iini

1. Colon, Rectum, & Anus
dr. M. Alif Qisthi Abi Rafdhi
Program Pendidikan Dokter Spesialis Ilmu Bedah
Fakultas Kedokteran Universitas Andalas
Rumah Sakit Umum Pusat Dr. M. Djamil
2022
Preseptor
dr. M. Iqbal Rivai, Sp.B., K.B.D.

2. Embryology
4th week of gestation  embryonic GIT
development
Endoderm  primitive gut  foregut, midgut, and
hindgut
Midgut  small intestine, ascending & proximal transverse
colon  blood supply from superior mesenteric artery
Hindgut  distal transverse & descending colon, rectum, &
proximal anus  blood supply from inferior mesenteric artery

3. Anatomy
Large intestine extends from ileocecal
valve to anus. Divided anatomically &
functionally into the colon, rectum, &
anal canal
Wall of colon & rectum comprise
five distinct layers: mucosa,
submucosa, inner circular muscle,
outer longitudinal muscle, & serosa
Cecum is widest diameter portion of
the colon (normally 7.5–8.5 cm) and has
thinnest muscular wall  most
vulnerable to perforation & least
vulnerable to obstruction
Sigmoid colon is narrowest part of large intestine &
extremely mobile  volvulus most common in
sigmoid colon & diseases affecting sigmoid colon,
such diverticulitis, may occasionally present as right-
sided abdominal pain
Narrow caliber of sigmoid colon 
most vulnerable to obstruction

4. Anorectal Landmarks

9. Anorectal Vascular Supply
Sympathetic  L1-L3  preaortic plexus  hypogastric plexus
Parasympathetic  S2-S4
External anal sphincter & puborectalis muscle : inferior rectal branch
Levator ani : internal pudendal nerve
Sensory : inferior rectal branch of pudendal nerve

10. Congenital Anomalies
Anatomic abnormalities of the colon, rectum, and anus.
Intestinal malrotation and colonic nonfixation.
Colonic duplication.
Imperforate anus and associated fistulas to the genitourinary tract.

11. Normal Physiology
Fluid and electrolyte exchanges
• Approx 90% water contained in ileal fluid absorbed in colon
• Up to 400 mEq sodium absorbed every day
• Protein and urea from bacterial degradation  ammonia  absorbed and transported to liver
Short-chain fatty acids
• Produced by bacterial fermentation of carbohydrates
• Fx : Source of energy for colonic mucosa, metabolism by colonocytes
• Lack of this : diversion colitis
Colonic microflora and intestinal gas
• Approx 30% of fecal dry weight composed of bacteria; anaerob (>>Bacteroides) and aerob (E. Coli)

12. Normal Physiology
Motility
• Cholinergic activation increases colonic motility
Defecation
• Defecation proceeds by coordinating increasing intra-abdominal pressure via a Valsalva maneuver
with rectal contraction, relaxation of the puborectalis muscle, and opening of the anal canal.
Continence
• Internal sphincter : responsible for most of the resting, involuntary sphincter tone (resting
pressure).
• External sphincter : responsible for most of the voluntary sphincter tone (squeeze pressure).
• Impaired continence result from poor rectal compliance, injury to the internal and/or external
sphincter or puborectalis, or neuropathy

13. Clinical Evaluation
Clinical Assessment
• Complete history, physical examination
Endoscopy
• Anoscopy
• Proctoscopy
• Flexible sigmoidoscopy and colonoscopy
• Capsule Endoscopy
Imaging
• Plain X-rays and contrast studies
• Computed Tomography (CT)
• Computed Tomography Coloonography (CTC)
• Magnetic Resonance Imaging (MRI)
• Positron Emission Tomography
• Scintigraphy to assess gastrointestinal bleeding
• Single Photon Emission Computed Tomography
(SPECT/CT)
• Angiography
• Endorectal & Endoanal Ultrasound

14. Physiologic and Pelvic Floor Investigations
Manometry
• Placing a pressure-sensitive catheter in the lower rectum, assesses the rectoanal
inhibitory reflex.
Neurophysiology
• Assesses function of the pudendal nerves and recruitment of puborectalis muscle
fibers
Rectal Evaluation
• Include balloon expulsion test and video defecography

15. Laboratory Studies
Fecal occult blood testing and fecal immunohistochemical testing
• Screening test for colonic neoplasms in asymptomatic, average risk individuals
Stool studies
• Etiology of diarrhea
Tumor markers
• Carcinoembryonic antigen (CEA) may be elevated in 60% to 90% of patients with colorectal
cancer
Genetic testing
• Familial colorectal cancer syndrome are rare, but information about the specific genetic
abnormalities underlying these disorders has led to significant interest in the role of genetic
testing for colorectal cancer

16. Evaluation of Common Symptoms
Abdominal Pain
• Related to the colon and rectum can result from obstruction (either
inflammatory or neoplastic), inflammation, perforation, or ischemia
• Plain X-ray and judicious use of contrast studies and/or a CT scan can often
confirm the diagnosis
• Sigmoidoscopy and/or colonoscopy performed by an experienced endoscopist
can assist in the diagnosis of ischemic colitis, infectious colitis, and inflammatory
bowel disease

17. Evaluation of Common Symptoms
Pelvic Pain
• Originate from the distal colon and rectum or from adjacent urogenital
structures
• Tenesmus may result from proctitis or from a rectal or retrorectal mass
• Cyclical pain associated with menses, especially when accompanied by rectal
bleeding, suggests a diagnosis of endometriosis
• Pelvic inflammatory disease also can produce significant abdominal and pelvic
pain
• CT scan and/or MRI may be useful in differentiating these diseases

18. Evaluation of Common Symptoms
Anorectal Pain
• Most often secondary to an anal fissure, perirectal abscess
and/or fistula, or a thrombosed hemorrhoid
• Less common causes of anorectal pain include anal canal
neoplasms, perianal skin infection, and dermatologic conditions
• Physical exam is critical in evaluating patients with anorectal
pain
• MRI or other imaging studies may be helpful in select cases
where the etiology of pain is elusive

19. Evaluation of Common Symptoms
Lower Gastrointestinal Bleeding
• The first goal is adequate resuscitation
• The second goal is to identify the source of hemorrhage
• Colonoscopy may identify the cause of the bleeding, and cautery or injection
of epinephrine into the bleeding site may be used to control hemorrhage
• Hematochezia is commonly caused by hemorrhoids or a fissure

20. Evaluation of Common Symptoms
Constipation and Obstructed Defecation
• Causes of constipation are underlying metabolic, pharmacologic, endocrine,
psychological, and neurologic causes
• The absence of an anorectal inhibitory reflex suggests Hirschsprung’s disease and
may prompt a rectal mucosal biopsy
• Medical management is the mainstay of therapy for constipation and includes fiber,
increased fluid intake, and laxatives

21. Evaluation of Common Symptoms
Diarrhea and Irritable Bowel Syndrome
• Diarrhea is a common complaint, usually a self-limited symptom of infectious
gastroenteritis
• Bloody diarrhea and pain are characteristic of colitis; etiology can be an infection,
inflammatory bowel disease (ulcerative colitis or Crohn’s colitis), or ischemia
• Chronic ulcerative colitis, Crohn’s colitis, infection, malabsorption, and short gut
syndrome can cause chronic diarrhea
• Irritable bowel syndrome is a particularly troubling constellation of symptoms
consisting of crampy abdominal pain, bloating, constipation, and urgent diarrhea.
With workup reveals no underlying anatomic or physiologic abnormality

22. Evaluation of Common Symptoms
Incontinence
• The incidence has been estimated to occur in 10 to 13 individuals per 1000 people
older than age 65 years
• The cause is multifactorial, diarrhea is often contributory.
• The causes can be classified as neurogenic or anatomic
• Neurogenic causes include diseases of the central nervous system and spinal cord
along with pudendal nerve injury
• Anatomic causes include congenital abnormalities, procidentia (rectal prolapse),
overflow incontinence secondary to impaction or an obstructing neoplasm, and
trauma
• Therapy depends on the underlying abnormality

23. General Surgical Considerations
Resections
• Resection principles: The mesenteric clearance technique dictates the
extent of resection and is determined by the nature of the primary pathology, the
intent of resection, the location of the lesion, and the condition of the mesentery.

25. Colectomy Ileocolic Resection
Transverse Colectomy
Left Colectomy
Sigmoid Colectomy
Total and Subtotal Colectomy
Extended Left Colectomy
Extended Right Colectomy
Right Colectomy

27. Proctocolectom
y
Total Proctocolectomy
Restorative Proctocolectomy
Anterior Resection
High Anterior Resection
Low Anterior Resection
Extended Low Anterior Resection
Hartmann’s Procedure and Mucus Fistula
Abdominoperineal Resection

28. Anastomoses
Anastomoses may be created between two segments of bowel in a multitude of ways
The geometry of the anastomosis may be end-to-end, end-to-side, side-to-end, or side-to-side
The anastomotic technique may be hand-sewn or stapled
The submucosal layer of the intestine provides the strength of the bowel wall and must be
incorporated in the anastomosis to assure healing
The choice of anastomosis depends on the operative anatomy and surgeon preference

29. Anastomoses
End-to-end End-to-side
Side-to-end Side-to-side
Anastomotic
Configuration

31. Anastomoses
Anastomotic
Technique
Hand-Sutured Technique.
May be single layer, using either running or interrupted stitches, or double layer. A
double-layer anastomosis usually consists of a continuous inner layer and an
interrupted outer layer. can be done in conjunction with an anal canal
mucosectomy to allow the anastomosis to be created at the dentate line.
Stapled Techniques.
Circular cutting/stapling devices can create end-to-end, end-to-side, or side-to-end
anastomoses. These instruments are particularly useful for creating low rectal or
anal canal anastomoses where the anatomy of the pelvis makes a hand-sewn
anastomosis technically difficult or impossible.

32. Ostomies and Preoperative Stoma Planning
A stoma may be temporary or permanent, depends on the clinical situation
Preoperative marking for a planned stoma is critical for a patient’s quality of life.
Ideally, a stoma should be located within the rectus muscle, in a location where the
patient can easily see and manipulate the appliance, and away from previous scars, bony
prominences, or abdominal creases.

33. Ileostomy
Temporary
Ileostomy
A segment of distal ileum is brought through the defect
in the abdominal wall as a loop, often used to “protect”
an anastomosis that is at risk for leakage (low in the
rectum, in an irradiated field, in an
immunocompromised or malnourished patient, and
during some emergency operations)
Permanent
Ileostomy
The end of the small intestine is brought through the
abdominal wall defect and matured, sometimes
required after total proctocolectomy or in patients with
obstruction.

34. Ileostomy

35. Colostomy
Most colostomies are created as end colostomies rather than loop colostomies
Most colostomies are created on the left side of the colon. An abdominal wall defect is
created and the end of the colon mobilized through it
The distal bowel may be brought through the abdominal wall as a mucus fistula
or left intra-abdominally as a Hartmann’s pouch
Closure of an end colostomy has traditionally required a laparotomy, but increasingly
minimally invasive techniques have been adopted.
The stoma is dissected free of the abdominal wall and the distal bowel identified. An
end-to-end anastomosis is then created.

36. Inflammatory Bowel Disease
Epidemiology It includes ulcerative colitis, Crohn’s disease, and indeterminate colitis
Ulcerative colitis occurs in 8 to 15 people per 100,000 in the United
States and Northern Europe
The incidence of Crohn’s disease is slightly lower,1 to 5 people per
100,000
In 15% of patients with inflammatory bowel disease, differentiation
between ulcerative colitis and Crohn’s colitis is impossible; these
patients are classified as having indeterminate colitis

37. Inflammatory Bowel Disease
Etiology Many different etiologies for inflammatory bowel disease have been proposed,
but none are proven
That included environmental factor such as diet or infection, alcohol and oral
contraceptive, smoking, family history, autoimmune mechanism and/or a defect in
the intestinal immune system, bacteria such as Mycobacterium paratuberculosis
and Listeria monocytogenes and viruses such as paramyxovirus and measles virus
Regardless of the underlying cause of either ulcerative colitis or Crohn’s disease,
both disorders are characterized by intestinal inflammation, and medical therapy
is largely based on reducing inflammation

38. Inflammatory Bowel Disease
Pathology
and
Differential
Diagnosis
Ulcerative colitis is a mucosal process in which the colonic
mucosa and submucosa are infiltrated with inflammatory cells
It may affect the rectum (proctitis), rectum and sigmoid colon
(proctosigmoiditis), rectum and left colon (left-sided colitis), or
the rectum and entire colon (pancolitis)
It does not involve the small intestine, but the terminal ileum
may demonstrate inflammatory changes (“backwash ileitis”)
A key feature of ulcerative colitis is the continuous
involvement of the rectum and colon, while rectal sparing or
skip lesions suggest a diagnosis of Crohn’s disease

39. Inflammatory Bowel Disease
In contrast to ulcerative colitis, Crohn’s disease is a
transmural inflammatory process that can affect any part
of the gastrointestinal tract from mouth to anus
Mucosal ulcerations, an inflammatory cell infiltrate, and
noncaseating granulomas are characteristic pathologic
findings
The endoscopic appearance of Crohn’s colitis is
characterized by deep serpiginous ulcers and a
“cobblestone” appearance
Skip lesions and rectal sparing are common

40. Inflammatory Bowel Disease
In 15% of patients with colitis from inflammatory
bowel disease, differentiation of ulcerative colitis
from Crohn’s colitis is impossible either grossly or
microscopically (indeterminate colitis)
Differential diagnoses include infectious colitides,
especially Campylobacter jejuni, Entamoeba
histolytica, C. difficile, Neisseria gonorrhoeae,
Salmonella, and Shigella species

41. Inflammatory Bowel Disease
Principles of
Nonoperative
Management:
The medical therapy focuses on decreasing inflammation
and alleviating symptoms, and many of the agents used
are the same for both ulcerative colitis and Crohn’s
disease
These agents include Salicylates (Sulfasalazine
(Azulfidine), 5-acetyl salicylic acid (5-ASA)), Antibiotics
(Metronidazole, Fluoroquinolones), Corticosteroids,
Immunomodulating Agents (Azathioprine and 6-
mercatopurine (6-MP), cyclosporine)), Biologic Agents
(Infliximab), and Nutrition

42. Ulcerative Colitis
Indications
for
Surgery:
It may be emergent or elective
Emergency surgery is required for patients with massive life-threatening
hemorrhage, toxic megacolon, or fulminant colitis who fail to respond
rapidly to medical therapy
Indications for elective surgery include intractability despite maximal
medical therapy and high-risk development of major complications of
medical therapy such as aseptic necrosis of joints secondary to chronic
steroid use
Elective surgery also is indicated in patients at significant risk of
developing colorectal carcinoma

43. Operative Management
Emergent
Operation
In a patient with fulminant colitis or toxic
megacolon, total abdominal colectomy with end
ileostomy (with or without a mucus fistula) is
recommended
Complex techniques, such as an ileal pouch–anal
reconstruction, generally are contraindicated in the
emergent setting

44. Operative Management
Elective
Operation
Because of the risk of ongoing inflammation, the
risk of malignancy, and the availability of
restorative proctocolectomy, most surgeons
recommend operations that include resection of
the rectum
Total proctocolectomy with end ileostomy has
been the “gold standard” for treating patients with
chronic ulcerative colitis

45. Crohn’s Disease
Indications
for
Surgery:
Because Crohn’s disease can affect any part of the
gastrointestinal tract, the therapeutic rationale is
fundamentally different from that of ulcerative colitis
The most common indications for surgery are internal
fistula or abscess (30%–38% of patients) and obstruction
(35%–37% of patients)
Other indications for surgery in chronic Crohn’s colitis are
intractability, complications of medical therapy, and risk
of or development of malignancy

46. Diverticular Disease
Diverticular disease is a clinical term used to describe the presence of symptomatic diverticula
Diverticulosis refers to the presence of diverticula without inflammation
Diverticulitis refers to inflammation and infection associated with diverticula
The sigmoid colon is the most common site of diverticulosis

47. Diverticulosis is thought to be an acquired disorder, but the etiology is poorly understood
The most accepted theory is that a lack of dietary fiber results in smaller stool volume,
requiring high intraluminal pressure and high colonic wall tension for propulsion
Chronic contraction then results in muscular hypertrophy and development of the process
of segmentation in which the colon acts like separate segments instead of functioning as a
continuous tube
As segmentation progresses, the high pressures are directed radially toward the colon wall
rather than to development of propulsive waves that move stool distally
The high radial pressures directed against the bowel wall create pulsion diverticula

48. Inflammatory
Complications
(Diverticulitis)
Refers to inflammation and infection associated with a
diverticulum and is estimated to occur in 10% to 25% of
people with diverticulosis
Most patients present with leftsided abdominal pain, with
or without fever, and leukocytosis
The differential diagnosis includes malignancy, ischemic
colitis, infectious colitis, and inflammatory bowel disease

49. Uncomplicate
d Diverticulitis
Characterized by left lower quadrant pain and
tenderness
Most patients with uncomplicated diverticulitis
will respond to outpatient therapy with broad-
spectrum oral antibiotics and a low-residue diet
Most patients with uncomplicated diverticulitis
will recover without surgery, and 50% to 70% will
have no further episodes

50. Complicated
Diverticulitis
Includes diverticulitis with abscess, obstruction, diffuse peritonitis
(free perforation), or fistulas between the colon and adjacent
structures
Colovesical, colovaginal, and coloenteric fistulas are long-term
sequelae of complicated diverticulitis
The Hinchey staging system is often used to describe the severity
of complicated diverticulitis: Stage I includes colonic inflammation
with an associated pericolic abscess; stage II includes colonic
inflammation with a retroperitoneal or pelvic abscess; stage III is
associated with purulent peritonitis; and stage IV is associated with
fecal peritonitis

51. Treatment depends on the patient’s overall clinical
condition and the degree of peritoneal contamination and
infection
Small abscesses (<2 cm in diameter) may be treated with
parenteral antibiotics
Larger abscesses are best treated with CT-guided
percutaneous drainage and antibiotics
Urgent or emergent laparotomy may be required if an
abscess is inaccessible to percutaneous drainage, if the
patient’s condition deteriorates or fails to improve, or if the
patient presents with free intra-abdominal air or peritonitis

52. Adenocarcinoma And Polyps
Incidence Colorectal carcinoma is the most common malignancy of
the gastrointestinal tract. Over 140,000 new cases are
diagnosed annually in the United States, and more than
50,000 patients die of this disease each year, making
colorectal cancer the third most lethal cancer in the United
States
The incidence is similar in men and women and has
remained fairly constant over the past 20 years

53. Adenocarcinoma And Polyps
Epidemiology
(Risk Factors):
Aging
Hereditary Risk Factors
Environmental and Dietary Factors
Inflammatory Bowel Disease
Other Risk Factorscigarette, increased level of human
growth hormone and insulin-like growth factor-1

54. Colorectal Cancer
Pathogenesis
of Colorectal
Cancer
A variety of mutations have been
identified in colorectal cancer. Mutations
may cause activation of oncogenes (K-ras)
and/or inactivation of tumor suppressor
genes (adenomatous polyposis coli [APC],
deleted in colorectal carcinoma [DCC],
p53)

55. Colorectal Cancer

56. Polyps
It is now well accepted that the majority of colorectal
carcinomas evolve from adenomatous polyps
Polyp is a nonspecific clinical term that describes any projection from
the surface of the intestinal mucosa regardless of its histologic nature
Colorectal polyps may be classified as neoplastic (tubular adenoma, villous
adenoma, tubulovillous adenomas, serrated adenomas/polyps), hyperplastic,
hamartomatous (juvenile, Peutz-Jeghers, Cronkite-Canada), or inflammatory
(pseudopolyp, benign lymphoid polyp

57. Prevention: Screening and Surveillance
Because the majority of colorectal cancers are thought to
arise from adenomatous polyps, preventive measures
focus on identification and removal of these
premalignant lesions
In addition, many cancers are asymptomatic, and
screening may detect these tumors at an early and
curable stage
Screening guidelines are meant for asymptomatic
patients. Any patient with a gastrointestinal complaint
(bleeding, change in bowel habits, pain, etc) requires a
complete evaluation, usually by colonoscopy

59. Staging and Preoperative Evaluation
Colorectal cancer staging is based on tumor depth and
the presence or absence of nodal or distant metastases
Older staging systems, such as the Dukes’ Classification
and its Astler-Coller modification, have been replaced
by the tumor-node-metastasis (TNM) staging system

62. Stage I
disease includes adenocarcinomas that are invasive through the muscularis mucosa
but are confined to the submucosa (T1) or the muscularis propria (T2) in the
absence of nodal metastases
Stage II
disease consists of tumors that invade through the bowel wall into the subserosa or
nonperitonealized pericolic or perirectal tissues (T3) or into other organs or tissues
or through the visceral peritoneum (T4) without nodal metastases
Stage III
disease includes any T stage with nodal metastases
Stage IV
disease denotes distant metastases

63. Therapy for Colonic Carcinoma
Principles
of
Resection
The objective in treatment of carcinoma of
the colon is to remove the primary tumor
along with its lymphovascular supply
Because the lymphatics of the colon
accompany the main arterial supply, the
length of bowel resected depends on which
vessels are supplying the segment involved
with the cancer

64. Stage-Specific Therapy
Stage 0
(Tis, N0, M0)
Polyps should be excised completely
Stage I:
The Malignant Polyp (T1,
N0, M0)
Treatment is based on the risk of local recurrence and the risk of lymph node
metastasis, segmental colectomy is indicated
Stages I and II: Localized
Colon Carcinoma (T1-3,
N0,M0)
Surgical resection without adjuvant chemotherapy, except selected patients with
stage II disease (young patients, tumors with “high-risk” histologic findings)
Stage III: Lymph Node
Metastasis (Tany, N1, M0) Adjuvant chemotherapy has been recommended routinely in these patients
Stage IV: Distant
Metastasis (Tany, Nany,
M1)
Survival is extremely limited, all patients require adjuvant chemotherapy

65. Therapy for Rectal Carcinoma

66. Other Benign Colorectal Conditions
Rectal
Prolapse
It refers to a circumferential, full-thickness protrusion of the
rectum through the anus and has also been called “first-degree”
prolapse, “complete” prolapse, or procidentia
In adults, this condition is far more common among women,
with a female-to-male ratio of 6:1. Prolapse becomes more
prevalent with age in women and peaks in the seventh decade
of life
Symptoms include tenesmus, a sensation of tissue protruding
from the anus that may or may not spontaneously reduce, and a
sensation of incomplete evacuation. Mucus discharge and
leakage may accompany the protrusion

67. The primary therapy for rectal prolapse is surgery, and more than 100
different procedures have been described to treat this condition
Operations can be categorized as either abdominal or perineal
Abdominal operations have taken three major approaches: (a)
reduction of the perineal hernia and closure of the cul-de-sac
(Moschowitz repair); (b) fixation of the rectum, either with a prosthetic
sling (Ripsten and Wells rectopexy) or by suture rectopexy; or (c)
resection of redundant sigmoid colon
Perineal approaches have focused on tightening the anus with a variety
of prosthetic materials, reefing the rectal mucosa (Delorme procedure),
or resecting the prolapsed bowel from the perineum (perineal
rectosigmoidectomy or Altemeier procedure)

68. Volvulus occurs when an air-filled segment of the colon twists
about its mesentery
The sigmoid colon is involved in up to 90% of cases,
but volvulus can involve the cecum (<20%) or
transverse colon
The symptoms of volvulus are those of acute bowel
obstruction. Patients present with abdominal
distention, nausea, and vomiting
A volvulus may reduce spontaneously, but sometimes
require surgery

69. Megacolon describes a chronically dilated, elongated, hypertrophied
large bowel, may be congenital or acquired and is usually
related to chronic mechanical or functional obstruction
Congenital megacolon caused by Hirschsprung’s disease
results from the failure of migration of neural crest cells
to the distal large intestine. The resulting absence of
ganglion cells in the distal colon results in a failure of
relaxation and causes a functional obstruction
Surgical resection of the aganglionic segment is curative

70. Anorectal Diseases
Hemorrhoids 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
Hemorrhoids are thought to function as part of the 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

71. External hemorrhoids are located distal to the dentate
line and are covered with anoderm, Because the
anoderm is richly innervated, thrombosis of an external
hemorrhoid may cause significant pain, It is for this
reason that external hemorrhoids should not be ligated
or excised without adequate local anesthetic
Treatment of external hemorrhoids and skin tags is only
indicated for symptomatic relief

72. • Internal hemorrhoids are located proximal to the dentate line
and covered by insensate anorectal mucosa
• Internal hemorrhoids may prolapse or bleed, but rarely become
painful unless they develop thrombosis and necrosis
• Internal hemorrhoids are graded according to the extent of
prolapse.
First-degree 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

73. 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
Rubber
Band
Ligation:
This indicated for persistent bleeding from first-, second-, and selected third-degree
hemorrhoids
Mucosa located 1 to 2 cm proximal to the dentate line is grasped and pulled into a
rubber band applier. After firing the ligator, the rubber band strangulates the
underlying tissue, causing scarring and preventing further bleeding or prolapse

74. Infrared
Photocoagulation An effective office treatment for small first- and second-degree
hemorrhoids.
The instrument is applied to the apex of each hemorrhoid to
coagulate the underlying plexus
Sclerotherapy
The injection of bleeding internal hemorrhoids with sclerosing
agents is another effective office technique for treatment of
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 of
each hemorrhoid

75. Operative Hemorrhoidectomy
Closed Submucosal
Hemorrhoidectom
y
Aften called the Parks or Ferguson hemorrhoidectomy, involves
resection of hemorrhoidal tissue and closure of the wounds with
absorbable suture
Open
Hemorrhoidectom
y
This technique, often called the Milligan and Morgan
hemorrhoidectomy, follows the same principles of excision described
earlier, but the wounds are left open and allowed to heal by
secondary intention

76. Whitehead’s
Hemorrhoidectomy Involves circumferential excision of the hemorrhoidal
cushions just proximal to the dentate line.
After excision, the rectal mucosa is then advanced and
sutured to the dentate line
Procedure for
Prolapse and
Hemorrhoids/Stapled
Hemorrhoidectomy
It does not involve excision of hemorrhoidal tissue, but
instead pexes the redundant mucosa above the dentate
line.
PPH removes a short circumferential segment of rectal
mucosa proximal to the dentate line using a circular
stapler

77. Anal Fissure
A fissure in ano is a tear in the anoderm distal to the dentate line
The pathophysiology of anal fissure is thought to be related to 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 of pain, spasm, and ischemia contributes to development of a poorly healing
wound that becomes a chronic fissure
The vast majority of anal fissures occur in the posterior midline. Ten percent to 15%
occur in the anterior midline. Less than 1% of fissures occur off midline

78. Treatment
Therapy focuses on breaking the cycle of pain, spasm, and ischemia thought to be
responsible for development of fissure in ano
First-line therapy to minimize anal trauma includes bulk agents, stool softeners, and
warm sitz baths
The addition of 2% lidocaine jelly or other analgesic creams can provide additional
symptomatic relief
Medical therapy is effective in most acute fissures, but will heal only approximately
50% of chronic fissures
Surgical therapy has traditionally been recommended for chronic fissures that have
failed medical therapy, and lateral internal sphincterotomy is the procedure of choice

79. Thank You