6. Hemorroids
Fissure in ano
Fistula in ano
Ano rectal abscess
Rectal prolapse and incontinence
Anal warts
Benign anal disorders
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by gkg
7. HEMORRHOIDS
Hemorrhoids: are cushions of submucosal
tissue containing venules, arterioles, and
smooth-muscle fibers that are located in the anal
canal
Three hemorrhoidal cushions are found in the left
lateral, right anterior, and right posterior
positions (3, 7 and 11 O’clock)
They do not constitute a disease unless
symptomatic
7
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8. Incidence
Exact incidence not known (prevalence rate of 4.4% in the United
States)
Peaks between age 45 and 65 years
Hemorrhoidectomies are performed 1.3x more commonly in males
than in females
8
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9. Classification
Internal:
located above the dentate line
covered by insensate anorectal mucosa
covered by transitional and
columnar epithelium
External
located below the dentate line
covered by the richly innervated anoderm
covered by squamous epithelium
Intero-external
both the internal and external hemorrhoids
exist at the same time
9
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10. Pathogenesis
The cause of hemorrhoids is still unknown
A sliding downward of the anal cushions is the correct
etiologic theory with gravity, straining, and irregular
bowel habits
Hypertrophy and congestion of the vascular tissue
are secondary
Hemorrhoids result from disruption of the anchoring and
flattening action of the submucosal muscle and its richly
intermingled elastic fibers
10
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11. Risk factors
Excessive straining, diarrhea,....
Increased abdominal pressure, erect posture
Hard stools, pregnancy, pelvic mass,...
increase venous engorgement of the hemorrhoidal
plexus and cause prolapse of hemorrhoidal tissue
11
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12. Clinical presentation and Dx
Soiling/discharge
Itching /anal irritation and pain
Prolpase
Not palpable unless they complicate
12
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13. Bright red painless rectal
bleeding splash in the pan
Anal mass
Discomfort
Pain
Contributing factors
◦ Old age
◦ Pregnancy
◦ Straining
◦ Heavy wt lifting
Inspection
◦ During straining
Digital rectal exam
Hct
proctoscopy
Proctosigmoidoscopy
Colonoscopy
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14. Internal hemorrhoids are graded according to the extent of prolapse:
1st degree: protrude into, but do not prolapse outside the anus
2nd degree: prolapse through the anus with defecation or straining but reduce
spontaneously
3rd degree: prolapse through the anal canal with defecation or straining and
require manual reduction
4th degree: prolapse but cannot be reduced
14
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18. Diagnosis
Based on history, physical examination, and
endoscopy.
18
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19. Treatment
is only indicated if they become symptomatic
Conservative care
luxatives
warm sitz bath
local steroids
Regular toilet
No straining and no prolonged sitting on toilet
High fiber diet
Adequate hydration
perianal hygiene
Injection therapy
5% phenol in almond oil
Infrared therapy
19
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20. Rubber band ligation
Cryosurgery
liquid nitrogen
Hemorrhoidectomy
Milligan-Morgan
Ferguson
Whitehead
20
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21. Indication
◦ Third and forth degree
◦ Complicated hemorrhoid
◦ Failed medical mgt with severe symptoms
Types
I. Open (Milligan Morgan)
II. Closed (Ferguson)
III. Stapled
IV. White head hemorrhoidectomy
Surgical therapy
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24. Rubber band ligation
Because of the risk for bleeding and sepsis, it is
preferable that patients are not taking anti platelet .
Subacute bacterial endocarditis prophylaxis is
administered to patients at risk.
Should be avoided in immunodeficient patients.
24
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25. Rubber band ligation
Simplest, most effective, and most widely
applied office proceduer
Can be performed in the office without sedation
through an anoscope using a ligator.
Preferably, only one site should be banded each
time
25
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27. Patients should be instructed to return to the
emergency department if develop
Pain
inability to void
fever
27
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28. Excision of Thrombosed External Hemorrhoids
Acutely thrombosed external hemorrhoids generally cause
intense pain and palpable perianal mass during the first 72
hours .
Can be treated with elliptical excision in office under local
anesthesia.
Because clot is usually loculated, simple incision and drainage
is rarely effective.
After 72 hours, the clot begins to resorb, and the pain resolves
spontaneously. Excision is unnecessary, but sitz baths and
analgesics often are helpful
28
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31. ANORECTAL ABSCESS
Infection of the peri anal and perirectal region
Caused by pyogenic infection of the anal gland
Polymicrobial
E-coli in (80%), S. Aureus, Bacteroides, ….
Blood borne infection can occur in immunocompromised patients
31
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33. Types
1) Perianal abscess
• the most common manifestation
2) Intersphincteric abscess
3) Ischiorectal abscess
4) Supralevator abscess
33
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34. ETIOLOGY
Numerous conditions, which may be classified as
specific or nonspecific.
Nonspecific ones are cryptoglandular in origin.
34
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35. Pathogenesis
Crypto glandular hypothesis
blockage of anal glands
accumulation of gland secretion
infection of the gland
abscess formation
discharge along the path of least resistance
fistula formation( 50%)
35
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36. Specific
IBD
tuberculosis (TB)
Actinomycosis
presence of a foreign body
carcinoma
lymphoma
lymphogranulomavenereum
pelvic inflammation
trauma (impalement, enemas,prostatic surgery,
episiotomy, hemorrhoidectomy)
radiation, and leukemia
36
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37. Clinical presentation
Severe anal pain is the most common
presentation
Walking, coughing, or straining can aggravate
the pain
P/E
Tender; round cystic lump at the anal verge below
the dentate line
37
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40. History
Pain
Swelling
Fever
Chills
Predisposing conditions
◦ AIDS
◦ DM
◦ elderly
Physical exam
Perianal mass
Skin color change
Tenderness
Systemic signs of
inflammation
Look for evidence of NSTI
Clinical presentation
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by gkg
41. Diagnosis
Usually clinical
throbbing perianal pain
perianal tender induration
tender boggy mass
fever, rigor and chills
Imaging
CT or MRI - if complex or atypical presentation
Ix
◦ WBC with differential
◦ Hct 41
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42. Treatment
Anal abscesses should be drained in a timely manner
Lack of fluctuance should not be a reason to delay
treatment
Incision and drainage: skin kept open after a
cruciate incision
Broad spectrum iv antibiotics(if systemic)
42
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43. Indications for Mx
Systemic manifestations (fever…)
Immunocompromised
AIDS
diabetes
cancer therapies
chronic medical
immunosuppression
complex, complicated abscess
43
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44. A cruciate skin and subcutaneous
incision is made over most
prominent part of the abscess
"dog ears" are excised to prevent
premature closure.
No packing is necessary
sitz baths are started next day
44
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45. Ischiorectal Abscesses
Drainage of horseshoe
abscess.
The deep postanal space is
entered, incising the
anococcygeal ligament.
Counter drainage incisions
are made for each limb of the
ischiorectal space
45
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46. Intersphincteric Abscess
Drained through a limited, usually posterior, internal
sphincterotomy
If it arises from the upward extension of an ischiorectal
abscess, drained through ischiorectal fossa.
• Drainage of this through the rectum may result in an
extrasphincteric fistula.
46
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Supralevator Abscess
47. Cont…
If it is 2ry to intra-abdominal disease,
Primary process requires treatment and the
abscess is drained via the most direct route
(transabdominally, rectally, or through the
ischiorectal fossa).
47
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49. FISTULA-IN-ANO
Definition
an abnormal communication between the anal canal
or the rectum with the perianal skin
Usually follows anorectal abscess
Suspect immunosuppression
Mostly cryptoglandular
Secondary fistula in ano:
◦ TB, Chron’s, Actinomycosis, malignancy, LGV,
….
49
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55. History
◦ Pain around perianal area which
ends with discharging wound
◦ Constant soiling of the underwear
◦ History related to the underlying
diseases and conditions
Persistent perianal discharge
Previous history of perianal
infection
Demonstration of the internal and
external openings
Physical exam
◦ Evidence of
immunosupression
PR findings
◦ Indurated small opening
around the perineum with
discharge
◦ Internal opening may be
found with induration in the
anorectum
Clinical presentation
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by gkg
56. Goodsall’s Law
Any fistula that originated anterior to the
transverse anal line will course anteriorly in a
direct route
Fistula that originates posterior to the
transverse anal line will have a curved path
Fistula tracts that diverge from this should
increase one’s suspicion of IBD
56
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58. ANOSCOPY AND SIGMOIDOSCOPY
Performed for at least three reasons
1) Identify internal opening in the anal canal.
2) Distinguish between a rectal and an anal canal opening.
3) Sigmoidoscopy allows examination of rectal mucosa to
determine presence of underlying proctocolitis.
• A rectal biopsy is performed if Crohn’s disease or malignancy is
suspected.
58
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60. Setons
It refers to any foreign material that can be
inserted into the fistula tract to encircle
the sphincter muscles.
Silk
Penrose drains
Silastic vessel loops
rubber bands
steel wire.
used for marking, draining, cutting, or
staging
60
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61. Post op care
Sitz baths
pain management
wound care
Wound healing after fistulotomy usually takes 4
to 8 weeks
61
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62. Failure to heal may ultimately require fecal
diversion.
Complex and/or nonhealing fistulas may result
from Crohn's disease, malignancy, radiation
proctitis, or unusual infection.
Proctoscopy should be performed in all cases.
Biopsies of the fistula tract should be taken to rule
out malignancy.
62
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63. ANAL FISSURE
Definition :
a tear in the lining of the anal canal below the
dentate line
Is the most painful perianal condition
Age:
all ages, however more in young and healthy
adults
Sex:
males and females are equally affected
63
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64. May present as acute or chronic
Situated in the midline and
posteriorly (90%), 10% anteriorly
Anterior fissure occurs secondary
to multiple deliveries
64
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65. Chronic anal fissure
It has four typical features
1. Boat shaped ulcer with indurated
edges
2. Fibers of whitish internal sphincter
forming the floor
3. A hypertrophic anal papilla at the
upper end
4. A sentinel skin tag at its lower end
65
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66. Causes
Primary cause
Trauma: mostly due to passage of hard stools through a markedly tight sphincter
Secondary
IBD
previous anal surgery e.g. hemorrhoidectomy
anterior anal fissure in women due to childbirth trauma
TB
sexual trauma
low fiber diet
66
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67. Anal fissure progression
Hard or dry stools tear of mucosa fissure
pain spasm of internal sphincter
arteriolar compression reduced tissue perfusion
delayed healing of acute anal fissure leading to
chronicity
67
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68. Clinical presentation
History
severe anal pain, triggered by defecation
bright red bleeding per rectum, mostly in streaks on toilet tissue
constipation
perianal discharge
Physical
examination should be done very gently
proctoscopy
examination under anesthesia
68
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70. Treatment: Acute Fissure
Medical therapy is effective in most acute fissures
High fiber diet with increased water intake and
warm sitz bath
Stool softeners
Glyceryl trinitrate
Diltiazem
Local anesthetic creams
Both oral and topical calcium channel blockers
70
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71. Chronic fissure: Surgery
Manual anal dilatation
Lateral internal sphincterotomy
Excision of the fissure
Anoplasty
Advancement flap
71
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72. Caused by HPV(human papiloma virus
One of STI’s
◦ HSV
◦ HIV
◦ LGV
◦ AIN
Causes sever purities and mucous discharge
Topical agents and surgical excision
Anal warts
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by gkg
73. Bowen’s disease/
AIN
Squamous cell ca
Epidermoid ca
Malignant
melanoma
Adenocarcinoma
Malignant anal diseases
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by gkg
74. Bowen’s disease
◦ Is a premalignant disorder
◦ Follow’s HPV infection
◦ Itching and mucous
discharge
◦ Biopsy is diagnostic
AIN
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by gkg
79. Rectal Prolapse (procidentia).
Refers to a circumferential, full-thickness
protrusion of the rectum through the anus
Internal prolapse occurs when the rectal wall
intussuscepts but does not protrude
Mucosal prolapse is a partial-thickness protrusion.
79
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80. Is far more common among women, female:male
ratio of 6:1.
More prevalent with age in women and peaks in
the seventh decade of life.
In men, prevalence is unrelated to age.
80
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81. PATHOPHYSIOLOGY
Weak levator ani and anal sphincter muscles,
Redundant rectosigmoid colon,
A deep cul-de-sac,
Loss of fixation of the rectum to the sacrum.
81
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83. Symptoms
Tenesmus,
A sensation of tissue protrusion
Incomplete evacuation.
Mucus discharge
Incontinence
Diarrhea
Constipation and outlet obstruction.
83
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84. PHYSICAL EXAMINATION
Rectum is obvious on inspection.
May become evident on strain.
Identify concomitant pelvic floor defects like
rectocele
cystocele
vaginal prolapse
enterocele
84
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85. DIAGNOSIS AND TESTING
Anorectal manometry,
Tests of pudendal nerve terminal motor latency,
Electromyography (EMG)
The colon should be evaluated by colonoscopy or
air-contrast barium enema to exclude neoplasms or
diverticular disease.
85
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86. TREATMENT
Acute Management
Involves early reduction.
Gentle constant pressure is often successful in
reducing the prolapse .
If the rectum continues to prolapse after reduction,
taping the buttocks together may help temporarily.
86
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87. If the prolapse has been neglected or unrecognized
for a prolonged period, it may not easily reduce.
Sedation, placing patient in Trendelenburg position.
Placement of salt or sugar topically can decrease
bowel edema and assist reduction.
87
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88. Cont….
If incarcerated rectum cannot be reduced, or if
there is evidence of ischemic compromise.
operative resection, typically a perineal
proctosigmoidectomy is indicated.
88
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89. surgery
The primary therapy for rectal prolapse
more than 100 different procedures have been
described .
Can be categorized as either abdominal or perineal.
89
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90. Abdominal
Three major approaches:
(a) reduction of the perineal hernia and closure of
the cul-de-sac (Moschcowitz's operation)
(b) fixation of the rectum, either with a prosthetic
sling (Ripstein and Wells rectopexy) or by suture
rectopexy
(c) resection of redundant sigmoid colon.
90
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92. In some cases, resection is combined with rectal
fixation (resection rectopexy).
Abdominal rectopexy with or without resection also
is increasingly performed laparoscopically.
92
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94. Lone Star retractor and incision for Delorme or
perineal proctectomy.
94
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95. . The Thiersch loop
used in high-risk elderly
patients
a loop of stainless steel
wire placed
subcutaneously around the
circumference of the anus
Complication: fecal
compaction, infection, or
erosion of the wire into the
rectum
95
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115. REFERENCES
Bailey and Love‘s: Short Practice of Surgery,
25th ed; 2008
Swartz’s: Principles of Surgery, 10th ed; 20150
Sabiston: Text Book of Surgery, 19th ed; 2013
UpToDate 20.3
115
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Editor's Notes
proctoscope (also known as a rectoscope
As an abscess enlarges, it spreads in one of several directions.
A perianal abscessis the most common manifestation and appears as a painful swelling at the anal verge.
Spread through the external sphincter below the level of the puborectalis produces an ischiorectal abscess. These abscesses may become extremely large and may not be visible in the perianal region. Digital rectal exam will reveal a painful swelling laterally in the ischiorectal fossa.
Intersphincteric abscesses occur in the intersphincteric space and are notoriously difficult to diagnose, often requiring an examination under anesthesia.
Pelvic and supralevator abscesses are uncommon and may result from extension of an intersphincteric or ischiorectal abscess upward or extension of an intraperitoneal abscess downward.
