Treatment options Slerotherapy Rubber band ligation Open hemmorhoidectomy Closed hemmorhoidectomy Stapled 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
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
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
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
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
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)
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