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Anal Abscess
Anal Cancer
Anal Fissure
Anal Warts
Cancer of the Anus
Cancer of the Rectum
Condyloma
Cryptitis
Enlarged Papillae
Fecal Incontinence
Fissure
Fistula-in-ano
Hemorrhoids
Levator Syndrome
Pilonidal Cyst
Polyps
Procidentia
Proctalgia Fugax
Proctitis
Pruritus Ani
Rectal Prolapse
Rectocele
Warts Venereal
Anorectal Anatomy
Arterial Supply
Nerve Supply
Inferior rectal A
middle rectal A
Sympathetic: Superior
hypogastric plexus
Venous drainage
Inferior rectal V
middle rectal V
3 hemorrhoidal
complexes
Parasympathetic:
S234 (nerviergentis
Pudendal Nerve:
Motor and sensory
L lateral
R antero-lateral
R posterolateral
Anal canal
Lymphatic drainage
Above dentate: Inf. Mesenteric
Below dentate: internal iliac
Anal verge
Pain?
-> painless
Bright red bleeding
Prolapse associated
with defecation
Internal
External
Anoderm
Swell, discomfort,
difficult hygiene
Pain?
-> Thrombosed
Anatomy
Haemorrhoids
Back Ground
L lateral
This combination
R anterior
is only in 19%
R posterior
Haemorrhoids
Pathogensis
Abnormal haemorrhoids are dilated cushions of arteriovenous
plexus with stretched suspesory fibromuscular stroma with
prolapsed rectal mucosa
3 main processes: 1. Increased venous pressure
2. Weakness in supporting fibromuscular stroma
3. Increased internal sphincter tone
Risk Factors
Habitual
Pathological
1.
2.
3.
4.
5.
6.
7.
8.
1.
2.
3.
4.
5.
6.
7.
Haemorrhoids
Classification:
Origin in relation to Dentate line
1.
2.
3.
Internal: above DL
External: below DL
Mixed
A:Thrombosed external
B:First-degree internal
viewed through anoscope
C:Second-degree internal
prolapsed, reduced
spontaneously
D:Third-degree internal
prolapsed, requiring
manual reduction
E:Fourth-degree strangulated
internal and thrombosed
external
Haemorrhoids
Clinical assessment
History ( Full history required)
Examination
Haemorrhoid directed:
acute/chronic/
Pain
cutaneous
Lump
acute/ sub-acute
Prolapse define grade
Bleeding fresh, post defecation
Pruritis and mucus
Local
General GI:
Digital:
Inspect for:
Lumps, note colour and
reducability
Fissures
Fistulae
Abscess
Masses
Character of blood and mucus
Haemorrhoids
Investigations:
The diagnosis of haemorrhoids is based on
clinical assessment and proctoscopy
Complications
1. Ulceration
2. Thrombosis
3. Sepsis and abscess formation
4. Incontinence
Thrombosed
internal
haemorrhoids
Thrombosed
external
haemorrhoids
Haemorrhoids
Internal H. Treatment :
Conservative Grade 1&2
Measures
Dietary modification: high fibre diet
Stool softeners
Bathing in warm water
Topical creams NOT MUCH VALUE
Minimally
invasive
injection sclerotherapy
Laser photocoagulation
Cryotherapy freezing
Stapled haemorrhoidectomy
Surgical
Indications:
1.
Failed other treatments
2.
Severely painful grade 3&4
3.
Concurrent other anal conditions
4.
Patient preference
Haemorrhoids
External H. Treatment :
Enucleate under LA or GA
Conservative measures
60
%
5%
Ischiorectal
20%
Intersphincteric
suprasphincteric
Trans-sphincteric
extrasphincteric
Pathophysiology
Glandular secretion
stasis
Infection &
suppuration
Anal crypts
obstruction
abscess
formation
Perianal Abscess
Perianal Abscess
Clinical presentation
Abscess
Clinical presentation
Perianal
Ischio-rectal
Intersphincteric
Supralevator
Peri-anal Fistula
Clinical presentation
External openings
Purulent discharge
Blood
Perianal pain
Godsalls law
Anterior: drain straight
Posterior: drain curved to anorectal
midline
Perianal Abscess
Management
Aim:
Perianal
Ischio-rectal
Intersphincteric
Supralevator
Treatment
Incision and drainge de-roof cavity
pack with gauze and iodine
IV AB, sitz bath tid, laxitives and anlgesia
F/U for fistula
I&D through interspgincteric plane.
Treat the underlying cause
Perianal fistula
Managment
Aim:
Define anatomy
Eliminate tract
preservation of sphincter function
Fistula
Perianal
Treatment
Fistulotomy vs fistulectomy
Anal Fissure
Anal Fissure
Clinical Assessment
Acute
Sever acute
pain
Fresh blood
spotting
Clean linear
tear.
Chronic
Pain mild to
moderate
More than 6
weeks
Hypertrophied
Int.sphincter
Skin tag
Granulation
around the
edge
Anal Fissure
Treatment
Conservative
High fibre diet
Medical
sphincterotomy:
GTN
Ca channel blockers
Butulinum toxins
Surgical
Lateral sphincterotomy
Pilonidal Sinus
Pathogenesis:
A sinus tract at natal cleft resulting from:
Folliculitis
Hair trapping
Caucasians
Hirsute
Sedentary occupations
Obese
Poor hygeine
abscess
Chronic
Pain and
discharge
History
Age
Hemorrhoids
Perianal haematomata
Fissure-in-ano-(acute)
Anorectal abscess
Pilonidal sinus
History
Sex
Hemorrhoids
Perianal haematomata
Fissure-in-ano
common in men
Anorectal abscess
Pilonidal sinus
Prolapse of rectum
History
Principal symptoms of rectal and anal
conditions:
Bleeding
Pain
Tenesmus
History - Bleeding
Can be fresh or altered
Example of altered is melaena
ways:
Mixed with faeces
On the surface of the faeces
Separate from the faeces: after/unrelated to
defaecation
On the toilet paper after cleaning
History - Bleeding
Diagnosis of anal conditions which
Blood
Blood
Blood
Blood
Pain alone
Fissure ( pain after defaction)
Proctalgia fugax (pain spontaneously at night)
Anorectal abscess
Pain with bleeding
Fissure
Pain with a lump
Perianal haematoma
Anorectal abscess
Pain, lump and bleeding
Prolapsed haemorrhoids/rectum
Carcinoma of the anal canal
Anorectal examination
abdominal disease.
Still its the least popular segment of the entire physical
examination.
Should not be omitted from your examination, especially in
middle-aged and older patient, why?
risks missing an asymptomatic carcinooma
is in bed. Turn patient on to left side with pelvis vertical. Ask patients
to draw knees up to chest with buttocks on the side of the couch
The Knee-elbow position. Patient kneeling on couch, resting on
elbows, of particular use when palpating the prostate and seminal
The Dorsal Position. This position with the patient lying on the back
with right leg flexed is useful when the patient is in severe pain, and
movement is contra-indicated. Enables assessment of rectovesical
pouch in abdominal emergencies.
Lithotomy. best position for examination but not always available.
Anorectal examination
External inspection:
Piles.
Skin tags (normal, Crohn's, hemorhoids).
Rectal prolapse.
Anal fissure.
Fistula.
Anal warts.
Carcinoma.
Signs of incontinence, diarrhea.
Anorectal examination
palpation
Lubricate index finger.
Insert finger slowly, assessing external sphincter tone
as enter.
Male: palpate prostate [anterior of rectum]:
Hard nodule (prostate cancer).
Tender (prostatitis).
Female: palpate cervix [anterior of rectum]:
Mass in pouch of Douglas.
Rotate finger, palpating along left, posterior, right walls.
Withdraw finger.
Wipe lubricant off pt.
Ask if was significant pain during examination.
Anorectal examination
Inspect withdrawn fingertip for:
Blood, melaena
Stool color
Pus
Mucous.
Acute Ano-rectal
Conditions
Rectal prolapse
Rectal prolapse is the abnormal movement of the
Mucosal prolapse
Rectal prolapse
Mucosal prolapse is more often seen in children
such as:
* Pinworms(Enterobiasis)
* Cystic fibrosis
* Malnutrition and malabsorption (Celiac disease)
* Constipation
* Prior trauma to the anus or pelvic area
Rectal prolapse
Symptoms:The main symptom is a protrusion of a reddish
mass from the anal opening, especially following a bowel
movement.
Treatment :
Complications
* Constipation
* Malnutrition or malabsorption
* Other complications of underlying condition
Proctitis
An inflammation of the rectum causing discomfort,
Proctitis
Symptoms:
pain, discomfort
rectal bleeding
rectal discharge, pus
stools, bloody
constipation
Tenesmus
*Tests:
proctoscopy
sigmoidoscopy
rectal culture
Proctitis
Treatment: treatment of the underlying
Types of Polyps
Juvenile Polyps
Commonest form of polyps in children
Are red pedunculated spheres lesions
Adenomatous Polyps
Are pedunculated lesions
Mainly occur in the rectum and sigmoid
colon
Are often asymptomatic but may produce
anaemia from chronic occult bleeding
May give rise to crampy pain
May secrete mucus
Have malignant potential
Treated by colonoscopic polypectomy
Villous Papillomas
Are flat, sessile lesions within the rectum
Secrete copious amount of mucus
Familial Polyposis
Is an autosomal dominant syndrome