra-abdominal
pressure inhibits venous return and the venous plexuses become distended. The
bulging mucosa is then dragged distally by the hard stool. Furthermore,
persistent straining at stool causes the pelvic floor to sag downwards extruding
the anal mucosa and causing a minor degree of prolapse.
3.
Hemorrhoids are classified into first, second and third degrees according to the
extent to which they prolapse through the anal canal.
First degree piles never prolapse, second degree piles prolapse during defecation
but then return spontaneously into the anal canal, whilst third degree piles
remain outside the anal margin unless replaced digitally.
Any piles may bleed from stool trauma during defection. Large piles may
thrombose if they prolapse and their venous return is obstructed by sphincter
tone. Such piles then become solid and cannot be effectively replaced within the
anal canal.
In extreme cases the hemorrhoid undergoes venous infarction and ulceration.
The local pain and irritation caused by piles results in increased anal sphincter
tone and spasm thus aggravating the problem of defecation and prolapse.
Long standing hemmorhoids appear to atrophy, probably by thrombosis and
fibrosis leaving small skin tags at the anal margin.
Thrombosed or strangulated piles present with acute pain and most patients are
admitted to hospital as an emergency. The diagnosis is usually obvious on
inspection as an edematous, congested purplish mass is seen at the anal margin.
Tight spasm of the anal sphincter makes digital examination extremely painful.
Strangulated hemorrhoids are even more painful than thrombosed hemorrhoids
and the strangulated mass become necrotic or even ulcerated.
Conservative management and prevention of hemorrhoids
1. A high fiber diet is the most important means of preventing and treating piles.
2. Advise the patient to spend minimal time in defecating and to avoid straining.
Some patients regularly spend a long time on the lavatory reading.
3. Pruritus ani can be helped greatly if the perineum is washed and dried after
defecation and kept dry by applying simple talcum powder.
4. Prolapsed piles should be replaced digitally after defecation.
4.
1. Injection
First degree hemorrhoids (which do not regress with dietary change and
avoidance of straining) and most second degree hemorrhoids are best treated by
injection. An irritant solution is injected submucosally around the pedicles of the
three major hemorrhoids. This provokes a fibrotic reaction, effectively
obliterating the hemorrhoidal vein and causing atrophy of the piles.
3-5 ml. of phenol-in-oil is injected just beneath the mucosa. Usually three
injections are given near the site at which each hemorrhoidal vein leaves the
hemorrhoidal plexuses at positions three, seven and eleven o’clock.
Direct injection into the hemorrhoid itself is extremely painful. Injection may be
repeated on two to three occasions at intervals of four to six weeks.
2. Banding
An alternative to injection is the application of Barron’s bands to obliterate the
hemorrhoidal vessels.
A cone of mucosa just above the hemorrhoidal neck is picked up in special
forceps and drown into the banding instrument. The bands are then released
around the base of the cone, constricting the hemorrhoidal vessels. The result is
that the hemorrhoid slowly shrinks.
Anal fissure
An anal fissure is a longitudinal tear in the mucosa and skin of the anal canal
caused by passage of a large, hard stool. The tear is nearly always in the midline
of the posterior anal margin.
5.
The fissure causes sphincter spasm and acute pain during defecation, which
persists for up to an hour. The result is a fear of defecation which aggravates the
constipation.
Sometimes, there is a small amount of fresh bleeding at defecation (the bleeding
is slight and only noted on the toilet paper).
Another theory is that of developing skin dimples (skin pits) in the skin between
the buttocks. These may develop from damaged hair follicles due to local
pressure or friction. Because of local pressure, growing hair in the natal cleft
may get pushed into the skin pits.
Whatever the cause, once hair fragments become 'stuck' in the skin they irritate
the skin and cause inflammation. Inflamed skin quickly becomes infected and so
a recurring or persistent infection tends to develop in the affected area.
Certain factors increase the risk of developing the condition and include:
• Sedentary occupation (sitting a lot).
• Obesity.
• A previous persistent irritation or injury to the affected area.
• Having a hairy, deep natal cleft.
• A family history of the condition.
Treatment
Acute symptoms
Painkillers (such as paracetamol and/or ibuprofen) may be very helpful to
improve the pain.
Emergent operation to incise and drain the abscess.
Chronic (persistent) symptoms
In most cases, an operation will be advised.
1. Wide excision and healing by secondary intention- this operation involves
cutting out the sinus but also cutting out a wide margin of skin which surrounds
the sinus. The wound is not stitched but just left to heal by normal healing
processes (healing by 'secondary intention'). This usually means that the wound
can take several weeks to heal and requires regular dressing until it heals. The
advantage of this method is that all inflamed tissue is removed and the chance of
recurrence is low.
2. Excision and primary closure. This means taking out the section of skin which
contains the sinus. This is done by cutting the skin either side of the sinus, taking
out the sinus, and stitching together the two sides. The advantage for this is, if
successful, the wound heals quite quickly. However, the risk of a recurrence, or
of developing an infection of the wound after the operation, is higher than the
above procedure.
Anal fistula
Anal fistulae usually develop as a complication of perianal, ischiorectal or
pararectal abscesses.
The fistula tracks from the lower rectum or upper anal canal through the abscess
site to the perianal skin at the point of previous drainage.
The communication between abscess cavity and bowel is established by
spontaneous drainage into the bowel either before surgical drainage or after
incomplete surgical drainage. Thus any abscess in the anal region should be
drained early and thoroughly.
The patient typically complains of an intermittent discharge in the perianal
region.
Patients often provide a reliable history of previous pain, swelling, and
spontaneous or planned surgical drainage of an anorectal abscess.
Important points in the history that may suggest a complex fistula include the
following::inflammatory bowel disease, diverticulitis, previous radiation therapy
for prostate or rectal cancer,tuberculosis, steroid therapy, HIV infection
8.
Parks classification of fistula-in-ano
• Intersphincteric
o Common course - Via internal sphincter to the intersphincteric
space and then to the perineum
o Seventy percent of all anal fistulae
• Transsphincteric
o Common course - Low via internal and external sphincters into the
ischiorectal fossa and then to the perineum
o Twenty-five percent of all anal fistulae
• Suprasphincteric
o Common course - Via intersphincteric space superiorly to above
puborectalis muscle into ischiorectal fossa and then to perineum
o Five percent of all anal fistulae
9.
• Extrasphincteric
o Common course - From perianal skin through levator ani muscles to
the rectal wall completely outside sphincter mechanism
o One percent of all anal fistulae
Digital rectal examination may reveal a fibrous tract or cord beneath the skin.
Lateral or posterior induration suggests deep postanal or ischiorectal extension.
The examiner should determine the relationship between the anorectal ring and
the position of the tract before the patient is relaxed by anesthesia. The sphincter
tone and voluntary squeeze pressures should be assessed before any surgical
intervention to delineate whether preoperative manometry is indicated.
Anoscopy is usually required to identify the internal opening.
Most anal fistulae are simple and superficial the internal orifice beginning below
puborectalis; these are known as low anal fistulae.
Assessment requires examination under anesthetic. A probe is gently
manipulated through the fistula to demonstrate the internal orifice.
If this is not found blue dye can be injected into the external orifice and may be
seen to merge in the anal canal.
If the fistula is situated entirely below the puborectalis muscle, it is laid open by
cutting down onto the probe with a scalpel, transsecting the anal margin and the
whole lengh of the fistula.
The wound heals spontaneously by secondary intention.
There is no loss of fecal continence but flatus may be less well controlled.
If the fistula lies above the puborectalis surgical treatment is difficult and highly
specialised because of the need to preserve the functional integrity of
puborectalis.
Rectal prolapse
A rectal prolapse is a hernia of the rectum through the pelvic floor.
In effect, the mucosa and muscle wall intussuscept through the anal canal.
In the early stages, the prolapse occurs only with defecation and retracts
spontaneously.
At a later stage, the rectum may prolapse when the patient merely stands up.
The patient thus becomes socially isolated.
In the elderly, rectal prolapse is either remarkably well tolerated or else
concealed. The patient becomes accustomed to reducing the prolapse manually
after defection and rarely complains about it.
A high fiber diet makes little difference to the problem since the anatomical
defect will never recover spontaneously.
If the prolapse occurs on standing or if incontinence develops the patient will
require surgical treatment.
This operation may fail because the ring is too tight (causing constipation) or too
loose (allowing recurrent prolapse ).
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