Diseases of Rectum and Diseases of Rectum and Anal CanalAnal Canal

Anatomy I.Anatomy I.

Rectum – distal part of gastrointestinal Rectum – distal part of gastrointestinal

tracttract

It´s about 14 – 16 cm long and it´s It´s about 14 – 16 cm long and it´s divided into three parts:divided into three parts:

1. proximal part1. proximal part

2. middle part2. middle part

3. distal part ( anal canal )3. distal part ( anal canal )

Anatomy II.Anatomy II.Blood supply :Blood supply : 1. superior rectal artery 1. superior rectal artery ( inferior mesenteric artery )( inferior mesenteric artery ) 2. two middle rectal arteries 2. two middle rectal arteries ( internal iliac artery )( internal iliac artery ) 3. two inferior rectal arteries 3. two inferior rectal arteries ( internal pudendal artery )( internal pudendal artery )

Internal rectal venous plexusInternal rectal venous plexus - lies in the submucosa of the - lies in the submucosa of the anal canal above the level of the dentate line ( internal anal canal above the level of the dentate line ( internal haemorrhoids)haemorrhoids)

External rectal venous plexus External rectal venous plexus - lies under the skin of the - lies under the skin of the anal canal below the dentate line ( external haemorrhoids )anal canal below the dentate line ( external haemorrhoids )

Congenital abnormalities I.Congenital abnormalities I.

Imperforate anusImperforate anus – one infant in 4500-5000 – one infant in 4500-5000 is born with imperforate anusis born with imperforate anus

A. Low abnormalitiesA. Low abnormalities : : anal stenosisanal stenosis ( dilatation ) ( dilatation ) anal membraneanal membrane - anus is covered - anus is covered with a thin membrane ( incision )with a thin membrane ( incision ) B. High abnormalitiesB. High abnormalities : : ano – rectal agenesisano – rectal agenesis ( 80-85 % ), ( 80-85 % ), often with recto-urethral often with recto-urethral or recto - vaginal fistulaor recto - vaginal fistula rectal atresiarectal atresia – anal canal – anal canal is normal but ends blindly above is normal but ends blindly above the pelvic floorthe pelvic floor

Congenital abnormalities II.Congenital abnormalities II.

Examination :Examination : inspection, inspection, X-ray picture ( infant is held X-ray picture ( infant is held upside down with the coin or metal button upside down with the coin or metal button in the site of the anus and the gas in the in the site of the anus and the gas in the rectum will rise to the top and indicaterectum will rise to the top and indicate the distance )the distance )

Treatment : Treatment : operation operation incisio, dilatation, colostomy, incisio, dilatation, colostomy, reconstruction of the anorectumreconstruction of the anorectum

Fissura-in-ano I.Fissura-in-ano I. - longitudinal ulcer in the distal part of anal canal- longitudinal ulcer in the distal part of anal canal

The site of location: - mid-line posteriorly - 80%The site of location: - mid-line posteriorly - 80% - mid-line anteriorly - 10%- mid-line anteriorly - 10% - lateral – 10 % ( Crohn´s disease )- lateral – 10 % ( Crohn´s disease )

Ethiology Ethiology – unknown ( passage of a hard stool )– unknown ( passage of a hard stool ) - resting anal pressure is raised, but this may be due - resting anal pressure is raised, but this may be due to secondary sphincter spasm induced by painto secondary sphincter spasm induced by pain

Two types: Two types: 1. acute1. acute 2. chronic2. chronic ( hypertrophic anal papila and ( hypertrophic anal papila and sentinel tag )sentinel tag )

Fissura-in-ano II.Fissura-in-ano II.

Symptoms :Symptoms : pain, bleeding, pain, bleeding,

pruritus,constipation.dischargepruritus,constipation.discharge

Management :Management :

1. conservative ( acute) - sitz baths, laxatives, 1. conservative ( acute) - sitz baths, laxatives,

anal dilatation, local creams anal dilatation, local creams

2. operation ( chronic) - excision of fissura,2. operation ( chronic) - excision of fissura,

posterior or lateral sphincterotomy posterior or lateral sphincterotomy

to reduce the high resting anal pressureto reduce the high resting anal pressure

Haemorrhoids ( Piles ) I.Haemorrhoids ( Piles ) I.Haemorhoids ( the dilatate rectal venous plexus )Haemorhoids ( the dilatate rectal venous plexus )

consist of an internal and external componentconsist of an internal and external component

( haemorhoideal disease ).( haemorhoideal disease ).

- very frequent disease- very frequent disease

Ethiology Ethiology - hereditary ( weakness of the vein - hereditary ( weakness of the vein

walls )walls )

- higher pelvic pressure ( pregnancy ), - higher pelvic pressure ( pregnancy ),

- constipation, straining at stool- constipation, straining at stool

Haemorrhoids II.Haemorrhoids II.

Symptoms :Symptoms : bleeding, prolapse of nodes, bleeding, prolapse of nodes,

pruritus, pain, dischargepruritus, pain, discharge

Diagnosis:Diagnosis: inspection - at 3,7 and 11 inspection - at 3,7 and 11

o´clock in litothomy position o´clock in litothomy position

rectoscopy, anoscopyrectoscopy, anoscopy

Complications :Complications : bleeding, thrombosis, bleeding, thrombosis,

inflamationinflamation

Haemorrhoids III.Haemorrhoids III.

Classification: Classification: 4 degrees4 degrees

I. degree :I. degree : occasional bleeding occasional bleeding

II. degree :II. degree : prolapse after defecation with prolapse after defecation with

spontaneous repositionspontaneous reposition

III. degree :III. degree : prolapse nodes need prolapse nodes need

to be replaced manuallyto be replaced manually

IV. degree :IV. degree : permanet prolaps with permanet prolaps with

inflamation, thrombosis etc.inflamation, thrombosis etc.

Haemorrhoids IV.Haemorrhoids IV.Management :Management :

A. conservative : sitz baths, local creams A. conservative : sitz baths, local creams and suppositories, venotonicsand suppositories, venotonics B. semoconservative : injection sclerotherapy, B. semoconservative : injection sclerotherapy, infrared coagulation, infrared coagulation, rubber band ligationrubber band ligation C. operative treatment :C. operative treatment : - open and closed haemorhoidectomy- open and closed haemorhoidectomy - PPH procedure- PPH procedure ( ( no external skin wound, recovery is rapid no external skin wound, recovery is rapid and relatively pain free )and relatively pain free )

Anal Abscess and Fistula I.Anal Abscess and Fistula I.

Anal abscess and fistula are two phases of the Anal abscess and fistula are two phases of the same disease.same disease.

Abscess - acute phaseAbscess - acute phase

Fistula – chronic phaseFistula – chronic phase

Ethiology :Ethiology :

- majority of abscesses originate in the - majority of abscesses originate in the

intersphincteric space from infection intersphincteric space from infection

of anal gland.of anal gland.

Anal Abscess and Fistula II.Anal Abscess and Fistula II.

Fistula-in-ano ( anal fistula )Fistula-in-ano ( anal fistula ) usually usually consists of :consists of :

- internal opening- internal opening

- primary tract - primary tract

- external opening- external opening

Primary tract connects the internal and Primary tract connects the internal and external openings.external openings.

Intersphincteric fistula Transsphincteric fistula

Suprasphincteric fistula Extrasphincteric fistula

Anal Abscess and Fistula III.Anal Abscess and Fistula III.Symptoms :Symptoms : acute abscess – pain, feweracute abscess – pain, fewer fistula- in- ano – chronic purulent dischargefistula- in- ano – chronic purulent discharge

Management :Management :

Acute abscess – surgical inicision and drainageAcute abscess – surgical inicision and drainage cavity is dressed with gause ( changing every 24 hours )cavity is dressed with gause ( changing every 24 hours ) wound is left open for secondary healingwound is left open for secondary healing

Anal fistula – treatment according to the type of fistula Anal fistula – treatment according to the type of fistula 1. discision ( lay open the primary track )1. discision ( lay open the primary track ) 2. drainage cum seton2. drainage cum seton 3. advancement flap3. advancement flap

Rectal TumorsRectal Tumors

1 . Benign tumors1 . Benign tumors

2. Malignant tumors2. Malignant tumors

Benign rectal tumorsBenign rectal tumorsThe most frequent are polyps.The most frequent are polyps.

PolypPolyp is a localised elevated lesion arising from an is a localised elevated lesion arising from an epithelial surface.epithelial surface.Polyp - adenoma : 90%Polyp - adenoma : 90% - other ( inflammatory, hyperplastic etc. ) : 10%- other ( inflammatory, hyperplastic etc. ) : 10%

2 types of adenoma : tubular ( pedunculated ) 20%2 types of adenoma : tubular ( pedunculated ) 20% villous ( sessile ) 80%villous ( sessile ) 80%

Symptoms :Symptoms : bleeding, producing of mucus ( villous ) bleeding, producing of mucus ( villous )

Treatment :Treatment : polypectomy by colonoscopy polypectomy by colonoscopy surgical excision – large sessile polypsurgical excision – large sessile polyp

Rectal carcinoma I.Rectal carcinoma I.Rectal cancer ( adenocarcinoma )Rectal cancer ( adenocarcinoma ) arising from arising from the epithelial cells of the rectal mucosa.the epithelial cells of the rectal mucosa.50% of all colorectal tumors are located 50% of all colorectal tumors are located in the rectum.in the rectum.Prognosis is related to typing, grading and staging.Prognosis is related to typing, grading and staging.Typing :Typing : adenocarcinoma adenocarcinoma signet ring cell carinoma ( with producing signet ring cell carinoma ( with producing of mucus ) , melanomaof mucus ) , melanomaGrading :Grading : - well differentiated carcinoma - well differentiated carcinoma - moderate - moderate - poor- poorStaging :Staging : Dukes classification (ABC), Dukes classification (ABC), TNM classificationTNM classification

Rectal carcinoma II.Rectal carcinoma II.

Symptoms:Symptoms: bleeding, sense of incomplete bleeding, sense of incomplete

defecation,defecation,

alteration in the bowel habit, alteration in the bowel habit,

passage of mucuspassage of mucus

Diagnosis:Diagnosis: rectal examination , rectoscopy, rectal examination , rectoscopy,

colonoscopy,biopsy, barium enema colonoscopy,biopsy, barium enema

examination, endorectal ultrasonography, examination, endorectal ultrasonography,

abdominal USG, CTabdominal USG, CT

Dissemination:Dissemination: local spread, lymphatic spread, local spread, lymphatic spread,

venous spreadvenous spread

Rectal carcinoma II.Rectal carcinoma II.Treatment :Treatment : - surgical terapy ( radical OP, - surgical terapy ( radical OP,

paliative OP) paliative OP)

- combined therapy ( surgery - combined therapy ( surgery

and oncotherapy )and oncotherapy )

Radical operations:Radical operations: anterior resection, anterior resection,

abdominoperineal resection, abdominoperineal resection,

radical excisionradical excision

Paliative operations :Paliative operations : cryotherapy, colostomy, cryotherapy, colostomy,

stents stents

- classic or laparoscopic procedures, T.E.M. - classic or laparoscopic procedures, T.E.M.