Anal Canal
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Anal Canal

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Anal Canal Anal Canal Presentation Transcript

  • Anal canal
    Dr. Tanuj Paul Bhatia
  • Anatomy
    Most distal portion of the alimentary canal.
    Extends for a distance of about 3 cm from the anorectal ring to the hairy skin of the anal verge.
    Anus provides continence for flatus and faeces.
  • Internal hem. plexus
    Anal crypts and columns
    Dentate line
    Int. sphincter
    Anal gland
    White line
    External sphincter
  • Nerve supply
    Below the dentate line, cutaneous sensations conveyed by afferent fibers in the inferior rectal nerves.
    Above the dentate line : parasympathetic fibres
  • Blood supply
    Arterial supply :
    The middle rectal arteries arise from the internal iliac arteries.
    The inferior rectal arteries, branches from the internal pudendal arteries.
    Venous drainage :
    Above dentate line : Int. hem. plexus sup rectal vein  Inf. Mesenteric vein
    Below dentate line : Ext. hem. Plexus
    • Middle rectal vein Int. iliac vein OR
    • Inf. Rectal vein  pudendal vein  Int. iliac vein
  • Sphincter complex
    External sphincter
    Extension of levatorani around anorectum
    Voluntary sphincter
    Supplied by pudendalnerver
    3 compnents :
    Subcutaneous
    Superficial
    Deep
  • Internal sphincter
    Involuntary sphincter
    Innervated by autonomic nervous system
    Formed by extension of rectal musculature
  • Formation of anal sphincters
  • Fecal incontinence
    The principal function of the anal canal is the regulation of defecation and maintenance of continence.
    Evaluated by manometry, defecography and electromyography.
  • causes
  • Management of fecal incontinence
  • hemorrhoids
  • Degree or stagewise classification
    1st degree: bleeding
    2nd degree: protrusion but spontaneous reduction
    3rd degree: protrusion that requires manual reduction
    4th degree: irreducible protrusion
  • External
    1st degree
    2nd degree
    3rd degree
    4th degree
  • Treatment options
    Slerotherapy
    Rubber band ligation
    Open hemmorhoidectomy
    Closed hemmorhoidectomy
    Stapled hemmorhoidectomy
  • Band ligation
  • Hemmorhoidectomy
  • STAPLED HEMORHOIDECTOMY
    DOUGHNUT OF HEM. TISSUE
  • Thrombosed external hemorrhoid
    DISEASE
  • ANAL FISSURE OR FISSURE-IN-ANO
    Linear ulcer of lower half of anal canal
    Posterior fissure is most common
    Anterior fissures commoner in women than men
    Fissure in any other location : suspect
    Crohn’s disease
    Hydradeinitissuppuritiva
    STDs
  • Posterior fissure-in-ano
  • pathogenesis
    passage of large, hard stools, which may be the initiating factor;
    inappropriate diet;
    previous anal surgery;
    childbirth; and
    laxative abuse.
  • symptoms
    With defecation, the ulcer is stretched, causing pain and mild bleeding.
  • types
    Acute fissure in ano
    Chronic fissure in ano
  • Acute fissure in ano
    Short history
    Painful
    No sentinel pile on examination
    Managed conservatively
  • Chronic fissure in ano
    Recurrent acute fissure
    Associated with sentinel pile
    Can be treated conservatively initially but may require surgery
    Sentinel pile :
    a skin tag formed due to chronic inflammation and fibrosis
  • treatment
    Non surgical
    Surgery
    AIM: To increase the blood supply to promote healing of the ulcer/fissure
  • Non surgical treatment
    Stool bulking agents
    Hot tub baths/ Sitz bath
    Local ointments
    Lignocaine
    Nitroglycerine
    Dietary modifications
    Botox injections
  • surgical
    Sphincterotomy
    Internal anal sphincter is cut to relieve the spasm and in turn increase blood supply to the fissure
    Midline sphincterotomies cause key hole defects, hence lateral sphincterotomy is done.
    2 types :
    Open
    Closed
  • Open sphincterotomy
  • Closed sphincterotomy
  • Anal sepsis and fistulae
    Anorectalabcess – acute form of anal sepsis
    Fistula in ano – chronic form of the disease process
    Anal fistula : communication between an internal opening in the anal canal and an external opening through which an abscess drained.
  • etiology
    Infection of obstructed anal glands : Most common cause
    Trauma
    Foreign body
    Tuberculosis
    Actinomycosis
    Inflamatory bowel disease
  • classification
  • treATMENT
  • Anorectalabcess
  • Perianal abscess
    Results frtom suppuration of anal gland or suppuration of a thrombosed external pile
    Lies in the region of subcutaneous portion of external sphincter
  • Clinical features
    Severe pain in perianal region
    Difficulty in sitting
    Tender smooth and soft swellling in the perianal region
  • treatment
    Sitz bath
    Antibiotics
    Drainage under GA
  • Ischiorectalabcess
    Due to extension of intermuscularabcess through external sphincter
    Can be blood born as well
    Fat in fossa more prone for infection as it is least vascularized
    Both these fossa are connected  one fossa infection may lead to the infection on other side HORSE SHOE ABCESS
  • Clinical features
    Tender, indurated, brawny swelling in the skin over ischiorectalfossa
    Fever
    Swelling is not well localized so it is difficult to elicit fluctuation.
  • treatment
    Cruciate incision and drainage
    Pus for c/s
    Look for any internal opening (for presence of internal fistula)
  • Submucousabcess
    Occurs above the dentate line
    Can be drained with a sinus forceps through proctoscope
  • Fistula in ano
    Etiology
    Cryptoglandular sepsis(most common)
    Trauma
    Crohn’s disease
    Malignancy
    Radiationtuberculosis,actinoymycosis
  • Clinical features
    Persistent drainage from internal or external opening
    Indurated tract can be palpable on per rectal examination .
    External opening easily found but finding the internal opening can be a challenge
  • Goodsall’s rule
    ‘In general, fitulas with external opening anteriorly connect to internal opening by a short,radial tract.’
    Fistulas with external opening posteriorly track in curvilinear fashion to posterior midline.
    EXCEPTION : anterior external opening >3cm from anal verge  usually follow curved track to posterior midline
  • Classifications of fistula in ano
    Park’s classification
    High and low fistula in ano
    Simple and complex fistula in ano
  • Park’s classification
    Intersphincteric
    Transsphincteric
    Suprasphincteric
    Extrasphincteric
  • Special investigations
    Trans rectal ultrasound (TRUS)/ Endoanal ultrasound
    Fistulogram
    MRI
  • Surgical management
    Fistulotomy
    Fistulectomy
    Setons
  • fistulotomy
    ‘Laying open of the fistula tract from its termination to source’
    Applied mainly to intersphincteric and transphincteric fistula involving less than 30% of voluntary muscle.
    Staged sphincterotomy : part of sphincter is divided and rest tied upon by a seton.
  • fistulectomy
    Coring out of the fistula
  • setons
    Latin for Bristle
    Loose and tight setons : depending upon the intent of cutting through the muscle.
    After tying, these are tightened in intervals of weeks.
    ‘Cheese wire cutting through ice’
    They gradually cut through the muscles without springing them apart
  • Staged fistulotomy
  • Recent advances
    Advancement flaps
    Tissue glues
  • Pilonidal sinus(jeep bottom)
    Pilus= hair , nidus = nest
    Of infective origin
    Occurs in sacral region between the buttocks
    Other sites : umbilicus, web spaces of fingers(in barbers)
  • pathology
    Hair penetrate skin causing dermatitis and infection
    Persistent infection leads to sinus formation
    Primary sinus : midline
    Secondary sinuses : paramedian
  • Clinical features
    Serosanguinous or purulent discharge
    Throbbing and persistent pain
    Sometimes tender swelling in the midline
    Tufts of hair may be seen in the opening of sinus
  • treatment
    Excision of the sinuses
    Laying open the sinus
    Z- plasty
    Rotation flaps
    Bescom’s operation
    Karydaki’s operation
  • Anal intraepithelial neoplasia
    Virally induced dysplasia
    Risk factors : anoreceptive intercourse and HIV
    Usually patients are asymptomatic
    Based on degree of dysplasia : AIN I, AIN II, and AIN III
    AIN II and III have chances of progressing to invasive carcinoma
  • Clinical features
    30%  asymptomatic
    Suspicious areas are raised, scaly, white, erythematous, pigented or fissured.
  • management
    Multiple mapping biopsies
    Excision followed by colostomy or flaps
    Topical imiquimod or retinoids have some effect on progression of diesease.
  • Non malignant strictures
    Spasmodic : due to anal fissure.
    Organic :
    Postoperative
    Irradiation stricture
    Senile anal stenosis
    Lyphogrnulomainguinale
    Inflamatory bowel disease
    Endometriosis
  • Clinical features
    Increasing difficulty in defecation
    ‘Pipe stem’ stools.
    Stricture can be palpated as annular or tubular on DRE.
  • treatment
    Dilatation by bougies.
    Anoplasty.
    Colostomy.
    Rectal excision and coloanalanastomosis.
  • Malignant tumors
    Below dentate line : SCC
    Above dentate line : basaloid, cloacogenic or transitional carcinomas.
  • Squamous cell carcinoma
    Risk factors :
    HPV infection
    AIN
    Immunosuppression
  • Clinical features
    Pain
    Bleeding
    Pruritus
    Fecal incontinence as a result of sphincter invasion.
    Palpable as indurated, irregular, tender ulcers.
  • management
    Primary treatment : chemoradiotherapy
    CMT(combined modality treatment)
    5-FU with mitomycin C or cisplatin
    Resection indicated in
    Small marginal tumors
    Persistent or recurrent disease  followed by colostomy
  • THANK YOU