Haemorrhoids and perianal diseases

1. Benign Anorectal DiseasesBenign Anorectal Diseases
Dr. SUNDARPRAKASH SIVALINGAMDr. SUNDARPRAKASH SIVALINGAM

2. ContentContent
HaemorrhoidsHaemorrhoids
Anorectal AbscessAnorectal Abscess
Anal fistulaAnal fistula
Anal fissureAnal fissure
Benign Anal TumorsBenign Anal Tumors

3. Rectal ProlapseRectal Prolapse
Pilonidal SinusPilonidal Sinus
ProctitisProctitis
Pruritis AniPruritis Ani

4. Anatomy of the RectumAnatomy of the Rectum
Length:Length: 12 cm.12 cm.
Diameter:Diameter: Upper partUpper part  same of sigmoidsame of sigmoid
(4cm) but lower is dilated (rectal ampulla).(4cm) but lower is dilated (rectal ampulla).
Beginning:Beginning: rectosigmoid junction (sacralrectosigmoid junction (sacral
promontory).promontory).
End:End: 2.5 cm below and in front of the tip of2.5 cm below and in front of the tip of
coccyx.coccyx.

5. Anatomy of rectumAnatomy of rectum
Male Female
Anterior Bladder
Seminal vesicles
Ureters
Prostate
Urethra
Pouch of douglas
Uterus
Cervix
Posterior vaginal
wall
Lateral Lateral lig
Middle rectal A.
Obturator internus
M
Side wall of pelvis
Levator ani M
Lateral lig
Middle rectal A.
Obturator internus
M
Side wall of pelvis
Levator ani M
Posterior Sacrum and
coccyx
Loose areolar
tissue
Facial
condensation
Superior rectal A
Lymphatics
Sacrum and
coccyx
Loose areolar
tissue
Facial
condensation
Superior rectal A
Lymphatics

6. Anatomy of rectumAnatomy of rectum

7. Anatomy of Anal CanalAnatomy of Anal Canal
Length:Length: 4 cm4 cm
Extent:Extent: fromfrom
anorectalanorectal
junction to the anus.junction to the anus.
Interior:Interior:
Upper part:Upper part:
Anal columnAnal column
Anal valveAnal valve
Anal sinusAnal sinus
Dentate lineDentate line
Middle part:Middle part:
Lower Part:Lower Part:

8. Anatomy of Anal CanalAnatomy of Anal Canal
Musculature:Musculature:
1.1. External anal sphincterExternal anal sphincter
2.2. Internal anal sphincterInternal anal sphincter
Arterial supply:Arterial supply:
– Superior and inferiorSuperior and inferior
rectal arteries.rectal arteries.
Venous Drainage:Venous Drainage:
Lymphatic Drainage.Lymphatic Drainage.

10. Clinical Features of AnorectalClinical Features of Anorectal
DiseaseDisease
1.1. Bleeding.Bleeding.
2.2. Pain.Pain.
3.3. Altered bowel habit.Altered bowel habit.
4.4. Discharge.Discharge.
5.5. Tenesmus.Tenesmus.
6.6. Prolapse.Prolapse.
7.7. Pruritis.Pruritis.
8.8. Loss of weightLoss of weight

11. InvestigationsInvestigations
ProctoscopeProctoscope
Inspect (10-12 cm)Inspect (10-12 cm)
Biopsy can be takenBiopsy can be taken
SigmoidoscopeSigmoidoscope
Lighted tube 2 cm in diameter.Lighted tube 2 cm in diameter.
20 to 25 cm long.20 to 25 cm long.
Reaches 20 to 25 cm from the dentate line.Reaches 20 to 25 cm from the dentate line.
20 to 25 % of colorectal tumors.20 to 25 % of colorectal tumors.
Safe and effective for screening low-risk adultsSafe and effective for screening low-risk adults
under 40 years of age.under 40 years of age.
An enema is sometimes used to prepare theAn enema is sometimes used to prepare the
patient before the examination.patient before the examination.

13. InvestigationInvestigation
Flexible sigmoidoscopeFlexible sigmoidoscope
A fiberoptic scope.A fiberoptic scope.
Measures 60 cm in length.Measures 60 cm in length.
Reach the proximal left colon or even the splenicReach the proximal left colon or even the splenic
flexure.flexure.
50 % of colorectal cancers.50 % of colorectal cancers.
Every 5 years beginning at age 50 is the currentEvery 5 years beginning at age 50 is the current
endoscopic screening method recommended forendoscopic screening method recommended for
asymptomatic persons at average risk for colorectalasymptomatic persons at average risk for colorectal
carcinoma.carcinoma.

15. HemorrhoidsHemorrhoids
DefinitionDefinition
– InternalInternal
– ExternalExternal
– Interno-ExternalInterno-External
SitesSites
1.1. Left lateral (3 o’clock).Left lateral (3 o’clock).
2.2. Right posteriolateral (7 o’clock).Right posteriolateral (7 o’clock).
3.3. Right anterolateral (11 o’clock).Right anterolateral (11 o’clock).

17. HemorrhoidsHemorrhoids
ClassificationClassification
1.1. 11stst
degreedegree
2.2. 22ndnd
degree.degree.
3.3. 33rdrd
degree.degree.
4.4. 44thth
degree.degree.
How hemorrhoids causes bleeding?How hemorrhoids causes bleeding?

19. HemorrhoidsHemorrhoids
DiagnosisDiagnosis
ComplicationComplication

23. Treatment of HemorrhoidTreatment of Hemorrhoid
11stst
degreedegree
ConservativeConservative
Dietary adviseDietary advise
Bulk laxativesBulk laxatives
Sitz bathSitz bath
Treatment will be effective at 6 monthTreatment will be effective at 6 month

24. Treatment of hemorrhoidsTreatment of hemorrhoids
22ndnd
degreedegree
Rubber band ligation.Rubber band ligation.
Complication of bandComplication of band
– HemorrhageHemorrhage
– SepsisSepsis
– PainPain
33rdrd
degreedegree
– HemorrhoidectomyHemorrhoidectomy

27. Treatment of hemorrhoidsTreatment of hemorrhoids
Complication of hemorrhoidectomyComplication of hemorrhoidectomy
Acute urinary retentionAcute urinary retention
Secondary hemorrhageSecondary hemorrhage
Anal stenosisAnal stenosis
Thrombosed hemorrhoidThrombosed hemorrhoid
Conservative (laxative, analgesic, iceConservative (laxative, analgesic, ice
packs)packs)
Operative manual dilatation of the anusOperative manual dilatation of the anus
and hemorrhoidectomyand hemorrhoidectomy

29. Anorectal AbscessAnorectal Abscess
Definition: Infection in one or more of analDefinition: Infection in one or more of anal
spaces, usually is bacterial infection ofspaces, usually is bacterial infection of
blocked anal gland at dentate line.blocked anal gland at dentate line.
OrganismsOrganisms
– EcoliEcoli
– Staph aureus.Staph aureus.

30. Anorectal AbscessAnorectal Abscess
SitesSites
1.1. Perianal.Perianal.
2.2. Ischiorectal.Ischiorectal.
3.3. Pelvirectal.Pelvirectal.
4.4. Intersphincteric.Intersphincteric.
Increase incidence with?Increase incidence with?

32. Anorectal AbscessAnorectal Abscess
HistoryHistory
Age, sex, symptomsAge, sex, symptoms
Examination:Examination:
PositionPosition
TendernessTenderness
Color / tempColor / temp
Shape, size, compositionShape, size, composition
Lymph drainageLymph drainage
Local tissueLocal tissue
General ExaminationGeneral Examination

33. Anorectal AbscessAnorectal Abscess
InvestigationInvestigation
TreatmentTreatment
Incisional and drainageIncisional and drainage
AntibioticsAntibiotics

35. Fissure-in-ano (anal fissureFissure-in-ano (anal fissure((
Definition:Definition:
Acute & chronicAcute & chronic
Longitudinal split in the skin of the analLongitudinal split in the skin of the anal
canal.canal.
Common sites:Common sites:
– Midline 6 and 12 o’clock.Midline 6 and 12 o’clock.
Rarely associated with crohns, HSV, HIV.Rarely associated with crohns, HSV, HIV.

37. Fissure-in-anoFissure-in-ano
DiagnosisDiagnosis
TreatmentTreatment
Non- operativeNon- operative
– Stool softeners and laxativesStool softeners and laxatives
– Improve hygiene.Improve hygiene.
– Anesthetic suppositories may be helpful.Anesthetic suppositories may be helpful.
OperativeOperative
– Anal dilation.Anal dilation.
– Lateral internal sphincterotomyLateral internal sphincterotomy
– Fissurectomy and midline sphincterotomy.Fissurectomy and midline sphincterotomy.

38. Anal FistulaAnal Fistula
DefinitionDefinition
secondary to crohn’s, TB, CA of rectum orsecondary to crohn’s, TB, CA of rectum or
lymphogranuloma.lymphogranuloma.
S/SS/S
– Watery or purulent discharge from theWatery or purulent discharge from the
external opening of fistulaexternal opening of fistula
– Recurrent episode of pain.Recurrent episode of pain.
– Pruritis.Pruritis.

43. ProctitisProctitis
CauseCause
– NonspecificNonspecific
– Ulcerative proctocolitisUlcerative proctocolitis
– Crohn’s diseaseCrohn’s disease
– InfectionInfection
Clostridium difficileClostridium difficile
Bacillary dysenteryBacillary dysentery
TB proctitisTB proctitis
SyphilisSyphilis
GonococcalGonococcal

44. ProctitisProctitis
Nonspecific proctitisNonspecific proctitis
is an inflammatory condition affecting theis an inflammatory condition affecting the
mucosa and, to a lesser extent, themucosa and, to a lesser extent, the
submucosa, confined to the terminalsubmucosa, confined to the terminal
rectum and anal canal.rectum and anal canal.
It is the most common variety.It is the most common variety.
Aetiology.Aetiology.
This is unknown.This is unknown.
The most acceptable hypothesis: It is aThe most acceptable hypothesis: It is a
limited form of ulcerative colitis (althoughlimited form of ulcerative colitis (although
actual ulceration is often not present(.actual ulceration is often not present(.

45. ProctitisProctitis
Clinical featuresClinical features
Middle-aged.Middle-aged.
Slight loss of blood in the motions.Slight loss of blood in the motions.
DiarrhoeaDiarrhoea
On rectal examination, the mucosa feels warmOn rectal examination, the mucosa feels warm
and smooth. Often there is some blood on theand smooth. Often there is some blood on the
examining finger.examining finger.
Proctoscopic and Sigmoidoscopic examination:Proctoscopic and Sigmoidoscopic examination:
– Inflamed mucous membrane of the rectum, butInflamed mucous membrane of the rectum, but
usually no ulceration. The mucosa above this levelusually no ulceration. The mucosa above this level
being quite normal.being quite normal.

46. ProctitisProctitis
TreatmentTreatment
Self-limiting.Self-limiting.
Sulphasalazine (Salazopyrin).Sulphasalazine (Salazopyrin).
Prednisolone retention enemas.Prednisolone retention enemas.
Severe casesSevere cases  oral steroids.oral steroids.
RarelyRarely  surgical treatment (last resort)surgical treatment (last resort)

47. Pruritis aniPruritis ani
Definition: Perianal itching, particularly theDefinition: Perianal itching, particularly the
frequent and distressing one.frequent and distressing one.
EtiologyEtiology
SymptomsSymptoms
TreatmentTreatment

48. Rectal ProlapseRectal Prolapse
Definition: Eversion of whole thickness ofDefinition: Eversion of whole thickness of
the lower part of rectum and anal canal.the lower part of rectum and anal canal.
TypesTypes
1.1. Partial prolapse.Partial prolapse.
2.2. Complete prolapse.Complete prolapse.
CauseCause
Predisposing factorsPredisposing factors
Differential diagnosisDifferential diagnosis

49. Rectal ProlapseRectal Prolapse
HistoryHistory
Age.Age.
Sex.Sex.
Symptoms.Symptoms.
ExaminationExamination

53. Rectal ProlapseRectal Prolapse
TreatmentTreatment
PartialPartial
– InfantInfant
– AdultAdult
Complete (Thiersch wire).Complete (Thiersch wire).

54. Pilonidal sinusPilonidal sinus
Definition: Sinus which contain tuft ofDefinition: Sinus which contain tuft of
hairs, mainly in skin covering the sacrumhairs, mainly in skin covering the sacrum
and coccyx but can occur between fingers,and coccyx but can occur between fingers,
in hair dressers, and the umbilicus.in hair dressers, and the umbilicus.
EtiologyEtiology
SymptomsSymptoms
TreatmentTreatment
– Acute abscessAcute abscess
– Chronic abscessChronic abscess

58. Benign Anal TumorsBenign Anal Tumors
Villous AdenomaVillous Adenoma
Tubular PolypsTubular Polyps