Bohomolets Surgery 4th year Lecture #9


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By. Prof Kucher M. from Faculty Surgery Department #1

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Bohomolets Surgery 4th year Lecture #9

  1. 1. LECTURE 9 Diseases of rectum and perineum National O. Bogomolets Medical University Faculty Surgery Department N1 Kyiv 2008 Prof. Kucher M.
  2. 2. Haemorrhoids <ul><li>Hemorrhoids are actually the a natomical term for “Cushions of tissue” filled with blood vessels at the junction of the rectum and the anus. </li></ul><ul><li>50% to 85% of the world's population will be affected by hemorrhoids at some time in their life. </li></ul>
  3. 3. <ul><li>Increased straining during bowel movements, by constipation or diarrhea . </li></ul><ul><li>It is thus a common condition due to constipation caused by water retention in women experiencing premenstrual syndrome or menstruation . </li></ul><ul><li>Hypertension , particularly portal hypertension , can also cause hemorrhoids because of the connections between the portal vein and the vena cava which occur in the rectal wall. </li></ul><ul><li>Obesity can be a factor by increasing rectal vein pressure. Sitting for prolonged periods of time can cause hemorrhoids. Poor muscle tone or poor posture can result in too much pressure on the rectal veins. </li></ul><ul><li>Pregnancy causes hypertension and increases strain during bowel movements, so hemorrhoids are often associated with pregnancy. </li></ul><ul><li>Excessive consumption of alcohol or caffeine can cause hemorrhoids. Both can cause diarrhea. Note that caffeine ingestion increases blood pressure transiently, but is not thought to cause chronic hypertension. Alcohol can also cause alcoholic liver disease leading to portal hypertension. </li></ul>Etiology
  4. 4. <ul><li>Hemorrhoids usually are not dangerous or life threatening. In most cases, hemorrhoidal symptoms will go away within a few days. </li></ul><ul><li>Although many people have hemorrhoids, not all experience symptoms. The most common symptom of internal hemorrhoids is bright red blood covering the stool, on toilet paper, or in the toilet bowl. However, an internal hemorrhoid may protrude through the anus outside the body, becoming irritated and painful. This is known as a protruding hemorrhoid. </li></ul><ul><li>Symptoms of external hemorrhoids may include painful swelling or a hard lump around the anus that results when a blood clot forms. This condition is known as a thrombosed external hemorrhoid. </li></ul><ul><li>In addition, excessive straining, rubbing, or cleaning around the anus may cause irritation with bleeding and/or itching, which may produce a vicious cycle of symptoms. Draining mucus may also cause itching. </li></ul>Symptoms
  5. 5. Classification <ul><ul><li>Grade I: The hemorrhoids do not prolapse . </li></ul></ul><ul><ul><li>Grade II: The hemorrhoids prolapse upon defecation but spontaneously reduce. </li></ul></ul><ul><ul><li>Grade III: The hemorrhoids prolapse upon defecation, but must be manually reduced . </li></ul></ul><ul><ul><li>Grade IV: The hemorrhoids are prolapsed and cannot be manually reduced. </li></ul></ul>
  6. 6. Examination <ul><ul><li>After visual examination of the anus and surrounding area for external or prolapsed hemorrhoids, a doctor would conduct a digital examination. Visual confirmation of hemorrhoids can be done by doing an anoscopy . </li></ul></ul><ul><ul><li>Endoscopic image of internal hemorrhoids seen on retroflexion of the flexible sigmoidoscope at the ano-rectal junction. </li></ul></ul>
  7. 7. Conservative treatment <ul><ul><li>Normalisation of bowel habits </li></ul></ul><ul><ul><li>Taking herbs and dietary supplements that strengthen vein walls </li></ul></ul><ul><ul><li>Using the squatting position for bowel movements </li></ul></ul>
  8. 8. Surgical treatment <ul><ul><li>Rubber band ligation. Elastic bands are applied onto an internal hemorrhoid to cut off its blood supply. Within several days, the withered hemorrhoid is sloughed off during normal bowel movement. </li></ul></ul><ul><ul><li>Hemorrhoidolysis/Galvanic Electrotherapy. Desiccation of the hemorrhoid by electrical current. </li></ul></ul><ul><ul><li>Sclerotherapy . Sclerosant is injected into hemorrhoids. This causes the vein walls to collapse and the hemorrhoids to shrivel up. </li></ul></ul><ul><ul><li>Cryosurgery. </li></ul></ul><ul><ul><li>Laser, infrared or BICAP coagulation. L aser, infrared beam, or electricity is used to cauterize the affected tissues. </li></ul></ul>
  9. 9. Surgical treatment <ul><ul><li>Hemorrhoidectomy. A true surgical procedure to excise and remove hemorrhoids. Is often now recommended only for severe (grade IV) hemorrhoids. </li></ul></ul><ul><ul><li>Stapled hemoroidectomy. Also called the procedure for prolapse and hemorrhoids, it is designed to resect soft tissue proximal to the dentate line, which disrupts the blood flow to the hemorrhoids. It is generally less painful than complete removal of hemorrhoids. It's meant for hemorrhoids that fall out or bleed. </li></ul></ul><ul><ul><li>Doppler Guided hemorrhoid artery ligation . The only evidence-based surgery for all grades of hemorrhoids. It does not involve cutting tissues or even a stay at the hospital; patients are usually back to work on the same day. It is the best treatment for bleeding piles, as the bleeding stops immediately. </li></ul></ul><ul><ul><li>Transanal hemorrhoidal dearterialization (THD) Similar to HAL, but more standardizable and therefore safer, less painful and has a shorter recovery time. </li></ul></ul>
  10. 10. Anal fissure <ul><li>Anal fissure is an unnatural crack or tear in the anus skin. As a fissure, these tiny tears may show as bright red rectal bleeding and cause severe periodic pain after defecation. The tear usually extends from the anal opening and located posteriorly in the midline. This location is probably because of the relatively unsupported nature of the anal wall in that location. </li></ul>
  11. 11. <ul><li>Most anal fissures are caused by stretching of the anal mucosa beyond its capability. </li></ul><ul><li>Anal fissures are common in women after childbirth. </li></ul><ul><li>Following excessive anal intercourse. </li></ul><ul><li>After difficult bowel movements. </li></ul><ul><li>In infants following constipation. </li></ul>Etiology
  12. 12. <ul><li>Many acute anal fissures will heal spontaneously. </li></ul><ul><li>Some fissures become chronic and will not heal. </li></ul><ul><li>The most common cause for this is spasm of the internal anal sphincter muscle. This spasm causes poor blood flow to the anal mucosa, hence producing an ulcer which does not heal since it is deprived of normal blood supply . </li></ul>Pathogenesis
  13. 13. <ul><li>bright red rectal bleeding. </li></ul><ul><li>severe pain during and after defecation. </li></ul>Symptoms
  14. 14. Conservative treatment <ul><ul><li>Local application of medications to relax the sphincter muscle, thus allowing the healing to proceed (nitroglycerine ointment, nifedipine ointment, topical diltiazem). </li></ul></ul><ul><ul><li>Botulinum toxin injection can also be used to relax the sphincter muscle. Combination of medical therapies may offer up to 98% cure rates, These medical treatments are used as first line therapy in treating chronic anal fissures. </li></ul></ul>
  15. 15. Surgical treatment <ul><ul><li>Surgical intervention may be required for persisting deep anal fissures unresponsive to the above conservative measures. </li></ul></ul><ul><ul><li>Procedures include: </li></ul></ul><ul><ul><li>Internal lateral sphincterotomy or excising a portion of the sphincter. </li></ul></ul><ul><ul><li>Anal dilation or stretching of the anal canal is no longer recommended because of the unacceptably high incidence of fecal incontinence. </li></ul></ul>
  16. 16. Perianal abscess <ul><li>A perianal abscess is a collection </li></ul><ul><li>of pus outside the anus. </li></ul><ul><li>It arises from an infection at one </li></ul><ul><li>of the anal crypts of Morgani </li></ul><ul><li>which leads to inflamation and </li></ul><ul><li>abscess formation. </li></ul><ul><li>Most cases of perianal abscesses </li></ul><ul><li>are sporadic. </li></ul>
  17. 17. <ul><li>Pain in the perianal area </li></ul><ul><li>constipation </li></ul><ul><li>drainage from the rectum </li></ul><ul><li>fever and chills </li></ul><ul><li>palpable mass near the anus </li></ul>Symptoms
  18. 18. <ul><li>physical exam </li></ul><ul><li>imaging studies which can help determine the diagnosis in cases of a deep non-palpable perirectal abscess (pelvic CT scan, MRI or trans-rectal ultrasound) </li></ul>Diagnosis
  19. 19. Treatment <ul><ul><li>Treatment of perianal abscesses include: </li></ul></ul><ul><ul><li>examination under anesthesia </li></ul></ul><ul><ul><li>Gabriel’s procedure or incision and drainage of the pus </li></ul></ul><ul><ul><li>antibiotics to cover rectal flora (and not skin flora) should be prescribed perioperatively </li></ul></ul><ul><ul><li>An anorectal abscess that is untreated or not fully drained can get worse and cause a severe local or systemic infection which can be life-threatening (Fornier's gangrane or sepsis). </li></ul></ul>
  20. 20. Anal fistula <ul><li>An anal fistula is an abnormal connection between the epithelialized surface of the anal canal and (usually) the perianal skin. </li></ul><ul><li>Anal fistulae originate from the anal glands, which are located between the two layers of the sphincters and which drain into the anal canal. </li></ul><ul><li>If the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula. </li></ul>
  21. 21. <ul><li>Pain </li></ul><ul><li>Discharge - either bloody or purulent </li></ul><ul><li>Pruritus ani (itching) </li></ul><ul><li>Systemic symptoms if abscess becomes infected </li></ul>Symptoms
  22. 22. Treatment <ul><ul><li>Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses. </li></ul></ul><ul><ul><li>Lay-open of fistula-in-ano </li></ul></ul><ul><ul><li>Fibrin glue injection </li></ul></ul><ul><ul><li>Fistula plug is an &quot;advanced&quot; version of the fibrin glue method. It involves &quot;plugging&quot; the fistula with a &quot;plug&quot; made of porcine small intestine submucosa </li></ul></ul><ul><ul><li>Endorectal advancement flap is a procedure in which the internal opening of the fistula is identified and a flap of mucosal tissue is cut around the opening. </li></ul></ul><ul><ul><li>Anal Fistula Plug. This treatment requires placement and fixing of a plug in the anal fistula by a special technique. The plug is made of highly sophisticated absorbent material; it provides a scaffold over which body’s collagen gets deposited and closes the fistula. </li></ul></ul>
  23. 23. Pilonidal sinus <ul><li>A pilonidal sinus is an infected tract under the skin, usually between the buttocks, in the natal cleft. It is usually a small cavity containing a tuft of hair and possibly can be oozing pus. </li></ul>
  24. 24. <ul><li>Pilonidal means &quot;nest of hairs&quot;. Ingrown hairs can be one of many causes of pilonidal sinus. </li></ul><ul><li>Pilonidal sinus between the buttocks could be caused by ingrown hairs. Due to increase moisture and pressure around the buttocks area, ingrown hairs find it easier to burrow into the skin. Pressure around the buttocks inhibits the body to reject the hair and thus allow it to continue to burow deeper until infection occurs. </li></ul>Etiology
  25. 25. Treatment <ul><ul><li>Surgery involves either drainage of the sinus, or complete excision. </li></ul></ul><ul><ul><li>Drainage is the preferred method of treatment; however, sinus can return even if it has been drained. The doctor lances the abscess and drains all the pus. The wound is left open and packed by a piece of gauze, which can fall out a few days later or be changed daily. This is a small operation and can cure the problem. 40% of patients have a recurrence of pilonidal disease. </li></ul></ul><ul><ul><li>Full-excision surgery is one way of removing the abscess and sinus tracts. The surgeon uses a scalpel to remove the cavity and sinus tracts. The wound can then be left open to heal, which causes new scar tissue to grow at the base of the wound which gradually fills in the cavity (this process is called granulation). Another way is to partially close the wound, which is called marsupialisation. The edges of the wound down to deeper tissues are stitched with absorbable stitches. This procedure ensures that the centre of the wound is healing as quickly as the sides. </li></ul></ul>
  26. 26. Rectal prolapse <ul><li>Rectal prolapse describes a medical condition wherein the walls of the rectum protrude through the anus and hence become visible outside the body. </li></ul><ul><li>There are three chief conditions which come under the title rectal prolapse: </li></ul><ul><li>Full-thickness rectal prolapse describes the entire rectum protruding through the anus </li></ul><ul><li>Mucosal prolapse describes only the rectal mucosa (not the entire wall) prolapsing </li></ul><ul><li>internal intussusception wherein the rectum collapses, but does not exit the anus </li></ul>
  27. 27. <ul><li>Rectal prolapse is caused by the weakening of the ligaments and muscles that hold the rectum in place: </li></ul><ul><li>advanced age </li></ul><ul><li>long term constipation </li></ul><ul><li>long term diarrhea </li></ul><ul><li>long term straining during defecation </li></ul><ul><li>pregnancy and stresses of childbirth </li></ul><ul><li>previous surgery </li></ul><ul><li>cystic fibrosis, COPD </li></ul><ul><li>multiple sclerosis, paralysis </li></ul><ul><li>anal sex, and other sexual activities involving the anus and the exploration thereof. </li></ul>Etiology
  28. 28. Progression <ul><ul><li>The condition of Rectal prolapse, a type of rectal rupture, undergoes progression: beginning with prolapsation during bowel movements, through Valsalva movements ( sneezing and so forth), then through daily activities such as walking until finally it may become chronic and ceases to retract </li></ul></ul>
  29. 29. Treatment <ul><ul><li>Surgery may be divided into two forms of procedure: abdominal surgery and perineal surgery. </li></ul></ul><ul><ul><li>Abdominal surgery - for younger patients, but is more dangerous: </li></ul></ul><ul><ul><ul><li>Anterior resection </li></ul></ul></ul><ul><ul><ul><li>Marlex rectopexy </li></ul></ul></ul><ul><ul><ul><li>Suture rectopexy </li></ul></ul></ul><ul><ul><ul><li>Resection rectopexy </li></ul></ul></ul><ul><ul><li>Perineal surgery - often performed on older patients and is less dangerous: </li></ul></ul><ul><ul><ul><li>Anal encirclement </li></ul></ul></ul><ul><ul><ul><li>Delorme mucosal sleeve resection </li></ul></ul></ul><ul><ul><ul><li>Altemeier perineal rectosigmoidectomy </li></ul></ul></ul><ul><ul><li>Children are treated with linear cauterization </li></ul></ul>