from schwartz 2015 and about aorectal disease

1. ANORECTAL
DISEASES
SCHWARTZ'S PRINCIPLES OF SURGERY 2015

2. Hemorrhoids
 cushions of submucosal tissue containing venules, arterioles, and smooth
muscle fibers that are located in the anal canal.
 left lateral, right anterior, and right posterior positions.
 Function: continence mechanism and aid in complete closure of the anal
canal at rest.
 Because hemorrhoids are a normal part of anorectal anatomy, treatment is
only indicated if they become symptomatic.
 Excessive straining, increased abdominal pressure, and hard stools increase
venous engorgement of the hemorrhoidal plexus and cause prolapse of
hemorrhoidal tissue.
 Bleeding, thrombosis, and symptomatic hemorrhoidal prolapse may result.

3. Hemorrhoids
 External hemorrhoids
 Distal to the dentate line and are covered with
anoderm.
 thrombosis may cause significant pain
 should not be ligated or excised without adequate
local anesthetic
 A skin tag often persisting as the residua of a
thrombosed external hemorrhoid. Skin tags are
often confused with symptomatic hemorrhoids.
 may cause itching and difficulty with hygiene if they
are large.
 Treatment of external hemorrhoids and skin tags is
only indicated for symptomatic relief

4. Hemorrhoids
 Internal hemorrhoids
 proximal to the dentate line and covered by insensate anorectal mucosa
 may prolapse or bleed, but rarely become painful unless they develop
thrombosis and necrosis(usually related to severe prolapse, incarceration,
and/or strangulation)
 graded according to the extent of prolapse : Firstdegree hemorrhoids bulge
into the anal canal and may prolapse beyond the dentate line on straining.
Second-degree hemorrhoids prolapse through the anus but reduce
spontaneously. Third-degree hemorrhoids prolapse through the anal canal
and require manual reduction. Fourth-degree hemorrhoids prolapse but
cannot be reduced and are at risk for strangulation.

5. Hemorrhoids
 Combined internal and external hemorrhoids
 Straddle the dentate line
 characteristics of both
 Hemorrhoidectomy is often required for large, symptomatic, combined
hemorrhoids.
 Postpartum hemorrhoids
 result from straining which results in edema, thrombosis, and/or
strangulation.
 Hemorrhoidectomy is often the treatment of choice, especially if the
patient has had chronic hemorrhoidal symptoms.

6. Hemorrhoids
 Portal hypertension
 Was long thought to increase the risk of hemorrhoidal bleeding
 Now understood that hemorrhoidal disease is no more common in
patients with portal hypertension.
 Rectal varices, however, may occur and may cause hemorrhage in these
patients
 rectal varices are best treated by lowering portal venous pressure.
 Rarely, suture ligation may be necessary if massive bleeding persists.
 Surgical hemorrhoidectomy should be avoided : risk of massive, difficult-
to-control variceal bleeding.

7. Hemorrhoids
Treatment
 Medical Therapy
 Bleeding from first- and second-degree hemorrhoids often improves with
the addition of dietary fiber, stool softeners, increased fluid intake, and
avoidance of straining.
 pruritus often may improve with improved hygiene.

8. Hemorrhoids
Treatment
Rubber band ligation
 Persistent bleeding from first-,
second-,and selected third-degree
 Severe pain will occur if the rubber
band is placed at or distal to the
dentate line
 Other complications:urinary retention,
infection, and bleeding

9. Hemorrhoids
Treatment
Infrared Photocoagulation
 small first- and second-degree
hemorrhoids
 All three quadrants may be treated
during the same visit
 Larger hemorrhoids and hemorrhoids
with a significant amount of prolapse
are not effectively treated with this
technique

10. Hemorrhoids
Treatment
 first-, second-, and some third-degree
hemorrhoids
 One to 3 mL of a sclerosing solution
(phenol in olive oil, sodium
morrhuate, or quinine urea) is injected
into the submucosa ofeach
hemorrhoid
 Few complications are associated with
sclerotherapy, but infection and
fibrosis have been reported
Sclerotherapy

11. Hemorrhoids
Treatment
Excision of Thrombosed
External Hemorrhoids
 Acutely thrombosed external
hemorrhoids generally cause intense
pain and a palpable perianal mass
during the first 24 to 72 hours after
thrombosis
 The thrombosis can be effectively
treated with an elliptical excision
performed in the office under local
anesthesia
 simple incision and drainage is rarely
effective

12. Hemorrhoids
Treatment
 Operative Hemorrhoidectomy
 Closed Submucosal Hemorrhoidectomy
 Open Hemorrhoidectomy
 Whitehead’s Hemorrhoidectomy
 Procedure for Prolapse and Hemorrhoids/Stapled Hemorrhoidectomy
 Doppler-Guided Hemorrhoidal Artery Ligation

13. Complications of Hemorrhoidectomy
 Postoperative pain following excisional hemorrhoidectomy requires
analgesia usually with oral narcotics. Nonsteroidal anti-inflammatory
drugs, muscle relaxants, topical analgesics, and comfort measures,
including sitz baths, are often useful as well
 Urinary retention is a common complication following hemorrhoidectomy
and occurs in 10% to 50% of patients. The risk of urinary retention can be
minimized by limiting intraoperative and perioperative intravenous fluids
and by providing adequate analgesia
 Pain can also lead to fecal impaction. Risk of impaction may be decreased
by preoperative enemas or a limited mechanical bowel preparation, liberal
use of laxatives postoperatively, and adequate pain control.

14. Complications of Hemorrhoidectomy
 small amount of bleeding, especially with bowel movements, is to be
expected
 massive hemorrhage can occur after hemorrhoidectomy. Bleeding may
occur in the immediate postoperative period (often in the recovery room)
as a result of inadequate ligation of the vascular pedicle. This type of
hemorrhage mandates an urgent return to the operating room where
suture ligation of the bleeding vessel will often solve the problem.
 Bleeding may also occur 7 to 10 days after hemorrhoidectomy when the
necrotic mucosa overlying the vascular pedicle sloughs. some of these
patients may be safely observed, others will require an exam under
anesthesia to ligate the bleeding vessel or to oversew the wounds if no
specific site of bleeding is identified.

15. Complications of Hemorrhoidectomy
 Infection is uncommon after hemorrhoidectomy. Severe pain, fever, and
urinary retention may be early signs of infection. emergent examination
under anesthesia, drainage of abscess, and/or débridement of all necrotic
tissue are required.
 Long-term sequelae of hemorrhoidectomy
 Incontinence
 Stenosis
 ectropion (Whitehead’s deformity)

16. Anal Fissure
 a tear in the anoderm distal to the dentate line
 trauma from either the passage of hard stool or prolonged diarrhea
 A tear in the anoderm causes spasm of the internal anal sphincter, which
results in pain, increased tearing, and decreased blood supply to the
anoderm
 This cycle contributes to development of a poorly healing wound that
becomes a chronic fissure
 vast majority posterior midline
 Ten percent to 15% occur in the anterior midline. Less than 1% of fissures
occur off midline.

17. Anal Fissure
Symptoms and Findings
 Characteristic symptoms:tearing pain with defecation and hematochezia
 sensation of intense and painful anal spasm lasting for several hours after
a bowel movement
 fissure can often be seen in the anoderm by gently separating the buttocks
 Patients are often too tender to tolerate digital rectal examination,
anoscopy, or proctoscopy
 acute fissure:superficial tear of the distal anoderm and almost always heals
with medical management.

18. Anal Fissure
 Chronic fissures
 develop ulceration and heaped-up
edges with the white fibers of the
internal anal sphincter visible at the base
of the ulcer
 often an associated external skin tag
and/or a hypertrophied anal papilla
internally
 more challenging to treat and may
require surgery
 A lateral location of a chronic anal
fissure may be evidence of an
underlying disease such as Crohn’s
disease, HIV, syphilis, tuberculosis or
leukemia

19. Anal Fissure
Treatment
 focuses on breaking the cycle of pain, spasm, and ischemia
 First-line therapy to minimize anal trauma includes bulk agents, stool softeners, and warm
sitz baths
 addition of 2% lidocaine jelly or other analgesic creams can provide additional symptomatic
relief
 Nitroglycerin ointment has been used locally to improve blood flow but often causes severe
headaches
 Both oral and topical calcium channel blockers (diltiazem and nifedipine) have also been
used to heal fissures and may have fewer side effects than topical nitrates
 Newer agents, such as arginine (a nitric oxide donor) and topical bethanechol (a muscarinic
agonist), have also been used to treat fissures
 Medical therapy is effective in most acute fissures, but will heal only approximately 50% of
chronic fissures

20. Anal Fissure
Treatment
 Botulinum toxin (Botox) causes temporary muscle paralysis. Injection of
botulinum toxin is used in some centers as an alternative to surgical
sphincterotomy for chronic fissure. Although there are few long-term
complications from the use of botulinum toxin, healing appears to be
equivalent to other medical therapies.

21. Anal Fissure
Treatment
 Surgical therapy
 recommended for chronic fissures that have failed medical therapy,
 lateral internal sphincterotomy is the procedure of choice.
 The aim of this procedure is to decrease spasm of the internal sphincter
 Approximately 30% of the internal sphincter fibers are divided laterally by
using either an open or closed technique
 Healing is achieved in more than 95% of patients using this technique and
most patients experience immediate pain relief
 Recurrence occurs in less than 10% of patients, and the risk of incontinence
(usually to flatus) ranges from 5% to 15%
 Advancement flaps (VY) with or without sphincterotomy have also been
reported to successfully treat chronic fissures.

22. lateral internal sphincterotomy

23. Advancement flaps (VY)

24. Cryptoglandular Abscess
 The majority of anorectal suppurative disease results from infections of the anal
glands (cryptoglandular infection) found in the intersphincteric plane
 perianal abscess is 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

25. Pathways of anorectal infection in
perianal spaces

26. Cryptoglandular Abscess
Diagnosis
 Severe anal pain is the most common presenting complaint
 A palpable mass is often detected by inspection of the perianal area or by
digital rectal examination
 Occasionally, patients will present with fever, urinary retention, or
lifethreatening sepsis
 The diagnosis of a perianal or ischiorectal abscess can usually be made
with physical exam alone (either in the office or in the operating room)
 complex or atypical presentations may require imaging studies such as CT
or MRI to fully delineate the anatomy of the abscess.

27. Cryptoglandular Abscess
Treatment
 Drainage as soon as the diagnosis is established
 If the diagnosis is in question, an examination and drainage under
anesthesia
 Delayed or inadequate treatment may occasionally cause extensive and
life-threatening suppuration with massive tissue necrosis and septicemia
 Antibiotics are only indicated if there is extensive overlying cellulitis or if
the patient is immunocompromised, has diabetes mellitus, or has valvular
heart disease

28. Perianal Abscess
 Most perianal abscesses can be
drained under local anesthesia in the
office, clinic, or emergency room
 Larger, more complicated abscesses
may require drainage in the operating
room
 A skin incision is created, and a disk of
skin excised to prevent premature
closure
 No packing is necessary, and sitz baths
are started the next day

29. Ischiorectal Abscess
 causes diffuse swelling in the
ischiorectal fossa that may involve one
or both sides, forming a “horseshoe”
abscess
 Simple ischiorectal abscesses are
drained through an incision in the
overlying skin
 Horseshoe abscesses require drainage
of the deep postanal space and often
require counterincisions over one or
both ischiorectal spaces

30. Intersphincteric Abscess
 difficult to diagnose because they produce little swelling and few perianal
signs
 Pain is typically described as being deep and “up inside” the anal area and
is usually exacerbated by coughing or sneezing
 The pain is so intense that it usually precludes a digital rectal examination
 The diagnosis is made based on a high index of suspicion and usually
requires an examination under anesthesia
 can be drained through a limited, usually posterior, internal
sphincterotomy

31. Supralevator Abscess
 uncommon and can be difficult to diagnose
 can mimic intra-abdominal conditions
 rectal examination may reveal an indurated, bulging mass above the anorectal
ring
 If the abscess is secondary to an upward extension of an intersphincteric abscess,
it should be drained through the rectum If it is drained through the ischiorectal
fossa, a complicated, suprasphincteric fistula may result.
 If a supralevator abscess arises from the upward extension of an ischiorectal
abscess, it should be drained through the ischiorectal fossa. Drainage of this type
of abscess through the rectum may result in an extrasphincteric fistula
 If the abscess is secondary to intra-abdominal disease, the primary process
requires treatment and the abscess is drained via the most direct
route(transabdominally, rectally, or through the ischiorectal fossa)