Post on 03-Jan-2016
description
Benign Anorectal ConditionsAhmed Badrek-Amoudi FRCS
Anorectal Anatomy
Anal verge
Anal canal
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
Lymphatic drainage
Above dentate: Inf. Mesenteric
Below dentate: internal iliac
Nerve Supply
Sympathetic: Superior hypogastric plexus
Parasympathetic :
S234 (nerviergentis
Pudendal Nerve :
Motor and sensory
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%
3 main processes: 1. Increased venous pressure
2. Weakness in supporting fibromuscular stroma
3. Increased internal sphincter tone
Risk Factors
Haemorrhoids
PathogensisAbnormal haemorrhoids are dilated cushions of arteriovenous
plexus with stretched suspesory fibromuscular stroma with prolapsed rectal mucosa
HabitualPathological
1. Constipation and straining
2. Low fibre high fat/spicy diet
3. Prolonged sitting in toilet
4. Pregnancy
5. Aging
6. Obesity
7. Office work
8. Family tendency
1. Chronic diarrhea (IBD)
2. Colon malignancy
3. Portal hypertension
4. Spinal cord injury
5. Rectal surgery
6. Episiotomy
7. Anal intercourse
Haemorrhoids
Classification:
Origin in relation to Dentate lineDegree of prolapse through anus
1. Internal: above DL
2. External: below DL
3. Mixed
•1st: bleed but no prolapse
•2nd: spontaneous reduction
•3rd: manual reduction
•4th: not reducable
Haemorrhoids
Clinical assessment
History ( Full history required)Examination
Haemorrhoid directed:•Pain acute/chronic/ cutaneous•Lump acute/ sub-acute•Prolapse define grade•Bleeding fresh, post defecation•Pruritis and mucus
General GI:•Change in bowel habit•Mucus discharge•Tenasmus/ back pain•Weight loss •Anorexia•Other system inquiry
Local•Inspect for:
–Lumps, note colour and reducability–Fissures–Fistulae–Abscess
•Digital:–Masses–Character of blood and mucus
•Perform proctoscopy and sigmoidoscopy
General abdominal examination
• Lab: CBC / Clotting profile/ Group and save
• Proctography: if rectal prolpse is suspected
• Colonoscopy: if higher colonic or sinister pathology is suspected
Haemorrhoids
Investigations:
The diagnosis of haemorrhoids is based on clinical assessment and proctoscopy
Further investigations should be based on a clinical index of suspicion
Thrombosed internal
haemorrhoids
Thrombosed external
haemorrhoids
Complications
1. Ulceration
2. Thrombosis
3. Sepsis and abscess formation
4. Incontinence
Haemorrhoids
Internal H. Treatment:
Conservative Measures
Grade 1&2• Dietary modification: high fibre diet• Stool softeners• Bathing in warm water• Topical creams NOT MUCH VALUE
Minimally invasive
Indicated in failed medical treatment and grades 3&4• injection sclerotherapy• Rubber band ligation• Laser photocoagulation• Cryotherapy freezing• Stapled haemorrhoidectomy
SurgicalIndications:
1. Failed other treatments
2. Severely painful grade 3&4
3. Concurrent other anal conditions
4. Patient preference
• 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
Haemorrhoids
External H. Treatment:
Perianal Fistula and Abscess
Perianal abscess almost always arise from a fistulous tract. It is an infection of the soft tissue surrounding the anus.
Aetiology & Pathogenesis:•4-10 glands at dentate line.•Infection of the cryptglandular epithelium resulting from obstruction of the glands.•Ascending infection into the intersphincteric space and other potential spaces.•Bacteria implicated:
E.Coli., Enterococci, bacteroides
Other causes:•Crohn•TB•Carcinoma, Lymphoma and Leukaemia•Trauma•Inflammatory pelvic conditions (appendicitis)
60% 5%
5%
Ischiorectal 20%
Intersphincteric
Trans-sphincteric extrasphincteric
suprasphincteric
Perianal AbscessClinical presentation
AbscessClinical presentation
Perianal•Perianal pain, discharge (pus) and fever
•Tender, fluctuant, erythematous subcutaneous lump
Ischio-rectal•Chills, fever, ischiorectal pain
•Indurated, erythematous mss, tender
Intersphincteric
Supralevator
•Rectal pain, chills and fever, discharge
•PR tender. Difficult to identify are. EUA needed
Peri-anal FistulaClinical presentation• Follow 40-60% of perianal
abscess and cryptgland infections
• Presentation:– External openings– Purulent discharge – Blood – Perianal pain
Also associated with:
•IBD
•Malignancy
•TB/ Actinomycosis
•Diverticular disease
Godsalls law
Anterior: drain straight
Posterior: drain curved to anorectal midline
Aim: adequate drainage of abscess
preservation of sphincter function
* Preop: full lab evaluation
*Always perform Examination under GA ( EUA) and obtain a biopsy.
Perianal AbscessManagement
AbscessTreatment
Perianal•Incision and drainge de-roof cavity
•pack with gauze and iodine
•IV AB, sitz bath tid, laxitives and anlgesia
•F/U for fistula Ischio-rectal
Intersphincteric
Supralevator
•I&D through interspgincteric plane.
•Treat the underlying cause
Aim: Define anatomy
Eliminate tract
preservation of sphincter function
* Preop: full lab evaluation
*Always perform Examination under GA ( EUA) and obtain a biopsy.
Perianal fistulaManagment
FistulaTreatment
Perianal•Fistulotomy vs fistulectomy
Trans/Extra/Supra
sphincteric
•Complex treatments using seton
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
Anal Fissure Clinical Assessment
AcuteChronic
•Sever acute pain
•Fresh blood spotting
•Clean linear tear.
•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 SinusPathogenesis:
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
• Also found: umbilicus, finger webs, perianal area
AcuteabscessIncision and drainage
Recurrence: 40%
ChronicPain and discharge
Wide local excision• with primary closure or• closure by secondary intension
Recurrence: 8-15%