Anorectal diseases


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anatomy of the rectum & anus
+ hemorrhoids

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Anorectal diseases

  1. 1. Done BY : Sara Al-Ghanem | 208009915Supervised BY: Dr. M. Yasser 1
  2. 2. To understand surgical anatomy of anus and rectum in relationto surgical disease and treatmentTo understand the pathology, CF, investigations, D/Ds andtreatmentTo appreciate that ano-rectal disease is common and conservativetreatment may be appropriate before surgeryTo understand that too aggressive or inappropriate surgery maybe dangerousBenign diseases overview: Anal Fissure, Haemorrhoid, PilonidalSinusAnorectal suppurations: Absesses & Fistulas.Rectal prolapsePer Rectal Examination 2
  3. 3. A 60 year old man known to have hemorrhoidscomplains of anal itching & discomfort , particularlytoward the end of the day .He has mild perianal pain when sitting down & findshim self sitting away to avoid the discomfort . 3
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  5. 5. 12-16 cm in length,starting at about the sacralpromontory extending todentate line of anal canalAnterior aspect of the upper 4-6 cm is intraperitoneal withserosal surface.Lower (majority of) rectumlies within extraperitonealpelvis, with no serosa. 5
  6. 6.  No taenia coli.Taeniae coli spread out at rectosigmoid junction to form a continuous,external longitudinal muscle layer No Sacculations. No appendices apiploicae transverse folds 6
  7. 7. Superior rectal valve Middle rectal valve Inferior rectal valveThree submucosalfolds ( the valves of Houston ) 7
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  9. 9. The superior rectal the terminal branch of the inferiorartery mesenteric artery(superior hemorrhoidal artery)The middle rectal artery The internal Iliac artery(middle hemorrhoidal artery) from the internal pudendal artery,The inferior rectal artery which is a branch of the internal (inferior hemorrhoidal artery) iliac artery. 9
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  11. 11. The superior into the portal system via the inferior rectal vein mesentericThe middle into the internal iliac veinrectal veinThe inferior into the internal pudendal vein, and rectal vein subsequently into the internal iliac 11
  12. 12. I- inferior mesenteric nodesLymph from the upper andmiddle rectum flows in channelsthat parallel the arterial supplyand is filtered by the inferiormesenteric nodes.II- the internal iliac lymph nodesLymph from the distal rectumflows into channels adjacent tothe middle and inferior rectalarteries. Thesechannels drain to iliac nodes. 12
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  16. 16.  It is the terminal part of the large intestine. It lies below the pelvic diaphragm level, in the ANALTRIANGLE OF PERINEUM, between the ischiorectal fossae. The anatomical anal canal extends from the perineal skin tothe linea dentata. The surgical anal canal measures 4 to 5cm in length andIt begins at the anorectal junction ( anorectal ring ) and terminates atthe anal verge. The anorectal ring This is the circular upper border of thepuborectal muscle which is digitally palpable upon rectal ex.It lies approximately 1-1.5 cm above the linea dentata. 16
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  18. 18. The dentate or pectinate line:marks the transition point between columnar rectal mucosa andsquamous anoderm.The anal transition zone: The 1 to 2 cm of mucosa just proximal to the dentate line shareshistologic characteristics of columnar, cuboidal, and squamousepithelium.The columns of Morgagni:The dentate line is surrounded by longitudinal mucosal folds,known as the columns of Morgagni, into which the anal cryptsempty. These crypts are the source of cryptoglandular abscesses 18
  19. 19. Canal includes dentate line, anal glands, internal and externalsphincter muscles, and hemorrhoidal vessels .The anal canal is lined by anoderm, a specialized epitheliumthat is devoid of hair follicles, sebaceous glands, or sweat glandsbut has a rich nerve supply.The junction between the anoderm and perianal skin is the analverge. 19
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  21. 21. The anal sphincter is comprised of three layers:Internal sphincter: continuance of the circular smoothmuscle of the rectum, involuntary and contractedduring rest, relaxes at defecation.Intersphincteric space. Small anal glands are locatedbetween the internal and external sphincters andcommunicate with the anal crypts via anal ducts.External sphincter: voluntary striated muscle, dividedin three layers that function as one unit.These three layers are continuous cranially with thepuborectal muscle and levator ani. 21
  22. 22. Above The dentate line Below The dentate lineArterial blood supply Superior rectal artery Middle rectal artery inferior rectal arteryVenous drainage Superior rectal vein middle & inferior rectal (Portal) veins (systemic )Lymphatic drainage upper part of anal canal: Lower part of anal canal  Internal iliac nodes into Superficial inguinal nodes.Innervations Autonomic Somatic 22
  23. 23.  Internal & external venous plexus. Internal or hemorroideal venous plexus lies in submucosa, external lies outside the muscle coat of canal.Both communicates with each other so it is a site ofportocaval anastomoses.Superior rectal (Portal) anastomoses freely with middle& inferior rectal veins (systemic ) •23
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  26. 26. Definition Etiology or risk factors Types & Classification Clinical picture & DDX Diagnosis& treatment 26
  27. 27.  Hemorrhoids basically means "blood flow" [Greek haima meaning "blood" + rhoia meaning "flow"]. Hemorrhoids are defined as the symptomatic enlargement and distal displacement of the normal anal cushions. The most common symptom of hemorrhoids is rectal bleeding associated with bowel movement. 27
  28. 28.  Hemorrhoids: Hemorrhoids are cushions of submucosal tissue containing venules, arterioles, and smooth muscle fiber. They are thought to play a role in maintaining continence. They are located in the left lateral , right anterior and right posterior. This normal tissue protects the sphincter during defecation and permits complete closure of the anus during rest. Risk factors: Constipation, pregnancy, increased pelvic pressure (ascites,tumors), portal hypertension 28
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  33. 33. Bleeding-fresh bright red mucous discharge prolapse pruritusAnal pain ?  complicated SARA AL-GHANEM 33
  34. 34. 1.Bleeding2.Strangulation3.Thrombosis4.Ulceration5.Gangrene6.Fibrosis7.Suppuration8.Pylephlebitis 34
  35. 35. Physical visualizeClinical Examination withhistory ( PR ) anoscope. 35
  36. 36. Medical Therapyminimally invasive techniques SURGICAL THERAPY 36
  37. 37. Bleeding from first- and second-degree hemorrhoidsoften improves with the addition of :dietary fiber stool softenersSitz bath increased fluid intakeavoidance of straining.Associated pruritus may often improve withimproved hygiene 37
  38. 38. Rubber band ligation CryosurgeryBipolar, infrared, and laser Laser hemorrhoidectomy coagulation Doppler-guided Sclerotherapy hemorrhoidal artery ligation 38
  39. 39. Failure of medical and nonoperative therapySymptomatic third-degree, fourth-degreemixed internal and external hemorrhoidsFibrosed hemorrhoidsExternal hemorrhoidsSymptomatic hemorrhoids in the presence of aconcomitant anorectal condition that requires surgeryPatient preference after discussion of the treatmentoptions with the referring physician and surgeon. 39
  40. 40. Sitz bathAnalgesicsAntibioticsLaxativeDressingP/R after 3 weeks 40
  41. 41. Early Late Secondary Pain hemorrhage Acuteretention of Anal fissure urineReactionary Analhemorrhage stricture Incontinence 41
  42. 42. Anorectal diseases lecture ,Dr.M.Yasser DaoudAnatomy of rectum & anus , Dr. MOHD. IMTIYAZNetter’s surgical anatomy reviewSchwartzs.Principles.of.Surgery.9EdNMS SurgeryFirst Aid SurgeryUptodate 42
  43. 43. SARA AL-GHANEM 43